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Cardiobacterium valvarum is a newly described HACEK ( Haemophilus spp., Aggregatibacter spp ., Cardiobacterium spp., Eikenella corrodens , and Kingella spp.) organism causing endocarditis. We report the second case of bioprosthetic aortic valve infective endocarditis, review the current literature, and investigate the phylogenetic relationships among clinical isolates of C. valvarum.

Conventional microscopy is the gold standard for malaria diagnosis. The CellaVision DM96 is a digital hematology analyzer that utilizes neural networks to locate, digitize, and preclassify leukocytes and characterize red blood cell morphology. This study compared the detection rates of Plasmodium and Babesia species on peripheral blood smears utilizing the CellaVision DM96 with the rates for a routine red blood cell morphology scan. A total of 281 slides were analyzed, consisting of 130 slides positive for Plasmodium or Babesia species and 151 negative controls. Slides were blinded, randomized, and analyzed by CellaVision and microscopy for red cell morphology scans. The technologists were blinded to prior identification results. The parasite detection rate was 73% (95/130) for CellaVision and 81% (105/130) for microscopy for positive samples. The interobserver agreement between CellaVision and microscopy was fair, as Cohen's kappa coefficient equaled 0.36. Pathologist review of CellaVision images identified an additional 15 slides with parasites, bringing the total number of detectable positive slides to 110 of 130 (85%). Plasmodium ovale had the lowest rate of detection at 56% (5 of 9); Plasmodium malariae and Babesia spp. had the highest rate of detection at 100% (3/3 and 6/6, respectively). The detection rate by CellaVision was 100% (23/23) when the parasitemia was ≥2.5%. The detection rate for

Background Current practices for ordering stool studies in patients with abdominal and gastrointestinal symptoms are not standardized. We hypothesized that an algorithm involving first-line use of a Cryptosporidium/Giardia combination antigen test and stricter use of ova and parasite (O&P) examinations would be clinically and cost effective. Methods In this study, stool O&P test results for pediatric patients in Dallas, Texas, were reviewed. All results obtained between 2009 and 2012 were included. Patient charts were reviewed to determine test results, symptoms, treatment, travel, and past medical history. Using these data, a retrospective modeling study was done to evaluate the utility of a diagnostic algorithm that limits O&P testing to those patients who are immunocompromised or have travelled outside the United States. Results Over the 3-year period of this study, we found that the prevalence of gastrointestinal parasitic disease in children was 1.9%. Analysis of the diagnostic algorithm for the judicious use of stool O&P showed that as much as 65% of testing may be unnecessary and could be eliminated. Conclusions Our findings show that the prevalence of pediatric gastrointestinal parasitic disease in Texas may be lower than expected. In addition, these data show that a diagnostic algorithm limiting O&P testing may be both clinically and cost effective in low-prevalence settings. However, such an algorithm would miss a significant number of infections due to Dientamoeba fragilis and Blastocystis hominis.

Many central nervous system infections are historically difficult to diagnose. Polymerase chain reaction (PCR) has revolutionized the diagnosis of these infections because of their high sensitivity despite the lack of data on clinical usefulness. We conducted a retrospective study that included patients with positive cerebrospinal fluid (CSF) PCR for herpes simplex virus, varicella-zoster virus, JC virus, cytomegalovirus (CMV), and Epstein-Barr virus (EBV) between January 2009 and December 2011. The positive results were grouped into definite, likely, and possible true positives and likely false-positive categories based on pre-specified definitions specific to each virus. Of 1663 CSF viral PCR tests, 88 were positive (5%). The combined positive predictive value (PPV) was 58%. The PPVs were least for CMV and EBV at 29 and 37%, respectively. A positive CSF viral PCR result has to be interpreted with caution due to several false-positive results.

Background Culture-directed antibiotic therapy remains imperative in the management paradigm of chronic rhinosinusitis (CRS). The objective of this study was to conduct a prospective, blinded comparison of endoscopically-guided swab and aspirate cultures from the same sinonasal site in patients presenting with acute infectious exacerbations post–sinus surgery. Methods Forty-nine CRS patients were prospectively enrolled in a tertiary care rhinology clinic. At the conclusion of the study, all cultures were unblinded to determine mean culture yield, most common pathogens, potential contaminants, and therapeutic correlation. Results The mean patient age was 49 years and 40.8% were males. All patients had evidence of symptomatic exacerbation with purulence on endoscopy at the time of presentation. There was a mean of 1.367 pathogens assayed per aspirate culture vs a mean of 1.102 per swab culture (p = 0.0032). The prevalence of Pseudomonas aeruginosa was 42% for aspirate vs 30% for swab cultures, respectively. The prevalence of Staphylococcus aureus was 49% for suction cultures vs 45% for swab cultures. There were 9 and 11 likely contaminants using aspirate and swab cultures, respectively. Therapeutic correlation was strong in 67%, moderate in 18%, and weak in 14% of patients. Conclusion This prospective analysis demonstrated higher culture yield, particularly with Pseudomonas, with aspirate vs swab cultures in postoperative patients. There is a strong clinical correlation between the 2 methods, and both aspirate and swab techniques serve as acceptable alternatives for endoscopic-guided cultures in patients with post–functional endoscopic sinus surgery infectious exacerbations.

Background Vancomycin-resistant Enterococcus faecium (VREfm) is commonly associated with hospital outbreaks and has been found to be associated with increased morbidity, mortality, length of stay, and health care costs. Methods We sought to investigate and control an outbreak of VREfm in the neonatal intensive care unit (NICU) of a public academic hospital with a level III NICU. The index case was an infant in the NICU incidentally identified with urinary colonization with VREfm. Aggressive control measures were initiated promptly. Investigation included active surveillance cultures in infants, parents of colonized infants, and birth mothers of newborn admitted to NICU; molecular strain typing of available isolates of VREfm including adult inpatients; and medical record review. Results After identification of index case, 13 additional infants were identified with VREfm colonization. Age at culture was 6 to 87 days; birth weight was 1,070 to 2,834 g. VREfm isolated from majority of infants (12/14 [85.7%]), the birth mother of a pair of colonized twins, and a pulse oximeter device used in adult inpatients belonged to a single strain. Outbreak control measures were successful in the NICU. The outbreak-causing strain was found to be endemic among adult inpatients. Adult patients with the outbreak-causing strain of VREfm were more likely to have received previous therapy with meropenem (Mann-Whitney 2-tailed P value = .038). VRE colonization was identified in 0.3% (1/310) of birth mothers with newborn admitted to NICU. Conclusion An endemic strain of VREfm among adult inpatients was responsible for a subsequently controlled outbreak in the NICU.

We present the case of a native Texan who was diagnosed with tuberculoid leprosy and later developed a cutaneous infection with M. haemophilum following iatrogenic immunosuppression. To our knowledge, there are no such reports of M. haemophilum and M. leprae infection occurring simultaneously in the same host.

Fascioliasis is a worldwide infection caused by the liver fluke, Fasciola hepatica. In the United States, fascioliasis is an uncommon infection and is mainly reported among the immigrant population. Fasciola hepatica infection comprises 2 distinct stages (hepatic and biliary) and manifests mainly as abdominal pain, elevated liver enzymes, and eosinophilia. Enzyme-linked immunosorbent assay (ELISA) testing is sensitive for both stages while stool exams for F. hepatica eggs are positive only in the biliary stage. Radiographic findings using computed tomography and ultrasonography are not specific but support the diagnosis. Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly used to diagnose F. hepatica and to remove the adult fluke from the biliary tree. Triclabendazole is currently the recommended drug for treating F. hepatica infection. The rarity of the disease in the United States can result in a delayed diagnosis and sometimes in mismanagement. Physicians should consider this infection in patients with abnormal liver function and peripheral eosinophilia, especially in the immigrant population.

1. What are this patient’s most striking clinical and laboratory findings? 2. What should be considered when evaluating a patient with travel-related fever? 3. How do you explain this patient’s most striking clinical and laboratory findings? 4. What additional laboratory tests should be ordered and why? 5. What is the patient’s most likely diagnosis? 6. Omitting dengue fever, what is the epidemiology, clinical presentation, and pathogenesis of the other condition that may have caused this patient’s travel-related illness? 7. What is an appropriate treatment and outcome for this patient? 8. Why should the United States be concerned about this relatively new pathogen?

1. What are this patient’s most striking clinical and laboratory findings? 2. How do you explain this patient’s most striking clinical and laboratory findings? 3. What is this patient’s most likely diagnosis? 4. What are the forms of presentation of this patient’s disease? 5. What laboratory methods are available for diagnosing this patient’s disease? 6. Why was fiberoptic bronchoscopy with collection of BALF performed on our patient? 7. What are other pulmonary infectious conditions that can occur in immunocompromised and HIV-infected individuals? 8. What are the measures to prevent infection with the pathogens that can cause infection in immunocompromised and HIV-infected individuals? 9. What is the most appropriate treatment of our patient’s disease?

Primary subcutaneous phaeohyphomycosis can rarely be caused by Cladophialophora bantiana, and we present the histologic and culture findings of such a case. A 32-year-old African American woman with systemic lupus erythematosus presented with a 2-year history of multiple, recurrent, tender, and ulcerated skin nodules with purulent drainage on her upper back. Histologic sections of the excision demonstrated features of phaeohyphomycosis. Culture findings were characteristic of C bantiana. Of interest, at age 10 she had sustained traumatic implantation of wood splinters into this area during a tornado, yet clinical symptoms of a subcutaneous infection did not manifest until she developed lupus erythematosus at age 27. Our case highlights the role of trauma and immunosuppression in the pathogenesis of subcutaneous phaeohyphomycosis.

The Food and Drug Administration (FDA) has approved the Hybrid Capture® II (HC II) assay to test for the presence of high-risk types of human papilloma virus (HPV) DNA using specimens in PreservCyt® fixative for up to 21 days after collection. The ability of HC II to determine the presence of HPV DNA in actual patient samples after longer periods of storage has not been shown. To determine if specimens older than 21 days can yield useful results, 207 patient specimens that had been tested for HPV DNA by HC II (primary test) were tested again after a significant period of storage ranging from approximately 2.5 to 13.5 mo (retest). The results of the primary test and the retest agreed in 86% of the cases. The high level of agreement in the results suggests that the presence of high-risk types of HPV DNA can be determined from actual cervical cytology material in PreservCyt® with the HC II assay for at least 3 mo after specimen collection. Diagn. Cytopathol. 2005;32:260–263. © 2005 Wiley-Liss, Inc.

1. What is (are) this patient’s most striking laboratory result(s)? 2. How do you explain this patient’s most striking laboratory result(s)? 3. Which additional laboratory test(s) is (are) paramount to the accurate diagnosis of this patient’s condition? 4. What is this patient’s most likely diagnosis? 5. What is the etiology of this patient’s disease? 6. What is the pathogenesis of this patient’s disease? 7. What are the principal complications found in this patient’s condition?

BACKGROUND Liquid-based ThinPrep technology has made reflex human papillomavirus (HPV) DNA testing possible. In the current study, the clinical performance of reflex HPV testing as an adjunct to routine ThinPrep testing (TPPT) and the impact of age on various test parameters in a predominantly high-risk, minority population were evaluated retrospectively. METHODS Reflex HPV testing was performed in 2114 women with atypical squamous cells of undetermined significance (ASCUS) and low-grade squamous intraepithelial lesion (LSIL) cytology, using probes for low-risk (LR) and high-risk (HR) HPV types. Six hundred thirty women underwent subsequent biopsies with which HPV testing results were correlated. RESULTS Approximately 86% of the patients were Hispanic and African-American and 12% were white. Of the younger women (ages 14–29 years), 81% were positive for HR types versus 50% in the older women (ages 30–77 years) (P < 0.0001). In women with ASCUS, 47% were found to be positive for HR types versus 78% of women with LSIL. The percentage of histologic high-grade lesions was 24% in younger patients versus 17% in older patients. Overall, 91% of high-grade lesions were positive for HPV DNA (HR-positive = 89% and LR-positive = 2%), and 9% were negative for both types. The sensitivities and specificities in “younger” versus “older” women were 92% (95% confidence interval [95% CI], 89–95%) and 22%% (95% CI, 17–26%), respectively, versus 84% (95% CI, 77–90%) and 59% (95% CI, 53–65%), respectively. CONCLUSIONS The results of the current study demonstrate that reflex HPV testing performed in a routine clinical practice helps to identify the majority of women with high-grade disease. However, testing may be more beneficial in older women (age ≥ 30 years) with ASCUS. Strategy using out-of-vial reflex testing is more cost-effective and sensitive than referring all women for colposcopies. Cancer (Cancer Cytopathol) 2003;99:149–55. © 2003 American Cancer Society.

Background. Our study aims to describe the epidemiology, microbial resistance patterns, and clinical outcomes of Acinetobacter infections at an academic university hospital. This retrospective study analyzed all inpatient clinical isolates of Acinetobacter collected at an academic medical center over 4 years. The data were obtained from an Academic tertiary referral center between January 2008 and December 2011. All consecutive inpatients during the study period who had a clinical culture positive for Acinetobacter were included in the study. Patients without medical records available for review or less than 18 years of age were excluded. Methods. Records were reviewed to determine source of isolation, risk factors for acquisition, drug resistance patterns, and clinical outcomes. Repetitive sequence-based polymerase chain reaction of selected banked isolates was used to determine patterns of clonal spread in and among institutions during periods of higher infection rates. Results. Four hundred eighty-seven clinical isolates of Acinetobacter were found in 212 patients (in 252 admissions). Patients with Acinetobacter infections were frequently admitted from healthcare facilities (HCFs) (59%). One hundred eighty-three of 248 (76%) initial isolates tested were resistant to meropenem. One hundred ninety-eight of 249 (79.5%) initial isolates were multidrug resistant (MDR). Factors associated with mortality included bacteremia (odds ratio [OR] = 1.93, P = .024), concomitant steroid use (OR = 2.87, P < .001), admission from a HCF (OR = 6.34, P = .004), and chronic obstructive pulmonary disease (OR = 3.17, P < .001). Conclusions. Acinetobacter isolates at our institution are frequently MDR and are more common among those who reside in HCFs. Our findings underline the need for new strategies to prevent and treat this pathogen, including stewardship efforts in long-term care settings.

Case Presentation A 9-year-old female with an unremarkable past medical history presented to a Tyler, Texas emergency department with a 7-day history of worsening frontal headache and bilateral lower extremity “aches.” During the previous 4 days she had also experienced a cough, nasal congestion, and rhinorrhea. Her condition rapidly progressed to include an increasingly severe headache, photophobia, nonbloody emesis, neck pain, fever (103.6°F), irritability, and disorientation along with episodes of verbal outbursts, purposeless movements, and eye rolling. The patient underwent a lumbar puncture, and cerebral spinal fluid was analyzed with the following results: glucose 71 mg/dL (Normal 40-70 mg/dL), protein 148 mg/dL (Normal 15-45 mg/dL), nucleated cells 1080 cell/μL consisting of 69% neutrophils, 25% lymphocytes, and 6% monocytes (Normal up to 20 lymphocytes/μL in children), red blood cells 126 cells/μL (Normal no RBCs). A presumed diagnosis of bacterial meningitis was made and ceftriaxone was started. The patient was transferred to Children’s Medical Center of Dallas where her medical condition continued to deteriorate. A head-computed tomography was performed and revealed no abnormalities. Upon further questioning it was discovered that the patient had been swimming in an eastern Texas lake shortly before the onset of symptoms. This increased the suspicion for primary amoebic meningoencephalitis (PAM). Empiric intrathecal amphotericin B and systemic rifampin was initiated. Subsequent wet mount analysis of the CSF revealed Naegleria fowleri trophozoites, the etiologic agent of PAM. The patient’s condition continued to worsen and she died several days later. Clinical Background Etiology of PAM Primary amoebic meningoencephalitis is a rapidly progressive disease that generally results in death within 7 to 10 days of symptom onset. The etiologic agent is the freeliving amoeba Naegleria fowleri. Infection occurs most commonly in young, healthy individuals following exposure to contaminated water sources. Inoculation occurs when contaminated water is forced into the nasal cavity. Access to the CNS is achieved by invasion into the olfactory neuroepithelium with subsequent penetration of the cribriform plate. Once in the CNS, the organisms colonize cerebral gray matter leading to a rapidly fatal meningoencephalitis. The genus Naegleria contains several species of which N fowleri is the only known human pathogen. These protozoa are found ubiquitously in the environment and are distributed worldwide. They can be found in warm, stagnant bodies of water, and even chlorinated swimming pools, making contact with humans inevitable. Etiology of Primary Amoebic Meningoencephalitis (PAM) Laboratory diagnosis of PAM The need for early detection of PAM Differentiating Naegleria fowleri from Acanthamoeba species Treatment and Prognosis

Many veterans who were involved in the Persian Gulf theater of operations have had a variety of unexplained physical complaints, collectively called the Gulf War syndrome or similar names. There has been much debate on the issue and numerous publications, both in the medical and the lay press. A method for examining urinary sediment that was developed in an effort to identify nonculturable bacteria has been used in Gulf War veterans and was the basis for intensive antimicrobial therapy in many of them.We evaluated eight Gulf War veterans with complaints compatible with Gulf War syndrome. Subjects were from various parts of the United States. A detailed history and physical examination were performed. Urine was obtained before and after prostatic massage (men) or before and after pelvic examinations (women) and was tested by a previously described microscopic method as well as by culture and conventional Gram stain. Age- and sex-matched healthy control subjects were tested similarly and concurrently.Two female Gulf War veterans had findings of Candida albicans and Klebsiella pneumoniae by conventional culture. The same organism types were seen both by the special method and by conventional Gram stain. All other subjects and controls were completely indistinguishable.Examining the urinary sediment by this elaborate method does not differentiate persons with Gulf War syndrome from normal, healthy control subjects who were never in the Persian Gulf area.

The Verigene Gram-positive blood culture (BC-GP) assay (Nanosphere, Northbrook, IL) is a molecular method for the rapid identification of Gram-positive organisms and resistance markers directly from blood culture bottles. A total of 148 VersaTREK REDOX 1 40-ml aerobic bottles demonstrating Gram-positive bacteria were tested. Results were compared with those from conventional biochemical and matrix-assisted laser desorption ionization–time of flight (MALDI-TOF) identifications. We obtained isolates of methicillin-resistant Staphylococcus aureus (MRSA) (24), methicillin-susceptible Staphylococcus aureus (MSSA) (14), methicillin-resistant Staphylococcus epidermidis (MRSE) (17), methicillin-susceptible Staphylococcus epidermidis (MSSE) (9), other coagulase-negative staphylococci (19), Streptococcus salivarius (5), Streptococcus parasanguinis (2), Streptococcus sanguinis (1), Streptococcus cristatus (1), the Streptococcus bovis group (5), Streptococcus agalactiae (9), the Streptococcus anginosus group (1), Streptococcus pneumoniae (6), vancomycin-resistant Enterococcus faecium (VRE FCM) (16), vancomycin-susceptible Enterococcus faecalis (3), Aerococcus viridans (2), Bacillus (6), Corynebacterium (8), Lactobacillus (2), Micrococcus (2), Neisseria mucosa (1), Escherichia coli (3), Candida tropicalis (1), Propionibacterium (1), and Rothia (1). Overall agreement with the culture results was 95%. A total of 137 of 138 (99%) monomicrobial cultures were concordant. We tested 9 polymicrobial samples and found 33% agreement. A chart review of 31 patients with MRSA, MSSA, or VRE demonstrated that the Nanosphere BC-GP assay might have led to more appropriate antibiotic selection for these patients an average of 42 h earlier. Additionally, contact isolation could have been initiated an average of 37 h earlier for patients with MRSA or VRE. The BC-GP assay may have a positive impact on patient care, health care costs, and antibiotic stewardship.

In 2012, Texas has reported the highest number of West Nile virus (WNV) cases in the United States to the Centers for Disease Control and Prevention. In this report, we conducted a retrospective chart review of 57 patients with WNV disease and analyzed the clinical features of these patients. Our results revealed that 25 (44%) patients were diagnosed with West Nile fever and 32 (56%) with West Nile neuroinvasive disease (WNND). The median age for patients with WNND was 54.5 years, and those with encephalitis were more likely to be >60 years old. Pre-existing conditions such as hypertension and diabetes were more frequent in patients with WNND. Testing both serum and cerebrospinal fluid (CSF) for antibodies diagnosed more cases of WNND than just testing serum or CSF alone. The increasing number of WNV cases during this epidemic highlights the need to increase efforts to control mosquito populations and educate the general public.

1. What are the most striking clinical and laboratory findings? 2. How do you explain the most striking findings? 3. What is the organism recovered from the patient’s stool? 4. What other organisms must be ruled out to make a definitive diagnosis? 5. What is this patient’s most likely diagnosis? 6. What is the major clinical concern with this diagnosis? 7. What is the most appropriate treatment for this patient?

From November 2011 through March 2012, we surveyed 272 babies in our neonatal intensive care unit for rectal colonization with vancomycin-resistant enterococci (VRE). Using Spectra VRE medium (Remel Diagnostics, Lenexa, KS), we identified one neonate colonized with vancomycin-resistant Enterococcus faecium . In addition, 55 (13%) of the surveillance cultures yielded false-positive results with vancomycin-susceptible Enterococcus faecalis . During the same time period, 580 rectal swabs were collected from adult patients resulting in 20 (3%) false-positive cultures. The difference in false-positive rates between cultures from babies and adults was statistically significant ( P < 0.001), prompting an investigation of factors that might influence the elevated false-positive rate in the neonates including patient demographics, nutrition, and topical ointments applied at the time of testing. Older neonates, with a median age of 6 weeks, were more likely to have false-positive cultures than younger neonates with a median age of 3 weeks ( P < 0.001). The younger neonates receiving Similac Expert Care products were less likely to have false-positive surveillance cultures than those receiving other formulas ( P < 0.001). Application of topical products was not associated with false-positive cultures. The false-positive E. faecalis strains were typed by Diversilab Rep-PCR (bioMérieux, Marcy l'Etoile, France) and found to represent eight different groups of isolates. The utility of the Spectra VRE media appeared to be significantly impacted by the age of the patients screened.

Cutaneous fusariosis is an opportunistic mycosis in immunocompromised patients. We present a novel variation of an immunocompromised patient who developed fusariosis in a previously irradiated site. Irradiation led to atrophy, contraction, fibrosis, barrier disruption, and an altered dermal environment in which the infection developed. Significantly, this is the first case report of fusariosis in a previously irradiated site of an immunocompromised patient. Treatment included debridement and voriconazole.

BACKGROUND: Fascioliasis is a common zoonotic infection worldwide, although cases in the United States are uncommon, sporadic, and predominantly found in the immigrant population. The small number of cases identified in the United States may reflect the unfamiliarity of physicians with this infection. CASE: A 28-year-old Hispanic woman who frequently visited northern Central Mexico presented at 36 weeks of gestation with nausea, vomiting, and right upper quadrant pain. She was diagnosed with cholelithiasis. Postpartum endoscopic retrograde cholangiopancreatography and sphincterotomy were performed, with discovery of the trematode Fasciola hepatica. The patient received triclabendazole, which led to clinical improvement. CONCLUSION: Fascioliasis often mimics another common problem in pregnancy, cholelithiasis; clinicians need to be aware of this disease in high-risk populations.

Ophthalmomyiasis externa is an uncommon condition in North America. If not recognized and managed accordingly, it can be complicated by the potentially fatal condition ophthalmomyiasis interna. Ophthalmomyiasis externa is mainly caused by the sheep bot fly Oestrus ovis; thus, it is more common in farming communities. We report a case of ophthalmomyiasis externa in a young woman from Dallas County, Texas, who had no known history of contact with farm animals.

A 77-year-old man presented to our hospital with a clinical scenario suspicious for endocarditis with septic emboli to the lungs and splenic abscess. Vibrio cholerae was isolated from purulent material aspirated from the abscess. Medical therapy and percutaneous drainage of the abscess were unsuccessful. The patient underwent splenectomy and distal pancreatectomy revealing a pancreatic tail carcinoma involving the spleen and colon. The patient later expired secondary to metastatic disease. This case represents the first isolation of V. cholerae from a splenic abscess but also illustrates that although newer imaging technologies have made the diagnosis of splenic abscess easier, the true etiology of the abscess may remain elusive.

Gen-Probe's DNA probes were evaluated for use in the identification of clinical isolates of Histoplasma capsulatum var. capsulatum and Cryptococcus neoformans. Ninety-five mould-phase fungi were probed, including 41 isolates of H. capsulatum var. capsulatum. Similarly, 98 yeasts, including 42 C. neoformans isolates, were examined by using the C. neoformans DNA probe. In the study, both probes demonstrated 100% specificity and 100% sensitivity. Their use in the clinical laboratory may significantly reduce the time required for definitive identification of fungi.

Prototheca wickerhamii is a rare cause of systemic infection in humans. While some cases occur in previously healthy individuals, others are associated with a variety of preexisting diseases. Here we present, for the first time, a case of P. wickerhamii algaemia in a patient with myasthenia gravis. The patient was successfully treated with amphotericin B.

Background Yersinia enterocolitica is frequently identified in cases of bacterial sepsis due to red cell transfusion. One of the features that makes Y. enterocolitica particularly dangerous is that, unlike most other bacterial contaminants of blood components, this organism can actively multiply in currently recommended refrigerator temperatures (1-6 degrees C). The effect of a colder than normal storage temperature on Y. enterocolitica growth was investigated to determine whether bacteria growth could be reduced or inhibited at 0 degree C. Study design and methods Twenty-four units of freshly collected donated blood were obtained. Three sets of 7 units each were inoculated with Y. enterocolitica O:3, Y. enterocolitica O:20, and Y. enterocolitica O:5, 27, respectively. The remaining 3 units served as uninoculated controls. Each of the 24 bags was split into two equal aliquots, with one aliquot stored at 4 degrees C and the other at 0 degree C. Bacteria growth was measured twice weekly for 6 weeks. Endotoxin and hemoglobin levels were also measured at selected intervals. Results Bacteria growth was detected earlier and in higher concentrations in the aliquots stored at 4 degrees C. Twenty-two of the 42 inoculated aliquots had measureable bacteria growth. Thirteen aliquots had been maintained at 4 degrees C, and nine had been stored at 0 degree C. Sixteen of these 22 aliquots were matched pairs. Exponential growth was detected after 14 to 32 days in the 4 degrees C aliquots and after 28 to 39 days in the 0 degree C aliquots. Final bacteria counts were much higher in the 4 degrees C aliquots (10(5)-10(14) colony-forming units/mL) than in the 0 degree C aliquots (10(1)-10(4) colony-forming units/mL) on Day 42. Endotoxin was present in all 13 of the 4 degrees C aliquots with actively growing Y. enterocolitica. Conclusion Storage of red cells at 0 degree C markedly prolongs the time required for Y. enterocolitica to achieve exponential grwoth and results in lower concentrations of bacteria.

This study examines the possibility of the family pet serving as a reservoir for group A beta-hemolytic streptococcal infections in humans. We obtained oropharyngeal cultures from children with acute pharyngitis and concurrent oropharyngeal cultures from their household pets. Children with culture-proved group A beta-hemolytic streptococcal pharyngitis were detected in 26 of 42 households surveyed. Oropharyngeal cultures were also collected from a group of children without pharyngitis and their pets. Additionally 149 dogs and cats from a local veterinary hospital were cultured from 371 body sites including the oropharynx, axilla and vagina. All beta-hemolytic bacterial isolates were identified by colonial and microscopic morphology, catalase and pyrrolidonylarylamidase production, bacitracin susceptibility and serogrouping. No group A beta-hemolytic streptococci were recovered from any of the body sites surveyed from a total of 230 animals. Based on these findings, the family pet seems to be an unlikely reservoir for group A beta-hemolytic streptococci.

Ophthalmomyiasis externa is an uncommon condition in North America. If not recognized and managed accordingly, it can be complicated by the potentially fatal condition ophthalmomyiasis interna. Ophthalmomyiasis externa is mainly caused by the sheep bot fly Oestrus ovis; thus, it is more common in farming communities. We report a case of ophthalmomyiasis externa in a young woman from Dallas County, Texas, who had no known history of contact with farm animals.

Apophysomyces elegans was isolated from the subcutaneous tissue, muscle and bone of a patient who had fallen from a height of 55 feet. Broad, sparsely septate hyphae were present in the tissue. Surgical debridement of wounds and amphotericin B treatment were not sufficient in controlling rapid tissue necrosis. Ultimately, amputation of the two affected limbs was necessary.

Perinatal acquisition of a rare pediatric pathogen, Achromobacter xylosoxidans, with evidence for in utero transmission, is described. Cultures from the mother and neonate demonstrated A. xylosoxidans. An ascending bacterial infection in the mother with clinical chorioamnionitis is presented as the probable mode of transmission. Postmortem examination of the infant confirmed Achromobacter meningitis. In contrast to the current case with transmission from mother to neonate, previously published neonatal cases of Achromobacter infections indicate that nosocomial transmission of the organism is most common (79%). In addition, the literature review revealed a high mortality associated with meningitis (77%), frequent hydrocephalus, and subsequent neurologic sequelae (36%). To the authors' knowledge, this is the first documented case of maternal-fetal transfer of A. xylosoxidans.

Primary subcutaneous phaeohyphomycosis can rarely be caused by Cladophialophora bantiana. Only two cases have been reported and we present the histologic and culture findings of another. A 32-year-old black female with systemic lupus erythematosus presented with a two-year history of multiple, recurrent, tender, ulcerated skin nodules with purulent drainage involving an area measuring approximately 27.0 × 15.0 cm on her upper back. She had been involved in a tornado at age 10 and had sustained traumatic implantation of wood splinters in this area. Sections of the excision showed scattered dark pinpoint foci with surrounding suppuration extending to the deep aspect of the specimen. Histology demonstrated features of phaeohyphomycosis – foci of granulomatous and acute inflammation with central clusters of dematiaceous fungal hyphae within a fibrotic dermis and subcutaneous tissue. Chains of brown-pigmented septate hyphae and unicellular conidia were identified. Culture revealed pigmented septate, branched hyphae and unbranched acropetal chains of conidia with no attachment hila. Dark gray, velvety colonies formed in one week on a potato dextrose agar plate incubated at 25 degrees Celsius. These culture features were characteristic of Cladophialophora bantiana. Despite surgical excision and itraconazole therapy, her skin lesions persisted for the next two years necessitating a re-excision.

A case is reported of relapsing fatal meningoencephalitis caused by a neurovirulent thymidine kinase-positive (TK+) type 2 herpes simplex virus (HSV) that developed thymidine kinase deficiency (TK-) during intravenous acyclovir therapy. A patient with AIDS was admitted for acyclovir treatment of a persistent perirectal herpetic ulcer. He subsequently developed meningoencephalitis. A TK+ type 2 HSV was isolated from a brain biopsy specimen. A progressive and fatal relapse occurred, and a TK- type 2 HSV was isolated from his cerebrospinal fluid. Restriction endonuclease analysis of viral DNA from perianal, brain, and cerebrospinal fluid isolates were similar, suggesting that they were the same viral strain. Animal virulence studies indicated significant cutaneous virulence in immunocompromised mice models for the TK- isolates. This case is notable because TK- HSV have, in the past, lacked neurovirulence and because acyclovir resistance developed during therapy and caused the patient's death.

The distribution of type 1 and P pili on individual cells of an O6 uropathogenic Escherichia coli strain, 6260, was determined immunologically with pilus-specific monoclonal antibodies by indirect immunofluorescence and immunogold electron microscopy. Variations in pilus expression under different culture conditions were monitored with an indirect immunofluorescence assay; 63% of piliated cells expressed type 1 pili when grown on agar at 37 degrees C versus 14 to 38% when grown in broth at 37 degrees C. In contrast, generally fewer cells with P pili (18 to 44%) were detected on agar than when grown in broth (up to 86%). Both type 1 and P pili were absent from cells cultured at 20 degrees C. Immunogold and immunofluorescence double labeling techniques with monoclonal antibodies 11-2 and 91-1 were used to study subpopulations of cells with type 1 and P pili; 39 to 41% of the piliated cells demonstrated only type 1 pili, and 12 to 16% of the cells showed only P pili. The immunogold method proved more sensitive than the immunofluorescence technique for detecting subpopulations expressing both pili types simultaneously, 19 versus 7%. We observed variations between type 1 and P pili, both in expression on individual cells and in the distribution of subpopulations of cells.

Multiple pilus types from a uropathogenic strain of Escherichia coli O6, strain 6260, were characterized by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), high-pressure liquid chromatography, binding assays, and erythrocyte adsorption. In addition, monoclonal antibodies were raised against purified pili of E. coli 6260 and used for immunological characterization. SDS-PAGE analysis of the purified pili showed at least three different subunits with molecular weights of 15,700, 17,800, and 19,300. SDS-PAGE analysis of four protein peaks from anion-exchange chromatography of intact pili showed polypeptides with molecular weights of 19,300 (fraction 1), 15,700 (fraction 2), and 17,800 and 15,700 (both fractions 3 and 4). Erythrocyte adsorption of the whole-pilus preparation removed the 17,800-molecular-weight subunit (17.8K subunit) and reduced the 15.7K subunit. Pili from an isogenic hemagglutination-negative variant of E. coli 6260, showing only the 15.7K and 19.3K subunits by SDS-PAGE, lacked the 17.8K subunit of fractions 3 and 4 present in the parent high-pressure liquid chromatography profile. Our data suggest that two of the pilus subunits, the 15.7K and 17.8K subunits, mediate mannose-resistant agglutination of human erythrocytes. Pili in fractions 1 and 2 from the parent strain bound specifically to mannose residues, while pili in fraction 4 bound to P-coated horse erythrocytes; no receptor specificity was identified for pili in fraction 3. Immunological analysis by the immunoblot technique showed that monoclonal antibody 11-2 reacted with the 19.3K subunit, monoclonal antibodies 34-3 and 73-3 reacted with the 15.7K subunit, and monoclonal antibodies 81-1, 82-1, and 91-1 reacted with polymers of subunits retained in the stacking gel. Intact pili precipitated by any of the six monoclonal antibodies showed two polypeptides by SDS-PAGE: 15.7K and 19.3K polypeptides for monoclonal antibody 11-2, and 15.7K and 17.8K polypeptides for monoclonal antibodies 34-3, 73-3, 81-1, 82-1, and 91-1. The cross-reactivity of the monoclonal antibodies with purified pili from other E. coli strains was determined by enzyme-linked immunosorbent assay. Monoclonal antibody 11-2 showed no significant cross-reactivity with heterogeneous pili. In contrast, the other monoclonal antibodies showed equivalent or greater reactivity with P pili from heterologous strains as compared with reactivity with E. coli 6260 pili.(ABSTRACT TRUNCATED AT 400 WORDS)

Adhesions of 211 strains of uropathogenic Escherichia coli and 19 strains of normal fecal E. coli were characterized by patterns of agglutination with human erythrocytes, Saccharomyces cerevisiae, and horse erythrocytes coated with the P blood-group receptor (P). Mannose-resistant (MR) hemagglutination was significantly associated with P agglutination (P less than .001). E. coli expressing MR and/or P (MR/P) agglutinins concurrently with mannose-sensitive (MS) agglutinins predominated in all clinical categories. The highest percentage of E. coli demonstrating MR/P agglutinins, in the absence of MS agglutinins, was recovered from patients with acute pyelonephritis (35%) compared with percentages of patients with chronic pyelonephritis (13%), asymptomatic bacteriuria (16%), cystitis (11%), and normal fecal control E. coli (11%). Sixty-nine percent of E. coli isolates causing acute pyelonephritis agglutinated P-coated horse erythrocytes compared with only 11% of the fecal isolates. Strains expressing MR/P agglutinins (in the absence of MS agglutinins) isolated from patients with acute pyelonephritis, chronic pyelonephritis, and asymptomatic bacteriuria were significantly associated with the presence of antibody-coated bacteria in patients' urine sediments (P less than .010), an observation indicative of an immune response associated with bacterial invasion of host tissues.

With the increased use of antibiotics in urinary tract infections, the appearance of resistant organisms. We demonstrated transfer of an R-factor in vitro at a transfer frequency rate of 0.5 to 1.0 × 10−7 and in vivo rate of 5 × 10−2. When urine was used instead of nutrient broth as the medium for in vitro transfer, recombinants were not recovered. Transfer of R-plasmids between place in the intestine and possibly elsewhere, depending on a number of factors. This mechanism is thought to be responsible for hospital and community outbreaks of infections with resistant organisms. We demonstrated transfer of an R-factor in vitro at a transfer frequency rate of 0.5 to 1.0 × 10−7 and in vivo rate of 5 × 10−2. When urine was used instead of nutrient broth as the medium for in vitro transfer, recombinants were not recovered. Transfer of R-plasmids between bacterial strains is thought to be the primary mechanism by which antibiotic resistance has flourished in bacterial populations and the finding of trans...

The monofunctional quinacrine mustard ICR-170 (2-methoxy-6-chloro-9-(3-[ethyl-2-chloroethyl] aminopropylamino) acridine dihydrochloride) has been observed to induce temperature-sensitive recessive sex-linked mutations in Drosophila melanogaster. Out of a total of 122 lethals recovered, five proved to be heat sensitive, one heat and cold sensitive, and one cold sensitive. This observation, plus the recovery of some leaky temperature-sensitive mutations, indicates that in Drosophila melanogaster ICR-170 may function by inducing some base-pair substitution mutations, probably by action of its alkylating nitrogen mustard moiety.

Twenty clinical isolates of Vibrio vulnificus were compared with 10 environmental strains by using electron microscopy and agglutination assays with human erythrocytes, guinea pig erythrocytes, and Saccharomyces cerevisiae. In addition, the isolates were tested for ability to adhere to the human epithelial cell lines HEp-2 and A549. When examined by electron microscopy, 16 (80%) of the 20 clinical isolates demonstrated the presence of piluslike structures; the composition of the bacterial populations ranged from 0 to 68% piliated cells. In contrast, only 3 (30%) of the 10 environmental isolates were piliated, with a range from 0 to 16% piliated cells. A significant association between the presence of piliated cells and the isolate source was found (P less than 0.05). None of the 30 strains agglutinated erythrocytes or yeast cells. V. vulnificus adherence results obtained with HEp-2 cells showed 10 (50%) of 20 clinical isolates and 0 (0%) of 10 environmental isolates with averages of greater than 10 adherent bacteria per cell, demonstrating a correlation between attachment and the isolate source (P less than 0.05). Selected strains were tested to determine whether methyl alpha-D-mannopyranoside, fructose, or alpha-L-(-)-fucose would inhibit bacterial adherence to HEp-2 cells. Multiple patterns of adherence inhibition were observed. Adherence to A549 cells showed 8 (40%) of 20 clinical isolates and 0 (0%) of 10 environmental strains with averages of greater than 10 adherent bacteria per cell. A statistical association between attachment and the isolate source was demonstrated (P less than 0.05). These data suggest that the presence of piluslike structures and the ability to adhere to human epithelial cell lines may be more closely associated with V. vulnificus isolates from clinical specimens than with environmental strains.

Persistent shigellosis, due to Shigellaflexneri resistant to multiple antibiotics, developed in a 40-yr-old homosexual man with human immunodeficiency virus infection. The Shigella strain demonstrated resistance to ampicillin, tetracycline, and trimethoprim-sulfamethoxazole. Although Shigellaflexneri isolates resistant to trimethoprim-sulfamethoxazole are uncommon in the United States, laboratories should monitor resistance patterns through routine in vitro susceptibility testing.

Conventional culture tubes were used in a modification of the spin-amplified adsorption procedure for recovery of herpes simplex virus (HSV) from clinical specimens. The sensitivity of isolation of HSV from 864 specimens adsorbed by the spin-amplified method was 100% (127 of 127), compared with 88.2% (112 of 127) for stationary-phase-adsorbed specimens. Cytopathic effect developed more rapidly in 32.1% (36 of 112) of isolates adsorbed by spin amplification than in those adsorbed by stationary means. In a separate quantitative study, cultures of HSV type 1 adsorbed by spin amplification yielded higher antigen levels and greater cytopathic effect than stationary-phase-adsorbed cultures. Cells grown in conventional tissue culture tubes may be used in a spin-amplified adsorption for rapid detection and increased sensitivity of HSV isolation.