The Prince Charles Hospital. Brisbane, Australia. TIMOTHY J. ... Aaron SD, Vandemheen KL, Ferris W, Fergusson D, Tullis E, Haase D,. Berthiaume Y, Brown N, ...
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antipanic medication alone or in association with asthma treatment, investigating the influence of such treatment on respiratory function and daily activities. The recommended treatment approaches for the two disorders sometimes conflict, for example, exposure to body sensations for PD versus avoidance of such triggers for asthma; relaxation to ameliorate anxiety, which could produce bronchoconstriction through a parasympathetic discharge, versus b-sympathetic agonists for asthma that could trigger panic; treatment of overperception and catastrophic interpretation of body sensations for PD versus improving poor symptom sensitivity and encouraging appropriate anxiety about symptoms for asthma. The presence of asthma may increase the risk of developing PD through a variety of cognitive and behavioral mechanisms, including producing threatening bodily sensations that could trigger panic among susceptible individuals, agoraphobic avoidance, and aversive conditioning to cues for respiratory impairment (5). Lehrer and colleagues (6) used a treatment approach that incorporated components of panic control therapy and asthma self-management programs. Both programs were adapted for the comorbid group, teaching participants to recognize the differences between asthma and panic symptoms and to engage in appropriate self-care for each (6). They observed significant therapeutic effects, presumably from early attention to teaching participants to distinguish asthma from panic symptoms, and treating each disorder appropriately. Conflict of Interest Statement: A.E.N. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.
ANTONIO E. NARDI Federal University of Rio de Janeiro Rio de Janeiro, Brazil References 1. Nardi AE. Where are the guidelines for the treatment of asthma with panic spectrum symptoms? Am J Respir Crit Care Med 2005;172:1055– 1056. 2. Livermore N, Butler JE, Sharpe L, McBain RA, Gandevia SC, McKenzie DK. Panic attacks and perception of inspiratory resistive loads in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2008;178:7–12. 3. Goodwin RD, Jacobi F, Thefeld W. Mental disorders and asthma in the community. Arch Gen Psychiatry 2003;60:1125–1130. 4. Hasler G, Gergen PJ, Kleinbaum DG, Ajdacic V, Gamma A, Eich D, Ro¨ssler W, Angst J. Asthma and panic in young adults: a 20-year prospective community study. Am J Respir Crit Care Med 2005;171: 1224–1230. 5. Nascimento I, Nardi AE, Valencxa AM, Lopes FL, Mezzasalma MA, Nascentes R, Zin WA. Psychiatric disorders in asthmatic outpatients. Psychiatry Res 2002;110:73–80. 6. Lehrer PM, Karavidas MK, Lu S-E, Feldman J, Kranitz L, Abraham S, Sanderson W, Reynolds R. Psychological treatment of comorbid asthma and panic disorder: a pilot study. J Anxiety Disord 2008;22:671–683.
Death after Lung Transplantation in Cystic Fibrosis Patients Infected with Burkholderia cepacia To the Editor:
We read with interest the article by Dr. Murray and colleagues (1), which examined the post–lung transplantation outcomes of patients with cystic fibrosis and Burkholderia cepacia complex infection. Excess mortality was largely seen in patients with B. cenocepacia infection, and infection with species other than B. cenocepacia was not associated with worse outcomes (1). These data support recent reports from other groups (2, 3). We have had recent experience of early mortality in two patients with cystic fibrosis following lung transplant with chronic
B. cepacia (genomovar I) infection. A 44-year-old female died 9 weeks post-transplant from overwhelming pulmonary infection. The early postoperative clinical course was excellent, including discharge from the hospital on Day 24 and no episodes of augmented immunosuppression. A male, 23 years of age, succumbed to progressive pulmonary infection 8 weeks post-transplant following the acquisition of an Influenza A and RSV coinfection on Day 53. The early postoperative clinical course was excellent, including discharge from hospital on Day 19. Treatment of the viral infection included ribavirin and pulse methylprednisolone therapy. Influenza vaccine had been administered pretransplant, but the antigenic component of the vaccine did not match the strain isolated from the patient. Bronchoscopy washing and blood cultures revealed B. cepacia. These deaths occurred despite the use of routine protocols for patients with B. cepacia complex infection aimed at reducing risk of sepsis, including IL-2 receptor blocker monoclonal antibodies, cyclosporine targeting low therapeutic levels, intravenous antibiotics based on multiple combination bactericidal testing, and avoidance of surveillance transbronchial biopsies. Kidd and colleagues (4) found that the proportion of Australian patients with cystic fibrosis and B. cepacia infection (previously known as genomovar I) is higher (11.2%) than most previous reports. Whereas early septic complications following lung transplantation have not been seen in our patients with B. cenocepacia, it has occurred in two patients with B. cepacia infection. The identification of a concurrent viral infection in one case could suggest a potential ‘‘priming’’ effect, which may have influenced the pathogenicity of B. cepacia infection. In each case, molecular typing demonstrated retention of the same B. cepacia strain after transplantation, but strains from each patient were unrelated. Despite antibiotic treatment based on available multiple combination bactericidal testing of B. cepacia (5), control of infection was not achievable. These cases exemplify the potential for ‘‘cepacia syndrome’’ post-transplant due to B. cepacia in patients with cystic fibrosis, adding to concerns about post-transplant outcomes in patients with B. cenocepacia and B. gladioli (1–3). Conflict of Interest Statement: P.M.H. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. T.J.K. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. C.C. served on a scientific advisory board for Wyeth Australia in 2005 and 2006, receiving AUD 1000; he received AUD 575 for chairing a meeting on behalf of Wyeth Australia in 2006; he was principal investigator for a laboratory research study which was supported by an unrestricted educational grant of $9,000 from Merck Sharp & Dohme (Australia). I.H.F. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. P.D. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. S.C.B. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.
PETER M. HOPKINS The Prince Charles Hospital Brisbane, Australia TIMOTHY J. KIDD University of Queensland and Pathology Queensland Brisbane, Australia CHRIS COULTER Pathology Queensland Brisbane, Australia IAIN H. FEATHER Gold Coast Hospital Southport, Australia
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PETRA DERRINGTON Pathology Queensland Southport, Australia SCOTT C. BELL University of Queensland and The Prince Charles Hospital Brisbane, Australia References 1. Murray S, Charbeneau J, Marshall BC, LiPuma JJ. Impact of Burkholderia infection on lung transplantation in cystic fibrosis. Am J Respir Crit Care Med 2008;178:363–371.
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2. Alexander BD, Petzold EW, Reller LB, Palmer SM, Davis RD, Woods CW, Lipuma JJ. Survival after lung transplantation of cystic fibrosis patients infected with Burkholderia cepacia complex. Am J Transplant 2008;8:1025–1030. 3. Boussaud V, Guillemain R, Grenet D, Coley N, Souilamas R, Bonnette P, Stern M. Clinical outcome following lung transplantation in patients with cystic fibrosis colonised with Burkholderia cepacia complex: results from two French centres. Thorax 2008;63:732–737. 4. Kidd TJ, Douglas JM, Bergh HA, Coulter C, Bell SC. Burkholderia cepacia complex epidemiology in persons with cystic fibrosis from Australia and New Zealand. Res Microbiol 2008;159:194–199. 5. Aaron SD, Vandemheen KL, Ferris W, Fergusson D, Tullis E, Haase D, Berthiaume Y, Brown N, Wilcox P, Yozghatlian V, et al. Combination antibiotic susceptibility testing to treat exacerbations of cystic fibrosis associated with multiresistant bacteria: a randomised, double-blind, controlled clinical trial. Lancet 2005;366:463–471.
