John H. Seabury

Actinomycosis and nocardiosis: A review of basic differences in therapy

Abstract Actinomycosis and nocardiosis are closely related and often clinically indistinguishable diseases, chronic pleuropulmonary involvement, subcutaneous abscesses and multiple draining sinuses typifying both. Nevertheless they possess too many essential differences to be considered anything but two separate and distinct diseases. Especially important is the difference in therapy. Stated in the most elementary fashion, if one chooses to treat with penicillin all diseases caused by branching, fragmenting, filamentous fungi, then most patients with actinomycosis will recover, while almost all patients with nocardiosis will die. The natural habitat of A. bovis is the human mouth; that of the nocardia is soil. Either can exist saprophytically in the oropharynx or respiratory tract, however, and mere recovery of the organism from sputum does not constitute absolute proof of the disease. A. bovis is extremely sensitive to penicillin and for actinomycosis this constitutes the treatment of choice. The sulfonamides, although responsible for many earlier cures, show a far inferior inhibitory effect. In vitro sensitivity studies and clinical use have also shown that, depending upon strain sensitivity, one or another of the broad-spectrum antibiotics may be highly effective, so much so that undoubtedly some cases of very early actinomycosis are cured by random antibiotic therapy of seemingly minor infections without even suspecting the possibility of actinomycosis. N. asteroides, the cause of most cases of systemic nocardiosis, is a relatively resistant organism, much less likely to be eradicated by indiscriminate drug administration. Perhaps this accounts for the growing importance of nocardiosis as opposed to the contrasting decrease in frequency of actinomycosis. All strains of nocardia that we have isolated have shown marked penicillin resistance. Sulfadiazine exhibits greater in vitro effectiveness and provides the best animal protection. More important still, its use in clinical nocardiosis has proved life-saving and has been responsible for practically every clinical recovery. The broadspectrum antibiotics and streptomycin show a less marked and more variable inhibitory effect. Because of the extremely serious implications of most nocardial infections sulfadiazine is probably best combined with whatever drug appears most effective in vitro . Regardless of sensitivity tests, however, sulfadiazine should constitute the one essential component of any drug regimen for nocardiosis. Basically, both actinomycosis and nocardiosis, like tuberculosis, are chronic diseases and a dramatic response to therapy should not be expected. Both diseases, but especially actinomycosis, produce a markedly fibrotic tissue reaction. This coupled with the tendency for organisms to accumulate in colonies in tissue (actinomycotic granules), makes it difficult to obtain effective drug levels in the areas of infection and within the compact granules themselves. Moreover, N. asteroides is notoriously resistant to all forms of therapy. Therefore, in both diseases the earlier treatment is instituted the greater the chance for cure. Chemotherapy must be continued in high dosage for prolonged periods if relapse is to be prevented. The judicious use of surgical procedures such as drainage and resection is likewise indispensable in certain cases.

A Cutaneous Manifestation of Systemic Candidiasis

Abstract Two patients with leukemia developed a disseminated, maculonodular rash as a manifestation of systemic candidiasis. Histological sections of these lesions from both patients showed subepid...

Actinomycosis and nocardiosis

Abstract As a reflection of the close relationship between their causative organisms, actinomycosis and nocardiosis present considerable over-all similarity, although possessing too many basic differences to be regarded as other than two separate and distinct diseases. Both are caused by branching, fragmenting, filamentous fungi, Actinomyces bovis being fastidious and growing only at incubator temperature under anaerobic or microaerophilic conditions, while Nocardia asteroides flourishes on all common laboratory media at both room and incubator temperatures. Both organisms are gram-positive, but N. asteroides is acid-fast whereas A. bovis is not. A. bovis exhibits little pathogenicity for laboratory animals; N. asteroides is typically quite lethal, yet either can reside as a saprophyte within the human tracheobronchial tree and elsewhere. The natural habitat of A. bovis is the human mouth and oropharynx, while that of N. asteroides is the soil. Hence actinomycosis is considered endogenous, and nocardiosis exogenous, in origin. Actinomycosis is fairly common; nocardiosis, perhaps unjustly so, is looked upon as rare. Each has a world-wide distribution. Clinically the two diseases may be indistinguishable, with chronic pleuro-pulmonary lesions, subcutaneous abscesses, and multiple draining sinuses typifying both. Any organ may be involved, but hematogenous dissemination is not only more common but almost characteristic of nocardiosis, with the combination of lung and brain involvment being quite outstanding. Histologically there is nothing to separate the two diseases, although actinomycotic granules (sulfur granules) are more characteristic of actinomycosis than nocardiosis. In each disease the basic lesion is more suppurative than granulomatous. Because of the tendency of both organisms to fragment into bacillary forms either may be mistaken for bacteria, with further confusion resulting from the acid-fastness of N. asteroides. Perhaps the sharpest practical distinction between the two diseases is in the matter of therapy. A. bovis is quite sensitive to penicillin, which is the drug of choice in actinomycosis, and to a lesser extent also to sulfadiazine and the broad-spectrum antibiotics. N. asteroides, on the other hand, is resistant to penicillin, and the drug of choice is sulfadiazine. In view of the extreme seriousness of most nocardial infections sulfadiazine is probably best given in combination with streptomycin or whatever broad-spectrum antibiotic appears most effective in vitro. In both diseases, but especially in nocardiosis, treatment must be instituted early if cure is to be effected and must be continued in high dosage for prolonged periods if relapse is to be prevented.

Spirometric evaluation of benadryl in asthma

Abstract 1.1. Spirometric studies were performed on sixteen patients, thirty minutes and one hour following the administration of 100 mg. of benadryl orally. 2.2. When compared with the initial spirometric tracings, no consistent changes were noted in the vital capacity, tidal air, minute ventilation, expiratory differential, respiratory rate, or degree of emphysema following benadryl. 3.3. Following the administration of epinephrine and aminophylline to five of these sixteen patients, there was a uniform increase in the vital capacity, tidal air, minute ventilation, expiratory differential, and no increase in the respiratory rate. 4.4. Six of the patients derived subjective benefit with decrease in dyspnea following the use of benadryl. In three of these, spirometric data were directly opposed to the subjective report. In one case the same response was obtained as found after the administration of epinephrine and aminophylline.

Bagassois III. Isolation of Thermophilic and Mesophilic Actinomycetes and Fungi from Moldy Bagasse

Summary and Conclusion Industrial workers who grind raw sugar cane fiber from which the sucrose content has been extracted and which has been stored in bales under high environmental temperature develop a characteristic respiratory illness called bagassosis. Precipitins against unknown antigens in crude bagasse have been detected in the sera of many patients with this disorder, and thermophilic microorganisms are suspected as likely sources of bagasse antigen. This report describes the most common thermophilic actinomycetes and fungi isolated from the “bagasse” fiber. These include M. vulgaris, S. thermoviolaceus, S. griseoflavus, S. fradiae, S. thermovulgaris, S. olivaceus, and H. lanuginosa. The sera of many patients with bagassosis contained precipitins against cellular extracts of M. vulgaris. Since bagassosis results almost exclusively from inhalation of dried stored sugar cane fiber and M. vulgaris has been the most common isolate from this type of bagasse, it is postulated that M. vulgaris is the main source of “moldy bagasse” antigens.

Bagassosis: IV. Precipitins against extracts of thermophilic actinomycetes in patients with bagassosis☆

Abstract Precipitating antibodies against extracts of crude moldy bagasse have previously been detected in the serum of patients with bagassosis and to a lesser extent in the serum of unaffected sugar cane workers. In this report serum specimens obtained from patients with bagassosis and appropriate control groups were analyzed for precipitins against thermophilic fungi and actinomycetes isolated from bagasse. The thermophilic actinomycete Micromonospora vulgaris was found to be an important source of bagassosis antigens. Sixty-four per cent of those with bagassosis of recent onset demonstrated precipitins against this organism and eight M. vulgaris antigens were identified using rabbit antiserum. Patients with bagassosis also demonstrated elevated levels of IgG and IgA and normal IgM levels. Only an occasional unaffected bagasse industry worker or unexposed Louisiana resident demonstrated precipitin arcs against the battery of actinomycete extracts employed and these arcs were generally not as well defined or intense as those developed by serum of patients with overt bagassosis. Precipitin arcs tended to decrease in number and intensity with clinical improvement. A positive precipitin reaction to M. vulgaris in a case of suspected active or recent onset bagassosis was considered to be of presumptive diagnostic significance.

New Orleans asthma: IV. Semiquantitative airborne spore sampling, 1967 and 1968

Abstract A semiquantitative survey of atmospheric spore concentrations in the city of New Orleans with the use of automatic intermittent rotoslide samplers was performed during the years 1967 and 1968. In comparison with our previous rotoslide pollen survey, spores were invariably detected in excess of pollen grains by a factor of 10 to 100. Relatively large spores of the deuteromycetes (fungi imperfecti) were easily identified morphologically. Identification of small spores was uncertain because of considerable group overlap and interspecies variation. Spores in this category were detected in highest quantity. Spores resembling large basidiospores were included in a third general category. Many myxomycete spores were also likely included in this category because of similar morphology. In all morphological categories, semiquantitative atmospheric spore counts were comparatively low in January and February. Counts increased sharply in March and April and increased variably throughout the summer and late fall months. Noticeable decreases were recorded in late November at or near the usual onset of local killing frosts. Petri plate colony identification, although performed only sporadically, was not as helpful as anticipated. Analysis of one typical large asthma epidemic (December, 1968) revealed high rotoslide catches in all major spore categories but no sharp increase in total cultural colony count or obvious change in colony composition.

Mycetoma mandibularis due to Nocardia pelletieri

Abstract An 11 year old child presented with extensive involvement of the right mandible due to Nocardia pelletieri. Medical treatment, consisting of sulfadiazine and alternating courses of neomycin and tetracycline, was successful with no evidence or reactivation during 5 years of posttreatment follow-up. The organism was studied by physiologic, biochemical and immunologie methods. It was compared with representative strains of Nocardia brasiliensis and Nocardia madurae. This is the second recorded case of mycetoma due to N. pelletieri in the United States.

Spirometric evaluation of Orthoxine in bronchial asthma

Abstract 1.1. Spirometric studies which were performed on twenty patients with moderate acute attacks of bronchial asthma indicate that orthomethoxy-β-phenylisopropyl methylamine hydrochloride (Orthoxine) is an effective bronchodilator and antiasthmatic drug. 2.2. There was no definite effect on the heart rate or the blood pressure following the ingestion of 100 mg. of Orthoxine, and no undesirable side effects were noted.

Spirometric evaluation of “Ethyl-Nor-Epinephrine” in bronchial asthma

Abstract 1.1. Spirometric studies were performed on ten patients with moderately acute attacks of asthma prior to and for one hour following the administration of 2 mg. of butanefrine. 2.2. There was a uniform response characterized by a combination of increase in vital capacity, reserve air, complemental air, expiratory differential, and an initial increase in the volume of minute ventilation with a tendency to return toward the initial volume one hour after the administration of butane-frine. 3.3. There was an increase in the heart rate, a lowering of the diastolic blood pressure, and an absence of side-effects following the injection of butanefrine. 4.4. Eight patients obtained complete symptomatic and objective relief. Two patients required additional medication.