Optimum steroid dosage in status asthmaticus.

We read with interest our case report in the December issue of Chest (1982; 82:800-01), and reaffirmed in our own minds what a unique case this indeed was. However, since some discussion of the uniqueness ofthe case seemed in order, and, in fact, was apparently inadvertently omitted from the case report, we wouldlike to offer the following: Pulmonary infections caused by atypical mycobacteria have increased in recent years, while those due to Mycobacterum tuberculosis continue to decline.’ However, disseminated infection remains an extremely uncommon manifestation of disease due to atypical mycobacteria, usually occurring in immunocompromised patients with a mortality rate of approximately 75 percent.2 Our patient, as presented in our case report, had no evidence of malignancy and had not received steroids prior to her illness. This appears to be more characteristic of disseminated infection associated with M intracellulare. In his review, Wolinsky found that 20 of 30 patients with disseminated M intracellulare did not have an underlying illness. The importance ofthe elevated antibody titer against Legionnella pneumophila is not clear. Recently, a patient was described with concurrent Legionnaires’ disease and active pulmonary tuberculosis3 indicating a possible association between the two diseases. In addition, studies have demonstrated cross-reactivity with significant elevation of Legionella titers in patients with certain other infections,45 as well as problems with standardization ofthe antigen for L pneumophila.6 While this may represent a nonspecific elevation ofLegionella antibodies in our patient, the possibility remains of an antecedent infection with L pneumophila which predisposed our otherwise healthy patient to disseminated infection with M intracellulare.