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Anti-fungal agents are classified under two major headings, systematic and topical agents. Only systematic anti-fungal agents will be discussed in this chapter. Since the discovery in 1955, amphotericin B has been the cornerstone of anti-fungal treatment. It is active against most species of fungi. However, Candida lusitaniae, Pseudallescheria boydii, and fusarium spp have primary resistance to amphotericin B. Recently, new liposomal preparations of amphotericin B have been developed. They are less nephrotoxic. The azole family of anti-fungal includes two broad classes: the imidazoles (clotrimazote, ketoconazote, miconazole) and the triazoles (flucouazole and itracouazole). Imidazoles are still widely used for the treatment of superficial mycoses and vaginal candidiasis. The systematic triazoles are more slowly metabolized and have less effect on human synthesis than imidazoles, hence they are preferred for systemic therapy. Flucytosine is a fluorinated pyrimidine. Clinically, the principal use of flucytosine is as adjunctive therapy with amphotericin B in the treatment of candidial or cryptococcal diseases, Griseofuluin is derived from penicillium. It is fungistatic in vitro for species of dermatophytes. It is useful for the treatment of tinea capitis and tinea unginum. [ABSTRACT FROM AUTHOR]

Varicella-zoster virus can cause neurological disease in primary and reactivated latent forms, with a wide spectrum of disorders throughout a person's lifetime. 35-year-old male with AIDS; histoplasmosis; mild, intermittent asthma; and hypertension presented to hospital with left-sided weakness and slurred speech. Exam showed left hemiparesis with left upper motor neurons facial palsy and dysarthria. Acute right basal ganglia infarct was detected in head CT without contrast. A subsequent MRI showed acute non-hemorrhagic infarct, right basal ganglia; fusiform dilatation, and proximal right middle cerebral artery. A CT angiogram of the bilateral carotid arteries revealed occlusion of the right anterior cerebral artery with conical dilatation at the origin; significant stenosis, and dilatation of the right middle cerebral artery. These findings were consistent with vasculitis. Patient was successfully treated with IV acyclovir. Rapid diagnosis of VZV vasculopathy is important because it is a treatable cause of stroke. Mortality rate is 25% without treatment.

Pyomyositis, an endemic disease of tropical origin, is increasingly reported in temperate zones, especially in patients with diabetes mellitus and in the immunocompromised. A 28-year-old renal transplant recipient presented with perforating skin lesions (Kyrle's disease), thigh pain, and swelling associated with fever. A gallium scan of the thigh led to surgical exploration and a diagnosis of pyomyositis. To our knowledge, the association of Kyrle's disease with pyomyositis has not been reported before. The significance of this combination of conditions in our patient remains unexplained.

Disseminated histoplasmosis is a serious opportunistic infection in patients with the acquired immunodeficiency syndrome (AIDS), often seen as the first manifestation of the syndrome. However, cases are reported almost exclusively from patients who live in or have traveled to endemic areas. We describe a case of disseminated histoplasmosis in a black woman with a 50-lb weight loss and marked weakness that occurred over a 6-month period. This case is one of the few in which disseminated histoplasmosis occurred as the first manifestation of AIDS in a patient in a nonendemic area. We believe it to be the first case reported in Michigan in which the patient has no history of prior residence in an endemic area. Disseminated histoplasmosis should be suspected in patients with AIDS and unexplained febrile illness, even in nonendemic areas.

Disseminated toxoplasmosis in AIDS is a rare condition. We present an unusual case of a fulminant form of disseminated toxoplasmosis in a young male homosexual. He was a 30-year-old HIV-positive (diagnosed 4 months earlier), admitted with a 5-day history of diarrhea, vomiting, fever, and cough. He had been generally healthy except for an 8-week history of weight loss and malaise. On admission, except for a temperature of 37.6 degrees C, the physical examination was normal. He was treated symptomatically. Four days after admission he suddenly became short of breath. Despite intensive management, he continued to deteriorate and expired 6 h later. Postmortem examination revealed disseminated toxoplasmosis involving the heart, lungs, brain, stomach, small intestine, and colon. This is an unusual presentation of disseminated toxoplasmosis because of its rapid course with no prior indication of infection. To our knowledge, such an atypical and rapid downhill course of toxoplasmosis (with minimal clinical and laboratory features) has not been reported previously. Increased awareness of this infection in all HIV patients and its possibly rapid course is needed.

We report three cases of group B streptococcal endocarditis of the tricuspid valve. Two patients were intravenous drug abusers. In the literature review, and including our cases, ten patients had group B streptococcal endocarditis of the tricuspid valve. Half of the patients were intravenous drug abusers. Four of the other patients had underlying conditions. All patients were treated with a penicillin with or without an aminoglycoside. Three patients underwent tricuspid valve surgery. The overall mortality was 20 percent. Both patients who died received medical therapy only.

Altered sleep patterns, including changes in bedtime, sleep latency, total sleep time, and arising time, have been reported to occur with increasing age. We examine self-reported sleep patterns in a geographically-defined population (n = 3097) of persons aged 65 years and older. Sleep patterns were characterized according to demographic variables, clinical conditions, and physical, psychological, and social functioning. Sleep latency and total hours of sleep increased with age, and older respondents went to bed earlier. The percentage of respondents who reported feeling rested in the morning decreased with age. Women went to bed later, had longer sleep latency, and fewer hours of sleep than men, and were less likely to report feeling rested than men. Sleep patterns were also related to educational attainment, self-perceived health status, physical functional status, psychotropic drug use, alcohol use, depressive symptoms, life satisfaction, and social and recreational activity level. This population study suggests that sleep problems among the elderly are sometimes associated with treatable health conditions and modifiable behavioral and environmental characteristics.

One thousand six surgical patients admitted between April 1983 and January 1984 to a hospital in Addis Ababa were studied for incidence of nosocomial infections. On admission, they were carefully examined clinically to exclude community-acquired infections and to determine any underlying risk factors. All patients were closely followed up for detection of developing nosocomial infections. Specimens collected from patients with clinically diagnosed bacterial infections were processed for culture; isolates were identified and tested for susceptibility to the locally used antimicrobial agents. Nosocomial infections were detected in 165 (16.4%) patients. Wound (59%), urinary tract (26%), and respiratory tract (6%) infections accounted for more than 90% of the infections. Fourteen of 18 deaths were attributed to nosocomial infections. About 72% of the patients were given prophylaxis, which was associated with infection (p less than 0.0005). Operations and other procedures were also associated with infection (p less than 0.0005). Anemia was found as a host risk factor (p less than 0.0005). Approximately 90% of the nosocomial pathogens were gram-negative bacteria, of which 84% were Enterobacteriaceae. They were mostly resistant to the commonly used antibiotics. Our findings should create awareness of the problem in this hospital and possibly in others in Addis Ababa and hence prompt measures for effective control.

Pneumococcal pneumonia in two or more lobes in frail, elderly patients; staphylococcal and Gram-negative rod pneumonia in patients of any age; lung abscesses; septicemia; endocarditis; peritonitis; and meningitis are life-threatening infections. To save patients with these infections, the physician should know the causative organism and educate himself by cultures; estimate the whole body bacterial burden and decrease bacterial numbers by incision and drainage where large collections of pus are accessible; choose antibiotics with care and use two antibiotics if serious prognostic signs are present initially, if there is a change for the worse, or if the laboratory report indicates that multiple organisms are present; check the serum bactericidal level and repeat this test if the route of antibiotic administration is changed; watch for and treat underlying disease; and always monitor for septic shock. Aged patients need special care, as they often have severe underlying disease. The bacterial burden is often high before infection is recognized in elderly patients, and age itself interferes with host defenses.

Patients admitted to a teaching hospital in Addis Ababa were studied for nosocomial infection. Of 2506 patients, 13% developed clinical infections, with the highest rate among obstetric/gynaecologic patients (17.0%). Wound infection was the most frequent type of nosocomial infection (49%) followed by urinary tract infection (25%). Antibiotic prophylaxis was given to 43% of the patients. Gram-negative bacteria comprised 88% of all isolated strains Enterobacteriaceae; 75% of all isolates were found in over 60% of the infection, Proteus 25%, Escherichia coli 20% and Klebsiella 19%. The most widely used antibiotics were ineffective against 65 to 85% of the Gram-negative strains. Cefotaxime and gentamicin were more effective. Staphylococcus aureus isolates were also similarly resistant, against which cephalothin, lincomycin and gentamicin were the more effective ones. Over 70% of the strains were multiple resistant. The findings underscore the need for a surveillance program and infection control system to reduce the high rate of infection and to institute appropriate guidelines for the use of prophylactic and therapeutic antibiotics.

Seven hundred patients admitted to the wards of the Department of Obstetrics/Gynaecology of Tikur Anbessa Hospital, Addis Ababa, between January and July 1984 were studied for the incidence of nosocomial infections. The overall hospital infection rate was 17.0%, with wound infection at 47% followed by urinary-tract infection at 15%. Over 80% of the bacterial isolates were Gram-negative bacteria, the majority of which were multiply resistant to the commonly used antibacterial drugs. Some hospital risk factors have been identified. The findings are discussed in the light of reports on nosocomial infections from hospitals of developed countries.

Three rapid diagnostic methods for the detection of bacterial antigen-COA (Coagglutination), LA (latex agglutination) and IEOP (immunoelectroosmophoresis); DM (direct microscopy after Gram staining) and culture of cerebrospinal fluid (CSF) have been compared in 53 bacterial meningitis patients and in 13 controls. Urine samples were assayed for antigens in connection with CSF in 32 for COA, LA, and IEOP. The cause of meningitis was S. pneumoniae in 31, H. influenzae type b in 16 and N. meningitidis in 6 using the methods for diagnosis by LA in 100%, COA in 94%, culture in 89%, IEOP in 81% and DM in 78% of the CSF samples. None of the CSF from controls were positive by any of the methods. LA and COA detected antigen in CSF in all 4 patients on 4th and 5th day of treatment but none of the tests were helpful 7-10 days later. LA was effective in detecting antigen in urine in 10/10 (100%) H. influenzae type b, 17/20 (85%) S. pneumoniae prior to antibiotic treatment. IEOP was helpful in antigen detection better in serum than in urine in 5/6 H. influenzae type b and 9/11 S. pneumoniae meningitis. In general we have found LA and COA as simple, rapid specific and sensitive tests and can be applied even in field situations and that LA can be used for antigen detection in urine and IEOP in serum. A large scale study is needed in order to standardize methods for antigen detection in serum and urine.