Edward D. Ralph

Acute paralysis following "a bad potato": a case of botulism.

PurposeIntensivists often encounter patients with respiratory failure as a result of neuromuscular disease, however, acute neuromuscular syndromes are less common. We present a case of food borne Clostridium botulism and discuss the diagnostic and therapeutic considerations.Clinical findingsA 35-yr-old healthy male presented with abdominal pain and blurred vision 12 hr after ingesting a “bad“ potato. During the next 17 hr, the patient demonstrated a gradual descending paralysis which ultimately resulted in no cranial nerve function and 0/5 strength in all extremities. Sensation was intact. The patient required intubation and mechanical ventilation. His blood count, biochemical profile, computerized tomography and magnetic resonance imaging of the head were normal. A lumbar puncture revealed no abnormalities. Due to the rapid deterioration and presentation of ’descending’ paralysis, botulism was suspected. The patient was treated empirically with botulinum anti-toxin. Samples of blood, stool and gastric contents were cultured for the presence of Clostridium botulinum and its toxin and these tests were positive for botulinum toxin A 12 days later. The patient’s neuromuscular function gradually improved over a prolonged period of time. Six and one-half months after his initial presentation, the patient was discharged home after completing an aggressive rehabilitation program.ConclusionsBotulism is a rare syndrome and presents as an acute, afebrile, descending paralysis beginning with the cranial nerves. If suspected, botulinum anti-toxin should be considered, particularly within the first 24 hr of onset of symptoms. Confirmation of the presence of botulinum requires days therefore the diagnosis and management rely on history and physical examination.RésuméObjectifBeaucoup de patients présentent une insuffisance respiratoire causée par une affection neuromusculaire, les syndromes neuromusculaires aigus étant plus rares. Nous présentons un cas d’intoxication alimentaire à Clostridium botulinum et discutons du diagnostic et du traitement.AbstractÉléments cliniquesUn homme sain de 35 ans a consulté pour des douleurs abdominales et une vision floue 12 h après avoir mangé une «mauvaise patate». Pendant les 17 h suivantes, une paralysie descendante graduelle s’est installée et a finalement provoqué la perte de fonction des nerfs crâniens et réduit à 0/5 la force des extrémités. La sensation était intacte. Il a fallu intuber et ventiler le patient. La numération plaquettaire, le profil biochimique, la tomographie par ordinateur et l’imagerie par résonance magnétique de la tête étaient normaux. Une ponction lombaire n’a révélé aucune anomalie. Devant la détérioration rapide et la paralysie «descendante», nous avons pensé au botulisme. Un traitement empirique avec une antitoxine botulinique a été administré. Les échantillons de sang, de selles et du contenu gastrique ont été mis en culture pour vérifier la présence du Clostridium botulinum. La présence de la toxine botulinique type A a été révélée 12 jours plus tard. La fonction neuromusculaire s’est graduellement améliorée sur une longue période. Six mois et demi après sa première visite, le patient a pu partir après un programme de réadaptation complet et énergique.ConclusionSyndrome rare, le botulisme se présente comme une paralysie aiguë, afébrile et descendante affectant d’abord les nerfs crâniens. S’il est soupçonné, il faut penser à l’antitoxine botulinique, surtout au cours des 24 premières heures de l’apparition des symptômes. La confirmation de la présence de Clostridium botulinum demandant des jours, le diagnostic et le traitement reposent sur l’histoire et l’examen physique.

Clinical Experience with Multilamellar Liposomal Amphotericin B in Patients with Proven and Suspected Fungal Infections

Over a 3-year period, an unsonicated multilamellar vesicle preparation containing a low ratio of amphotericin B (5 mole %) was used as a routine alternative to amphotericin B-deoxycholate in treating 17 patients with a variety of systemic fungal infections representative of those commonly encountered on a tertiary care centre infectious disease service. Patient acceptability and convenience of administration were noteworthy. In 6/7 patients who had been given the liposomal drug after experiencing severe side effects (primarily hypokalemia and marked elevation of serum creatinine) on the non-liposomal form, the problems that had led to institution of the liposomal drug were reversed during treatment. However, multilamellar liposomal amphotericin B at conventional dosage was not without detectable toxicity in this patient population. Three transplant patients receiving cyclosporin at the same time as liposomal amphotericin B experienced a rise in serum creatinine, and 4 patients became hypokalemic during treatment: none of these effects was severe or required discontinuation of therapy. One or more liver enzymes rose measurably in 7 patients during treatment with liposomal amphotericin B, but remained unchanged or actually decreased in the remaining patients.

Liposomal Amphotericin B: An Effective, Nontoxic Preparation for the Treatment of Urinary Tract Infections Caused by Candida albicans

Liposomal amphotericin B without prior administration of Fungizone was found to be an effective treatment in 4 patients with urinary tract infections caused by Candida albicans. Urine typically became culture negative after 1-4 days of dosing at 50 mg/day, demonstrating that therapeutic levels of amphotericin B were reached in the urine at conventional doses given in liposomal form. The low incidence of toxicity with this preparation was particularly useful in patients with impaired renal function, including renal transplant patients on cyclosporine immunosuppression.

Serum Sickness-like Reaction Possibly Associated with Meropenem Use

Serum sickness-like reactions most commonly occur secondary to drug administration. We describe a serum sickness-like reaction that was possibly associated with meropenem therapy.

Micronutrient deficiency and treatment adherence in a randomized controlled trial of micronutrient supplementation in ART-naive persons with HIV.

Introduction The MAINTAIN study is an on-going RCT comparing high-dose micronutrient and anti-oxidant supplementation versus recommended daily allowance (RDA) vitamins in slowing HIV immune deficiency progression in ART-naïve people with HIV infection. Objective We planned analysis of the first 127 participants to determine the baseline prevalence of serum micronutrient deficiencies and correlates, as well as tolerance and adherence to study interventions. Methods Participants receive eight capsules twice daily of 1) high-dose or 2) RDA supplements for two years and are followed-up quarterly for measures of immune deficiency progression, safety and tolerability. Regression analysis was used to identify correlates of micronutrient levels at baseline. Adherence was measured by residual pill count, self-report using the General Treatment Scale (GTS) and short-term recall HIV Adherence Treatment Scale (HATS). Results Prior micronutrient supplementation (within 30 days) was 27% at screening and 10% of study population, and was not correlated with baseline micronutrient levels. Low levels were frequent for carotene (24%<1 nmol/L), vitamin D (24%<40 nmol/L) and serum folate (20%<15 nmol/L). The proportion with B12 deficiency (<133 pmol/L) was 2.4%. Lower baseline levels of B12 correlated lower baseline CD4 count (r = 0.21, p = 0.02) with a 21 pmol/L reduction in B12 per 100 cells/µL CD4. Vitamin D levels were higher in men (p<0.001). After a median follow-up of 1.63 years, there were 19 (15%) early withdrawals from the study treatment. Mean treatment adherence using pill count was 88%. Subjective adherence by the GTS was 81% and was moderately but significantly correlated with pill count (r = 0.29, p<0.001). Adherence based on short-term recall (HATS) was >80% in 75% of participants. Conclusion Micronutrient levels in asymptomatic HIV+ persons are in keeping with population norms, but micronutrient deficiencies are frequent. Adherence levels are high, and will permit a valid evaluation of treatment effects. Trial Registration ClinicalTrials.gov NCT00798772

Group A streptococcal brain abscess.

A 48-y-old woman with an acute Group A streptococcal brain abscess is described. The abscess enlarged rapidly with neurological deterioration and required open drainage and excision. The patient was treated with antibiotics for 6 weeks and recovered completely. Group A streptococcus is a rare cause of brain abscess in the antibiotic era and may require urgent neurosurgical intervention.

Polymerase chain reaction- and RNA hybridization-based method for the investigation of deep-seated candidiasis

OBJECTIVE To determine the usefulness of a polymerase chain reaction (PCR) and RNA hybridization method for the diagnosis of invasive candidiasis and to compare its sensitivity with blood cultures. DESIGN Blood cultures and a blood sample for PCR were taken from patients with suspected invasive candidiasis. A 105 base pair conserved segment within the rDNA of Candida species was amplified. The amplicon was detected by hybridization and gel electrophoresis. SETTING Intensive care units of two tertiary care hospitals. PATIENTS One hundred and eighteen patients 16 years of age or older with four more risk factors for invasive candidiasis were enrolled. Present or recent past treatment with broad spectrum antibiotics, cancer chemotherapy, immunosuppressive drugs, granulocytopenia or granulocytosis, intravascular catheterization, tracheal intubation, recent abdominal surgery and parenteral nutrition were considered risk factors. RESULTS Forty-three patients had invasive candidiasis. PCR detected infections in 28 and 26 patients (sensitivity 65.1% and 60.4%) by hybridization and gel electrophoresis, respectively. The sensitivity of blood cultures was 58.1%. Of 25 patients with positive blood cultures, 17 were positive by PCR with the hybridization method. Eleven patients with invasive candidiasis had negative blood cultures but were positive by PCR. CONCLUSION PCR, especially with a hybridization detection method, is more sensitive than blood culture for invasive candidiasis and may facilitate the diagnosis of nonfungemic disease.