Glenn E. Mathisen

Botulism Associated with Clostridium botulinum Sinusitis after Intranasal Cocaine Abuse

Excerpt Wound botulism has been identified as a risk of parenteral cocaine abuse (1-3). We report a case of botulism associated with maxillary sinusitis after intranasal cocaine abuse;Clostridium b...

Clinical and laboratory features of measles in hospitalized adults

PURPOSE Description of the epidemiology, morbidity, and mortality of hospitalized adults with typical measles. PATIENTS AND METHODS Retrospective case analysis of 33 adults who required acute care for complications of measles in a public hospital in Los Angeles, California. The diagnosis of measles was established on standard clinical or serologic grounds. RESULTS Of 68 patients (age greater than 14) with signs and symptoms of measles who presented for medical care, 33 (19 males and 14 females) required hospitalization; 18 were natives of the United States. The patient age was 26.1 +/- 7.3 (mean +/- SD) years; four patients, all natives of the U.S., were born before 1957. The duration of hospitalization was 6.8 +/- 8.8 days for all patients and 13.4 +/- 14.2 days for the nine patients who required intensive care unit (ICU) care. Six of the ICU patients required mechanical ventilation for 11.0 +/- 15.0 days; two deaths occurred among these patients. During the course of their illness, 7 of 25 (28%), 11 of 28 (39%), 6 of 28 (21%), and 5 of 16 patients (31%) had peak lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, and creatine kinase values, respectively, that were greater than 5 times the upper limit of normal. Fifteen of 28 patients (54%) developed total serum calcium levels less than or equal to 2.0 mmol/L. Ten cases were serologically confirmed; 23 cases were diagnosed as probable measles on clinical grounds. There were no significant demographic, clinical, or laboratory differences between patients with confirmed and probable measles. No patients had characteristic manifestations of atypical measles. The sole immunocompromised patient died. CONCLUSIONS Measles in adults may result in severe, life-threatening complications that utilize substantial medical resources. Physicians need to appreciate the clinical presentations and manifestations of severe measles in adults and to provide measles vaccine to nonimmune adults during community-wide outbreaks.

Treatment of severe falciparum malaria during pregnancy with quinidine and exchange transfusion

Malaria during pregnancy may be associated with significant morbidity and mortality in both mother and fetus. Treatment of severe chloroquine-resistant malaria during pregnancy may be problematic since quinine and related compounds may have a deleterious effect on the course of labor. This article reports the case of a 21-year-old primigravida Liberian woman who presented with high-grade (greater than 12%) parasitemia with Plasmodium falciparum. The patient was initially treated with chloroquine; however, she developed bilateral pulmonary infiltrates and premature labor, and her condition appeared to clinically deteriorate. Therapy was changed to intravenous quinidine, and red blood cell exchange transfusion was instituted. This resulted in a decreased parasitemia and clinical improvement. The patient underwent a cesarean section, and a healthy child was delivered. Although most cases of malaria may be managed with conventional chemotherapy, the use of intravenous quinidine in combination with exchange transfusion with careful monitoring should be considered in selected cases of severe, complicated malaria in pregnant women.

Case Report: Aggressive Kaposi's Sarcoma and Campylobacter Bacteremia in a Female with Transfusion Associated AIDS

The vast majority of patients with Kaposis sarcoma (KS) of the epidemic, endemic or sporadic variety are men. Although 35 percent of men with AIDS will develop KS, only three percent of women will develop this malignancy. To date, a single case report of transfusion associated KS in an HIV-infected female has been described in the medical literature. We report a second case. A 54-year-old HIV-infected female without other identifiable risk factors for AIDS developed disseminated KS six years after a blood transfusion. Her illness was marked by rapidly proliferating tumors not responsive to a single course of chemotherapy. Another unusual aspect of this case is that, in conjunction with weight loss and diarrhea, Campylobactercinaedi was recovered from her blood. This enteric pathogen has previously been described exclusively in homosexual men. Autopsy studies showed KS tumors involving all major visceral organs. This case report demonstrates that in HIV-infected females KS may follow an aggressive course similar to that seen occasionally in male KS patients with profound immunosuppression.

Erythrocytosis after Zidovudine for AIDS

To the Editors: Anemia, granulocytopenia, and myositis appear to be the limiting toxicities in patients receiving zidovudine (1). We report the case of a 29-year-old homosexual man whose hemoglobin...

A comparison of screening batteries in the detection of neurocognitive impairment in HIV-infected Spanish speakers

BACKGROUND A substantial number of Spanish-speaking individuals from Mexico and Central America are now living in the United States. These individuals are at heightened risk for HIV infection and, due to late diagnosis and limited resources, for HIV-associated neurocognitive disorders (HAND). Early detection is key, yet adequate methods for detecting HAND in Spanish speakers, especially in resource-poor areas, remains problematic. Therefore, it is necessary to identify accurate yet efficient neurocognitive screening tools that are appropriate for use in resource-limited AIDS clinics serving Spanish-speaking patients. METHODS Twenty-one Spanish-speaking, HIV-positive adults who migrated from Mexico or Central America underwent neuromedical and neurocognitive evaluation in Spanish. The concordance of three neurocognitive screening measures (the HIV Dementia Scale [HDS], the Mini-Mental State Examination [MMSE], and the NEUROPSI) with a comprehensive neuropsychological battery was examined. In addition, accuracy in detecting neurocognitive impairment using standard and alternative cutoff scores was examined. RESULTS The HDS and the NEUROPSI showed high correlation with the comprehensive neuropsychological battery. The HDS and the NEUROPSI also had the highest sensitivity (67% and 75%, respectively) and specificity (50% and 38%, respectively). Both measures also showed greater sensitivity than the MMSE to very mild forms of HAND. CONCLUSION In this small sample of HIV-positive Spanish speakers from Mexico and Central America living in the United States, the HDS and the NEUROPSI demonstrated reasonable accuracy in detecting neurocognitive impairment, while the MMSE demonstrated very poor accuracy. The HDS and the NEUROPSI were equally sensitive in detecting mild HAND. Continued test development is required to capture this disorder, especially in resource-limited settings.

MRI Ventral Nerve Root Enhancement in Five Patients Presenting With Extremity Weakness Secondary to Neuroinvasive West Nile Virus.

Approximately 80% of individuals infected with West Nile virus (WNV) are asymptomatic. The remainder may experience fever, myalgias, and nuchal rigidity. About 1% of individuals will suffer from WNV neuroinvasion that can include encephalopathy, cranial nerve involvement, tremor, motor weakness, and in severe cases, flaccid paralysis. A 2-year retrospective study was performed to identify patients with confirmed neuroinvasive WNV, who initially presented with extremity motor weakness. Spine MRI reports were further reviewed to identify the subset of patients with ventral nerve root enhancement. Patient demographics, laboratory diagnostics, hospitalization course, and posthospitalization follow-up were reviewed. Five patients were identified (3 males) with mean age of 55.8 6 9.0 years (see Table 1 for patient summary). Each presented with complaint of subjective fever and progressive lower or upper extremity weakness (of duration 1, 4, 7, 9, and 21 days). WNV was confirmed with elevated immunoglobulin G (IgG) and immunoglobulin M in cerebrospinal FIGURE 1.Magnetic resonance imaging post-contrast T1-weighted sagittal views of lumbar (patients 1–4) and cervical (patient 5) spinal cord demonstrating ventral root enhancement. Black bar represents 1 cm. Journal of CLINICAL NEUROMUSCULAR DISEASE

The Case of the “Chocolate” Blood Culture

CASE REPORT A 57-year-old, otherwise healthy cooking student presented to the emergency department with 4 days of nausea/vomiting, abdominal pain, and nonbloody diarrhea. Upon presentation, she was found to have high-grade fever (>39.0 °C), bibasilar pulmonary rales, and diffuse abdominal painwith voluntary guarding on abdominal examination. Blood tests showed a white blood cell count of 1900 cells per cubic millimeter (93.3% neutrophils, 6% lymphocytes, 0.5%monocytes, and 0.3% eosinophils). Blood chemistry showed hypokalemia (K of 3.1 mmol/L) and mild renal insufficiency (creatinine of 1.58mg/dL). The patient’s oxygen saturation was 99% (on room air), and the result of the chest radiograph was normal (Fig. 3). An abdominal computed tomographic scan with contrast showed evidence of small bowel enteritis. The patient was admitted for intravenous fluid hydration and parenteral antibiotics. Stool studies obtained on admission including stool white blood cell count, stool cultures, Clostridium difficile toxin testing, as well as examination for ova and parasites were negative. Within a few days of hospitalization, automated blood cultures obtained on admission were detected as “positive” and exhibited a dark brown “chocolate” color, as seen in Figure 1. Despite the positive blood culture, the Gram stain and the subculture of the bottles were negative. What is your diagnosis?