Acute respiratory distress related to chemotherapy of advanced pulmonary tuberculosis: a study of two cases and review of the literature.

Two patients with non-miliary pulmonary tuberculosis developed a syndrome resembling adult respiratory distress following initiation of drug treatment. They were studied clinically and with a representative range of in vitro and in vivo tests of immune function. Both were alcoholic, malnourished and presented with radiologically widespread, smear-positive disease and lymphocytopenia. One had cutaneous anergy in vivo and profound reduction on mononuclear cell proliferative and interferon responses to tuberculoprotein (PPD) in vitro; the other patient, who died two weeks after starting treatment, had relatively normal values for these measures of cell-mediated immunity. In both cases there was a progressive increase during treatment, in peripheral blood lymphocyte counts, skin reactions and in vitro cellular responses to PPD, and a sudden rise in ESR at the time of their deterioration. We propose that the reactions may represent local manifestations of heightened delayed hypersensitivity, mounted by increasing numbers of 'resuscitated' lymphocytes against immunogenic cell wall substances released from dying tubercle bacilli in patients whose level of cellular immunity is being enhanced as a result of chemotherapy. The likelihood of an acute respiratory reaction during treatment may therefore depend on the bacillary load, the extent of lung disease present, and its severity may be related to the pre-treatment immune status of the patient.