Aaron E. Glatt

Hiv prevalence, immunosuppression, and drug resistance in patients with tuberculosis in an area endemic for Aids

From October 1987 to June 1988, we attempted to determine the prevalence of HIV infection among patients hospitalized with tuberculosis and the extent of immunosuppression among those tuberculosis patients infected with HIV. Of 178 consecutive patients, 18–65 years of age, who were hospitalized with newly diagnosed, previously untreated tuberculosis, 46% (82 out of 178) had clinical or serological evidence of HIV infection, 30% (54 out of 178) were HIV-seronegative, and 24% (42 out of 178) could not be assessed for the presence of HIV infection. Among the HIV-seropositive patients without an AIDS-defining diagnosis by non-tuberculous criteria, the median CD4 lymphocyte (CD4) count was 133 ± 106 cells/l (range: 11–677 ± 106); among the HIV-seronegative patients, the median CD4 count was 613 ± 106 cells/l (range: 238–1614 ± 106; P < 0.001). Among the HIV-seropositive patients, those with disseminated tuberculosis (median CD4 = 79 ± 106 cells/l) and those with pulmonary tuberculosis who had radiographic evidence of mediastinal or hilar adenopathy (median CD4 = 45 ± 106 cells/l) had the most severe CD4 depletion, whereas those with localized extrapulmonary tuberculosis (median CD4 = 242 ± 106 cells/l) and those with pulmonary tuberculosis without adenopathy (median CD4 = 299 ± 106 cells/l) were less severely immunosuppressed. Of the 178 patients, 6% (11 out of 178) were infected with strains of Mycobacterium tuberculosis resistant to both isoniazid and rifampin.

Salmonella osteomyelitis and arthritis in sickle cell disease.

Salmonellosis is one of the most frequent serious infections in sickle cell patients and remains a significant cause of morbidity and mortality in this population. Capillary occlusion secondary to intravascular sickling may devitalize and infarct the gut, permitting Salmonella invasion. Reduced function of the liver and spleen, together with interference with reticuloendothelial system function due to erythrophagocytosis, suppresses clearing of these organisms from the blood stream. Abnormal opsonizing and complement function probably also play a role. The expanded bone marrow with sluggish flow leads to an ischemic focus for salmonella localization. The majority of Salmonella infections in sickle cell patients involve bones (especially long bones) and joints and occur most frequently in early childhood. Multiple sites, often symmetrical, are usually involved. It is imperative to distinguish Salmonella osteomyelitis from bone infarctions. While clinical and hematologic data may be suggestive, radionuclide bone imaging studies, particularly combined technetium and gallium scintigraphy and technetium sulphur colloid bone marrow scans, and magnetic resonance imaging appear more sensitive and specific. Salmonella osteomyelitis is best managed medically. Chloramphenicol, ampicillin, and trimethoprim/sulfamethoxazole have been used most frequently; however, newer beta lactams and quinolones are more active. Septic arthritis carries a poorer prognosis and often requires aggressive surgical intervention.

Acinetobacter calcoaceticus anitratus outbreak in the intensive care unit traced to a peak flow meter

BACKGROUND A cluster of seven cases of Acinetobacter caleoaceticus anitratus in a community teaching hospital intensive care unit was discovered (the seventh case was located in a step-down unit next to an infected patient recently transferred from the intensive care unit.) METHODS An outbreak investigation, including detailed epidemiologic, clinical, and laboratory investigation, was performed. RESULTS A single strain of A. calcoaceticus anitratus was responsible for infection in all seven patients. All patients had tracheostomies, were in respiratory failure, and were ventilator dependent. Patients ranged in age from 27 to 81 years. No common causative variable or explanatory findings were present except that the same peak flow meter (manual weaning criteria machine) was used to facilitate weaning all seven patients from mechanical ventilation. Culture of the mouthpiece isolated a A. calcoaceticus anitratus strain with the identical susceptibility pattern and biochemical profile as that from the infected patients. CONCLUSION A. calcoaceticus anitratus was transmitted by a peak flow meter nosocomially to seven patients receiving mechanical ventilation. Disposable mouthpieces were introduced to prevent cross-contamination. A 2% glutaraldehyde solution was used to disinfect the machine between uses. No further outbreaks of A. calcoaceticus anitratus pneumonia were identified during 3 years of follow-up.

Toxoplasma Seroprevalence Rates

Correspondence Toxoplasma Seroprevalence Rates Sir—I read with interest the fine paper by Falusi et al. [1] in the 1 December 2002 issue of Clinical Infectious Diseases. This large study confirms previously published data on Toxoplasma seroprevalence rates. The authors state that such data come from small, predominantly male cohorts in which the range of prevalence is 3%–22%. The authors neglect to cite our earlier publication [2], which demonstrates a se-roprevalence rate of nearly 23% in a co-hort of 319 HIV-seropositive patients (22.6% Toxoplasma seroprevalence among the 93 women in this cohort). Our sero-prevalence findings and ethnicity (e.g., birth country) data from 10 years ago are corroborated by Falusi et al. [1]. However, unlike their study, ours did not demonstrate a higher seroprevalence rate among patients with lower CD4 cell counts. Indeed , although our results were not statistically significant, our 138 patients with cell counts of !200 CD4 cells/mL had a lower Toxoplasma seroprevalence rate than did our patients with cell counts of у200 CD4 cells/mL.alence and predictors of Toxoplasma seroposi-tivity in women with and at risk for human immunodeficiency virus infection. Sir—We appreciate Dr. Glatts interest [1] in our study of Toxoplasma seroprevalence in HIV-infected women in the United States [2]. We regret the omission of the study by Glatt et al. [3] from our references but failed to find the article in the Medline search performed during our literature review process. It is interesting to note that the 22.6% Toxoplasma seroprev-alence rate reported in their cohort of 319 patients (which included 93 women) was just slightly greater than the range we cited in our study (3%–22%). As stated in our study discussion, we were unable to explain the higher Toxo-plasma seroprevalence rate among patients with CD4 cell counts of 200–500 cells/ mm 3. It is important to note that, although there was a trend towards higher sero-prevalence rates among patients with lower CD4 cell counts, this was statistically significant only for patients with CD4 cell counts of 200–500 cells/mm 3 (on univar-iate and multivariate analysis) and not for patients with CD4 cell counts of !200 cells/mm 3. This association with CD4 cell count stratum could not be explained by country of birth or by age, because these variables were controlled for in the multi-variate analysis. Consistent with the observations of Glatt et al. [3], we found that, among HIV-infected women in the United States, country of birth (i.e., …

Kikuchi's disease: A noninfectious benign cause of fever and lymphadenopathy: Report of three cases and discussion

We describe three cases of Kikuchi’s disease, a noninfectious process that presents with fever, cervical lymphadenopathy, and transitory leukopenia. It is primarily seen in young adult women, frequently those of Asian origin, and it is now becoming increasingly more recognized in the United States. The etiology of Kikuchi’s disease remains unknown, but there is an association with systemic lupus erythematosus. Whilst the illness may be progressive, it is usually self-limited. This entity should be considered when patients present with fever and a cervical mass. Kikuchi’s Disease is a self-limiting noninfectious condition of unknown etiology that often presents with fever and cervical lymphadenopathy. It is more frequently seen in young women of Asian extraction. Histologically, Kikuchi’s disease must be differentiated from nonHodgkin’s lymphoma, systemic lupus erythematosus (SLE), and carcinoma. We report three cases of Kikuchi’s disease that masqueraded as infection.

Second-generation cephalosporins.

The rapid proliferation of β-lactam antibiotics has provided physicians with a well-stocked arsenal to deploy against infection. The clinical uses of second-generation drugs are discussed, and third-generation agents are previewed.