The challenge of bilateral bronchopleural fistula.

938 Communications to the Editor Room air ABG measurement revealed a pH of7.43, Pco2 30 mm Hg and Po2 76 mm Hg (92 percent saturation). Electrolyte levels were within normal limits, with a serum bicarbonate of 22.5 mEq/ L. Chest roentgenogram revealed new diffuse interstitial and alveolar infiltrates (Fig 1). The patient was admitted and treated with intravenous fluids, oral diphenhydramine and acetaminophen therap He defervesced quickly, blood pressure stabilized at 100/68 and dyspnea resolved. Antibiotic therapy was withheld, in anticipatio)n of bronchoscopy should symptoms recur. Twenty-femr hours after admission, temperature increase to 39.5#{176}C(oral) with a mild, diffuse headache prompting a lumbar puncture, which was negative. Arterial blood gas levels revealed improved oxygenation (pH 7.43, Pco2 32 mm Hg, and Po2 89 mm Hg on room air). Serial chest roentgenograms showed rapid clearing ofthe diffuse infiltrates (Fig 2). The remainder ofhis hospital course was uneventful, with discharge two) days later off medication. Adverse reactions to trimethoprim-sulfamethoxazole in AIDS patients, including fever, rash, and CI side effects, have been documented in the past.#{176}5 We feel our patient suffered a reaction similar to that described by Silvestri et al, resolving quickly without specific therapy. Cardinal manifestations of this reaction appear to) be: 1) drug re-exposure; 2) rapid development o)f pulmonary infiltrates, dyspnea, and hypoxemia; 3) acute fever; 4) hypotension; 5) erythematous rash, and 6) rapid resolution after drug discontinuation. Re-exposure to TMP/SMX can indeed mimic progression of the underlying pulmonary infection, presenting the clinician with a difficult diagnostic problem, and may result in a life-threatening reaction.