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...

Tracheobronchial clearance was measured by a radioaerosol technique in 12 patients with bronchiectasis, seven patients with chronic obstructive lung disease expectorating mucoid sputum daily (group X), eight patients with chronic obstructive lung disease but negligible sputum expectoration (group Y), and 10 healthy subjects. The patients with bronchiectasis all expectorated purulent sputum daily (mean wet weight 47 g/day), had reduced forced expiratory volume in one second (FEV1) (mean 47 5% predicted), and were unable to avoid coughing during the six hour observation period. None of the patients with bronchiectasis or the healthy subjects were current smokers. There were five current smokers in group X and six in group Y. The mean FEV1 in group X was 41% predicted and in group Y 52% predicted, both values similar to that of the patients with bronchiectasis.Tracheobronchial clearance in the first six hours after inhalation of radioaerosol was significantly (p < 0-01) slower in patients with bronchiectasis than in matched healthy subjects despite more proximal deposition of radioaerosol (p = 0 01) and more coughing (p < 001) in the former. Tracheobronchial clearance in patients with bronchiectasis was impaired to a similar degree to that in patients with chronic obstructive lung disease but no bronchiectasis.

Bronchograms and plain chest radiographs of 27 patients with chronic sputum production were reported separately in random order and independently by two pulmonary radiologists to establish the diagnostic rate of each investigation and to assess interobserver variation.Both Two main groups of patients with bronchiectasis were identified by bronchography: 11 with bronchiectasis alone and eight with bronchiectasis and bronchographic features suggestive of "chronic bronchitis". There was no clinical difference between these two groups.Plain chest radiographs were insensitive, being diagnostic (both radiologists agreeing) of bronchiectasis in only nine of 19 (47%) patients with definite bronchiectasis on bronchography.Bronchiectasis is usually defined as irreversible dilatation of the bronchial tree. Reid described three different bronchographic appearances of bronchiectasis-namely, cylindrical, varicose, and saccular (cystic)-and related these to pathological changes in the bronchi.' In cylindrical bronchiectasis the bronchi have regular outlines, show no great increase in diameter, and usually end squarely and abruptly. Varicose bronchi show irregular dilatation and bulbous termination, while saccular bronchiectasis is characterised by bronchial dilatation that increases progressively towards the periphery of the lung, with a ballooned outline and few bronchial subdivisions.By contrast, in established chronic bronchitis (cough, sputum, and breathlessness for more than one year with some degree of disability without evidence of another cause)2 the principal bronchographic abnormalities are localised beaded bronchial dilatation, diverticulosis (mucus pits), poor peripheral filling of bronchi and bronchioles, peripheral pooling of contrast medium, and excessive vari-

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Bronchograms and computed tomograms were performed in 27 patients who presented consecutively for bronchography with chronic sputum production. The films were reported separately by three consultant radiologists, who had been asked to give a diagnostic interpretation of the films for each bronchopulmonary segment. The reporting of bronchiectasis on computed tomograms was compared with that on bronchograms. The sensitivity and specificity of computed tomography at segmental level compared with bronchography was 66% and 92%, respectively. We conclude that computed tomography alone is not yet suitable for accurate characterisation and localisation of disease in patients in whom surgery is contemplated. Computed tomography may be useful in patients in whom bronchography is contraindicated and for monitoring progression of disease after initial combined computed tomography and bronchography.Bronchography has been used for many years as a definitive investigation to identify the presence, severity, and extent of bronchial abnormalities, particularly bronchiectasis, but it is an invasive investigation and unpleasant for the patient. Despite refinements in technique and contrast medium, complications may occur, which include allergic and foreign body reaction to the contrast medium, pulmonary infection, and a temporary reduction in pulmonary function with impaired ventilation and diffusion.' Bronchiectasis, as the term is used in this study, is permanent, irreversible dilatation of the bronchial tree, and its features as seen by the newer technique of computed tomography (CT) have been described by Naidich et al.2 Mootoosamy et al recently concluded that CT was useful in assessing bronchiectasis,3 but Muller et al, on the other hand, found it unreliable in diagnosing cylindrical and varicose bronchiectasis.4In view of the apparent conflict in current reports, we conducted a controlled study to assess the sensitivity and specificity of CT compared with bronchography in the diagnosis of bronchiectasis.Address for reprint requests: Dr J Cooke, Department of Radiology, Royal Marsden Hospital, London SW3 6JJ.Accepted I October 1986 Patients and methods PATIENTSTwenty seven patients who presented consecutively for bronchography with symptoms of cough and sputum were studied. Of these, 26 expectorated sputum daily (median duration eight years) and the sputum in 24 was purulent; one expectorated sputum intermittently. All but one of the patients were examined more than three months after an exacerbation, the exception having a repeat CT scan three months later; only the second scan was included in the analysis. INVESTIGATIONS