Harold D. Rose

Pulmonary aspergilloma: A rational approach to treatment

A prospective study of 15 patients with pulmonary aspergilloma was undertaken over an 11 year period. Serious underlying diseases, particularly chronic obstructive pulmonary disease and alcoholic cirrhosis, were present in 12 of them. Eight of 15 patients whose clinical and roentgenographic course was followed for an average of 50 months, received no specific therapy. There were four deaths in this group, none attributable to aspergilloma. The aspergilloma had lysed spontaneously in two, decreased in size in one and was unchanged in one. In the four surviving patients who had no treatment, the aspergilloma lysed spontaneously in one, remained unchanged in two and increased in size in one. Of the seven patients who were treated medically or surgically, three died. Among the seven deaths (untreated and treated patients combined), six were clearly related to underlying disease. The prognosis of aspergilloma is related primarily to the nature and severity of the underlying disease(s). Contrary to the conclusions of previous reports, the experience in our series of patients suggests that routine surgical excision of aspergilloma is not indicated.

Deep mycotic infection in the hospitalized adult: a study of 123 patients.

A prospective study of patients hospitalized in a large Veterans Administration Hospital between November 1963 and November 1973 revealed 123 patients with deep mycotic infections. The incidence of these infections almost doubled during the last 5 years. Candida (55 patients) and Aspergillus (26 patients) were the major causative agents. Nine other fungal caused infection in the remaining patients. Candidemia was rare prior to the introduction of commerical percutaneously-inserted venous catheters in 1965. The incidence increased further following the introduction of parenteral hyperalimentation in 1969, and Torulopsis fungemia (5 patients) appeared for the first time. Invasive pneumonia caused by spore-forming Aspergillus decreased when patients were moved from an old, naturally-ventilated hospital to a new, mechanically-ventilated one. The air in both hospitals was sampled on one occasion for the presence of fungal spores, and spores of Aspergillus fumigatus were detected only in the old hospital. Our experience suggests that hospital-acquired Aspergillus infection of the lung might be eliminated if all incoming hospital air is filtered, properly vented, and not recirculated. Efforts to decrease hospital-acquired fungal infections include vigorous infection control procedures for intravenous therapy, judicious use of any therapy that predisposes to infection, and further evaluation of improved mechanical control of hospital ventilation.

In vitro quantitative adherence of bacteria to intravascular catheters.

Adapting standard techniques, a simple in vitro system was devised to compare quantitative bacterial adherence to iv catheters of different compositions. Upon brief immersion of catheters in suspensions of Staphylococcus aureus, coagulase-negative staphylococci, and Escherichia coli, organisms adhered to catheter surfaces. After overnight growth in broth, organisms remained adherent and formed colonies, as shown by light and scanning electron microscopy. In addition, quantitative adherence using a blood agar roll technique, expressed as bacteria per square centimeter of catheter surface area per 10(6) colonies per milliliter inoculum, was calculated. Adherence was greater on polyvinylchloride (PVC) catheters (geometric mean 342) than on Teflon catheters (geometric mean 49.6) for coagulase-negative staphylococci (P less than 0.005). Also, the number of coagulase-negative staphylococci adherent to PVC catheters was significantly greater than for E. coli (geometric mean 70.6) at analogous inocula (P less than 0.02). Differences in bacterial adherence to the surface of iv devices may be important in the pathogenesis of catheter-associated infections. This in vitro method could prove useful in testing bacterial adherence properties of newly developed catheter materials, and allow development of catheters less prone to be associated with bacterial adherence and catheter-related infections.

Gram-negative pneumonia.

Abstract The chest films of 58 patients with proved pneumonia due to Pseudomonas, Klebsiella, Enterobacter, Escherichia coli, Proteus, or Bacteroides were reviewed. Pseudomonas pneumonia was characterized by diffuse alveolar involvement with rapid progression to extensive macrocavitation. Fulminating lobar consolidation with bulging of adjacent fissures, massive cavitation, and empyema occurred in only a few cases of Klebsiella pneumonia but were felt to constitute the most diagnostic findings. No specific roentgenographic features could be attributed to the remaining pathogens, with the exception of massive empyema and lobar consolidation in Bacteroides infection.

Acute Pasteurella multocida pneumonia

Acute pneumonia caused by Pasteurella multocida appeared in two elderly patients. One patient had chronic obstructive lung disease and the other developed aspiration pneumonia after an episode of cardiac arrest. Pasteurella multocida was not isolated from the initial sputum cultures. The delay in recognizing the pathogen resulted in extension of the pneumonia and abscess formation in the patient with obstructive lung disease. Pasteurella multocida was isolated from a percutaneous transtracheal aspirate in both patients and from the blood of one. They recovered after treatment with a penicillin administered in higher than usual dosage over a period of several weeks.

Localized oral blastomycosis mimicking actinomycosis

A case of blastomycosis limited to the oral cavity is presented. The disease apparently originated in the mandible and eroded into the oral cavity. Secondary bacterial infection of the sinus tracts resulted in a clinical picture that mimicked cervicofacial actinomycosis. Appropriate microbiologic studies, including culture confirmation of the causative organism, were necessary to establish a definitive diagnosis.

Jaundice associated with nonhepaticStaphylococcus aureus infection

SummaryA previously healthy young man developed jaundice early in the course of a febrile illness caused by an unrecognized deep-seatedStaphylococcus aureus abscess. The serum bilirubin level peaked 11 days before the abscess was discovered and drained. During this time the bilirubin level returned to normal, circulating immune complexes were detected, and the serum free teichoic acid antibody titer was elevated. Indirect immunofluorescent staining of liver tissue for teichoic acid revealed 2+ nuclear fluorescence of the hepatocytes. These findings suggested that circulating free teichoic acid was deposited in the liver and may have had an endotoxin-like effect in the hepatocytes. With the appearance of specific antibody in the serum, circulating teichoic acid was neutralized and further hepatic injury ceased.

Lymphocyte function in relapsed pulmonary blastomycosis

Lymphocyte function was studied in two patients with multiple relapses of pulmonary blastomycosis following antifungal therapy. Neither patient was anergic to routine delayed hypersensitivity skin testing with common antigens. Both had normal in vitro lymphocyte transformation responses to standard mitogens and common microbial antigens. The ability of lymphocytes from the two patients to respond to antigens of the infecting organism was evaluated using a yeast phase Blastomyces dermatitidis extract in tests of in vitro lymphocyte function. Both patients demonstrated positive responses to this extract in standard assays of two in vitro parameters of lymphocyte function, lymphocyte transformation, and lymphokine production. Therefore if an immunologic defect is responsible for the repeated relapses of treated pulmonary blastomycosis in these two patients, it apparently is not one of deficient lymphocyte responsiveness against the infecting organism, as has been found using similar techniques in patients with disseminated deep infections caused by other fungal organisms.

Absence of Circulating Interferon in Patients with Malaria and with American Trypanosomiasis

Summary Interferon could not be detected in 50 sera obtained during the acute illness from 42 patients with clinical malaria. Similarly negative results were obtained when 40 sera from patients with subclinical T. cruzi infection were studied. The authors thank Dr. Wendell H. Hall from the Minneapolis V.A. Hospital who provided some of the malarial sera. Miss J. Balay provided capable technical assistance. Studies of Chagas disease were supported in part by a grant-in-aid from the S. C. Johnson Foundation.

Medium for susceptibility testing and yeast phase conversion of Blastomyces dermatitidis

Cottonseed protein agar and a modified Tween-albumin casein hydrolysate (TAC) medium were compared for the yeast phase conversion of Blastomyces dermatitidis strains including fresh isolates as well as strains maintained in long-term storage. It was found that both media converted all the B. dermatitidis (mycelial phase) strains studied to yeast phase in three days. The TAC medium has the added advantage that it is clear and the growth can be recognized earlier than in the opaque cottonseed agar medium. The conversion in most cases was more than 95% and the morphology of the yeast cells was uniformly typical with broad base budding. There was a striking difference between the sensitivity of the yeast and mycelial phases of B. dermatitidis strains. The yeast phase was usually more sensitive to Amphotericin B than the mycelial phase of B. dermatitidis. Similarly, the yeast phases of four out of six strains were more sensitive to ketoconazole than their respective mycelial phases, while two strains showed identical sensitivity in cottonseed agar. The yeast phase organism was more susceptible to Amphotericin B when cottonseed medium was used whereas the yeast phase showed more susceptibility to ketoconazole in TAC medium. Since the sensitivity among the various strains differed, it is necessary to determine the antifungal susceptibility of the pathogenic phase of the organism for initiating proper therapy and monitoring effectiveness.