Atypical mycobacterial pulmonary disease and bronchial obstruction in HIV-negative children

Atypical mycobacterial infection in HIV-negative children usually presents with cervical lymphadenopathy. We report on 10 children who are HIV-negative and who presented with pulmonary disease, in whom either culture-proven atypical mycobacterium infection (four), positive avian Mantoux test (five), or lack of response to human tuberculosis treatment (one) had been observed. One case was subsequently diagnosed as chronic granulomatous disease and illustrates that children with atypical mycobacterial pulmonary infection should have their immune status fully investigated. Bronchial obstruction was observed in eight cases, and of these, endobronchial disease was found in six children. The diagnosis of atypical mycobacterial disease is difficult, and a negative avian Mantoux test does not exclude the diagnosis. The availability of clarithromycin and rifabutin has offered new therapeutic options in treating atypical mycobacterial pulmonary infection, but management of these cases can be prolonged and difficult.     

Disease caused by Mycobacterium kansasii in patients with HIV infection

BACKGROUND: To describe the clinical features and response to therapy in Mycobacterium kansasii disease among HIV infected patients, an increasing problem in our setting. METHODS: A retrospective survey of all charts from patients with HIV infection with Mycobacterium kansasii infection recorded between April 1985 and December 1991. RESULTS: A total of 13 patients were identified. All of them had clinically significant respiratory tract samples with a definite M. kansasii isolation. Only three had disseminated disease. In all but two cases, CD4 cell count at diagnosis time was lower than 200/mm3. Chest X-ray films showed interstitial pattern (8 cases) or alveolar condensation (3 cases) and lung cavities were seen in 4 patients. All patients with lung disease and one with disseminated disease responded well to anti-tuberculous therapy. CONCLUSION: Mycobacterium kansasii produces disease in advances stages of HIV-induced immunosuppression. The most common primary location is pulmonary, but disseminated forms can also be seen. The infection can be controlled with standard anti-tuberculous therapy.     

The great imitator: Rocky Mountain spotted fever occurring after hospitalization for unrelated illnesses

We describe two patients who had Rocky Mountain spotted fever after they were admitted to the hospital for emergency and elective surgical procedures. We initially thought one patient had a hospital-acquired infection; the correct diagnosis was deduced from epidemiologic clues elicited by consultants. These two cases were also unusual in that one patient had a recurrent rash after an abbreviated course of low-dose doxycycline therapy and the other patient had transient and self-limiting postinfectious polyneuropathy. These cases illustrate that community-acquired infection with Rickettsia rickettsii can occur simultaneously with other disease processes and sometimes mimic a nosocomial infection.     

Thrombin inhibition by antithrombin III on the subendothelium is explained by the isoform AT beta

Rhinocerebral mucormycosis is a well-described fulminant fungal infection that typically presents acutely in patients with diabetic ketoacidosis or immunosuppression. Chronic presentations of rhinocerebral mucormycosis have also been described. In the chronic infection, the disease course is indolent and slowly progressive, often occurring over weeks to months. The authors report 2 cases of chronic rhinocerebral mucormycosis (CRM) treated at their institution and review 16 other cases reported in the English-language literature. In these cases, the median time from symptom onset to diagnosis was 7 months. The most common presenting features of CRM are ophthalmologic and include ptosis, proptosis, visual loss, and ophthalmoplegia. CRM occurs predominantly in patients with diabetes and ketoacidosis. The incidence of internal carotid artery and cavernous sinus thrombosis is higher in CRM patients than in those with the acute disease, although the overall survival rate for CRM patients is 83%. CRM is clinically distinct from chronic Entomophthorales infection.     

Detection of cytomegalovirus (CMV) antigen for rapid diagnosis and monitoring of CMV diseases in AIDS

Ten to forty percent of the patients with acquired immunodeficiency syndrome (AIDS) develop sight- or life-threatening cytomegalovirus (CMV) infections. In some patients with AIDS, CMV is detected in the bronchoalveolar lavage fluid (BALF), urine, and other specimens, even when there are no symptoms of CMV disease. An indicator of active CMV infection is needed to facilitate the diagnosis of CMV disease in patients with AIDS or HIV infection and the evaluation of the efficacy of subsequent treatment. The present study was conducted during the period from 1993 to 1994. The subjects consisted of three patients with AIDS and a confirmed diagnosis of CMV disease (one case of retinitis, one case of gastrointestinal disease and one case of pneumonia), and five HIV-positive patients in whom CMV associated disease was ruled out. Those patients were monitored occasionally for the following parameters of active CMV infection and disease: expression of CMV antigen in the nucleus of polymorphonuclear leukocyte (CMV antigenemia), as it was determined with a monoclonal antibody against a lower matrix protein (p65); infectious CMV detected by shell vial method; CMV DNA detected by PCR; anti-CMV antibody titer; and histological findings. CMV p65 antigen was detected in the leukocytes of both the peripheral blood and BALF during the early phase of CMV disease in three out of three cases of the CMV disease group, and this antigen became negative in two out of two cases who responded to the therapy. All the five patients in the CMV-related-disease-negative group were negative for CMV antigenemia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pulmonary cavitation lesions in patients infected with the human immunodeficiency virus: an analysis of a series of 78 cases

BACKGROUND: To assess the clinical, radiologic and microbiological features of lung cavitation and HIV infection. Evaluation of the differences related to this disease in the last years. PATIENTS AND METHODS: Retrospective review of all patients with lung cavitation and HIV infection admitted at our hospital from January 1989 until December 1994 and prospective study of all patients with the same characteristics during 1995 and 1996. Lung cavitation was defined as any parenchymal lesion, with air content, visible in a simple X-ray and greater than 1 cm of diameter. Criteria for confirmed, probable or possible diagnosis were defined. RESULTS: 78 cases of lung cavitation have been identified in 73 patients. The radiologic patterns included unilobar and multilobular involvement in 31 and 47 cases, respectively. Cavities were multiple and single in 40 and 38 cases respectively. Findings with fine needle aspiration biopsy (FNAB) were diagnostic in 11 out of 14 cases. A clinical diagnosis was performed in all 78 cases, with microbiological results in 69 cases (88.5%): Mycobacterium tuberculosis in 20, Pneumocystis carinii in nine, Pseudomonas aeruginosa in nine, Staphylococcus aureus in eight (5 endocarditis with cavitary septic emboli), Rhodococcus equi in six, P. aeruginosa and S. aureus in three, Salmonella enteritidis in three, Cryptococcus neoformans in two, Aspergillus fumigatus in two and others in 7 cases. Confirmed, probable and possible diagnosis was considered in 54, 15 and 9 cases, respectively. Thirteen episodes of spontaneous pneumothorax were found. CONCLUSIONS: The lung cavitation rate is low, compared with the number of admissions related to HIV infection; nevertheless, many of them are in close relationship with HIV infection, and most of them are caused by treatable infections. It is important to know the clinical and radiological characteristics, in order to establish an early diagnosis and an appropriate therapy. Pseudomonas aeruginosa is becoming an important cause of lung cavitation. In our series, spontaneous pneumo-thorax was not related to Pneumocystis carinii pneumonia in 61.5% of cases.     

Investigations into the significance of routine health examinations for tuberculosis in teachers based on the analysis of results of extraordinary health examinations

School teachers are regarded as one of the danger groups in contracting tuberculosis infection and are subjected to strict tuberculosis controls, since when they develop tuberculosis, many school children are exposed to infection to the disease. However, the recent decrease in the incidence of tuberculosis in Japan has led to disputes concerning the significance of routine mass health examinations for tuberculosis. In this study, the significance of routine health examinations for tuberculosis in teachers was investigated by the analysis of the results of extraordinary health examinations carried out for tuberculosis in teachers as the index cases. A total of 496 extraordinary health examinations were carried out by Nagoya City from 1975 to 1986 and by Aichi Prefecture from 1980 to 1995. In 49 instances of these examinations, teachers were regarded as index cases, which included 25 teachers of public primary, middle or high schools and 14 teachers of private schools, including private instructors for piano, painting or calligraphy, and teachers for supplementary education. The results of these examinations in both groups were compared, regarding the routes of notification, the disease status of the index cases, and the frequency and the scale of the infections of tuberculosis observed among contacts with the index cases. "Group infections of tuberculosis" was defined as instances the infection in which 20 or more cases were infected by the index case, "small scale group infection" as 5-19 infected cases, and "cases with infection" as 1-4 infected cases. The result obtained were as follows. 1. The response rates to routine health examinations were 99.9% in the teachers of public primary, middle or high schools, and about 20-30% in the teachers of private schools. 2. The proportion of the cases notefied by routine examinations were 68.0% in the former group and 21.4% in the latter group. The cases notefied before the onset of the symptoms in the former group was significantly more frequent than in the latter group. 3. In the former group, no far advanced cases were identified, whereas 2 (14.3%) far advanced cases were identified in the latter group. The cases with amount of tubercle bacilli in sputum exceed 3 on the Gaffky scale were 32.0% in the former group and 61.5% in the latter group. 4. One (4.0%) case of the "group infections of tuberculosis" was observed in the former group, and 2 (14.3%) cases in the latter group. "Small scale group infection" was observed in 4.0% of the former group and in 21.4% of the latter group, and "cases with infection" in 8.0% of the former group and in 35.7% of the latter group. The frequency and the scale of the infections of tuberculosis observed among contacts with the index cases was significantly smaller in the former group than in the latter group. In conclusion, routine health examinations for tuberculosis for teachers seems valuable for the early diagnosis of tuberculosis cases and for the prevension of the infection of tuberculosis in schools.     

Spectrum of parvovirus B19 infection: analysis of an outbreak of 43 cases in Cadiz, Spain

In the spring of 1993, an epidemic of infection with human parvovirus B19 occurred in Cadiz, Spain. Evaluation of the 43 patients in whom this diagnosis was confirmed revealed four groups of predominant manifestations: (1) hematologic manifestations in six cases (13.9%), including four of aplastic crisis and two of pancytopenia; (2) dermatologic manifestations in 23 cases (53.4%), including 10 of erythema infectiosum and one of erythema multiforme ampullosum; (3) arthralgias/arthritis in nine cases (20.9%), including two with a chronic course; and (4) infection during pregnancy in three cases (7.0%), including two that ended in abortion. Of the 43 patients, 37.2% presented with fever and adenopathies, and these were the only manifestations in two cases. The appearance of clinical disease correlated with modifications in isotype and serum level of specific antibodies to parvovirus B19; the disappearance of IgM antibodies coincided with the resolution of clinical manifestations. Although their presence did not correlate with the course of the disease, the detection of circulating immune complexes in 81.6% of cases supports the possibility that some manifestations were immune mediated.     

Lung cancer in patients with HIV-infection

PURPOSE: To identify and review the clinical characteristics and natural history of lung cancer in HIV-seropositive patients. A secondary objective was to compare the clinical features of HIV-seropositive and HIV-indeterminate lung cancer cases at our institution. PATIENTS AND METHODS: Sixteen patients with HIV infection and lung cancer were diagnosed between January 1988 and March 1995 at our institution and the clinical records were reviewed. HIV-indeterminate lung cancer cases were identified by the Albany Medical Center Hospital (AMCH) Tumor Registry. A Medline database search of HIV infection/AIDS and lung cancer was undertaken through December 1994. The New York State Department of Health (NYSDOH), Bureau of Cancer Epidemiology provided information on the incidence of lung cancer among residents of New York State by county of residence. Case reports and series regarding the clinical features of HIV-seropositive patients with lung cancer were reviewed. A more focused comparison between HIV-seropositive and HIV-indeterminate male lung cancer cases between 35 and 54 years of age at our institution was performed. The following clinical variables were identified in our 16 patients and 109 cases extracted from available clinical reports: sex, age, year and county of residence at time of lung cancer diagnosis, cigarette smoking history, HIV risk behavior, CD4 count at time of lung cancer diagnosis, CDC classification of HIV disease, interval in months from time of HIV seropositivity to lung cancer diagnosis, pathology and stage of lung cancer, performance status, treatment, response, and survival. RESULTS: Lung cancer in HIV-seropositive patients is characterized by the following: a younger age at time of diagnosis when compared to HIV-indeterminate cases; the majority of cases occur in a background of extensive cigarette smoking; over 80% of patients present with advanced stage of lung cancer (stage III and IV); up to 50% of cases have asymptomatic to mildly symptomatic HIV infection with a median CD4 lymphocyte count of 233 per microliter; there is a predominance of adenocarcinoma histopathology; and shortened survival when compared to HIV-indeterminate cases. CONCLUSION: Current reports of lung carcinoma in HIV-seropositive patients suggest that the natural history of this disease is different than in HIV-indeterminate cases. Lung cancer must be considered in the differential diagnosis of a solitary mass lesion on chest X-ray in HIV-seropositive patients.     

Pulmonary tuberculosis in five young infants with nursery exposure: clinical, radiographic and CT findings

Clinical, radiographic (n = 5) and CT findings (n = 4) of five Korean infants ranging in age from 2 to 3 months with confirmed tuberculosis were retrospectively analysed. All of the patients were symptomatic, anergic to tuberculin, and had a positive culture of Mycobacterium tuberculosis in gastric aspirates. The probable source of infection was the hospital in which they were born. CT scans demonstrated hilar and mediastinal lymph node enlargement with central low attenuation and peripheral enhancement in all cases. CT may be useful in diagnosis by demonstrating characteristic adenopathy and disseminated disease in young infants.     

Isolated lymphadenopathy as manifestation of the early stage of Lyme borreliosis

The paper reports 4 cases of early Lyme borreliosis which presented as lymphadenopathy at the site of the tick bite. Erythema migrans and dissemination of infection were absent. The diagnosis was verified via diagnostic titer of antibodies to Borrelia. Administration of antibiotics at the stage of lymphadenopathy contributed to better prognosis. One patient did not receive antibacterial treatment in acute disease and had progression with infection dissemination. Regional lymphadenopathy may serve a clinical marker of early Lime borreliosis.     

Time course of 8-methoxypsoralen-induced skin photosensitization in PUVA-bath photochemotherapy

Yeasts belonging to the genus Hansenula are rarely encountered as the cause of infection in clinical practice. A wide spectrum of infections caused by these fungi can be seen, ranging from asymptomatic fungaemia to severe disease. We describe an outbreak of 24 cases of infection due to H. anomala in an oncological hospital in Rio de Janeiro, Brazil. The median age of the patients was 11 years, of whom 54.2% were female; 91.7% of the Hansenula fungaemia occurred in the haematology unit. The most frequent primary disease diagnosis was leukaemia (62.5%), and all of those infected had had a central venous catheter or peripheral venous catheter and had been treated previously with broad-spectrum antibiotics. Numerous other risk factors were observed in our cases: previous use of steroids, chemotherapy, radiation therapy and neutropenia (data not shown). No deaths could be attributed to Hansenula.     

Burkitt's lymphoma in adults with and without human immunodeficiency virus infection: a single-institution clinicopathologic study of 75 patients

BACKGROUND: Burkitt's lymphoma (BL) accounts for 1-2% of all cases of non-Hodgkin's lymphoma (NHL) in the general population and for 35-40% in the setting of human immunodeficiency virus (HIV) infection. The authors report a 9-year single-institution experience with 75 adult BL patients (46 with and 29 without HIV infection) and compare the clinical and pathologic features of the disease in the two groups of patients. METHODS: Between May 1987 and June 1995, 131 patients with HIV infection and systemic NHL were diagnosed and treated at the National Cancer Institute in Aviano, Italy. In 46 cases (35%), the diagnosis was BL. During the same period, 29 of 1004 HIV negative NHL patients (2.8%) were diagnosed with BL and treated at the same institution. RESULTS: No statistical differences were found in the general characteristics of the two groups at the time that BL was diagnosed. Complete response rate was significantly lower for patients with HIV infection than for those without HIV infection (40% vs. 65%, P = 0.03). The median overall survival was significantly shorter for patients with HIV infection (7 months vs. not yet reached, P = 0.0001). However, the disease free survival (DFS) at 4 years was identical for the two groups of patients (74% for HIV positive patients vs. 73% for HIV negative patients, P = 0.70). CONCLUSIONS: The data from this study show that patients with BL with and without HIV infection share similar clinicopathologic characteristics at presentation. Although the median overall survival is significantly shorter for patients with HIV infection, the DFS is identical for both groups.     

Improved algorithm for statistical batch-by-batch analysis of corneal topographic data

Congenital parvovirus infection was diagnosed in two liveborn premature infants born at 24 and 35 weeks of gestational age. The illnesses were associated with placentomegaly, petechial rash, edema, hepatomegaly, anemia and thrombocytopenia, respiratory insufficiency, and death at 5 and 6 days of age. The syndromes exhibited by these cases shared common but nonspecific features with other life-threatening congenital infections. Serological studies in one case supported the diagnosis of parvoviral infection. Postmortem examination of both revealed nuclear inclusions in erythroid precursor cells characteristic of parvovirus infection. Use of the polymerase chain reaction confirmed the presence of parvovirus DNA in one of the cases. Intrauterine parvovirus B19 infection is most commonly associated with hydrops fetalis, "transient" hydrops, or a favorable outcome in infants found to be viremic after birth. These and previously reported examples of congenital B19 disease exemplify an exceptional form of human parvovirus infection.     

Day case arthroscopic anterior cruciate ligament reconstruction

Renal abscess, a very uncommon renal disease in the pediatric patient is often complicated by irrelevant antibiotics treated urinary tract infection or due to other unknown reasons. In this paper, two cases of renal abscess were reported though they had been treated with antibiotics. The diagnosis had been made soon by sonography and computed tomography (CT). In addition, during the period of treatment, a series of sonography were performed to monitor resolution of abscess. In one, the lesion was resolved by antibiotics alone for 2 months duration, the other nearly disappeared 3 weeks later after antibiotics treatment combined with tube-drainage. These imaging techniques permit a prompt diagnosis as well as percutaneous drainage performed if antibiotic treatment dose not lead to resolution of the abscess.     

Moraxella (Branhamella) catarrhalis: its isolation in the respiratory secretions of adult patients

OBJECTIVE: We have designed a retrospective study in order to know the clinical significance of the isolation of Moraxella (Branhamella) catarrhalis (MC) in respiratory specimens of adult hospitalized patients. METHODS: We performed a Gram stain and culture on blood-agar, MacConkey media and quantitative culture in chocolate-agar to all respiratory samples. In patients with a clinical diagnosis of pneumonia BCYE-alpha was added. During 2 years (1992-1993) MC was isolated in respiratory specimens from 52 patients. We revised the clinical history of all these patients. RESULTS: MC was isolated in 60 respiratory specimens (sputum and/or tracheobronchial aspirates) from 52 patients. The Gram stain showed gram-negative cocci in 77% and gram-positive cocci in 17% of the cases. MC grew in pure culture in 28 specimens (46.6%). In 23% of cases MC was isolated with Streptococcus pneumoniae and in 21% with Haemophilus influenzae. Fifty-two stocks (86.6%) produced beta-lactamase. Twelve patients had a clinical diagnosis of pneumonia, 8 of them had an underlying chronic respiratory disease. Other 24 patients with an underlying chronic respiratory disease had a bronchial infection as a cause of exacerbation of their respiratory disease. Seven patients without an underlying chronic respiratory disease had a clinical episode of acute bronchitis. Finally, in 9 patients the isolation of MC was considered a colonization. CONCLUSIONS: In 17% cases MC was identified as a gram-positive cocci in the Gram stain, which may cause false diagnosis. The etiological importance of MC in episodes of acute exacerbation of patients with an underlying chronic respiratory disease is high.     

Diagnosis of meningoencephalitis caused by herpes simplex virus type 1 using nested PCR in CSF samples

BACKGROUND: The aim of this study was to achieve the early diagnosis of the neurologic alteration caused by the Herpes Simplex virus type 1 (HSV-1) with the nested PCR technique in CSF. PATIENTS AND METHODS: From January, 1994 to October, 1995, 140 CSF from 140 patients were studied in our laboratory. Ninety-five were diagnosed with viral meningoencephalitis (Group A) and 45 with other neurologic diseases (Group B). Nested PCR of HSV-1 and conventional viral cultures were carried out in all the cases. RESULTS: Laboratory diagnosis was achieved in 13 (13.68%) of Group A patients: in 12 (12.63%) HSV-1 genome was detected by nested PCR and in one patient adenovirus was isolated. In Group B, the HSV-1 was detected by nested PCR in 2 patients (4.44%). CONCLUSIONS: The results obtained demonstrate the usefulness of nested PCR in HSV-1 infection for the diagnosis of herpetic meningoencephalitis in initial stages of the disease, from a single CSF sample.     

Measuring lateral skin temperature profile of premature infants in incubators with thermography

Tuberculosis is still one of the most widespread infection known to mankind. Although lung is the predominant site of disease, a sizeable population in Pakistan gets intestinal disease. Clinical presentation, radiologic and endoscopic examination provide clues to the diagnosis. However, a definitive diagnosis requires biopsy material with granulomas and/or caseation complemented by acid fast staining and culture. There are many occasions when biopsy material is scanty and even in some intestinal resection cases histologic evaluation fails to confirm or rule out tuberculosis. Therefore, an investigation was conducted to assess the efficacy of PCR in the detection of mycobacterial DNA in paraffin embedded intestinal tissue. In this study 12 histologically confirmed cases of intestinal tuberculosis and 2 cases with non specific inflammation but clinically suspected for abdominal tuberculosis were selected. One case of rectal polyp was included to serve as a negative control. M. tuberculosis DNA was amplified in 8 out of 12 histologically confirmed cases and in 2 cases diagnosed with non specific inflammation. Amplified products were obtained in 6 out of 10 PCR positive specimens with IS6110 region specific primers while 4 samples were negative, suggesting the absence of insertion sequence 6110 in these strains. However, amplification was obtained in these negative specimens with a second primer pair confirming them as M. tuberculosis complex species. On the basis of this study we conclude that; (1) Processed and paraffin embedded tissue material is suitable for PCR analysis, (2) PCR assay can be used to complement the diagnosis of intestinal tuberculosis especially in situations where a definite conclusion can not be drawn by conventional methods, (3) M. tuberculosis species lacking insertion sequence 6110 element are present in our population. Therefore, several primer pair sets should be included when applying PCR for the detection of mycobacterial DNA.     

Incidental lung carcinoma detected at CT in patients selected for lung volume reduction surgery to treat severe pulmonary emphysema

OBJECTIVE: Ovarian vein thrombosis (OVT) is a pathologic entity classically considered a postpartum complication and only rarely associated with other disease processes. Before modern imaging methods, diagnosis was primarily made clinically or at exploratory surgery. Our objective was to show that with CT and sonographic imaging, OVT can be detected in atypical clinical situations and that the condition may also be occult. CONCLUSION: Only two of six cases at our institution fit the classic picture of postpartum infection complicated by OVT. The other four cases occurred in conjunction with other pathologic conditions, one of which has not to our knowledge been previously associated with OVT. The diagnosis was not clinically suspected in these four cases. On CT and sonography, OVT was detected incidentally, because clinical symptoms were atypical or absent. Such atypical presentations of OVT pose a clinical dilemma as to appropriate management.     

Diagnosing sternal wound infections with 99mTc-labeled monoclonal granulocyte antibody scintigraphy

BACKGROUND: Postoperative mediastinitis is a serious complication of thoracic operations. The diagnosis can sometimes be difficult, especially in cases with subacute clinical presentation. The aim of this study was to assess the clinical use of granulocyte scintigraphy and tomography in the diagnosis of postoperative wound infection and mediastinitis. METHODS: Twenty-nine patients after cardiothoracic operations were included, of whom 5 patients with a normal postoperative course formed the control group. We injected technetium 99m-monoclonal antigranulocyte antibodies and performed single-photon emission computed tomography after 4 and 20 hours. RESULTS: Twenty-three patients had both the early and the later scan; the remaining 6 had only the early scan. Seven scans indicated infection: 3 cases of mediastinitis, 2 cases of superficial wound infection, 1 case of infection in a synthetic aortic graft, and 1 case of osteitis. All were verified by bacterial culture. There was one false-negative scan; this patient had only the early registration and then was explored. CONCLUSIONS: This method when combined with the tomographic scan option is able to distinguish between deep and superficial infections. Two registrations must be made for optimal results.