John R. Middleton

Post-cesarean section endometritis: causative organisms and risk factors.

THE CLINICAL DIAGNOSIS of post-cesarean section endometritis is based on the presence of fever and uterine tenderness, but there are no uniformly satisfactory microbiologic methods for confirming the clinical impression. Therefore, we undertook a prospective stud) by means of a culturing technique previously described to determine the clinical significance of isolates from amniotic fluid and the lower uterine segment.’ We also examined the risk factors for the development of endometritis. Patients undergoing cesarean section at the Martland Hospital, Newark, New Jersey, were studied according to the previously described technique.’ The following data were collected for each patient: age, history of prior cesarean section, duration of ruptured membranes, number of vaginal examinations, hematocrit, peripheral leukocyte count, indication for cesarean section. type of anesthesia, duration of anesthesia, and history of prior amniocentesis. Patients who developed fever greater than 100” F determined orally in two separate 24-hour periods with uterine tenderness and who had no other source of fever were classified as demonstrating clinical evidence of endometritis. We defined laboratory evidence of infection as growth fi-om either the amniotic fluid or lower uterine segment specimens. Thirty-six of 105 patients in ;I G-month period developed clinical and laboratory evidence of infection (Table I). In an additional 43 patients there was neither clinical nor laboratory data indicating infection. Twelve patients developed clinical but nor laboratory evidence of endometritis and in 14 cases cultures were positive (three of the amniotic fluid and 1 1 of the lower uterine segment) but the patients did not develop clinical manifestations of infection.

Aortotomy site infections: case presentation and review of the literature

A patient with Aspergillus fumigatus infection involving an aortotomy site with multiple peripheral emboli following implantation of an aortic valve prosthesis for rheumatic heart disease is described. Eleven aortotomy site infections are reviewed from the literature. Eight cases were caused by fungi with Aspergillus sp accounting for four cases. Presenting symptoms were nondiagnostic and multiple. However, the diagnosis of aortotomy site infection should be entertained in patients who have had aortic valve surgery who develop fever and embolic phenomena with or without positive blood cultures coupled with no evidence of valve dysfunction, and who respond inappropriately to antibiotic therapy. Ten of the 11 patients reviewed from the literature died. Therapy should be directed at early recognition followed by prompt early surgery combined with the use of proper antimicrobial agents directed against the isolated microorganism.

Abdominal Tuberculosis: An Immigrant's Disease in the United States.

Background: Abdominal tuberculosis (TB) is an uncommon condition in the United States (US) except for patients with human immunodeficiency virus (HIV). An increasing number of cases have been reported in western countries amongst immigrants. It is important to be aware of the data and clinical characteristics in the immigrant population. Aims: The purpose of this study is to determine the epidemiologic characteristics of abdominal TB among immigrants in the US and to review the clinical presentations of abdominal TB with a focus particularly on unusual features. Materials and Methods: In a community teaching hospital in New Jersey, patients diagnosed with abdominal TB were examined and included in this report. All nine patients were immigrants from countries with high prevalence of TB and a majority had resided in the US for at least 5 years. None had clinical evidence of HIV and those that were tested were not found to be positive for HIV. Initial examination, diagnostic workup, and response to therapy were all pertinent to the management and diagnosis of these patients. Results: Three patients had atypical clinical presentations with normal chest X-rays and either negative or unknown tuberculin tests leading to delayed diagnosis and inappropriate therapy in at least one patient. With antituberculous therapy, all except for one patient had satisfactory outcomes. Immigrant patients with a diagnosis of abdominal TB had no evidence of HIV infection or other associated conditions in contrast to native-born individuals. Conclusion: Atypical presentations may cause diagnostic difficulties. Failure to perform appropriate tests may lead to inappropriate therapy with adverse outcomes. Although there is a decline in the number of TB cases in the US and screening for latent pulmonary infection in foreigners has been implemented effectively, the diagnosis of abdominal TB continues to be under diagnosed.

Thoracic actinomycosis: a rare occurrence

Actinomyces israelii is a branching anaerobic bacilli microorganism that can be identified as normal flora throughout various portions of the human alimentary canal. It is crucial to establish a diagnosis as treatment will vary depending on the clinical form of the disease. We report a case of a 78-year-old man who initially presented with an acute onset of respiratory distress displayed contrast leakage on computed tomography from the site of a previously inserted esophageal stent for an unsuccessful surgical repair of an esophageal rupture. In addition to the contrast leakage, the presence of a bronchopulmonary fistula imaging prompted the need for further investigation. Our patient was empirically treated with antibiotics and obtained blood cultures, which returned positive A. israelii.

Hansen's disease in a native-born, United States resident, after a brief stay in an endemic area abroad

Abstract Despite the overall decline in number of leprosy cases in the United States, small numbers of patients with the disease continue to be reported, predominantly among immigrant populations. Occasional cases occur among native-born American residents, predominantly from the southern United States. The source of the reservoir and transmission among indigenous HD cases remains unexplained, although armadillos in the state of Texas and Louisiana have been implicated. Since most patients among the indigenous cases occur in older age groups, the possibility of reactivation of the disease through immunosenescence has been raised. In most patients, unfamiliarity with the clinical picture of HD among physicians in the United States accounts for delayed or incorrect diagnosis. High index of suspicion in a patient with unusual skin lesions, particularly with sensory loss, should be followed by a biopsy looking for the characteristic histologic changes found in various forms of leprosy. Reversal reactions and erythema nodosum leprosum are relatively frequent complications of treatment. Treatment and periodic follow-up of these patients should be done, preferably by physicians with experience with the disease entity.

Hypercalcemia and weight loss—Malignancy or infection?

A 73-year-old man was seen for weight loss of 20 pounds and progressive weakness of 3 months’ duration. He complained of decreased appetite and constipation for 2 months. He denied fever, chills, and any respiratory symptoms. He had no prior major medical illness. Four months previously, a cyst that was found in the left parotid gland had been incised and drained and found to be non-infectious.The patient was born in the Philippines and had lived in the United States for 14 years. Pertinent physical examination revealed body temperature of 98.4”E heart rate 90 beats per minute, and blood pressure 174/100 mm Hg. There was no adenopathy There was no evidence of hepatosplenomegaly or ascites. Signiticant laboratory findings showed hemoglobin 11 .O g/dL; hematocrit 3 1.4%; white blood cell count 8700/mm3. Urinalysis was unremarkable. Blood glucose was 118 mg/dL (normal range [N] = 70-100 mg/dL), blood urea nitrogen 55 mg/dL (N = 9-21 mg/dL), and creatinine 2.8 mg/dL (N = 0.71.4 mg/dL). Other results included alkaline phosphatase (ALP) 128 IU (N = 28-126 IU); aspartate aminotransfemse (ASI) 45 RJ (N = 5-40 IU); lactic dehydrogenase (LDH) 645 U/L (N = 313-618 U/L); total protein 9.0 g/dL (N = 6.3-8.2 g/dL); albumin 3.7 g/dL (N = 3.9-5.0 g/dL); phosphate 4.10 mg/dL (N = 2.2-4.10 mg/dL). Serum calcium was 12.0 mg/dL and 12.3 mg/dL (N = 8.4-10.2 mg/dL) on two occasions; ionized calcium was also elevated at 6.8 mg/dL (N = 4.5-5.6 mg/dL), but parathyroid hormone midmolecule concentration was normal at 0.7 ng/mL (N = <0.9 ng/mL).A chest x-ray was normal. Because of high serum calcium, occult malignancy was suspected. Computerized tomography (CT) of the abdomen showed diffuse thickening of the mesentery and small retroperitoneal and mesenteric nodes. Extensive investigations for underlying malignancy, including bone scan and various serum tumor markers, revealed no neoplasia. Exploratory laparotomy by an experienced oncologist indicated findings consistent with extensive