Occult fever in surgical intensive care unit patients is seldom caused by sinusitis

Febrile intensive care unit (ICU) patients were evaluated prospectively for sinusitis. Of 598 admissions, 26 patients with transnasal cannulas, ICU stays over 48 hours, and occult fevers were identified. These 26 underwent physical examinations and sinus computed tomographic (CT) scans. Maxillary centeses and cultures were done in patients with CT abnormalities. Patients with positive scans had nasal tubes removed and received decongestants. Scans were abnormal in 19 (73%). All patients with major CT changes had positive maxillary taps. Most infections were polymicrobial; enteric bacilli were common. Fever resolved with nonoperative care in 18 (95%) patients; in only 1 patient was fever primarily from sinusitis. Sinus CT scans are often abnormal in ICU patients with occult fevers and transnasal cannulas. Pneumatic otoscopy can serve as a screening tool. Most patients respond to nonoperative management. Remote infections are often present. Although radiographic nosocomial ICU sinusitis is common, it is seldom the sole source of fever or the proximate cause of significant morbidity.     

Clinical criteria for acute maxillary sinusitis in general practice

The purpose of the investigation was to examine the diagnostic value of various symptoms, clinical findings, erythrocyte sedimentation rate (ESR) and serum C-reactive protein (CRP) in acute maxillary sinusitis using the aspiration of purulent or mucopurulent from the sinus of a patient with a pathological CT-scanning as the golden standard. Of 174 patients with suspected acute maxillary sinusitis seen in general practice we found 70% to have a pathological CT-scanning and 53% to have pus or mucous pus in the sinus aspirate. Only the ESR and CRP level were found to be significantly and independently associated with a positive diagnosis as defined by the golden standard. A clinical criterion based on either an elevated ESR and/or CRP level in a patient with pain related to the maxillary sinus region had sensitivity of 0.82, a specificity of 0.57, a positive predictive value of 0.68 and a negative predictive value of 0.75, and was diagnostically superior to the clinical examination. The investigation also confirms that this disease is most likely overdiagnosed in general practice.     

Primary-care-based randomised placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis

BACKGROUND: The value of antibiotics in acute rhinosinusitis is uncertain. Although maxillary sinusitis is commonly diagnosed and treated in general practice, no effectiveness studies have been done on unselected primary-care patients. We used a randomised, placebo-controlled design to test the hypothesis that there would be an improvement associated with amoxycillin treatment for acute maxillary sinusitis patients presenting to general practice. METHODS: Adult patients with suspected acute maxillary sinusitis were referred by general practitioners for radiographs of the maxillary sinus. Those with radiographic abnormalities (n = 214) were randomly assigned treatment with amoxycillin (750 mg three times daily for 7 days; n = 108) or placebo (n = 106). Clinical course was assessed after 1 week and 2 weeks, and reported relapses and complications were recorded during the following year. FINDINGS: After 2 weeks, symptoms had improved substantially or disappeared in 83% of patients in the study group and 77% of patients taking placebo. Amoxycillin did not influence the clinical course of maxillary sinusitis nor the frequency of relapses during the 1-year follow-up. Radiographs had no prognostic value, nor were they an effect modifier. Side-effects were recorded in 28% of patients given amoxycillin and in 9% of those taking placebo (p < 0.01). The occurrence of relapses was similar in both groups (21 vs 17%) during the follow-up year. INTERPRETATION: Antibiotic treatment did not improve the clinical course of acute maxillary sinusitis presenting to general practice. For these patients, an initial radiographic examination is not necessary and initial management can be limited to symptomatic treatment. Whether antibiotics are necessary in more severe cases warrants further study.     

Use of the computed tomographic whole body scanner to stage and follow patients with advanced ovarian carcinoma

Advanced ovarian carcinoma continues to be a difficult tumor to evaluate noninvasively. Recent developments in chemotherapy have enhanced response rates in this disease, thus improving the likelihood of tumor regression. Computed Tomography (CT) allows the noninvasive estimation of tumor extent in patients with ovarian carcinoma. Seventeen patients with epithelial ovarian carcinoma had 22 whole body CT scans performed either just prior to or following laparotomy. For determination of tumor involvement, when the CT was positive, a high pathologic correlation was found at liver, ascitic, peritoneal, mesenteric, and omental sites (sensitivity). When the cT was negative, high pathologic correlation was found at ascitic and mesenteric sites (specificity). Lower and negative correlation at other disease sites is attributed to difficulty of CT detection of small (1 cm) tumor nodules on visceral surfaces. Eighteen patients with advanced ovarian carcinoma were followed prospectively during treatment with repetitive CT scans. CT results were compared with physical examination, other radiologic studies, and clinical status. In 83% (15/18) of patients and 88% (59/67) of CT scans performed, CT was found to contribute useful management information. Clinical decisions were made on the basis of CT alone in 43% (29/67) of scans performed. These data suggest that CT scanning is very useful in the staging and follow-up of patients with ovarian carcinoma and can replace other radiologic procedures, but it is not completely accurate and needs to be correlated with physical examination and in cases without tumors visible with CT, with laparotomy.     

Role of technetium-99m sestamibi in localisation of thyroid cancer metastases

Technetium-99m sestamibi (MIBI) is a routinely used myocardial perfusion imaging agent. We have studied groups of patients with differentiated thyroid carcinoma, in order to evaluate the usefulness of this agent in localising regional neck and nodal disease and metastases. There are three groups of patients. Group 1 consisted of patients with known nodal disease or metastases (22 patients) and with raised serum thyroglobulin levels (Tg). Group 2 comprised patients with normal I-131 scans and normal Tg levels (nine patients). Non-thyroid malignancies (six patients) comprised an additional group 3. In group 1, the MIBI scan showed 47 sites of metastases, while the I-131 scan revealed 49 sites. The MIBI scan was positive in two patients where the I-131 scan was negative, while in two other patients, the MIBI study was negative whereas the I-131 scan was positive. In group 2, 6/9 patients had no disease, 2/9 had thyroid remnants, and 1/9 had a fresh primary lung tumour, unrelated to the earlier thyroid cancer. All of them had normal MIBI scans. In group 3, two patients with lung cancer and two with breast cancer and metastases had normal MIBI scans. A further two patients with nasopharyngeal cancer (NPC) had mildly increased MIBI localisation in neck nodes and bone metastases. In summary, Tc-99m sestamibi appears to be as good as I-131 in search for thyroid carcinoma metastatic spread, especially nodal disease and this tracer does not localise well in the primary or metastases of other cancers.(ABSTRACT TRUNCATED AT 250 WORDS)     

Chronic mycoses of the paranasal sinuses--value of endonasal paranasal sinus surgery

BACKGROUND: Many host factors even in immunocompetent patients may have an influence on development of a fungal diseases within the paranasal sinuses. Fungal sinusitis can occur in an acute form or more often to a chronic type of the disease. These mainly relatively asymptomatic chronic forms and further divided into a chronic noninvasive, chronic allergic, and chronic invasive disease. Endonasal microsurgery has significantly changed the management of chronic fungal sinusitis and allows adequate removal of pathologic tissue even in advanced situations. The aim of this study was to analyze the efficacy of endonasal surgery in chronic fungal sinusitis. MATERIAL AND METHODS: In a retrospective study we assessed a group of 40 patients who had endonasal surgery for chronic fungal sinusitis. Patient records, CT and MRI scans, microbiology and histology as well as the postoperative clinical follow-up including endoscopic photo documentation were evaluated over a period of 5 years. All patients underwent endonasal surgery using endoscopic techniques. The microscopic was of additional help in a few cases with extended disease and multiple dehiscences of the skull base. RESULTS: Twenty-four patients had a chronic noninvasive of fungal sinusitis and 16 patients had a chronic invasive form. All these patients underwent endonasal surgery without external incision. The fungal disease was erradicated in 39 cases, and revision surgery was required in only one case in which involvement of the contralateral side was not initially detected. in two cases scar tissue in the middle meatus was later excised but without evidence of residual fungal disease. Only in 6 cases was antifungal chemotherapy required, where the disease had spread into surrounding tissue or the patient had severe symptoms. CONCLUSIONS: Endonasal microsurgical techniques are today the appropriate approach for managing chronic fungal sinus disease even in severe cases with radiologic evidence of expansion or invasion of surrounding tissue. Additional antifungal chemotherapy is only rarely indicated, specifically when the fungal disease invades surrounding tissue.     

Evidence for selective use of bone scans in early stage breast cancer

To determine the usefulness of bone scans in detecting metastatic disease in women with early stage breast cancer, records of 193 patients who had bone scans preformed and underwent breast conservation therapy at a single institution were reviewed. Patients with invasive T1 or T2 breast carcinomas were eligible for this study; patients with a true positive bone scan were excluded from conservation therapy and, thus, were excluded from this study. The incidence of false positive bone scans in this study population was 32.6% (63/193 patients). Patients over 50 years of age had a significantly greater incidence of false positive bone scans (p<0. 05). In the 63 patients with false positive bone scans, 101 radiographs were performed to exclude metastatic disease in areas of increased uptake identified on bone scan. No significant difference in the rate of false positive bone scans was seen in relation to tumor size, pathologic or clinical nodal status or hormone receptor activity of the primary tumor. Thus, selective use of bone scans is advocated in patients with early stage (T1 or T2) breast cancer.     

The demonstration of cartilaginous involvement in laryngeal carcinoma by computerized tomography

Thirty-six patients with laryngeal carcinoma were investigated by computerized tomography (CT). In 8 patients invasion of cartilage was shown at subsequent pathological examination of the excised larynges. In all there were 14 areas of cartilage involvement, 11 of which could be diagnosed on retrospective examination of the CT scans. Involvement of tumour was shown either as areas of decreased density (chondrolysis) or areas of local increased density (chondrosclerosis) due to cartilage ossification. False positive and false negative evidence of cartilage involvement was recorded in the series, but the accuracy of diagnosis in positive terms was approximately 79%. Histological evidence is put forward that the presence of carcinoma in relation to the cartilage produces perichondritis, which enhances ossification and the latter process may then in itself facilitate invasion by the tumour. Previous radiotherapy may also be a factor in the causation of the perichondritis and ossification.     

DTPA aerosol in ventilation/perfusion scintigraphy for diagnosing pulmonary embolism

The use of lung scintigraphy in evaluating suspected pulmonary embolism (PE) is controversial. Several diagnostic methods have been described for lung scans, of which the most widely applied uses 99mTc-MAA for perfusion, 133Xe for ventilation and PIOPED diagnostic criteria. This study evaluates the accuracy of lung scintigraphy using an alternative ventilation agent, 99mTc-diethylenetriamine pentacetic acid (DTPA) aerosol, and specific criteria. METHODS: Diagnostic criteria for DTPA aerosol ventilation were prospectively applied to 5017 patients over a 9-yr period. Lung scan interpretations were analyzed for frequency of occurrence, and results were compared to those of angiography in 455 patients. RESULTS: Scans were interpreted as normal, low or high probability in 79% of patients and as either indeterminate or medium probability in 21% of patients. Three patients had normal scans and negative angiography. In patients with low-probability scans, 111 angiograms were performed: 103 (93%) were negative, and 8 (7%) were positive. In patients with indeterminate scans, 114 angiograms were performed: 85 (75%) were negative, and 29 (25%) were positive. In patients with medium-probability scans, 149 angiograms were performed: 86 (58%) were negative, and 63 (42%) were positive. In patients with high-probability scans, 78 angiograms were performed: 6 (8%) were negative, and 72 (92%) were positive. CONCLUSION: These results indicate that lung scintigraphy using DTPA aerosol and our criteria is accurate in diagnosing and stratifying risk of pulmonary embolic disease. Compared with 133Xe and PIOPED criteria, DTPA ventilation and our criteria reduced the false-negative rate in low-probability scans (7% versus 16%, p < 0.005) and decreased the fraction of intermediate-probability scans (21 % versus 39%, p < 0.01).     

The relationship between the serum level of prostate specific antigen and bone and CT scans in the staging of the primary carcinoma of the prostate

OBJECTIVE: To determine the relationship between the serum level of prostate-specific antigen (PSA) and the presence of abnormalities in a skeletal or CT scan in patients with primary carcinoma of the prostate. DESIGN: Retrospective. SETTING: Academic Medical Centre, Amsterdam. PATIENTS AND METHODS: The serum PSA levels were compared with the findings in the skeletal and CT scans of 440 patients with carcinoma of the prostate without clinical signs of metastases, seen in the period from January 1990 to December 1994 in the outpatient clinics for Urology of the Academic Medical Centre (AMC) in Amsterdam, Hospital Gooi-Noord in Blaricum and Hospital De Heel in Zaandam. CT scan data were analysed only from the AMC and Hospital Gooi-Noord. RESULTS: There were 76 patients with a positive bone scan (17.3%) and 31 (out of 337; 9.2%) with a positive CT scan. Higher PSA serum levels went together with increasing risk of abnormalities in bone or CT scan. Of 85 patients with PSA values < 10 micrograms/l, none had a positive bone scan and one (out of 73; 1%) a positive CT scan; of the 180 patients with PSA levels < 20 micrograms/l, 4 (2.2%) had a positive bone scan and 2 (out of 154; 1.3%) a positive CT scan. The T stage, the histological grading and the serum alkaline phosphatase activity appeared not to have any supplementary value. CONCLUSION: In view of the low frequency of abnormalities in a bone or CT scan in patients with low PSA levels, it appears justified no longer to recommend bone or CT scanning for staging of patients for a clinically non-metastasized carcinoma of the prostate and serum PSA levels < 20 micrograms/l.     

Improved selection of patients for reoperation for medullary thyroid cancer by imaging with radiolabeled anticarcinoembryonic antigen antibodies

BACKGROUND: This study examined the utility of using radiolabeled anticarcinoembryonic antigen (CEA) monoclonal antibodies (MAbs) as a noninvasive imaging method to aid in the selection of patients for reoperation after operation for medullary thyroid carcinoma (MTC). METHODS: Sixteen patients with persistent or recurrent hypercalcitoninemia since operation or MTC, but had negative or equivocal conventional imaging study results, were given 99mTc-, 123I-, or 131I-labeled NP-4 or MN-14 anti-CEA MAbs. Scintigraphic images were then performed to determine detection of tumor lesions. RESULTS: The MAb scans were positive in 13 (81%) of the 16 patients studied. However, in only three of 13 patients was disease confined to the cervical or mediastinal nodes. In 10 patients, disease was additionally or solely found in distant organs such as liver (five patients), bone (four patients), and periaortic nodes (one patient). On the basis of our studies, only three of the 13 patients with positive scans would benefit from repeat neck exploration, another three would possibly benefit from neck or mediastinal exploration and hepatic resection, and the remaining seven patients would not benefit from any reoperation with curative intent. CONCLUSIONS: MTC imaging with anti-CEA MAbs could be very useful in determining the ideal candidates for repeat neck exploration.     

Differentiating sigmoid diverticulitis from carcinoma on CT scans: mesenteric inflammation suggests diverticulitis

OBJECTIVE: The purpose of this study was to analyze the usefulness of two specific CT signs of sigmoid mesenteric inflammation (fluid at the root of the mesentery and vascular engorgement) for identifying and differentiating sigmoid diverticulitis from carcinoma. MATERIALS AND METHODS: CT scans of 69 patients with surgically proved sigmoid diverticulitis were retrospectively reviewed and compared with CT findings in 29 patients with surgically proved sigmoid carcinoma. Two specific patterns of inflammation of the sigmoid mesentery were analyzed: fluid at the root of the sigmoid mesentery and engorgement of the sigmoid mesenteric vessels. RESULTS: The CT findings were present more often in patients with sigmoid diverticulitis than in those with carcinoma (p < .001). Fluid at the base of the mesentery had a sensitivity, specificity, and positive predictive value for diverticulitis of 36%, 90%, and 89% respectively. Vascular engorgement alone had a sensitivity, specificity, and positive predictive value of 29%, 100%, and 100%, respectively. CONCLUSION: Our results suggest that CT findings of fluid at the root of the mesentery and vascular engorgement are useful in distinguishing sigmoid diverticulitis from carcinoma of the sigmoid.     

Gallium-67 scanning for carcinoma of the lung

Gallium-67 citrate scanning was prospectively evaluated in 55 patients who had lung lesions suspected to be primary carcinoma on chest x-ray films and in whom subsequent histologic diagnosis was obtained. Of 47 patients with histologically proved carcinoma of the lung, 44 (94 per cent) had a positive 67Ga scan. No patient with a positive scan had a benign lesion, so that the positive scan accuracy rate was 100 per cent. All 8 patients with a benign lesion and 3 patients with a malignant lesion had negative scans, for a negative scan accurary rate of 72 per cent for benign lesions. These results give statistical validity for the usefulness of the 67Ga scan in diagnosing carcinoma of the lung (p less than 0.001). Tumor cell type had little effect on the sensitivity of 67Ga scan. The 67Ga scan was equally useful in the evaluation of peripheral and central lesions. There was little difference amount T1, T2, and T3 classified lesions in their ability to take up 67Ga. The 67Ga scan was competitive with mediastinoscopy in assessing mediastinal lymph node metastases and provides a noninvasive method of assessing hilar lymph node metastases. There was a good correlation between the clinical staging of patients with lung cancer based on a chest x-ray film and 67Ga scanning and the staging after surgical treatment based on the histology of the resected specimens.     

Immunoepidemiology of Dracunculus medinensis infections I. Antibody responses in relation to infection status

OBJECTIVES: The sites of recurrent carcinoma of the prostate were localized with radiolabeled monoclonal antibody, and these sites were correlated with the response of patients treated with pelvic radiation after prostatectomy. METHODS: Radionuclide scans were performed with indium 111-labeled CYT-356, a monoclonal antibody that binds to prostate epithelial cells, in 48 men diagnosed with recurrent carcinoma detected by prostate-specific antigen (PSA) screening after radical retropubic prostatectomy. RESULTS: In 48 patients with recurrent carcinoma detected by PSA screening following radical retropubic prostatectomy, 73% had monoclonal antibody activity beyond the prostatic fossa, and only 3 patients (6%) had activity in the prostatic fossa alone; 65% had monoclonal antibody activity in pelvic lymph nodes despite the fact that lymph node dissections were pathologically negative at the time of prostatectomy in 90% of the patients; and 23% of patients had monoclonal antibody activity in abdominal and extrapelvic retroperitoneal nodes. Of 48 patients, 13 underwent external beam radiation therapy after monoclonal antibody scans. Six patients had scans showing activity beyond the field of radiation, and radiation therapy failed in 4 of these patients. Seven patients had scans with no activity beyond the field of radiation therapy, and radiation therapy failed in only 2 of these patients. CONCLUSIONS: The scans frequently show monoclonal antibody uptake in pelvic, abdominal, and extrapelvic retroperitoneal sites beyond the region of limited obturator node dissections and may account for the understaging and subsequent failure of radical prostatectomy in some patients. The monoclonal antibody scan seems to be a good predictor of which patients will respond to radiation therapy after radical prostatectomy, but because these patients often have nodal activity beyond the radiated field, this initial response may not be curative.     

CT appearance of pulmonary vasculitis in children

OBJECTIVE: The aim of this study was to determine whether a CT pattern that may represent early or subtle changes of pulmonary vasculitis in children exists. MATERIALS AND METHODS: High-resolution CT scans of the chest for 107 children were retrospectively reviewed by two radiologists who were unaware of the original study findings. Chest CT scans (conventional) for another 54 children who had symptoms or a diagnosis of vasculitis also were reviewed. RESULTS: We identified hazy or fluffy centrilobular, perivascular densities in 10 children, two of whom had small airways disease and eight of whom had vasculitis (Wegener's granulomatosis [n = 5], systemic lupus erythematosus [n = 1], scleroderma-polymyositis overlap syndrome [n = 1], and Churg-Strauss syndrome [n = 1]). The latter eight children underwent 35 scans, 17 of which were positive for these perivascular densities. All positive scans were associated with active disease of new onset (5/17) or with clinical exacerbation of preexisting systemic disease (12/17). The positive scans also were associated with an elevated erythrocyte sedimentation rate (13/17) and biopsy evidence of vasculitis from a variety of sites, including the lungs (n = 1), kidneys (n = 7), oropharynx (n = 5), skin (n = 9), lymph nodes (n = 1), and myocardium (n = 2). The single lung biopsy showed an angiocentric inflammatory-hemorrhagic process. Of the five patients who had positive scans, underwent therapy, and then had repeat studies, four patients had scans revert to normal in association with inactive disease. The remaining patient whose scan did not normalize failed to respond to treatment. CONCLUSION: The fluffy centrilobular pattern likely represents subtle changes of pulmonary vasculitis. In the appropriate clinical setting, such a finding may obviate the need for a lung biopsy.     

The maxillary sinus and odontogenic cysts

An unilateral maxillary sinusitis is frequently caused by dental pathology. An odontogenic cyst in the maxillary sinus usually lacks accompanying symptoms of infection. In three patients, a 35-year-old man and two women aged 16 and 28, an odontogenic cyst in the maxillary sinus was diagnosed. Consultation of a maxillofacial surgeon is needed because orthopantomographic imaging is diagnostically most helpful. In these patients combined treatment by an ENT surgeon and a maxillofacial surgeon is important.     

Comparison of reticuloendothelial scans with bone scans in malignant disease

Thirty patients with histologically proven malignant disease were selected for reticuloendothelial scans and bone scans because of suspected bone or bone marrow involvement. Reticuloendothelial scans were abnormal in 83% of the patients and bone scans were abnormal in 47%. Focal defects on the reticuloendothelial marrow scan correlated better with tumor infiltration of the marrow than did diffusely abnormal scans. Focal defects were found in nine patients (30% of total), four of whom had negative or equivocal bone scans. In multiple myeloma, reticuloendothelial marrow scans were more sensitive than bone scans, but were not clearly better than bone scans in patients with solid tumors. In the interpretation of reticuloendothelial scans, consideration must be given to the effects of radiation, chemotherapy, and uremia, all of which may cause decreased reticuloendothelial uptake and falsely positive reticuloendothelial scans. Reticuloendothelial scans seem most useful for hematologic malignancies that have not been previously treated. The advantages and disadvantages of reticuloendothelial scans are discussed.     

Thymic uptake of iodine-131 in the anterior mediastinum

Two thyroidectomized patients with a history of differentiated thyroid carcinoma are presented who had nonmetastatic mediastinal 131I uptake following therapeutic doses of 131I. Chest CT scans in both patients demonstrated an anterior mediastinal mass. Surgical excision in one patient and a percutaneous CT-guided fine needle aspiration biopsy in the other disclosed normal thymus tissue. Iodine-131 uptake in the anterior mediastinum in patients thyroidectomized for follicular or papillary thyroid carcinoma may represent the thymus.     

Value of perfusion lung scan in the diagnosis of pulmonary embolism: results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED)

To assess the value of perfusion lung scan in the diagnosis of pulmonary embolism, we prospectively evaluated 890 consecutive patients with suspected pulmonary embolism. Prior to lung scanning, each patient was assigned a clinical probability of pulmonary embolism (very likely, possible, unlikely). Perfusion scans were independently classified as follows: (1) normal, (2) near-normal, (3) abnormal compatible with pulmonary embolism (PE+: single or multiple wedge-shaped perfusion defects), or (4) abnormal not compatible with pulmonary embolism (PE-: perfusion defects other than wedge-shaped). The study design required pulmonary angiography and clinical and scintigraphic follow-up in all patients with abnormal scans. Of 890 scans, 220 were classified as normal/or near-normal and 670 as abnormal. A definitive diagnosis was established in 563 (84%) patients with abnormal scans. The overall prevalence of pulmonary embolism was 39%. Most patients with angiographically proven pulmonary embolism had PE+ scans (sensitivity: 92%). Conversely, most patients without emboli on angiography had PE- scans (specificity: 87%). A PE+ scan associated with a very likely or possible clinical presentation of pulmonary embolism had positive predictive values of 99 and 92%, respectively. A PE- scan paired with an unlikely clinical presentation had a negative predictive value of 97%. Clinical assessment combined with perfusion-scan evaluation established or excluded pulmonary embolism in the majority of patients with abnormal scans. Our data indicate that accurate diagnosis of pulmonary embolism is possible by perfusion scanning alone, without ventilation imaging. Combining perfusion scanning with clinical assessment helps to restrict the need for angiography to a minority of patients with suspected pulmonary embolism.     

Histoplasma capsulatum sinusitis

Sinusitis is commonly reported in patients with AIDS. In addition to the usual bacterial pathogens isolated from immunocompetent patients, sinusitis in patients with AIDS may be caused by a variety of unusual bacteria, viruses, fungi, parasites, and mycobacteria. Histoplasma capsulatum has not typically been associated with sinusitis in either group of patients. We report a case of sinusitis caused by H. capsulatum in a patient with AIDS.