serologic evidence of Legionnaires' disease ...

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Soup. 672 COMMUNICATIONSTO THE EDITOR. CHEST, 78: 4, OCTOBER, .... as those convalescing from illness; its flesh is fine, it dissolves a kidney stone.

Prolonged cavitating pneumonia in a patient with serologic evidence of Legionnaires' disease. R T Gibney, F A Herbert, E G King and J F Elliot Chest 1980;78;671-672 DOI 10.1378/chest.78.4.671 The online version of this article, along with updated information and services can be found online on the World Wide Web at:

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1980by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. ( ISSN:0012-3692

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no evidence

of metastases in the other lobes of either lung, nor in other organs. This patient’s course illustrates dramatically a characteristic feature of osteogenic sarcoma in that pulmonary metastases may appear long after radical excision of the primary tumor. A noteworthy aspect of this case was the unusual location of the pulmonary metastasis to a single lobe, and the massive infarction of the right lung due to tumor invasion of the right pulmonary artery. Shlo,no Dux, M.D.; Silvio Pitlik, M.D.; and Joseph B. Rosenfeld, M.D. Department of Medicine C, Beilinson Medical Center, Sackler School of Medicine, Tel Aviv University Medical School, Tel Aviv, Israel REFERENCE

1 Dahlin 600

DC, Coventry MB: Osteogenic sarcoma: J Bone Joint Surg 1967; 49:101-110

a study



Prolonged Cavifafing Pneumonia in a Pafienf wifh Serologic Evidence of Legionnaires’

Disease To the Editor: Legionnaires’ limiting illness.


of this

pneumonia gionnella FIctmE

disease usually Little is known


in a patient pneumophila

presents about the

We describe with serology

as an chronic

acute selfmanifestaa case of necrotizing indicating recent Le-



also negative. One week after admission he was apyrexic, symptomatically improved and was discharged. Two weeks thereafter, he was readmitted with recurrence of high fever (39#{176}C), chills, chest pain and dyspnea. While the findings on physical examination were unchanged, the chest x-ray film showed the infiltration previously seen in the right middle lobe to be denser, with bulging of the interlobar fissure. An abscess formation was suspected, and antibiotic treatment with cindamycin commenced. His condition deteriorated rapidly, and 12 hours after readmission, he required ventilatory support with a Bennett respirator. A repeated chest x-ray film now showed infiltration of the entire right lung. The patient died two hours later, with a clinical picture of respiratory failure and shock. At autopsy, the middle lobe of the right lung was found to be infiltrated by multiple metastasic tumors, one of which had invaded the right pulmonary artery producing massive infarction of the right lung. No metastases were detectable in any of the other lobes of the lungs, nor in other organs (Fig


COMMENT Multiple lung metastases are common findings in the natural history of osteogenic sarcoma, and are present in approximately 80 percent of patients dying of this disease.1 While a primary tumor of the lung occurs infrequently in the middle lobe, metastatic tumors tend to be scattered over two

or more lobes. Therefore, bacterial pneumonia was considered to be the most likely cause of the right middle lobe syndrome. The autopsy findings, however, showed the right middle lobe to be almost replaced by metastatic tumor, with

CHEST, 78: 4, OCTOBER, 1980



A 73-year-old male smoker was admitted to hospital complaining of malaise and 5 kg weight loss over a six-week period. Four weeks prior to admission he developed an increase in dyspnea with a cough productive of purulent blood-stained sputum. He was on no medication. On physical examination he was febrile with right upper lobe consolidation. This was confirmed by chest roentgenograms, which also revealed multiple areas of cavitation (Fig 1). His white blood cell count was 23,900/cu mm, with 76 percent polymorphs, 12 percent lymphocytes, 1 percent monocytes and 11 percent band forms. The tuberculin skin test was negative at 5 TU. Culture of sputum showed Pseudomonas fluocescens. Sputum analysis for malignant cells and Mycobacterium tuberculosis was negative. Fiberoptic bronchoscopic examination was unrevealing. A diagnosis of aspiration pneumonia was made and the patient was treated with intravenous penicillin-C. Over the following week his general condition improved with return of his temperature and white blood cell count to normal. Results of acute phase serum indirect fluorescent antibody studies for Legionnaires’ disease (CDC, Atlanta) returned after the patient’s discharge were positive to a titer of 1/32. Convalescent phase serum was positive to a titer of 1/512. DIscussIoN Necrotizing pneumonia with abscess formation has recently been described as a complication of Legionnaires’ disease, but only in the immunosuppressed or in patients with fulminant disease.1,2 However, we have been unable to find a report of a prolonged cavitating pneumonia in association with Legionnaires’ disease.


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of Chicken


To the Editor: In a much earlier era, the therapeutic efficacy of chicken, chicken soup and other fowl is extensively described in the medical writings of Moses Mairnonides.’ In his book On the Causes of Symptoms,2 also known as Medical Response,3 he recommends the meat of hens or roosters (or chickens or pullets) and their broth because this type of fowl has the property of rectifying corrupted humors, especially the black humor (ie, black bile, an excess of which was thought to cause melancholy), so much so that physicians mention that chicken broth is beneficial in leprosy. The type of chicken to be used is described by Maimonides: One two

should not use the too large, that is of more than years of age; nor the too small, that is those in whom the mucus still prevails; neither the too lean, nor those who through feeding become obese; but those that are fat by nature, without being stuffed. The chicken or pullet can be boiled or stewed or steamed or boiled with fresh coriander, or with some green fennel added to the soup. This dish is especially suitable in winter. The soup, however, where lemon juice or citron juice or






False-positive serology Legionnaires’ disease has been reported in psittacosis, plague, tularemia and leptospirosis.3 One strain of Pseudomonas fluorescens stains specifically with fluorescent antibody to L pneumophilo,4 but to date, there has been no report of false positive serologic reactions in patients with Pseudomonas fluorescens infections, although this was considered in our case. The most likely explanation for our patient’s illness is L pneumophila pneumonia which later became superinfected with Pseudomonas fluorescens or a mixture of anaerobic organism which responded to pencillin therapy. T. Noel Gibney, M.B., B.Ch.; Garner King, M.D., F.C.C.P.; and J. F. Elliot, M.D., Division of Respiratory Disease, Department of Medicine; University of Alberta, Edmonton, Alberta, Canada

R. F.






1 Lewin

S. Brettman LR, Goldstein EJC, Holzman RS, H, Taubman F, Sierra MF, Edelstein PH. Legiondisease: A cause of severe abscess forming pneumonia. Am J Med 1979; 67:339-342 2 Gump DW, Frank RO, Winn WC, Foster RS, Broome CV, Cherry WB. Legionnaire’s disease in patients with associated serious disease. Ann hit Med 1979; 90:538-542 3 Tsai TF, Fraser DW. The diagnosis of Legionnaire’s disease. Ann Intern Med 1978; 89:413-414 4 Cherry WB, Pittman B, Harris PP. Herbert GA, Thomason BM, Thacker L, Weaver RE. Detection of Legionnaire’s disease: Bacteria by direct immunofluorescent staining. J Clin Microbiol 1978; 8:329-338 Devila naire’s


are The


to the


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of breeding and feeding the chickens is also discussed in some detail. Maimonides’ conclusion is that “these procedures have been verified and their usefulness is clear.” He does not state, however, whether or not he conducted a double-blind randomized study. The most voluminous of Maimonides’ medical writings is his Medical Aphorisms of Moses which is comprised of 1,500 aphorisms based mainly on Greek medical writers. There are 25 chapters, each dealing with a different area of medicine including anatomy, physiology, pathology, symptomatology and diagnosis, etiology of disease and therapeutics, fevers, blood-letting or phlebotomy, laxatives and emetics, surgery, gynecology, hygiene, exercise, bathing, diet, drugs and medical curiosities. In the chapter on diet, Maimonides states that boiled chicken soup neutralizes body constitution. Chicken soup is both an excellent food, as well as a medication for the beginning of leprosy, and fattens the body substance of the emaciated and those convalescing from illness. Turtle doves increase memory, improve intellect and sharpen the senses. The consumption of fowl, continues Maimonides, is beneficial for feebleness, hemiplegia, facial paresis and the pain of edema. It also increases sexual potential. House pigeons that graze in the streets increase natural body heat. Soup made from the bird called kanaber loosens cramps of colic. The quail helps the healthy, as well as those convalescing from illness; its flesh is fine, it dissolves a kidney stone and it stimulates urine flow. Maimonides further states that chicken testicles provide excellent nourishment. They are especially useful to nourish a weakened or convalescent individual. Testicles of all living creatures are warming and moistening in their action and aid the libido in a strongly perceptible manner. Pigeon eggs are good aphrodisiacs. Similarly, all eggs help the libido, especially if they are cooked with onion or turnip. Finally, baby chicks that are separated from their mother alleviate heat that occurs in the stomach. Soup made from an old chicken is of benefit against chronic fevers that develop from white bile and also aids the cough which is called asthma. In his Treatise on Asthma, Maimonides advises the consumption of chicken meat that is not fat for sufferers of


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Prolonged cavitating pneumonia in a patient with serologic evidence of Legionnaires' disease. R T Gibney, F A Herbert, E G King and J F Elliot Chest 1980;78; 671-672 DOI 10.1378/chest.78.4.671 This information is current as of January 15, 2012 Updated Information & Services Updated Information and services can be found at: Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Reprints Information about ordering reprints can be found online: Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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