Heparin therapy: 1998 (current use of the 80-year-old heparin)

OBJECTIVES: Describe the different features of a common disease: Mycoplasma pneumoniae pneumonia. PATIENTS AND METHODS: The hospital files of 10 consecutive patients with microbiologically proven Mycoplasma pneumoniae pneumonia were reviewed retrospectively. These 10 patients were hospitalized over a 15-month period among 150 patients admitted to the Versailles general hospital for community-acquired pneumonia. We compared our series with data in the literature. RESULTS: Most of the patients with Mycoplasma pneumoniae pneumonia were young apparently healthy adults. A bronchial risk factor (smoking, allergy) was however found in 60% of the patients. The principle symptom was persistent cough (100%), with fever and joint pain, or sometimes headache and signs of ENT involvement. Dyspnea was frequent, related more to associated bronchospasticity than to the severity of the pneumonia. Radiographic findings were quite variable. In one case hemolytic anemia and cold agglutinins suggested the diagnosis. Certain diagnosis was based on positive serology after hospitalization due to the long delay between symptom onset and hospitalization. The prehospital period was characterized by a succession of ineffective empirical antibiotic regimens. In routine practice, macrolides or fluoroquinolones administered for 2 to 3 weeks are the empirical antibiotics of choice. Outcome is generally favorable with rapid clinical and radiological improvement. Antibiotic therapy is not however sufficient alone to achieve improvement in the respiratory impairment: bronchodilators and corticosteroids are necessary to treat the bronchospasticity. CONCLUSION: Despite the benign nature of community-acquired pneumonia due to Mycoplasma pneumoniae, clinical manifestations, particularly bronchial inflammation may have important consequences.     

Severe pneumonia caused by Chlamydia pneumoniae in a patient treated with steroids for bronchial asthma

A case of bilateral severe pneumonia caused by Chlamydia pneumoniae has been described in a female patient with bronchial asthma. Both the clinical course and massive radiological changes, as-well as the fact that pneumonia occurred during the patients hospitalization and the treatment with, among other drugs, prednisone lead to the presumptive diagnosis of hospital acquired pneumonia or tuberculosis. The instituted therapy turned out ineffective. Only when Chlamydia pneumoniae was found in the culture infected by the material from the patient, the appropriate diagnosis could be made. The erythromycin therapy was prescribed which soon resulted in remission od clinical and radiological symptoms.     

Pneumonia due to Mycoplasma pneumoniae. Clinicoradiological study of 28 cases (author's transl)

Pneumonia due to Mycoplasma pneumoniae may present at any age after age five. The clinical picture varies from an acute febrile illness to a prolonged disease with affected general state and little pulmonary involvement. The radiological picture is varied but the alveolar pattern predominates, making the differential diagnosis with the bacterial pneumonias difficult. However, in the presence of an interstitial or mixed pattern, especially if generalized, pneumonia due to Mycoplasma pneumoniae must be suspected. This radiological picture is particularly frequent in elderly patients, often affected by other diseases able to induce immunodepression. In such patients the radiology and the unspecific clinical picture frequently cause diagnostic delays. The presence of a pneumonia with multisystem involvement (blood, nervous system, joints, etc.) should suggest the possibility of Mycoplasma pneumoniae infection.     

Community-acquired pneumonia: prospective study of 101 adult, immunocompetent patients for 1 year

BACKGROUND: A one year prospective study was carried out to assess the etiology of community-acquired pneumonia (CAP), and also to know the incidence, characteristics and evolution of infection by Chlamydia pneumoniae; and the effectiveness of DNA probes in CAP due to Mycoplasma pneumoniae and Legionella. METHODS: One hundred and ten patients with a diagnosis of CAP in the emergency department were studied. Serologic studies were performed, and also tests commonly used for the diagnosis of respiratory tract pathogens in respiratory samples, including serology and culture of Chlamydia pneumoniae and DNA probes for Mycoplasma pneumoniae and Legionella. RESULTS: In 72 cases (71.3%) some pathogen was found and in 5 cases more than one microorganism was involved. The etiology was bacterial in 31% of the cases, with S. pneumoniae being the most frequent (19 cases). Forty percent of the cases were "atypical" pneumonias with 33 cases of M. pneumoniae and 5 by Chlamydia pneumoniae. Diagnostic data of viral pneumonia were found in 2 cases. DNA probes were not useful for the diagnosis of pneumonia by Legionella pneumophila and had low effectiveness (31.8%) in Mycoplasma pneumoniae CAP. CONCLUSIONS: a) M. pneumoniae was the most frequent pathogen (33%). b) DNA probes for M. pneumoniae had low sensitivity in sputum (31.8%) and none in pharyngeal exudate. c) Acute infection by C. pneumoniae was diagnosed in 5 cases. Previous data of infection were recorded in 60.4% of the patients. d) Bacterial pneumonia (31%) was underestimated due to a low rate of bacteremic cases (7.9%) and the low number of positive cultures with definitive diagnostic value. e) The evolution was good except in two cases (death due to staphylococcal pneumonia with alcohol withdrawal syndrome and multiorganic failure by disseminated chicken-pox).     

Bronchiolitis obliterans organizing pneumonia (BOOP)--chronic organized pneumonia (COP). Diagnosis, therapy and course

Cryptogenic organizing pneumonia (COP) or bronchiolitis obliterans organizing pneumonia (BOOP) designates a disease characterized by particular histopathological features. Symptoms and clinical findings are more or less typical and the etiology of the disease is unknown in most of the cases. We report on 7 patients in whom the diagnosis was established by open lung biopsy during a workup for persistent pulmonary infiltrates. The clinical findings, the radiological features and the course during treatment with corticosteroids are analyzed. In all patients the symptoms improved. In two cases we observed relapses after discontinuing the corticosteroids or diminishing the dose. These relapses again responded to steroids, but in one patient progressive pulmonary restriction was noticed despite continuous treatment.     

Aerobic and anaerobic microbiology of empyema. A retrospective review in two military hospitals

The microbiology and clinical features of empyema were studied retrospectively in 197 patients whose specimens yielded bacterial growth after inoculation for aerobic and anaerobic bacteria. Three hundred forty-three organisms (216 aerobic or facultative and 127 anaerobic organisms) were isolated. Aerobic bacteria were isolated in 127 (64 percent) patients, anaerobic bacteria in 25 (13 percent), and mixed aerobic and anaerobic bacteria in 45 (23 percent). The predominant aerobic or facultative organisms were Streptococcus pneumoniae (70 isolates), Staphylococcus aureus (58), Escherichia coli (17), Klebsiella pneumoniae (16), and Haemophilus influenzae (12). The predominant anaerobes were pigmented Prevotella and Porphyromonas species (24), Bacteroides fragilis group (22), anaerobic cocci (36), and Fusobacterium species (20). beta-Lactamase-producing organisms were recovered in 49 (38 percent) of 128 tested specimens. These included all 42 tested S aureus and 15 B fragilis group, 4 of 9 K pneumoniae, 3 of 9 H influenzae, 3 of 8 pigmented Prevotella and Porphyromonas species, and 2 of 6 E coli. Most patients from whom S pneumoniae and H influenzae were recovered had pneumonia, and most patients with S aureus had pneumonia, aspiration pneumonia, and lung abscesses. The recovery of anaerobic bacteria was mostly associated with the concomitant diagnosis of aspiration pneumonia, and lung, subdiaphragmatic, dental, and oropharyngeal abscesses. These data highlight the importance of anaerobic bacteria in selected cases of empyema.     

Bacteremic pneumonia in neutropenic patients with cancer: causes, empirical antibiotic therapy, and outcome

BACKGROUND: Bacteremic pneumonia is a major cause of death among neutropenic patients with cancer. METHODS: We analyzed the causes, empirical antibiotic therapy, and outcome of 40 consecutive cases of bacteremic pneumonia identified among 408 episodes of bacteremia in adult neutropenic patients with cancer, prospectively documented from 1986 to 1995. RESULTS: The most frequent causative organisms were Pseudomonas aeruginosa (17 cases), Streptococcus pneumoniae (12 cases), Escherichia coli (5 cases), and Streptococcus mitis (3 cases). Overall, P. aeruginosa and S. pneumoniae caused 72.5% of all episodes of bacteremic pneumonia, compared with 11.4% of bacteremic episodes from other sources (P< .001). Thirty patients received ceftazidime and 10 patients received imipenem as the beta-lactam component of the initial empirical treatment. All strains of P. aeruginosa were susceptible to both agents. Forty-seven percent of streptococcal strains were penicillin resistant and showed a decreased susceptibility to ceftazidime (minimum inhibitory concentration ranged from 1 to 64 microg/mL). Five patients (12.5%) were considered to have received inappropriate empirical antibiotic therapy. Attributable mortality in patients with bacteremic pneumonia was higher than in patients with bacteremia from other sources; 22 (55%) of the 40 patients with bacteremic pneumonia died, whereas 39 (10.6%) of the 368 patients with bacteremia from other sources died (P<.001). CONCLUSIONS: Our data suggest that bacteremic pneumonia in neutropenic cancer patients is associated with a poor outcome and that empirical antibiotic therapy for neutropenic patients with pneumonia should include agents active against both P. aeruginosa and cephalosporin-resistant streptococci.     

Cruciate hemiplegia associated with basilar impression, Arnold-Chiari malformation and syringomyelia. Case report

The aim of this study was to determine the relationship between the radiological pattern of Mycoplasma pneumoniae and the level of cell-mediated immunity of the host. Computed tomographic (CT) scans of the chest and the results of the purified protein derivative (PPD) test were studied during the acute stage of infection in 54 patients with M. pneumoniae pneumonia. The CT findings were used to divide the patients into two groups: one group had a predominance of nodular opacities with a centrilobular distribution (Group N; n = 29); and the other showed a predominance of an airspace consolidation (Group C; n = 25). Forty out of 54 subjects had negative tuberculin skin tests ( < 10 mm induration). The positive rate of PPD reaction was higher in Group N (13 out of 29) compared to Group C (1 out of 25) (p = 0.0005); whilst pleural effusion appeared more frequently in Group C (10 out of 25) than in Group N (3 out of 29) (p = 0.023). There was no significant difference between Groups N and C in white blood cell and lymphocyte counts, level of antibodies to M. pneumoniae in sera, and severity of the disease. These findings suggest that the characteristics of the host cell-mediated immunity might influence the pattern of pulmonary lesions in M. pneumoniae infection.     

Endocarditis due to penicillin-sensitive and -resistant pneumococci: the current perspectives on the disease

BACKGROUND: To evaluate the clinic characteristics and therapeutic aspects of endocarditis by Streptococcus pneumoniae sensitive and resistant to penicillin. METHODS: Twelve cases of pneumococcal endocarditis evaluated in 4 Spanish hospitals over the last 10 years were studied, analyzing their clinical characteristics and the existence of resistance to penicillin. The features were compared with a series of 98 cases found in a review of the literature. RESULTS: All the patients were males, most being alcoholics. The course of the disease was acute (2 weeks) in all the cases and evolved with great aggressivity: cardiac failure (9 patients), myocardial abscess (7 patients), multiple arterial embolisms (5 patients), septic arthritis (4 patients). Three patients had simultaneous pneumococcal meningitis but only one had pneumonia. The valve most affected was the aortic (9 cases). Three cases were due to strains of Streptococcus pneumoniae with moderate resistance to penicillin (CMI 0.5-1 micrograms/ml). Global mortality was 42%. All the patients receiving inadequate antibiotic treatment died. Vancomycin and cefotaxime appear to be effective in the treatment of cases produced by strains of pneumococcus with intermediate sensitivity to penicillin. There were no apparent differences in mortality between the cases of endocarditis by pneumococcus sensitive or moderately resistant to penicillin. CONCLUSIONS: Pneumococcal endocarditis continues to condition a high mortality similar to that produced in previously made series. The classic relation with meningitis and pneumonia is infrequent today. The appearance of strains resistant to penicillin may increase the incidence of this infection and further worsen prognosis.     

Clinical and serological studies in six cases of chlamydial pneumonia

Clinical and serological studies of chlamydial pneumonia were done in six patients (three men and three women). The other three patients had no avian contact and showed almost the same clinical symptom. Acute infection with Chlamydia psittaci and Chlamydia pneumoniae were diagnosed in two patients and in one patient, respectively, by MFA. Because in some cases Chlamydia psittaci pneumonia and Chlamydia pneumoniae pneumonia are difficult to differentiate, it is necessary to use a test that allows different chlamydia species to be distinguished.     

Pyogenic bacterial pneumonia in human immunodeficiency virus-infected inpatients: a clinical, radiological, microbiological, and epidemiological study

We prospectively studied features of pyogenic bacterial pneumonia in 263 consecutive human immunodeficiency virus-infected inpatients over a 6-month study period. Risk factors for bacterial pneumonia were examined by a case-control study that included 33 cases who presented with at least one episode of bacterial pneumonia and 80 controls without bacterial pneumonia. The estimated cumulative incidence of bacterial pneumonia per year was 12.5 cases per 100 inpatients (95% confidence interval [CI], 8.8-17.2). The 38 episodes of bacterial pneumonia that occurred in the 33 inpatients were mainly unilateral, but 32 episodes were patchy lobar or diffuse infiltrates. Microbiological etiologies were obtained in 33 of the 38 episodes of bacterial pneumonia. Thirty-seven pathogens were identified, including Streptococcus pneumoniae (16, of which 12 had a decreased susceptibility to penicillin), Haemophilus influenzae (6), and Pseudomonas aeruginosa (6). The risk factors for bacterial pneumonia that were identified after logistic regression included prior sinusitis within 1 month before admission (odds ratio [OR], 3.2; 95% CI, 1.1-9.1) and prior bacterial infection of the lower respiratory tract within 6 months before admission (OR, 3.1; 95% CI, 1.1-8.3).     

"Goodbye Dolly?" The ethics of human cloning

A randomized controlled study was carried out to assess the efficacy of a single dose of benzathine penicillin for treating children 2-12 years old with presumed S. pneumoniae pneumonia. One-hundred-and-seventy-six children screened at self-referral pediatric emergency services in Belo Horizonte, Brazil, were randomized to only one injection of benzathine penicillin (n = 93, case-group) or a 7-day procaine penicillin regimen (n = 83, control-group), upon diagnosis of pneumococcal pneumonia based on clinical and radiological characteristics. Follow-up was carried out on the second day after treatment and around the 7th and/or 14th day after treatment allocation. No statistical significant difference was found for sociodemographic, clinical, laboratory or radiographic characteristics among the two groups. Evident or total radiographic clearing was demonstrated for 92.3 and 95.1 per cent of the benzathine penicillin and procaine penicillin groups, respectively (P = 0.54). Benzathine penicillin may be considered an alternative to classic regimens for treating pneumonia due to sensitive strains of S. pneumoniae among children 2-12 years old. Other benefits are its lower cost, better compliance and low rates of adverse reactions.     

Etiology of childhood pneumonia: serologic results of a prospective, population-based study

BACKGROUND: To investigate the etiology of pediatric community-acquired pneumonia, we conducted a prospective, population-based study covering the total population <15 years of age (n = 8851) in 4 municipalities in eastern Finland. MATERIALS AND METHODS: The number of patients was 201; chest radiographs were available for all cases and paired sera for serologic assays were available for >90% of cases. The methods included assays for antibody response to 3 pneumococcal antigens, specific pneumococcal immune complex assays and conventional antibody tests for mycoplasmal, chlamydial and viral infections. RESULTS: Serologic evidence of specific microbial etiology was obtained in 133 (66%) of the pneumonia patients. Bacterial infection was diagnosed in 102 cases (51%) and viral infection in 51 cases (25%). Streptococcus pneumoniae was the most common agent (57 cases; 28%), followed by Mycoplasma pneumoniae (44; 22%), respiratory syncytial virus (43; 21%) and Chlamydia spp. (29; 14%). Haemophilus influenzae was identified in only 6% and Moraxella catarrhalis in only 3% of the children. More than one specific infection was found in 51 patients (25%). The proportion of pneumococcal cases varied from 24 to 36% by age. Mycoplasma infections were seen mostly in patients > or =5 years and Chlamydia infections in patients > or =10 years of age. CONCLUSIONS: The results of our prospective, strictly population-based study confirm the importance of S. pneumoniae in the etiology of community-acquired pneumonia in children of all ages. M. pneumoniae and Chlamydia pneumoniae are important from the age of 5 years onwards.     

Detection of Mycoplasma pneumoniae by polymerase chain reaction in lung aspirates from patients with community-acquired pneumonia

STUDY OBJECTIVE: This study was designed to evaluate the usefulness of polymerase chain reaction (PCR) to detect Mycoplasma pneumoniae DNA in samples obtained by transthoracic needle aspiration (TNA). DESIGN: Prospective study of cases. SETTING: A university hospital in Lleida, Spain. PATIENTS: A total of 101 unselected patients, admitted between January 1993 and March 1994 in the emergency department, with a clinical and radiologic picture of community-acquired pneumonia, and without contraindications for TNA application. INTERVENTIONS: Patients were studied with conventional diagnostic techniques for community-acquired pneumonia. In addition, a sample obtained by TNA was processed by the following methods: culture in standard media, culture in selective media for Legionella, detection of capsular antigens for Streptococcus pneumoniae and Haemophilus influenzae, and detection of M pneumoniae specific genome by PCR. RESULTS: Serologic data were not available in eight patients and were excluded from this analysis. M pneumoniae PCR amplification was possible in eight cases, well correlated with serologic responses indicating current infection. Samples from ten additional patients, negative by PCR, were found to be demonstrative of recent M pneumoniae infection by serologic study. Finally, in all the remaining 75 cases, including the 59 patients for whom a different microbial diagnosis was established, M pneumoniae PCR test gave negative results. CONCLUSION: This study indicates that PCR, applied to samples obtained by TNA, appears to be a moderately sensitive and highly specific method for rapid detection of M pneumoniae lung infection.     

Community-acquired pneumonia: Etiological diagnosis

Microbiological and immunoserological approaches were used in etiological diagnosis of community-acquired pneumonia. It was concluded that Streptococcus pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa, Legionella pneumophila and Klebsiella pneumoniae predominated in the etiological structure of present severe community-acquired pneumonia. The most actual causative agents of nonsevere community-acquired pneumonia in persons under 60 were S. pneumoniae, Hemophilus influenzae, Mycoplasma pneumoniae and Chlamydia pneumoniae. Nonsevere community-acquired pneumonia in persons over 60 and/ or at the background of chronic obstructive pulmonary diseases, diabetes mellitus or other affections was most frequently due to S. pneumoniae, H. influenzae and aerobic gramnegative microbes.     

A clinical study of chronic lower respiratory infection with Haemophilus influenza by transtracheal aspiration

We have performed a clinical study on chronic lower respiratory tract infection (CLRTI) with Haemophilus influenzae (H. influenzae) by transtracheal aspiration (TTA) and analyzed clinical factors of the acute exacerbation. In 40 episodes (38 cases) of H. influenzae isolated from CLRTI, monobacterial infection with H. influenzae were 21 episodes and polymicrobial infection were 19 episodes. We classified the disease into acute exacerbated (27 episodes) and stable (13 episodes) phase and the former episodes were divided into bronchitis type (7 episodes) and pneumonia type (20 episodes). Polymicrobial infections were seen more in the pneumonia type (13 episodes) than in the bronchitis type (2 episodes). The principal organism detected with H. influenzae were alpha-Streptococcus and Neisseria sp. in the bronchitis type and S. pneumoniae in the pneumonia type. The acute exacerbated cases were divided into the following 4 patterns; 1. polymicrobial infection with continuous infection of P. aeruginosa, 2. monomicrobial infection after acute upper respiratory tract infection, 3. polymicrobial infection with S. pneumoniae after continuous infection of H. influenzae, 4. bacterial replacement by P. aeruginosa after acute exacerbation. The results of the study suggests that polymicrobial infection is an important chronic lower respiratory tract infection when caused H. influenzae.     

The tumor-suppressor function of E-cadherin

STUDY OBJECTIVE: To compare the etiology of community-acquired pneumonia in Japan and Western countries, the causative pathogens were prospectively investigated in patients requiring hospitalization. DESIGN: Prospective study over a 3-year period. SETTING: A community general hospital in Japan. PATIENTS: Three hundred twenty-six episodes of community-acquired pneumonia in 318 patients admitted to the hospital between July 1994 and June 1997. METHODS: The microbiological diagnosis was based on the results of quantitative sputum culture, blood culture, and other invasive procedures, including transthoracic needle aspiration or bronchoscopic examination. Serologic tests for Mycoplasma pneumoniae, Chlamydia spp, Legionella spp, and viruses were also routinely performed. RESULTS: Causative pathogens were identified in 199 episodes (61%). Streptococcus pneumoniae was the most common pathogen (23%), followed by Haemophilus influenzae (7.4%), M pneumoniae (4.9%), and Klebsiella pneumoniae (4.3%). The Streptococcus milleri group and Chlamydia pneumoniae were detected in 3.7 and 3.4% of the episodes, respectively. Pneumonia due to Legionella spp was recognized in only two patients. CONCLUSIONS: The etiology of community-acquired pneumonia in Japan did not differ markedly when compared with that of Western countries except for the low incidence of Legionella pneumonia. C pneumoniae and the S milleri group, which are emerging or newly recognized pathogens, were also significant causative microorganisms.     

Current status of acute respiratory infections in children under five years of age in Nairobi, Kenya

Two hundreds and twenty-six children under five years of age with pneumonia were recruited from an urban poor area in Nairobi, Kenya, and examined for pathogens for 1 year from February 1997. One hundred and twenty-eight of the 226 patients were pathogen-positive cases. The patients under 1-year-old were 61.8% of the pathogen-positive cases. A total 192 organisms were isolated from 128 pathogen-positive patients. Streptococcus pneumoniae had the highest prevalence rate of 31.3%, followed by respiratory syncytial virus with 10.4%, Candida albicans with 9.9%, Moraxella (B) catarrhalis with 7.8%. In S. pneumoniae, 66.7% of the organism was resistant to oxacillin. It was also shown that 51.1% and 65.1% of the S. pneumoniae strains were resistant to gentamicin and trimethoprim/sulfam, respectively. From these results, it is clear that a lot of multi-drug resistant S. pneumoniae strains including penicillin-resistant S. pneumoniae were frequently detected in an urban poor area.     

Diagnosis of Mycoplasma pneumoniae pneumonia in pediatric patients by polymerase chain reaction (PCR)

Polymerase chain reaction (PCR) testing was performed on respiratory tract specimens obtained by throat swab in 21 children admitted to the hospital with suspected Mycoplasma pneumoniae pneumonia. Of 13 patients with a clinical condition compatible with mycoplasma infection and an immunological response to M. pneumoniae, 11 were positive by PCR. Eight patients were negative by serology and/or had a clinical condition not compatible with mycoplasma infection, and all were negative by PCR. The antibody response to M. pneumoniae was delayed for a week or more in 3 (23%) of the 13 patients with documented mycoplasma infection. These results suggest that PCR performed on a respiratory tract specimen obtained by a throat swab may be useful in the initial evaluation of children with suspected M. pneumoniae pneumonia, especially in patients in whom the serological response is delayed.     

Neutralization of macrophage inflammatory protein-2 attenuates neutrophil recruitment and bacterial clearance in murine Klebsiella pneumonia

The role of macrophage inflammatory protein-2 (MIP-2) in bacterial pneumonia was characterized. Mice were challenged with Klebsiella pneumoniae intratracheally, and organs were harvested at 8, 24, and 48 h. Inoculation with K. pneumoniae resulted in the time-dependent expression of MIP-2 mRNA and protein within the lung, which was maximal 48 h after inoculation. Mice were then passively immunized with rabbit anti-murine MIP-2 serum intraperitoneally 2 h before administration of K. pneumoniae. Treatment with anti-MIP-2 serum resulted in a 60% decrease in lung neutrophil (PMNL) influx and a significant increase in K. pneumoniae colony-forming units in both lung and liver homogenates. Finally, treatment with anti-MIP-2 serum decreased early (48-72 h) but not late (after 72 h) survival in animals with Klebsiella pneumonia. This study indicates that MIP-2 is produced during Klebsiella pneumonia and inhibition of MIP-2 bioactivity in vivo results in decreased PMNL influx and lung bacterial clearance in murine Klebsiella pneumonia. MIP-2 is produced during Klebsiella pneumonia and inhibition of MIP-2 bioactivity in vivo results in decreased PMNL influx and lung bacterial clearance in murine Klebsiella pneumonia.