Opportunistic fungal infections: filamentous fungi and cryptococcosis

Older patients with diabetes mellitus or pulmonary diseases and those receiving immunosuppressive drugs are at an increased risk of infection with environmentally-acquired, opportunistic fungal diseases. Aspergillus most often produces invasive pulmonary or sinus infection in severely immuno-compromised patients. Chronic necrotizing pulmonary and sino-orbital aspergillosis present subacutely and are often misdiagnosed. Mucormycosis classically presents with rhinocerebral disease in diabetic patients with ketoacidosis, whereas pulmonary infection mimics invasive pulmonary aspergillosis and occurs mostly in patients who are neutropenic. Cryptococcal meningitis in the older patient may manifest simply as confusion. Amphotericin B is the preferred initial treatment for all three fungal infections.     

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.     

Opportunistic infections occurring during highly active antiretroviral treatment

OBJECTIVE: To analyse the characteristics of opportunistic infections in patients receiving highly active antiretroviral treatment (HAART). DESIGN AND METHODS: A retrospective study performed in seven hospitals, included all patients starting treatment by ritonavir or indinavir between 26 March and 31 December 1996. Patients were evaluated for the development of AIDS-defining events. Clinical evaluation, plasma HIV-1 RNA quantification, CD4 cell count were recorded at baseline and at the onset of the event. RESULTS: Four hundred and eighty-six patients were included: 44.2% had a CD4 cell count below 50 x 10(6) cells/l. Fifty clinical events were recorded in 46 patients with a mean follow-up of 6.1 months, of which 34 events (68%) were observed during the first 2 months of HAART. Eighteen of these occurred despite a reduction of viral load by at least 1.5 log10) and a 100% increase of the CD4 cell count compared with that at the onset of the event, corresponding to 11 cytomegalovirus infections, five mycobacterial infections, one case of cryptococcosis, and one case of Varicella-Zoster virus-related acute retinal necrosis. Among the 16 events observed after the second month, six occurred despite a marked biological improvement, corresponding to a recurrence in five of six patients who had stopped their maintenance therapy. Events were one cytomegalovirus infection, two mycobacterial infections, one episode of oesophageal candidiasis and one cryptococcal meningitis. CONCLUSION: In patients at high risk of developing an opportunistic infection prior to the institution of a HAART regimen, prophylaxis should not be discontinued during the first 2 months of treatment, and maintenance therapy should be carried on despite a significant increase in the CD4 cell count.     

Endogenous fungal endophthalmitis

Endogenous fungal endophthalmitis has increased in the past half-century because of the advent of antibiotics and indwelling catheters. The disease process can produce highly suggestive, though nonpathognomonic, ocular signs that assist the clinician in reaching a diagnosis. Intraocular inflammation, especially if it is granulomatous in nature in a patient with one or more of the risk factors already discussed, should raise the suspicion of fungal endophthalmitis. If a diagnosis remains elusive, vitreous biopsy is indicated for proper identification of a fungal organism. Although a particular therapeutic regimen has not yet been prospectively established, compelling arguments can be made to treat nearly all patients with endogenous fungal endophthalmitis with a systemic antifungal such as amphotericin B or fluconazole. A possible exception includes an IVDA-related endophthalmitis in a patient with negative blood cultures and without other evidence of fungemia. Vitrectomy and intravitreal amphotericin B (with or without intravitreal corticosteroid) should be considered in cases of endogenous fungal endophthalmitis in which there is substantial vitreous involvement, and also in cases in which there is clear progression of disease despite initial therapy with an appropriate systemic antifungal agent. Prompt therapy following early diagnosis will help reduce significant visual loss in all forms of fungal endophthalmitis.     

Analytical Model for Analyzing Construction Claims and Opportunistic Bidding

Construction claims are considered by many project participants to be one of the most disruptive and unpleasant events of a project. Construction claims occur for various reasons. There is a need to understand the dynamic nature between construction claims and opportunistic bidding. An analytical model, the Claims Decision Model (CDM), based on “game theory,” was developed to study opportunistic bidding and construction claims. This model explains (1) how people behave during a potential or existing claiming situation, (2) how different claiming situations are related to opportunistic bidding behavior, and (3) what situations encourage or discourage opportunistic behavior. The results of this pilot study indicate that the equilibrium solution of a construction claim is to negotiate and settle, which concurs with most of the claim cases in the industry. The possible range of a negotiation settlement is obtained in this paper. The model provides the rationale for recent innovations to manage disputes. The model can also help project owners identify the possibility of opportunistic bidding, and can assist the project participants in analyzing construction claims.     

Postoperative pneumonia

Thoracic surgical patients are susceptible to pneumonia because of impaired systemic and lung host defenses. The incidence of pneumonia is higher with more extensive lung resections. Current prophylactic antibiotic therapy is based primarily on general surgical experience with emphasis on wound infection, not pneumonia. With expansion of indications for lung resection to include higher risk patients, there is a need to render antibiotic prophylaxis more specific to bacteria causative of pneumonia.     

Nosocomial pneumonia

A unique, symmetrical onychodystrophy is described in 18 dogs. A rather sudden onset of onychomadesis is followed by chronic onychodystrophy affecting all claws. Pain and lameness are recognized in half of the patients, but the dogs are healthy otherwise. Histopathologically, this disorder is characterized by hydropic and lichenoid interface dermatitis. Nine dogs were treated with a commercial, fatty-acid supplement and had good-to-excellent responses. Due to the clinicopathological characteristics of this disorder, the authors propose the name "symmetrical lupoid onychodystrophy."     

Community-acquired pneumonia

Within the scope of producing cartilage tissue in a three-dimensional culture design, the stability of the used delivery substance in-vitro tissue product has to be improved. For this, carrier materials consisting of bioresorbable polymers, e. g. poly(L[+]-lactic acid) and poly(glycolic acid) can be used. In respect of the biocompatibility of these polymers, the effect of degradation products on chondrocytes is of major interest. The available biomaterials were tested on chondrocytes in form of their monomers, glycolic acid and L(+)-lactic acid. Effects in regard of cell activity were determined with the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazoliumbromide( MTT)test. A non-pH-effect was examined by buffering with concentrated NaOH. In a short-term testing with increasing monomer concentrations as well as in a test over a twelve-day period, L(+)-lactic acid proved to have a lower cytotoxic effect on chondrocytes than glycolic acid. Similar results were obtained with buffered culture media. Therefore, poly(L[+]-lactic acid) can be recommended for the development of chondrocytes-polymer constructs for in-vitro engineering of cartilage tissue.     

Community-acquired pneumonia

Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality in all age groups, especially the elderly, which is a patient population that continues to grow. Recently the spectrum and clinical picture of pneumonia has been changing as a reflection of this aging population; this requires a reassessment of and a new approach to the patient with pneumonia. Currently, pneumonia patients are classified as having either community-acquired or hospital-acquired infection rather than typical versus atypical. Patients who have CAP are categorized by age, presence of a coexisting medical illness, and the severity of the pneumonia. The rationale behind categorizing patients is to stratify them in terms of mortality risk to help determine the location of therapy (e.g., outpatient, inpatient, intensive care unit) and focus the choice of initial antimicrobial therapy. Once the decision to hospitalize a patient with pneumonia is made, the next step is to decide on an appropriate diagnostic evaluation and antibiotic therapy. Both decisions have evolved over the last several years since the publication of the American Thoracic Society's CAP guidelines. The current approach to the diagnostic work-up of pneumonia stresses a limited role of diagnostic tests and procedures. The antimicrobial regimen has now evolved into one that is empiric in nature and based on the age of the patient, the presence of coexisting medical disease, and the overall severity of the pneumonia. This process is a dynamic once because bacterial resistance to commonly used antibiotics can further complicate the course of pneumonia therapy, but the impact of resistance on outcome is less clear. Resistance of Streptococcus pneumoniae to penicillin is a prime example of this growing problem, and adjustment to pneumonia therapy may be required. A difficult but not uncommon problem in pneumonia patients is slow recovery and delayed resolution of radiographic infiltrates. Factors that impact negatively on pneumonia resolution include advanced age and the presence of serious comorbid illnesses such as diabetes mellitus, renal disease, or chronic obstructive pulmonary disease. In addition, certain organism factors (e.g., intrinsic virulence) may interact with host factors and advanced age to delay pneumonia resolution. For example, 50% of patients with pneumococcal pneumonia have radiographic clearing at 5 weeks, and the majority clear within 2 to 3 months. Recent data demonstrate that radiographic resolution of CAP is most influenced by the number of lobes involved and the age of the patient. Radiographic clearance of CAP decreases by 20% per decade after age 20, and patients with multilobar infiltrates take longer to clear than those with unilobar disease. In general, when approaching slowly resolving infiltrates after pneumonia, bronchoscopic evaluation and lung biopsy are more likely to yield a specific diagnosis if the patient is a nonsmoker younger than 55 years old with multilobar disease. If the patients has either no identifiable factors associated with prolonged pneumonia resolution or the repeat chest radiograph at 1 month shows no appreciable change, further diagnostic testing is indicated. The route and duration of antibiotic therapy, another detail of the management of CAP patients that has changed recently, is complicated by the fact that the majority of patients with CAP have no pathogen identified. Therefore, in most instances the physician initiates empiric antibiotics on the basis of epidemiologic data. If an etiologic pathogen is identified (either initially or at a later time), then the antibiotic spectrum can be narrowed. When no pathogen is discovered, broad-spectrum empiric antibiotics are continued. (ABSTRACT TRUNCATED)     

Community-acquired pneumonia

This seminar reviews the aetiology, clinical presentation, approach to diagnosis, and management of immunocompetent adults with community-acquired pneumonia (CAP). Pneumonia is a common clinical entity, particularly among the elderly. A thorough understanding of the epidemiology and microbiology of CAP is essential for appropriate diagnosis and management. Although the microbiology of CAP has remained relatively stable over the last decade, there is new information on the incidence of atypical pathogens, particularly in patients not admitted to hospital, and new information on the incidence of pathogens in cases of severe CAP and in CAP in the elderly. Recent studies have provided new data on risk factors for mortality in CAP, which can assist the clinician in decisions about the need for hospital admission. The emergence of antimicrobial resistance in Streptococcus pneumoniae, the organism responsible for most cases of CAP, has greatly affected the approach to therapy, especially in those patients who are treated empirically. Guidelines for the therapy of CAP have been published by the American Thoracic Society, the British Thoracic Society, and, most recently, the Infectious Diseases Society of America. These guidelines differ in their emphasis on empirical versus pathogenic-specific management.     

Nosocomial pneumonia

The phosphoromonothioate oligonucleotide HPV (human papilloma virus) sequence (monothioate HPV) 5'-TTG,CTT,CCA,TCT,TCC,TCG,TC-3' was photocoupled via three different sites (the 5'-end, the 3'-end and the midpoint) to PPD (purified protein derivative) and OA (ovalbumin), and the three types of conjugates (5'-HPV/carrier, 3'-HPV/carrier and midpoint-HPV/carrier) were used for the immunization of mice. Furthermore, a group of mice were immunized with the HPV sequence alone. No detectable antibody response against the monothioate HPV oligonucleotide was seen in mice receiving only the unconjugated monothioate HPV sequence. The OA-coupled monothioate HPV sequence also failed to elicit a detectable antibody response against the monothioate HPV oligonucleotide. However the PPD-conjugated monothioate HPV sequences induced a significant anti-monothioate HPV antibody response in BCG (bacille Calmette Guérin)-primed mice, a result that must be ascribed to the effect of using PPD as a carrier in BCG-primed mice. The antisera from all groups were tested on plates coated with the corresponding OA conjugates. By far the strongest response was obtained in mice receiving the HPV sequence coupled at the midpoint position. Further, all three groups of antisera obtained by immunizing with the different PPD conjugates were tested on microtiter plates coated with one of the three different OA conjugates. The antisera differed in their response depending on which OA conjugate was used for coating of the plate. Again, the midpoint-HPV/PPD antiserum showed the highest response, and this conjugate apparently represents the most efficient immunogen. Results from inhibition experiments with various relevant analogs of the monothiate HPV sequence showed that the three antiserum pools contained antibodies predominantly directed against the conformation of the monothioate backbone structure, but that at least a subpopulation of the antibodies recognized structures, which depended on the specific HPV base sequence.     

小儿肺炎支原体肺炎34例临床分析

目的:探讨小儿肺炎支原体肺炎的临床特征.方法:对34例肺炎支原体肺炎患儿的临床资料进行回顾性分析.结果:治愈28例,明显好转4例,总有效率94.2%.2例转院做肺泡灌洗治疗,随访治愈.结论:小儿肺炎支原体肺炎好发于学龄前及学龄儿童,血清学检测、胸部X线检查为诊断的主要手段,大环内酯类抗生素是治疗有效的药物.