Search

We initiated a therapeutic program of continuous ambulatory peritoneal dialysis for patients with chronic renal failure. Our program resulted in many episodes of peritonitis arising from contamination due to the technical aspects of the procedure. Microbiologic evaluation showed that 73% of 97 episodes were culture positive, with gram-positive organisms causing most of the cases, especially early in dialysis. Gram-negative rods tended to occur later. Gram stains of dialysate effluent resulted in a disappointingly low yield of only 9% positivity. Cell counts were a dependable indicator of the presence of peritoneal inflammation and also of therapeutic success. Most patients responded well to intraperitoneal cephalothin, 125 mg/L for 10 to 14 d. The occurrence of peritonitis resulted in 0.93 years of hospitalization during the total of 15.45 patient-years on dialysis, which essentially negated the financial advantages of this method of treatment of chronic renal failure. For this to be a successful mode of therapy, advances in the prevention of peritonitis must be made. [ABSTRACT FROM AUTHOR]

Expansion of activated T cells expressing the T-cell receptor (TCR) gamma/delta, CD45RO, and HLA-DR antigens is a prominent feature of acute infection with Ehrlichia chaffeensis in humans. The fate of these activated cells and the resolution of the gamma/delta T-cell response with return to the usual alpha/beta T-cell populations in this disease are not clearly understood. At a morphologic level, apoptotic cells are present in the peripheral blood during the acute and resolution phases of the infection. Simple culture of density gradient-separated lymphocytes from the blood of patients with acute ehrlichiosis produced cell death rapidly in the media compared to alpha/beta T cells. This loss of viability after incubation was apparently mediated by apoptosis, based on flow cytometric and morphologic analyses. The results suggest that most primed (CD45RO+) and activated (HLA-DR+) gamma/delta T cells in acute ehrlichiosis might be subject to removal from the body by programmed or apoptotic cell death.

Esophageal involvement with histoplasmosis is uncommon, but has been recognized in two clinical settings. Most commonly, the esophagus becomes involved as a result of contiguous mediastinal lymphadenopathy. Such patients usually present with dysphagia secondary to midesophageal compression or stricture. The esophagus can also be involved in cases of disseminated histoplasmosis. Esophageal ulcers or nodular lesions are the usual clinical manifestations in this setting. We report a case of mediastinal histoplasmosis with esophageal narrowing and mucosal ulceration that presented with dysphagia. The diagnosis was established at thoracotomy by the histologic finding of necrotizing granulomas and a positive fungal stain. The case was successfully treated with amphotericin B. The literature on esophageal and gastrointestinal histoplasmosis is reviewed.

The majority of T cells in peripheral blood express a T-cell receptor (TCR) comprised of alpha and beta chains. An alternate form of the TCR is comprised of gamma and delta chains. These gamma/delta T cells are associated with certain infectious lesions, and modestly elevated in peripheral blood in certain disease states. Human ehrlichiosis is characterized by hematologic abnormalities including multi-lineage cytopenias. In most cases reported, a lymphocytopenia has been present either at diagnosis, or at some time during the illness. Early in the course of antibiotic treatment (48-72 hours), the lymphocytopenia corrects itself and is rapidly followed by a lymphocytosis of T cells that express CD3, but are negative for CD4 and CD8, as well as the major form of the TCR formed by the alpha/beta heterodimer. Instead, these CD3+4-8- T cells express the gamma/delta heterodimer associated with V gamma 9 and V delta 2 chains, a population of cells usually the distinctive minority of peripheral blood T cells, but constituting the major phenotype of peripheral gamma/delta T cells.

Objective: To identify and prospectively follow patients with suspected human ehrlichiosis regarding clinical manifestations, laboratory variables, methods for confirming the diagnosis, and complications., Design: Prospective case study., Setting: University and Veterans Affairs hospital and clinics., Patients: Observations in 30 adult patients with acute febrile illness or with unexplained fevers and cytopenias or abnormal liver profiles or both., Measurements: Serial clinical examinations, hematologic profiles, liver profiles, electrolyte determinations, chest radiographs, and response to therapy; other studies appropriate for patient care., Intervention: Therapy with doxycycline., Results: Thirty cases of ehrlichiosis were identified between 1989 and 1992. Tick exposure was strongly associated with the illness (P = 0.0001). Symptoms were nonspecific; fever, chills, and headache predominated but many other symptoms also occurred. Fever and skin rashes with various morphologic characteristics were the most common physical findings. Laboratory investigations indicate that the hematologic, hepatic, and central nervous systems are commonly involved in human ehrlichiosis. Twenty of 23 patients (87%) tested by the polymerase chain reaction using Ehrlichia chaffeensis sequences and whole blood samples were positive for E. chaffeensis., Conclusions: The syndrome of human ehrlichiosis is not commonly recognized by physicians. Ehrlichiosis should be considered in the differential diagnosis of patients with febrile illness after known or possible tick exposure, particularly if accompanying cytopenias or abnormal liver profiles or both are present. The therapeutic response to doxycycline is prompt, and complications are uncommon in promptly treated patients. The polymerase chain reaction applied to whole blood samples is a promising test for rapid confirmation of the diagnosis within 24 to 48 hours.

In conclusion, the recommendations provided in this document represent a distillation of various experiences, as well as data obtained from published studies. It is hoped that this compilation will provide a basis upon which future developments and advances can be made in the therapeutic approach to infectious complications of peritoneal dialysis.

Both direct and indirect techniques are available for the detection of gastric infections due to Campylobacter pylori. These techniques vary in their degree of efficacy, invasiveness, and convenience. They fall into five major categories, based on either the particular characteristic of the C. pylori organism or the manifestation of the C. pylori infection that they detect. The five categories include histologic examination of culture biopsy specimens, serologic examination, rapid urease tests, and carbon isotype breath tests. The observed efficacies of the techniques for detection of C. pylori are influenced by the standard with which they are compared. At present, the best candidate for the "gold standard" appears to be histologic detection by examination of multiple mucosal biopsy specimens.

The antimicrobial therapy of systemic salmonella infections is presently limited to ampicillin, chloramphenicol, and sulfamethoxazole and trimethoprim. Infrequently, alternative therapy may be necessary. We report the successful treatment of a case of Salmonella vertebral osteomyelitis with cefotaxime sodium.

The in vitro bactericidal activity of certain antimicrobials, especially aminoglycosides, is markedly diminished at an acid pH. In an attempt to correlate this factor with the poor response of gram-negative bacillary pneumonia to aminoglycoside therapy, the endobronchial pH of selected groups of subjects was measured via a bronchoscopically directed pH electrode. The average peripheral, i.e., subsegmental, endobronchial pH of normal persons, patients with chronic lung disease, and patients with pneumonia was 6.58 +/- 0.06, 6.62 +/- 0.10, and 6.61 +/- 0.06, respectively. The average central airway, i.e., major bronchi or tracheal, pH at 6.64 +/- 0.07 did not vary significantly from that of peripheral airways. The presence of pneumonia in individual bronchi was associated with a significantly lower pH than that in noninfected bronchi: 6.48 +/- 0.12 versus 6.69 +/- 0.13 (p less than 0.05). This relatively acid environment appears exaggerated within pneumonic airways and may contribute toward decreasing the effectiveness of aminoglycosides and certain other antimicrobials used in treating lung infection.

A case of lymphocutaneous sporotrichosis was thought to represent bacterial pyoderma. Lack of recognition led to excessive costs and a delay in the institution of specific therapy. The differential and an approach to diagnosis of pus-containing nodules are discussed.

In five patients, peritonitis caused by uncommon agents was acquired during continuous ambulatory peritoneal dialysis. Three patients had yeast (two Candida albicans, one C parapsilosis), one Aspergillus fumigatus, and one Nocardia asteroides infections. A review of the literature indicates that yeasts are the most common cause of peritoneal dialysis-associated fungal peritonitis; only one other possible case of Aspergillus sp and no Nocardia infections have been proved, to our knowledge. Observations are recorded in reference to diagnosis and suggested methods of treatment.

Transient, usually asymptomatic bacteremia occurs in a wide variety of procedures and manipulations, particularly those associated with mucous membrane trauma. It may also occur with such daily functions as tooth brushing and bowel movements. These brief bacteremias are especially common in tooth extraction and other dental procedures. Although numerical risk is uncertain, these bacteremias can occasionally give rise to infective endocarditis in the susceptible patient. While no proof exists that antibiotics given prior to procedures causing bacteremia prevent endocarditis in humans, experimental evidence in rabbits supports their use. Therefore, in situations where bacteremia is highly predictable, it would seem wise to administer prophylactic antimicrobials. Procedures in the susceptible host where prophylactic antibiotics seem prudent include dental manipulations and urinary tract instrumentation. Whether patients with acquired valvular or congenital heart disease who are to undergo abdominal surgical procedures should routinely receive prophylactic antibiotics is unclear. However, until the incidence of transient bacteremia associated with various abdominal procedures is further defined, endocarditis-prone patients should probably receive prophylaxis. Furthermore, patients with prosthetic valves who are subjected to upper gastrointestinal endoscopy, sigmoidoscopy, liver biopsy, or barium enema should also probably have antibiotic pretreatment. For dental procedures and for upper gastrointestinal endoscopy in patients with prosthetic valves, a combination of penicillin and streptomycin or vancomycin alone is recommended. For urinary tract instrumentation in all patients and for sigmoidoscopy, liver biopsy, or barium enema in patients with prosthetic valves, prophylaxis should be with ampicillin and gentamicin or vancomycin and gentamicin.

We present a patient with an acute amebic liver abscess with nonreactive serologic tests. Motile hematophagous trophozoites of Entamoeba histolytica were seen microscopically in scrapings from the wall of the abscess. Postoperative serologies revealed rapidly rising then falling titers by SAFA and IHA antibody assays. Serologic tests for amebiasis may be reative in greater than 95% of patients with invasive amebiasis. Nevertheless, a reactive serologic test should not be relied upon exclusively to establish the diagnosis. Sequential serologic testing and surgical intervention to obtain material for microscopic examination, gram stain and bacteriologic culture are warranted in patients with hepatic abscess and nonreactive serologic tests for antibodies to E. histolytica.

Two patients receiving preoperative carbenicillin manifested platelet dysfunction and severe wound hemorrhage. Platelet transfusions appeared beneficial. Investigations indicate that hemostatic abnormalities, especially platelet aggregation defects, may be produced by carbenicillin. Extreme caution and awareness of possible hemorrhage are advised when carbenicillin is used preoperatively.

Patients infected with Histoplasma capsulatum exhibit protean clinical manifestations and similarly express variable humoral immune responses. Therefore, the specific goals of this study were to more clearly define host immune responses by determining the concentrations of total and H. capsulatum-specific immunoglobulins in sera from patients with acute or chronic pulmonary and disseminated histoplasmosis. H. capsulatum-specific (AS) IgG, IgA and IgM, and total IgE were determined by radioimmunoassays while total IgG, IgA, and IgM were quantitated by laser nephelometry. In general, total IgG and IgA were elevated, while IgM and IgE were either decreased or normal for the three clinical forms of histoplasmosis studies. Antigen-specific IgG and IgA were markedly elevated in all classes of disease, whereas AS-IgM was only slightly increased. Total and AS-IgG were elevated in the sera of chronic patients directly proportional to the number of demonstrable precipitin bands.

A prospective study of the risk of bacteremia in 84 women having insertion and in 16 women having removal of intrauterine devices was performed. Bacteremia was not found in any of these 100 women at 1 to 3, 15, or 30 minutes after the procedure or in any of 57 women studied again 1.5 hours later. Because of the remote risk of bacteremia, the presence of congenital or valvular heart disease need not be an absolute contraindication to the use of an intrauterine device for contraception in an otherwise healthy young woman. Prophylactic antimicrobial therapy during insertion or removal of an intrauterine device appears to be unnecessary in the absence of evident pelvic infections. The risk of bacteremia during removal of an intrauterine device from an infected uterus cannot be determined from this study.