Low-cost self-irrigating bipolar forceps

Escherichia vulneris was isolated from an infected soccer wound, a finding which has not apparently been described in Europe before, but by questioning Danish clinical microbiological laboratories a further 12 cases were discovered. Treatment with simple debridement and cefuroxime quickly eradicated the bacteria in our case.     

Operative site bacteriology as an indicator of postoperative infectious complications in elective colorectal surgery

Toward the completion of elective colorectal operations, 75 patients had qualitative aerobic and anaerobic cultures of specimens obtained from peritoneal irrigation fluid, anastomoses sites, and abdominal wound irrigation fluid to determine if a correlation exists between intraoperative flora and postoperative infectious complications. Patients enrolled in this prospective study received a mechanical bowel prep and a 12-18 hour course of perioperative intravenous antibiotics. Comparisons were made between the 60 (80%) patients who had no postoperative infections and the 15 (20%) who developed postoperative infectious complications (9 wound infections, 6 intraabdominal infections). There were significantly more low anterior resections in patients who developed postoperative infection compared to those who had no postoperative infection (26% vs 2%), while there were more colocolostomies in the group with no infections (38% vs 7%). Streptococcus spp., Bacteroides fragilis group, and Escherichia coli were the most commonly isolated organisms from each of the three sites sampled. Isolation of > or = 3 organisms from incisional wound cultures (P = 0.017) and < or = 4 organisms from peritoneal irrigation (P = 0.009) or anastomotic culture (P = 0.004) correlated with development of postoperative infectious complications. Thus, patients with infectious complications had significantly more isolates than those without infectious complications, and were more likely to have had a low anterior resection. These data suggest that future clinical studies should reexamine the duration of perioperative antimicrobials based on early laboratory reports of qualitative and quantitative operative site bacteriology.     

Public health hazards of meat from small ruminants: the perspective of Australia

We report on a case of subcutaneous infection of the arm caused by the coelomycetous fungus Nattrassia mangiferae (formerly Hendersonula toruloidea) in a steroid-dependent diabetic man with chronic obstructive lung disease. The man was a resident of Arizona, where the fungus is known to be endemic on Eucalyptus camaldulensis and on citrus trees. Diagnosis of fungal infection was made by observation of narrow hyphal filaments by histopathology of biopsy specimens and isolation of a fast-growing black mold which demonstrated hyphae and arthroconidia of varying widths typical of the Scytalidium synanamorph (S. dimidiatum). The formation of pycnidia, which at maturity expressed conidia with a central median dark band, allowed for the confirmation of the isolate as N. mangiferae. Remission of the lesions occurred following intravenous therapy with amphotericin B, followed by topical clotrimazole treatment. We use this patient's case report as an opportunity to review the literature on cases of deep infection caused by Scytalidium species, to evaluate the antifungal susceptibilities of a spectrum of Scytalidium isolates, and to review the taxonomy of Scytalidium species isolated from human infections.     

Medical cuneiform fracture-dislocation associated with medial and intermediate cuneiform fractures

We report the microbiological characteristics of two Rahnella aquatilis strains isolated in the faeces of two patients with acute gastroenteritis, one of whom is an AIDS patient. The biochemical behaviour was studied with different automated identification systems, and the few clinical cases to be found in the literature were reviewed. Of the nine strains isolated in clinical samples, two were obtained from blood cultures, two from respiratory samples, one from urine, one from a burn wound, one from a surgical wound, and two (our strains) from faeces. In almost all cases the patient presented an underlying condition facilitating infection by opportunistic microorganisms. The majority of strains are characterized by their resistance to ampicillin, cephalothin and cefoxitin. Due to the rarity of the isolation of R. aquatilis in human samples it is not yet possible to establish, with any degree of certainty, its true pathogenic capacity.     

Microbiological examinations and in-vitro testing of different antibiotics in therapeutic endoscopy of the biliary system

BACKGROUND AND STUDY AIMS: Prior to endoscopic therapeutic procedures, no antibiotic prophylaxis is administered routinely. Because of the reported incidence of infectious complications, which may reach up to 10%, a prospective study was undertaken to investigate the effects of a prophylactic dose of cefuroxime on the incidence of bacteremia and clinical signs of infection, but no significant effects could be demonstrated. In addition to this published work, blood and bile cultures obtained in this trial were also investigated, and the in-vitro susceptibility to several antibiotics was tested in order to recommend the appropriate substances. PATIENTS AND METHODS: Ninety-nine consecutive patients (51 men, 48 women; mean age 61.4 +/- 17 years) with biliary obstruction who underwent an endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography with drainage (PTCD) were included. Sequential blood cultures were taken before and up to 60 minutes after the endoscopic intervention. Bile cultures were obtained in 56 patients with biliary drainage. Aerobic and anaerobic cultures were prepared from all obtained specimens and the isolated organisms were identified. In the case of positive cultures, an in-vitro resistance test for 15 different antibiotics was performed. RESULTS: The incidence of bacteremia was 11.1% (n = 11), and 16 bacteria were isolated. Twelve different microorganisms were detected, with Escherichia coli found in four cases. From 41 positive out of 56 prepared bile cultures (73.2%), 91 isolates were found with 25 different species. A single agent was detected in eight cases (19.5%), while a mixed growth, with pathogens ranging from two to six species, was found in 33 cases (80.5%). The seven most frequently isolated germs were E. coli and Enterococcus (each n = 19), Klebsiella (n = 10), Streptococcus viridans (n = 9), Staphylococcus epidermidis (n = 5), Morganella morganii (n = 4), and Bacteroides fragilis (n = 3), representing 76% of all agents. Examination for fungal infection revealed positive cultures of Candida albicans in 16.1% of bile cultures (nine of 56). Interestingly, the use of proton-pump inhibitors (PPIs), with a consequent rise in the gastric pH value, led to an increase in the rate of bacteremia to 26.2% (five of 19) compared to the other patients not on PPIs (n = 80), who developed bacteremia in only six cases (7.5%; p = 0.02). In-vitro testing of different antibiotics was carried out in 73 isolates. Imipenem showed the best antimicrobial activity (98.4%), followed by trimethoprim and sulfamethoxazole (90%), amoxicillin plus clavulanic acid (87.3%), vancomycin (82.4%), and ofloxacin (76.9%). CONCLUSIONS: Escherichia coli was found to be the pathogen most frequently detected in blood and bile following endoscopic interventions in the biliary tract. Enterococci, Klebsiella and Streptococcus viridans were found in bile cultures with an incidence exceeding 10%. In view of the in-vitro test results, possible side effects, and contraindications, amoxicillin plus beta-lactamase inhibitors or quinolones are considered to be suitable antibiotics for the prophylaxis of biliary infections.     

Methicillin-resistant Staphylococcus aureus: a four-year experience in a spinal cord injury unit in Spain

Methicillin-Resistant Staphylococcus aureus (MRSA) infection poses a problem for both acute and long-term-care facilities, Spinal Cord Injury units included. This paper describes the 4-year evolution of MRSA outbreaks in a SCI unit in a university hospital where control measures were implemented from the first case detected. The protocol procedure was as follows: contact isolation, washing with antiseptic soap both those infected and those sharing the same room, contacts study and monitoring of MRSA patients up to the time when three consecutive negative cultures (sampled at time lapses of over 48 h) were obtained, antiseptic soap for the health-care personnel to wash their hands, and cultures of the nares done on the personnel in the event of an outbreak. Twenty-one (3.4%) MRSA positive cases were detected out of 550 admissions registered during the study period (November 1990 through October 1994). The evolution occurred in three outbreaks and six isolated MRSA positive patients without secondary cases. 71.5% of the cases were nosocomial. Seven (33%) were colonizated and 14 (67%) infected. The 14 patients infected presented 15 infections: nine with urinary tract infections, three surgical wound infections, two tracheostomy wound infections, and one patient with a decubitus ulcer infection. Two of those with urinary tract infections presented with secondary sepsis. No carriers were detected amongst the personnel. Urinary tract colonizations responded to treatment with cotrimoxazol except in two cases in which combined treatment was required (cotrimoxazol plus rifampicin). The patients with a MRSA positive tracheal aspirate were negative after combined treatment. Wounds and cultures of the nares responded favorably to initial treatment. One of the patients with a urinary tract infection and sepsis died the infection being a contributing cause. The prospective follow-up of the patients with MRSA positive cultures and the precocious implementation of isolation measures allow for the limitation of transmission, even although complete eradication is not possible.     

Propionibacterium acnes isolated from synovial tissue and fluid in a patient with oligoarthritis associated with acne and pustulosis

This report describes the case of a patient with a 14-month course of severe oligoarthritis associated with acne. Pure cultures of Propionibacterium acnes were isolated from synovial tissue and synovial fluid specimens collected from the same joint after a 4-month interval. After 2 months of treatment with roxithromycin 300 mg/day, rifampicin 1,200 mg/day, and a nonsteroidal antiinflammatory drug (NSAID), followed by 4 months of treatment with azithromycin 1 gm/week and an NSAID, the synovitis persisted. Cultures of skin lesions and synovial fluid at this time were negative. Although P acnes has previously been isolated from bone specimens obtained from patients with osteitis associated with acne, this is the first report of the isolation of this microorganism from the synovial tissue of a patient with arthritis associated with acne. Our findings raise the question of the role of P acnes in the pathogenesis of arthritis associated with acne.     

Cytogenetic analysis using simultaneous and sequential fluorescence in situ hybridization

BACKGROUND: Trichosporon beigelii, causal agent of white piedra can cause disseminated infection in immunodepressed subjects. Systemic infections due to this pathogen have been reported mainly in neutropenic patients and rarely in AIDS patients. CASE REPORT: A 36-year-old HIV+ man from Senegal was hospitalized for fever and meningoencephalitis associated with skin lesions. T. beigelii was isolated from skin biopsies and cerebrospinal fluid cultures. The patients was treated with amphotericin B with regression of the skin lesions. The diagnosis of disseminated T. beigelii infection was retained. DISCUSSION: Disseminated T. beigelii infections are known to occur in immunodepressed subjects, especially in case of neutropenia. In our patient, the presence of two proven localizations (meninges and skin) and the favorable outcome with amphotericin B favored disseminated infection. The good response to treatment can probably be explained by the absence of neutropenia. Skin lesions are frequent, usually occurring as disseminated papulae or purpural nodules. Pathology examination and skin biopsy culture can provide rapid diagnosis allowing appropriate treatment.     

An outbreak of Pontiac fever among children following use of a whirlpool

We investigated an outbreak of fever, most likely due to a contaminated whirlpool, among nine adults and six children residing in a summerhouse. The outbreak was characterized by a high attack rate, short incubation periods, influenza-like symptoms, and rapid recoveries, all features typical of Pontiac fever. However, the children had less-characteristic symptoms than the adults, and they did not have any sequelae. Findings on the children's chest radiographs were unremarkable, and none of the children had leukocytosis. Evidence of Legionella pneumophila infection was found in six cases: in one case by isolation of L. pneumophila serogroup 1 and detection of legionellae by PCR, and in five cases by seroconversion to the clinical isolate. Six additional cases had presumptive evidence of legionella infection, with seroconversion to Legionella micdadei antigen; a PCR assay was also positive for legionellae for one of these cases. In contrast, two adult nonusers of the whirlpool had no symptoms and no serological evidence of infection. Serological testing and cultures for other pathogens, as well as cultures of all environmental samples, were negative. This investigation demonstrates the differences between adults and children with respect to the clinical picture of Pontiac fever; furthermore, it shows that culture and PCR assay of tracheal aspirates for legionellae can be performed in a hospital setting for rapid diagnosis, although the sensitivities of these methods are low.     

Traumatic spinal cord injuries in Thailand: an epidemiologic study in Siriraj Hospital, 1989-1994

AIM: The term zygomycosis comprise mycotic infections produced by mucorales and entomophtorales. Mucorales become pathogenic in some conditions, principally diabetes mellitus, immunosuppression, trauma or burn. METHODS: We describe two cases of leukaemic patients who developed disseminated zygomycosis by Absidia corymbifera during the aplastic phase by antineoplastic chemotherapy. RESULTS: In both cases, the first symptom was high fever unresponsive to broad spectrum antibiotics neither fluconazole. Initial sites of infection were sinonasal region in one case and bowel in the other one. The diagnosis was confirmed by culture of nasal swab and peritoneal fluid respectively. One patient was early diagnosed and he received prolonged amphotericin B therapy but no surgical debridement. The other one had a postmortem diagnosis at autopsy. None of them survived. Death was directly related to the fungal infection. CONCLUSIONS: Although this infection is infrequent, it must be suspected in high-risk patients because early diagnosis and quick combined therapy appear to improve the prognosis.     

Subglottic stenosis in a child: a complication of prolonged endotracheal intubation

A case of septicemia and meningitis due to Streptococcus zooepidemicus in an immunocompetent patient is reported. This organism is an uncommon human pathogen that sometimes causes severe infection, usually in immunocompromised patients. In the reported case, the patient required to be mechanically ventilated for one week and was treated with intravenous ampicillin and gentamicin. He recovered and was discharged from hospital three weeks after the initial presentation. Streptococcus zooepidemicus sensitive to all penicillins, was isolated from all blood cultures and the cerebrospinal fluid.     

Citrobacter sedlakii meningitis and brain abscess in a premature infant

Citrobacter sedlakii was isolated from blood and cerebrospinal fluid cultures of a 5-day-old premature infant with sepsis, meningitis, and brain abscess. This newly described organism was difficult to identify due to discrepancies between the Vitek and API 20E identification systems. To our knowledge, this is the first report of the isolation of C. sedlakii from cerebrospinal fluid.     

Mixed bacterial meningitis: a complication of ventriculo- and lumboperitoneal shunts

Infectious complications of ventriculo- and lumboperitoneal shunts in two patients are presented. Cerebrospinal fluid infection due to aerobic and anaerobic enteric flora was characteristic of each case. Both infections occurred several months after shunt surgery and were associated with colonic perforation by the distal limb of the peritoneal catheter. These cases emphasize this unusual hazard of peritoneal shunts and demonstrate methods for diagnosis and effective therapy.     

Encephalomyeloradiculopathy associated with Epstein-Barr virus: primary infection or reactivation?

INTRODUCTION: Encephalomyeloradiculopathy (EMR) is a new syndrome, characterized by extensive involvement of the nervous system at different levels, including brain, medulla and spinal roots. We describe a patient presenting with prodromal febrile illness, followed by a wide infection of the nervous system with transverse myelitis and less severe meningitis, encephalitis and polyradiculopathy. The patient was treated with high-dose corticosteroids, antibiotics and acyclovir; in spite of therapy his condition improved very slowly, with severe neurological sequelae. MATERIAL AND METHODS: Antiviral antibodies were searched for in serum and cerebrospinal fluid (CSF) by commercially available ELISA kits. Viral investigations were performed by cell culture isolation and search for viral antigens, and genomic nucleic acids were investigated by polymerase chain reaction (PCR). RESULTS: Virological and serological studies evidenced a primary infection by cytomegalovirus (CMV), possibly responsible for the prodromal illness, persisting in the course of the disease. PCR performed in the peripheral blood mononuclear cells (PBMCs), DNA collected early and in the CSF drawn 30 days after the onset of the disease showed Epstein-Barr virus (EBV) DNA. The serum panel of EBV antibodies was typical of an intercurrent virus reactivation, more than of a primary infection. CONCLUSION: EBV is known to be highly infectious for the nervous system, in this case of EMR the presence of DNA sequences in the PBMCs and CSF suggests that EBV plays a role in the development of this newly described syndrome.     

A case of Legionnaires'' disease due to aspiration of hot spring water and isolation of Legionella pneumophila from hot spring water

We report a case of fulminant pneumonia that was due to aspiration of contaminated hot spring water and was not affected by beta-lactam antibiotics. We suspected that the patient had Legionnaires' disease and treated the clinical symptoms with erythromycin. Legionellaceae could not be isolated from sputum or lung biopsy material, but an elevated titer to Legionella pneumophila serogroup 4 was found by indirect immunofluorescence test. We diagnosed the patent as having Legionnaires' disease with improved clinical symptoms. Furthermore, we went to the hot spring that he visited and tried to isolate Legionellaceae. Hot spring water was collected from the bathroom and water, hot water, and shower water from the guest-room. After using a low-pH method, samples were cultured on BCYE alpha medium. Serogroups are classified by agglutination method with immune rabbit serum. As a result, we successfully isolated Legionella pneumophila serogroup 4 from hot spring water (42 degrees C) from the bath. No bacteria could be isolated from the other samples. Therefore, we believe that this case of Legionnaires' disease was caused by aspiration of contaminated hot spring water. The infection route of Legionnaires' disease is unclear. There are no previous reports of isolation of Legionellaceae from Japanese hot springs. This case would provide important information when considering the infection route of Legionnaires' disease in Japan.     

Cecal infarct: report of a case

PURPOSE: The purpose of this article is to present a case of an uncommon opportunistic fungal infection that appears in immunologically or metabolically compromised patients and is usually fatal. METHOD: A 54-year-old woman with an acute lymphoblastic leukemia had acute abdominal pain with peritoneal symptoms during her hospital stay. A laparotomy was performed and a cecal infarct firmly adherent to about 30 cm of infiltrated jejunal loop was discovered. RESULTS: Microscopic studies revealed an infiltration of the jejunal wall by abnormal lymphocytes. The cecal and ileal walls were infiltrated by leukocytes. Blood vessels were invaded by giant cells and large, unseptated, right-angle branching hyphea. CONCLUSIONS: These findings were considered typical of invasive mucormycosis of the cecum and the terminal ileum.     

Thoracic empyema in HIV-infected patients: microbiology, management, and outcome

OBJECTIVES: To evaluate etiology, bacteriology, stage of disease, treatment, and outcome of HIV-infected patients with thoracic empyema (TE) over a 9-year period at a hospital teaching center. DESIGN: We have retrospectively reviewed the charts of all HIV-infected patients with a hospital discharge diagnosis of empyema between January 1985 and November 1993. PATIENTS: Twenty-three patients were identified (22 male and 1 female). The average patient age was 28.7+/-5.3 years. All the patients were injection-drug users, and 10 (43%) fulfilled criteria for an AIDS diagnosis. In 15 cases (65%), the empyema was the first cause of medical consultation, which then led to an HIV infection diagnosis in 11 of them (48%). MEASUREMENTS: In each case, symptoms, chest studies, culture results, procedure timing, length of hospitalization, and outcome were reviewed. RESULTS: Twenty-one patients (91%) had developed an empyema secondary to community-acquired pneumonia. The cultures of pleural fluid were positive in 19 cases (83%). Anaerobes were isolated from 6 patients and aerobes from 13. A single bacteria was isolated from 10 (52%), and multiple organisms (average 2.66 per case) grew in the remaining 9 positive cultures. The most common organism culture growths were Staphylococcus aureus (23%) and Gram-negative bacilli (36%). Length of hospitalization averaged 25.6 days (+/-15). Intercostal tube drainage was necessary in 18 patients and none required surgery. Patients with AIDS diagnosis needed a longer period of hospitalization, and the presence of bacteremia and bronchopleural fistula was more frequent. However, this did not influence a patient's final outcome. A follow-up was available in 18 cases, with 4 deaths recorded (average survival, 35 months; range, 4 to 84 months). CONCLUSIONS: In our series, TE associated with HIV infection was often the primary cause leading to hospital admission and later HIV diagnosis. IV drug abuse was the predominant factor for HIV infection and was also related to clinical presentation and microbiological findings. The best approach to treatment is--as with other patient groups--a prompt drainage and appropriate antibiotic treatment, since a favorable outcome is expected.     

Clinicopathologic implications of MDM2, p53 and K-ras gene alterations in osteosarcomas: MDM2 amplification and p53 mutations found in progressive tumors

The role of rapidly growing mycobacteria in the pathogenesis of pulmonary disease is being increasingly recognized; however, the clinical significance of these mycobacteria in patients with underlying malignancy has not been well studied. Over a 6-year period, 37 cancer patients with rapidly growing mycobacteria isolated from respiratory specimens were identified at our center. Mycobacterium chelonae group was isolated in 24 cases and Mycobacterium fortuitum in 13 cases. Of the 24 cases with cultures yielding Mycobacterium chelonae group, eight met the study criteria for infection and were determined to be clinically significant, whereas only one of the Mycobacterium fortuitum isolates was determined to represent infection. An average of two antimicrobial agents were used for treatment, most commonly clarithromycin, ciprofloxacin, and trimethoprim/sulfamethoxazole. Although the isolation of rapidly growing mycobacteria represents colonization in most cases, these bacteria, especially the Mycobacterium chelonae group, may cause pulmonary disease in cancer patients. The clinical and radiological findings are usually non-specific in this population, and patients with respiratory cultures yielding rapidly growing mycobacteria should be assessed carefully to distinguish infection from colonization. Effective therapy can be provided with oral regimens that include at least two antibiotics to which the organism is susceptible.     

Re: Management of idiopathic carpal tunnel syndrome

A male fetus of gestation day 187 was aborted from a Holstein-Friesian cow in an epizootic of the Aino virus (AINOV) in September 1995. Neutralizing antibody titers against AINOV were 1:128, 1:16 and 1:64 in the dam serum, fetal ascites and cerebrospinal fluid, respectively. A 10% brain suspension of the aborted fetus was prepared immediately after autopsy, rinsed three times and sonicated before centrifugation. The supernatant was then inoculated into HmLu-1 cell cultures. A cytopathic effect was noted on post-inoculation day 7. The isolated virus was identified as the AINOV based on the physicochemical properties and cross neutralization test. This is the first report on the isolation of AINOV from an aborted bovine fetus.     

Iodixanol in cardioangiography in patients with coronary artery disease. Tolerability, cardiac and renal effects

PURPOSE: Complications following transvaginal ultrasound-directed follicle aspiration are rare, making it difficult to assess their true incidence. During a 4-year prospective study the complications arising from a series of 2670 consecutive procedures were monitored. RESULTS: Vaginal hemorrhage occurred in 229 (8.6%) of the cases, with a significant loss (> 100 ml) in 22 (0.8%). Postoperative pelvic infection occurred in 18 (0.6%) of the cases. Hemorrhage from the ovary with hemoperitoneum formation was seen on two occasions and necessitated emergency laparotomy in one instance. A single case of pelvic haematoma formation from a punctured iliac vessel was also recorded; this settled without intervention. Of the 18 cases with infection, 9 were severe with pelvic abscess formation; microbiological examination of the pus from these cases suggests that the most common route of infection in such cases is probably by direct inoculation of vaginal organisms into the peritoneal cavity by the collecting needle. CONCLUSION: The low incidence of pelvic infection questions the value of using prophylactic antibiotics. No increased risk of infection was demonstrated in cases with preexisting peritoneal damage.