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Unlike the osseous variety, extraskeletal small cell tumors histologically identical to Ewing's sarcoma of bone frequently respond to radical surgical excision. The relative infrequence of this tumor, compounded by the comprehensive eponym "Ewing's sarcoma," may deter surgical intervention in this group of patients. This patient's course demonstrates the value of surgery alone, but emphasizes the role of combined surgery, irradiation, and chemotherapy as the best management for extraskeletal Ewing's sarcoma.

Pleural involvement has generally been considered an unusual aspect of sarcoidosis. In this paper, five previously unreported cases of sarcoidosis involving the pleura were discussed. Pleural sarcoidosis may be manifested by the presence of a pleural effusion, and the diagnosis is based on the exclusion of all other possible causes and the demonstration of noncaseating granulomas in the pleura. When the pleura is involved without effusion, it may only be recognized if noncaseating granulomas involving the pleura are looked for specifically. Including the five cases form this study, there have been 73 cases of pleural sarcoidosis reported, but only 37 have been verified by histologic evidence. When strict diagnostic criteria are used, clinical involvement of the pleura in sarsoidosis remains an unusual entity, but it may be that histologic involvement of the pleura is more common than generally appreciated.

The indications and usefulness of outpatient serum theophylline determinations were prospectively evaluated by doing 151 of these studies in 137 consecutive cases of chronic obstructive pulmonary disease. We found that evaluations were done for the following three groups of indications: group A, worsening bronchospasm; group B, stable asymptomatic cases, and group C, symptoms suggesting theophylline toxicity. When the three clinical groups were compared for frequency of nontherapeutic values, only an increased frequency of subtherapeutic values in patients with bronchospasm (group A) was significant (P<.01). Increasing the dosage up to 15 mg per kg of body weight a day while theophylline determinations are pending appears to be safe in this group of patients. Toxic symptoms were rarely associated with concentrations greater than 20 mug per ml (3/13) and infrequently occurred in patients with concentrations greater than 20 mug per ml (3/29). Nontherapeutic theophylline values did not always result in an adjustment of theophylline dosage. This was influenced by a correlation of symptoms, timing of the theophylline determination and the use of other bronchodilators.

The cellular content of bronchial lavage was studied in 14 patients with sarcoidosis and 20 normal volunteers. There was no alteration in the total number of cells recovered, except for the expected increase in cellularity in smokers. Nonsmoking patients with sarcoidosis had 19.6 per cent lymphocytes, compared to 8.1 per cent lymphocytes in nonsmoking control subjects. The percentage of alveolar macrophages showing spontaneous adherence of one or more bronchial lymphocytes were, respectively, 10.8 and 8.4 in nonsmoking and smoking patients with sarcoidosis, compared to 1.8 and 2.1, respectively, in nonsmoking and smoking control subjects.

The efficacy of administering continuous positive airway pressure (CPAP) by face mask was evaluated in 40 consecutive patients treated with 10 cm of water pressure or greater. Thirty-five patients were treated for progressive hypoxemia with all patients improving their PaO2/FIO2 ratio within the first hour of therapy. Oxygen delivery, when measured, also improved in each patient, although five patients ultimately required endotracheal intubation and higher CPAP levels to further improve their arterial hypoxemia. Five other patients were treated for atelectasis unresponsive to the usual therapeutic measures, with three patients demonstrating roentgenographic improvement. Face mask CPAP proved to be a safe and effective method for treating hypoxemia associated with early progressive respiratory distress in alert, spontaneously breathing patients.

A 13-year-old hypertensive girl with a history of severe headaches following exercise developed circulatory collapse after "squat jumps." Pulmonary edema was present without evidence of a cerebral mass. The patient died with increased intracranial pressure despite decompressive craniectomy. Neuropathological evaluation revealed diffuse cerebral edema and a pheochromocytoma in the right adrenal gland. Examination of urine revealed elevation of vanillylmandelic acid levels.

Acute respiratory failure developed in three patients needing ventilatory support within hours after total parenteral nutrition was started. We postulate that the high carbohydrate load provided in the parenteral solution resulted in the use of glucose as the primary energy source, with the development of substantial increases in the carbon dioxide production and the respiratory quotient. Because these patients had a relatively fixed ventilatory response, hypercapnia ensued. Excessive carbohydrate loading may precipitate respiratory acidosis in patients unable to adequately improve their alveolar ventilation when compensating for increased carbon dioxide production.

Legionnaire's disease presenting as empyema has not been previously described, although pleural effusions are not uncommon. A 56-year-old woman had a ten-day history of pleuritic chest pain and a large loculated empyema. Legionnaires' disease was documented by serum indirect fluorescent antibody studies.