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.