Background -Primary ciliary dyskinesia is characterised by chronic rhinosinusitis, chronic bronchial sepsis (usually with bronchiectasis), dextrocardia in approximately 50% of cases, and male infertility. The latter, described in patients attending infertility clinics, results from immotile but viable spermatozoa. Experience in a respiratory clinic suggests that infertility in men is not invariable. Methods -The seminal fluid of 12 men with primary ciliary dyskinesia, six with dextrocardia, who presented consecutively with upper and lower respiratory tract sepsis was examined. Nasal ciliary beating was dyskinetic or absent in ali cases, and nasal ciliary ultrastructure was abnormal in those 11 patients examined. Results -Viable but immotile spermatozoa with abnormal tail ultrastructure were found in the ejaculate of only two patients. Two other patients had apparently fathered children; seminology in both these cases showed a normal spermatozoa count, one with normal spermatozoal motility and normal ultrastructure, the other with moderately reduced spermatozoal motility and abnormal ultrastructure (dynein arm deficiency on the peripheral microtubule doublets). A further two patients had normal spermatozoa counts, normal spermatozoa tail ultrastructure, and normal or only moderately reduced motility of spermatozoa. The spermatozoa of one patient were normally motile but there was severe oligozoospermia, and five patients were azoospermic. Conclusions -Not all men with primary ciliary dyskinesia have immotile spermatozoa. Seminal analysis is recommended in men with primary ciliary dyskinesia so that accurate counselling about reproductive capability may be given.inner and outer dynein arms which interact with neighbouring microtubules to produce movement.Primary ciliary dyskinesia is a congenital condition characterised by purulent rhinosinusitis, chronic bronchial sepsis which is usually associated with bronchiectasis, and, frequently, male infertility.2' About 50% of patients have dextrocardia with or without situs inversus and meet the criteria for Kartagener's syndrome. The characteristic seminal analysis in primary ciliary dyskinesia is a normal number of viable but immotile spermatozoa. A common defect -usually partial or complete deficiency of one or both sets of dynein arms -may account for the dyskinetic beating of the respiratory cilia and the immotility of spermatozoan tails in this condition.2Most men with primary ciliary dyskinesia are infertile because of immotile spermatozoa.45 This may be because of a bias in case selection towards those attending for investigation of infertility whose respiratory symptoms were only fully investigated once immotile spermatozoa were noted. There are single case reports of men presenting with respiratory disease due to primary ciliary dyskinesia with normal seminal analysis6 and azoospermia.7 We examined the fertility of men with primary ciliary dyskinesia who presented consecutively with respiratory symptoms. Methods PATIENTSAll patients with persistent resp...

A high index of suspicion helps diagnose ocular tuberculosis in areas of low prevalence of the disease. It forms part of the differential diagnosis of any chronic or recurrent uveitis, especially in an at-risk patient. Antitubercular treatment seems highly effective.

Background:Haemoptysis is a common clinical symptom. A small proportion of patients present with haemoptysis and normal chest radiograph. The investigation strategy for this group of patients is unclear. The aim of this study is to see whether further investigations for this group of patients are justified.Methods:A retrospective analysis was conducted of consecutive patients presenting with haemoptysis and normal chest radiograph over a period of 56 months irrespective of their smoking status. These patients were investigated by CT of the thorax and fibreoptic bronchoscopy.Results:275 episodes of haemoptysis with normal chest radiograph were investigated further in 270 patients (60% males). The median age was 60 years. Twenty-six patients were diagnosed to have respiratory tract malignancies (larynx, 1; trachea, 1; lung, 22; carcinoid, 1; and leiomyoma, 1). Eight (31%) of the 26 patients with respiratory tract malignancy had radical treatment. Fibreoptic bronchoscopy was diagnostic of cancer in 14 (54%) of the 26 patients with malignancy. CT of the thorax was suggestive of cancer in 24 (96%) of the 25 patients with malignancy.Conclusion:It is concluded that further investigation of haemoptysis in smokers is justified regardless of the amount or frequency of haemoptysis based on a 9.6% rate of malignancy in this consecutive series. It is recommended that these patients are investigated with CT of the thorax followed by fibreoptic bronchoscopy.

Allergic bronchopulmonary aspergillosis often requires treatment with oral corticosteroids to control the host response to Aspergillus fumigatus. In a double blind study 25 patients with allergic bronchopulmonary aspergillosis taking maintenance oral corticosteroids were randomly allocated to receive 5 mg natamycin or placebo by nebuliser twice daily for one year. The primary aim of the study was to assess the steroid sparing potential of natamycin. Standardised reductions in corticosteroid dosage were therefore undertaken every five weeks, unless clinically contraindicated. Five patients were withdrawn in the first four months: two (1 natamycin, 1 placebo) died, two (1 natamycin, 1 placebo) had suspected drug reactions, and one (natamycin) was non-compliant. The pretreatment characteristics of the 20 patients (10 in each group) who completed the study were similar, 17 (9 natamycin, 8 placebo) having evidence of recent disease activity. At the end of the study prednisolone dose had been reduced by a similar amount in each group (median natamycin 2 25 mg, placebo 2-5 mg). Evidence of disease activity during the study year (transient shadowing on the chest radiograph, blood eosinophilia, or increases in antibodies to A fumigatus, or any combination of these)-was observed in similar numbers of patients in each group (5 natamycin, 7 placebo). There was no evidence that natamycin conferred benefit on these patients with allergic bronchopulmonary aspergillosis.Prolonged oral corticosteroid treatment is often used in patients with allergic bronchopulmonary aspergillosis in an attempt to control the host inflammatory response to Aspergillus fumigatus, but corticosteroids are associated with significant morbidity.'2 A fumigatus is found more frequently in the respiratory tract of patients with untreated allergic bronchopulmonary aspergillosis (58%) and in larger quantities than in patients with other respiratory disease."4 Antifungal agents might therefore reduce the requirement for corticosteroids.Nebulised antifungal agents, nystatin and natamycin (pimaricin), and nebulised brilliant green have been administered in an attempt to reduce the fungal load.7 The studies that have been reported were inadequately controlled and have shown equivocal evidence of benefit. In a group of eight patients with bronchopulmonary aspergillosis (initial culture positive for A fumigatus) treated with nebulised natamycin (2-5 mg thrice daily for one month and thereafter twice daily) A fumigatus disappeared from the sputum after a median of six (range 4-30) weeks.7 In a further study of four patients with allergic bronchopulmonary aspergillosis not receiving oral corticosteroids oral ketoconazole was associated with improvement in symptoms of asthma and a reduction in antibodies to A fumigatus,' but the risk of hepatotoxicity9 renders ketoconazole unsuitable as a long term alternative to corticosteroids.In a pilot study six of seven patients with allergic bronchopulmonary aspergillosis treated with nebulised natamycin (2-5 mg thrice...