Antileukotriene drugs are new therapeutic agents that have recently been approved for the treatment of asthma. Several cases of eosinophilic conditions including ChurgStrauss syndrome have been reported to be associated with zafirlukast, a cysteinyl leukotriene type 1 receptor antagonist. So far no other leukotriene modifier has been associated with the syndrome. The case history is presented of a man with allergic rhinitis and asthma who had received intermittent pulse therapy with oral corticosteroids. Pulmonary eosinophilia developed while he was receiving treatment with montelukast, a chemically distinct cysteinyl leukotriene type 1 receptor antagonist. After discontinuation of montelukast therapy and administration of systemic corticosteroids the patient's symptoms reversed rapidly and there was prompt resolution of the pulmonary infiltrates. We believe that cysteinyl leukotriene type 1 receptor antagonists are safe and eVective drugs for most patients with asthma but caution is needed for those with more severe disease who require systemic corticosteroids, especially if they show characteristics of the atypical allergic diathesis seen in the prodromal phase of Churg-Strauss syndrome. (Thorax 1999;54:558-560) Keywords: montelukast; side eVects; pulmonary eosinophiliaThe antileukotriene drugs are new therapeutic agents which have recently been approved and are now available for the treatment of asthma in several countries. These drugs include one enzyme inhibitor of 5-lipoxygenase, zileuton, and three chemically distinct cysteinyl leukotriene type 1 receptor antagonists, zafirlukast, pranlukast and montelukast. As the use of these drugs increases, adverse events occurring at low frequency or in populations not examined in clinical trials may become manifest.2 Several cases of eosinophilic conditions including Churg-Strauss syndrome have been reported in patients who have been treated with zafirlukast. [2][3][4] No other leukotriene modifier has yet been associated with the syndrome.In this case report we describe an asthmatic patient in whom pulmonary eosinophilia developed while receiving montelukast therapy. Case reportA 26 year old man with a three year history of asthma had received treatment with salbutamol, nedocromil, theophylline, and beclomethasone. There was a five year history of allergic rhinitis with positive skin tests for house dust mite and cat dander. Because asthma symptoms were not well controlled, treatment was started with fluticasone 1000 µg daily and salmeterol twice a day. Allergen immunotherapy was also prescribed. Nonetheless, short courses of oral prednisone 40 mg or deflazacort 60 mg daily were required on several occasions to control asthma exacerbations. A decision was made to initiate treatment with montelukast at a dose of 10 mg daily in the evening. Treatment with fluticasone was continued.After approximately four months of treatment with montelukast the patient developed headache, malaise, myalgia, nasal congestion, and fever up to 39ºC. Oral cefuroxime and parac...

The common feature of the reports by Franco et al 1 and Oliver et al 2 is the use of spiral (or volumetric) computed tomography to demonstrate features which would not be readily identifiable on conventional computed tomographic (CT) scanning. The advantages of spiral CT over conventional CT scanning are twofold: increased speed of data acquisition and volumetric (rather than slice by slice) data acquisition. The attribute of speed means that most thoracic examinations can be performed within a single breath hold and the timing of intravenous contrast administration can be precisely tailored, thus allowing reproducible enhancement of any desired part of the vasculature-for example, the pulmonary arteries in cases of suspected pulmonary embolism. Because an entire volume of data is acquired (with almost equal spatial resolution in the three axes) it is possible to reconstruct images in any plane, including threedimensional (3-D) reconstructions.3 Most examinations acquired with spiral CT scanning are presented as a series of transaxial slices, reflecting the traditional presentation of conventional CT images.In the report by Franco et al 1 the clarity with which the anomalous arteries feeding the sequestrated lung are shown on the 3-D reconstructions is striking. In the past a separate preoperative examination (either aortography or possibly magnetic resonance angiography) to identify the vascular supply would have been regarded as mandatory. Other imaging tests such as radionuclide scintigraphy or ultrasound may answer specific questions in cases of pulmonary sequestration, but the wealth of information now available from a single spiral CT examination is remarkable. Quite apart from their aesthetic appeal, the main benefit of these readily produced 3-D reconstructions is an easy appreciation of what can be complex anatomy. Nevertheless, claims for the increased diagnostic gain from these 3-D reconstructions should not be too extravagant: the anomalous vessels would be identifiable on images presented in the standard transaxial format, although without such immediacy. Furthermore, demonstration of the venous drainage into the pulmonary circulation (for the classic intralobar sequestrations) may not be so readily obtained with a single spiral CT examination. However, the ability to extract so much information from a spiral CT examination represents a substantial advance on conventional CT scanning. Spiral CT pulmonary angiography is an eVective way of demonstrating pulmonary embolism in segmental and larger arteries. 4 The basic sign of a filling defect within a well opacified pulmonary artery is straightforward enough. The case report by Oliver et al 2 highlights the fact that there may be ancillary signs of pulmonary embolism on spiral CT scanning-in this case shift of the interventricular septum-which corroborates the diagnosis and, more controversially, provides prognostic information. Shift of the interventricular septum and other signs of right ventricular dysfunction are readily demonstrated on echocardiog...

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Pre-operative templating is an unreliable and inaccurate tool. There is no relation between coronal deformity and accuracy of templating.

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