Invasive pulmonary aspergillosis caused by Aspergillus ochraceus

Invasive pulmonary aspergillosis (IPA) is a frequent complication in patients with severe neutropenia resulting from cytotoxic chemotherapy. In Europe, Aspergillus fumigatus is most common pathogen of IPA. In our case, IPA was recognised in 54 year old female suffering from acute lymphoblastic leukemia with pancytopenia. The patient developed severe granulocytopenia during chemotherapy. Chest radiograph revealed progressive bilateral infiltrations with cavitation. In sputum culture Aspergillus ochraceus was found. The results of precipitating tests were positive for A. ochraceus and A. fumigatus. Treatment with amphotericin B was used successfully leading soon to clinical improvement, yet radiological lesions remained largely unchanged. The patient received itraconazole, which was very effective and caused almost complete regression. Two episodes of IPA recurrence were treated with antifungal therapy with good results.     

Invasive pulmonary aspergillosis: a study of 33 cases

Invasive pulmonary aspergillosis (IPA) is an infectious complication appearing mainly in immunosuppressed patients, whose diagnosis is often difficult and lately made, and that usually bears a dismal prognosis. Patients diagnosed as having IPA from 1989 to 1994 were retrospectively analyzed. Probable IPA was diagnosed on the basis of a positive culture for Aspergillus together with a consistent radiological image. Confirmed IPA was diagnosed if there was, in addition to the former, a pathological examination showing Aspergillus hifae invading pulmonary parenchyma and/or pulmonary vessels. There were 25 men and 8 women with a mean age of 53.7 +/- 16.9 years (range: 22-86 years). IPA was confirmed in 11 cases and probable in 22. Sixty three percent of the patients had hematologic malignancy or solid cancer, whereas 30.3% did not have prior granulocytopenia or immunosuppressive therapy. The mean (SD) interval between admission and diagnosis was 40.2 (37.1) days (range: 1-180 days), and the diagnosis was made while the patient was still alive in 75% of the cases. Fifteen percent of the patients had extrapulmonary aspergillosis. The most frequent finding both on X-ray film of the chest and pulmonary computed tomography were bilateral multiple pulmonary nodules. Thirteen patients were treated with itraconazole, 6 with amphotericin B, 5 received both drugs, and 2 received fluconazole. Nineteen patients (57.6%) died and the case-fatality rate among treated patients was 46.1%. IPA presents mainly in immunosuppressed patients, but there was a not negligible proportion of patients lacking the classical risk factors. IPA is often a lately made diagnosis and in a quarter of the patients it is not made when the patient is alive. The most frequent radiological presentation are multiple bilateral nodules. The case-fatality rate of IPA is exceedingly high, even when if the patient has been adequately treated.     

Invasive aspergillosis: nosocomial origin of epidemics. Review of the literature

The growing incidence of nosocomial invasive aspergillosis is related with the development of new therapies and the presence of Aspergillus spores in the patients'vicinity. Earth moving, demolition or renovation works adjacent to or inside the hospital are undoubtfully implied in this process. Potted plants and individual sachets of ground pepper distributed to patients are another significant source of Aspergillus spores. The extrinsic and multiple causes of hospital contamination may explain the numerous problems in our studies of strain typing, whatever the methods used (phenotype and genotype).     

Effects of rumen-undegradable protein on dairy cow performance: a 12-year literature review

In order to integrate and analyze knowledge on the use of protein supplements and protein nutrition of lactating dairy cows, we compiled a review of 108 studies published throughout the world, but principally in the Journal of Dairy Science between 1985 and 1997. In 29 comparisons from 15 metabolism trials, soybean meal was replaced by high amounts of rumen undegradable protein (RUP) as a supplement; the benefits were not consistently observed for flow to the duodenum, essential amino acids, or lysine and methionine. High RUP diets resulted in decreased microbial protein synthesis in 76% of the comparisons. However, fish meal provided a good balance of lysine and methionine when calculated as a percentage of total essential amino acids. In 127 comparisons from 88 lactation trials that were published from 1985 to 1997, researchers studied the effects of replacing soybean meal with high RUP sources, such as heated and chemically treated soybean meal, corn gluten meal, distillers grains, brewers grains, blood meal, meat and bone meal, feather meal, or blends of these sources; milk yield was significantly higher in only 17% of the comparisons. Fish meal and treated soybean meal accounted for most of the positive effects on milk yield from RUP; corn gluten meal resulted in mostly negative results. The percentage of fat in milk was depressed more by fish meal than by other RUP sources. Protein percentage was decreased in 28 comparisons and increased in only 6 comparisons, probably reflecting the decrease in microbial protein synthesis, as was observed for diets high in RUP. The data strongly suggest that increased RUP per se in dairy cow diets, which often results in a decrease in RDP and a change in absorbed AA profiles, does not consistently improve lactational performance.     

Invasive pulmonary aspergillosis in AIDS: radiographic, CT, and pathologic findings

PURPOSE: To review the radiographic and computed tomographic (CT) manifestations of invasive pulmonary aspergillosis and to correlate the imaging and pathologic findings in patients with acquired immunodeficiency syndrome (AIDS). MATERIALS AND METHODS: Chest radiographs, CT scans, and pathologic specimens were reviewed retrospectively in 10 AIDS patients with proved invasive pulmonary aspergillosis. RESULTS: The most common radiographic finding was the presence of thick-walled cavitary lesions. Less common findings included nodules, consolidation, and pleural effusion. CT depicted more nodules and cavities than did radiography. The predominant pathologic abnormalities consisted of tissue invasion and abscess formation and angioinvasion with or without infarction. All patients had infection with Aspergillus fumigatus as well as other pathogens, the most common being cytomegalovirus and Pseudomonas aeruginosa. CONCLUSION: Thick-walled cavitary lesions are the most common radiologic manifestation of invasive pulmonary aspergillosis in AIDS. The findings are more numerous and better defined on CT scans. The radiologic findings reflect a spectrum of pathologic abnormalities.     

Invasive sinonasal disease due to Scopulariopsis candida: case report and review of scopulariopsosis

Sinonasal infection with fungi of the order Mucorales--termed mucormycosis or zygomycosis--is sometimes seen in immunosuppressed patients, including those with diabetic ketoacidosis and malignancy. We describe a case of invasive sinonasal infection with Scopulariopsis candida (not among the Mucorales organisms) in a 12-year-old girl who was being treated for non-Hodgkin's lymphoma. Only a few cases of invasive infection with Scopulariopsis species have been reported previously; five of six of these cases were associated with persistent or fatal disease. Our patient survived without undergoing radical surgical debridement and was treated with granulocyte colony-stimulating factor, amphotericin B, and itraconazole; chemotherapy was stopped. In vitro susceptibility testing of our patient's Scopulariopsis isolate showed that it was resistant to amphotericin B and that it was relatively susceptible to itraconazole and miconazole. The case described herein demonstrates the expanding spectrum of fungal organisms that may cause invasive sinonasal infection in immunocompromised hosts and the need for reliable antifungal susceptibility testing.     

Malignant tumours of the parotid gland: a 12-year review

Malignant parotid tumours are uncommon and present a significant management challenge. Fifty-one such patients (25 male, 26 female, median age 64 years) operated on in the Newcastle Plastic Surgery Unit between 1983 and 1994 were retrospectively evaluated. Preoperative investigations included FNA cytology (n = 20), and for staging CT and/or MRI scans (n = 21). Of the 35 primary tumours 32 were epithelial and three lymphomatous. Metastatic tumours were squamous cell carcinoma (7), melanoma (6), renal cell carcinoma (2) and sebaceous carcinoma (1). FNA cytology correctly diagnosed malignancy with an 88% sensitivity (false negatives = 2). A total or radical parotidectomy was required in 60% of patients, the rest undergoing superficial parotidectomy. In continuity neck dissection was undertaken in 23 (45%) cases. Postparotidectomy reconstruction included 10 free, 3 myocutaneous, and 4 local transposition/rotation flaps. Thirty-seven patients (73%) received postoperative radiotherapy. Seventy-two per cent of patients are alive after a mean follow-up of 42 months. The crude 5- and 10-year survival rates were 68% and 49% respectively while the loco-regional control rate (Kaplan-Meier method) at 10 years was 79%. Fifteen patients (30%) have permanent facial palsy. It is concluded that radical surgery with appropriate reconstruction followed by planned postoperative adjuvant radiotherapy gives effective control of malignant parotid tumours.     

Infectious aneurysm due to Listeria monocytogenes: a new case and review of the literature

INTRODUCTION: Infections due to Listeria monocytogenes usually occur in pregnant women, in the elderly and in immunocompromised patients. Arterial aneurysms due to this germ are rare. Only 16 cases have been previously described in the literature. EXEGESIS: We report the case of a patient who had been hospitalized for recurrent fever over the past 3 months. Aortic mycotic aneurysm was diagnosed; blood and aneurysm cultures revealed Gram-positive bacilli consistent with the presence of Listeria monocytogenes. We also review previous reports focusing on infections due to Listeria monocytogenes. Mycotic aneurysms due to this germ are mainly observed in elderly male patients and occur on large arteries. In the present study, only one patient was immunocompromised. Furthermore, all patients who were not operated on died. CONCLUSION: Arterial aneurysm due to Listeria moncytogenes is best managed via surgical resection in combination with antimicrobial therapy. Immunosuppression is not necessary for the development of arterial aneurysm due to Listeria. Bacteriological and histological examinations should be done systematically when surgical resection of an aneurysm is required.     

Invasive mold sinusitis: 17 cases in immunocompromised patients and review of the literature

A 10-year retrospective analysis of invasive mold infections in hospitalized patients was performed to characterize the epidemiology and clinical features of invasive fungal sinusitis. Seventeen cases of invasive mold sinusitis were identified. Eleven cases were caused by Aspergillus flavus, three were caused by unspecified species, and one each was caused by Aspergillus fumigatus, Rhizopus species, and Alternaria species, respectively. Fifteen patients had hematologic malignancies, and two had end-stage liver disease. The most common presenting symptom was periorbital swelling (seven patients). Sinusitis was diagnosed a median of 19 days after admission. Eight patients (47%) survived; six of these patients were treated with both amphotericin B and surgery. Postmortem examination of six patients showed evidence of disseminated disease; the brain was the most common extrapulmonary site (four patients). To our knowledge, this is the largest currently reported series on invasive mold sinusitis; our report extends the information on invasive mold sinusitis and shows that aggressive therapeutic and surgical interventions are needed to prevent rapid progression of disease in immunocompromised patients.     

Invasive aspergillosis of the paranasal sinuses: a medical emergency

A rare case of invasive aspergillosis of the paranasal sinuses in a previously healthy individual is presented. The disease caused severe complications and proved fatal. Classification, aetiology and presentation of sinus aspergillosis are discussed. Early diagnosis and management is stressed to avoid the high incidence of morbidity and mortality.     

Treatment of pulmonary disease due to Mycobacterium kansasii: recent experience with rifampin

Records of 244 patients with Mycobacterium kansasii isolated from their sputum were reviewed. Of the 244 patients, 82 failed to meet study criteria and were excluded. Response to treatment and posttreatment follow-up was evaluated in 162 patients. Overall, 135 patients (83%) achieved negative sputum cultures within six months. Among 32 patients whose drug regimen included rifampin, all 32 (100%) had negative cultures at the fourth and fifth months, but two relapsed during the sixth month, with cultures resistant to 1.0 and 25 micrograms of rifampin/ml. Among 130 patients whose regimen did not include rifampin, negative sputum cultures were achieved by the sixth month in 101 (80%). In these patients, no significant influence could be attributed to (1) the use of three-drug vs. two-drug regimens; (2) the in vitro susceptibility of pretreatment cultures to isoniazid; (3) the coexistence of obstructive airway disease; or (4) the early use of pulmonary resection. The susceptibility of pretreatment cultures to streptomycin in those who received this drug may have influenced outcome. The late follow-up showed a cumulative relapse rate of 13% over five years in those who had achieved negative cultures initially, and the relapse rate did not appear to be influenced by pulmonary resection as part of the treatment.     

Intrahepatic cholestasis due to systemic mastocytosis: a case report and review of literature

A 35-yr-old female presented with symptoms of obstructive jaundice. Liver biopsy, bone marrow aspiration, and biopsy revealed systemic mastocytosis and acute myeloid leukemia. The liver biopsy specimen showed infiltration of mast cells within portal tracts with periductal and portal edema, irregularity of interlobular duct epithelium, and centrizonal cholestasis. Endoscopic retrograde cholangiography was normal. Following chemotherapy treatment with idarubicin and cytarabine for seven days for AML, the bilirubin levels continued to increase for two weeks and then decreased, reaching normal levels in two months. Infiltration of mast cells in the liver leads to hepatomegaly, liver function abnormality and rarely portal hypertension. Intrahepatic cholestasis due to systemic mastocytosis has never been reported. We report a rare case of systemic mastocytosis causing intrahepatic cholestasis that resolved with remission of AML following chemotherapy.     

The ultrastructure of ependymoma: personal experience and the review of the literature

I report here the ultrastructure of 29 ependymal tumors. The ultrastructural pattern was florid and characteristic with a picture dominated by the presence of microlumina, cilia with basal bodies (blepharoplast), microvilli and long, interdigitating intercellular junctions of the zonulae adherentes (adhesive plaque junctions) type. Tumor cells themselves were not particularly peculiar but they formed typical patterns of rosettes (so called mini- or ultrastructural rosettes) cell gatherings around small, electron-lucent lumina which are filled with numerous microvilli. Empty microlumina were rare. The apical and lateral portions of the cells surrounding microlumina were sealed by intercellular junctions which are long, tortuous and clearly different from the zonulae occludentes (tight junctions) of epithelial tumors. Clusters of apparently "redundant" junctions were occasionally visible comprising segments of different lengths. Ependymoma cells contained myriads of 10 nm intermediate filaments (glial filaments), occasionally forming thick bundles, virtually identical to those encountered in astrocytic tumors and forming an ultrastructural correlate for the GFAP immunostaining. The glycogen granules were often remarkably numerous. Numerous cilia, with a typical 9+1 pattern or with a distorted pattern were frequently observed in longitudinal or cross-sections.     

The ultrastructure of oligodendroglioma: personal experience and the review of the literature

Five cases of stress fracture of the patella in athletes are presented. Four of these occurred transversally in the lower part and one longitudinally in the lateral part of the patella. Three of the patients were females (endurance runner, high jumper, and orienteerer) and two males (volleyball and soccer player). The diagnosis was made 2-8 months from the onset of the symptoms. Conservative treatment was successful in only one patient; all others were treated surgically, with good end result. Drilling of the fracture line was performed twice with metal wire cerclage fixation, excision of the lateral fragment was carried out once, and a bone graft with K wires and cerclage compression (tension band) was performed once. In all cases the patellar retinaculum was intact, indicating a stress injury. Stress fracture of the patella is a rare overuse injury, and therefore difficulties and delays in the diagnosis and treatment may occur. In cases with delayed diagnosis we recommend operative treatment.     

Septicemia due to Shigella. A case report and review of the literature

To develop a proper protocol for biological exposure monitoring of acetone, we evaluated whether exposure to acetone on the previous day affects the biological monitoring value at the end of a work day. One hundred and ten male workers exposed to acetone in three acetate fiber manufacturing plants were monitored using a liquid passive sampler on two consecutive working days after 2 days without exposure. Urine samples were collected at the start of the workshift and the end of the shift on both days for each subject. For ten exposed workers urine samples were collected approximately every 2 h during and after the first working day until the following morning. Acetone concentrations in urine (Cu) at the start of the first working day were 1.3 +/- 2.4 (range: ND-14.1) mg/l in nonexposed workers and 2.4 +/- 5.6 (range: ND-40.3) mg/l in exposed workers. The urinary acetone concentration at the beginning of the second working day indicated that urinary levels of acetone do not decline to background level by the following morning when exposure concentration exceeds 300 ppm. However, linear regression analysis demonstrated that the relationship between environmental exposure level and urine level was similar on the 1st day and the 2nd day. Thus, although urine acetone levels did not return completely to baseline after high exposures, under the present exposure levels the exposure on the previous day did not significantly affect urinary acetone at the end of the workshift of the next day.     

Editorial: Opportunistic infections due to Aspergillus

Changes in plasma thyroxine (T4) concentrations were followed in 27 fetal sheep after surgical implantation of catheters. Fourteen days were required before stable concentrations of T4 were achieved, whether surgery was performed between 90 and 96 days or 109 and 120 days gestation. Twenty-three fetuses were followed to birth, and during the last four days the T4 concentrations showed no change in 11 fetuses and a significant decrease in the other 12. Birth occurred between 142 and 157 days gestation in both groups. There was a significant rise in T4 concentration during labour in all 23 fetuses. There were large differences among the plasma T4 concentrations of individual ewes which were not related to ambient temperature.