Julie A. Larkin

Rapidly Progressive Herpetic Retinal Necrosis: A Blinding Disease Characteristic of Advanced AIDS

Eleven patients with rapidly progressive herpetic retinal necrosis (RPHRN) complicating AIDS were investigated retrospectively to study the disease spectrum, systemic involvement, and therapy. The mean CD4 cell count was 24/microL. There was a characteristic disease pattern with rapid progression, 82% bilaterality, relative resistance to intravenous antiviral therapy, and 70% retinal detachment. Varicella-zoster virus was the probable cause in 10 patients (detected by polymerase chain reaction in two eyes investigated), and herpes simplex virus was the probable cause in one. Cutaneous zoster occurred previously in 73% but was not concurrent. Seventy-three percent had central nervous system disease, possibly virus-related. RPHRN may be a local herpetic recrudescence in an immune-privileged site with transneural spread. Only four of 20 affected eyes retained useful vision. Poor ocular bioavailability, retinal ischemia, acquired drug resistance, and strain pathogenicity may underlie treatment failure. Acyclovir therapy appears relatively ineffective. Combined intravenous and intravitreal therapy with foscarnet and ganciclovir may be the best current management. Research advances are needed urgently.

Congenital tuberculosis and management of exposures in a neonatal intensive care unit.

OBJECTIVES We report a case of congenital tuberculosis in a neonatal intensive care unit (NICU) and the management of exposure to other neonates in the hospital. We review the literature regarding congenital tuberculosis and management of exposures in the NICU. DESIGN Case report and a survey of exposures with a 3-month follow-up. SETTING Urban hospital. PATIENTS Neonates exposed to a case of congenital tuberculosis. INTERVENTIONS Exposure to tuberculosis was treated with isoniazid. Purified protein derivative tests were placed at baseline and 3 to 4 months after exposure. Chest radiographs were performed if clinically indicated. RESULTS Congenital tuberculosis was diagnosed in our patient at 21 days of age during a prolonged hospital course. After initiation of anti-tuberculous medications, the patient gradually recovered from his illness. While he was treated in the NICU, there were 37 potentially exposed infants. Of these, 36 were administered tuberculin skin tests (average age, 1.7 months), all of which were read as 0 mm of induration. Of those 37, 35 began prophylaxis with isoniazid, and 30 were able to complete treatment with a minimum of 3 months of isoniazid therapy. Of those 30, two infants received 6 months of therapy. Additionally, 29 of the 37 infants had chest radiographs, none of which showed suspicious infiltrates or adenopathy. Finally, 30 of the 36 infants had repeat tuberculin skin tests at 3 months, all of which were read as 0 mm of induration (average age, 3.7 months). CONCLUSION Congenital tuberculosis is an uncommon disease t hat requires early diagnosis for successful therapy and vigilant follow-up of potential exposures in the NICU.

Primary cutaneous aspergillosis : Case report and review of the literature

Primary cutaneous aspergillosis is an uncommon entity that may occur in immunosuppressed hosts, usually resulting from contact with contaminated medical devices used in patient care. The infection spreads locally with subsequent skin necrosis due to angioinvasion and thrombosis. We report primary cutaneous aspergillosis following contact with contaminated gauze, and we review the relevant literature.

Staphylococcus epidermidis Endocarditis Treated with RP 59500 (Quinapristin/Dalfopristin)

Staphylococcus epidermidis is a common cause of prosthetic valve endocarditis (PVE). Treatment for this condition consists of combination antibiotic therapy including vancomycin, rifampin, and gentamicin. We describe a patient who had a severe allergic response to vancomycin during therapy for PVE due to methicillinresistant Staphylococcus epidermidis (MRSE). A 44-year-old male with a history of St. Jude mitral-valve replacement 6 months earlier presented with cough, fever, and dyspnea. Physical examination revealed only a systolic murmur. A transesophageal echocardiogram (TEE) revealed a mitral annular abscess, multiple vegetations, and instability of the prosthetic valve

Human T-Cell Lymphotropic Virus-Type I

HTLV-I is a retrovirus now identified as the etiologic agent of two diverse disease processes: ATLL, an aggressive T-cell malignancy; and TSP/HAM, a chronic progressive myelopathy. Transmission can occur horizontally through blood transfusions, IV drug abuse and sexual intercourse. Vertical transmission may also occur. Available diagnostic modalities are serologic in nature and include the EIA and the more specific confirmatory assays WIB and RIPA. These studies are thus far suboptimal in terms of sensitivity and specificity, and await refinement. DNA amplification by the polymerase chain reaction seems to hold the most immediate diagnostic promise for the future. AZT apparently is not useful clinically, and current treatment is only palliative in nature. The diverse diseases caused by HTLV-I underscore the insidious nature of the Retroviridae family. These subtle cell-associated pathogens will undoubtedly be shown to play a significant role in other disease processes of uncertain etiology.

A Graceful Exit: Life and Death on Your Own Terms

Death is a punishment to some, to some a gift, and to many a favor .—Seneca (4 BC-65 AD) In A Graceful Exit , Lofty Basta, MD, a renowned cardiologist, offers a unique perspective on life and death. His book is based both on his personal battle with prostate cancer and on a lifetime of joining patients in their often losing battles against disease. Dr Basta paints a dramatic image of the medical torture we might experience in the hospital at the end of life if we cannot face the reality and inevitability of death. In A Graceful Exit he explores and illuminates many issues involving the end of life. He introduces definitions of death, the impact of advancing medical technology, excessive treatment, landmark legal cases, euthanasia, and living wills. He explores the slippery slope of prolonging life vs prolonging dying. Basta addresses the controversy over defining death and resolves that