Purnendu Sen

Superinfection: Another look

Superinfection in the compromised host often poses a diagnostic and therapeutic dilemma for the physician who is concerned that a perplexing array of microorganisms might be involved. We believe that the differential diagnosis list can often be narrowed considerably by separating superinfection in the compromised host into five convenient categories: (1) infections due to the underlying disease itself; (2) infections due to the underlying disease plus therapy for that disease; (3) infections due solely to medicaments, operations, or procedures; (4) infections increased in severity but probably not in incidence; and (5) societally related infections. Use of this or a similar categorization should result in a more rational approach to differential diagnosis, should encourage a more focused diagnostic work-up, whould reduce the necessity for invasive procedures, should provide the microbiology laboratory information about specific organisms that should be sought sedulously, and should permit the selection of a more rational antimicrobial regimen prior to the availability of definitive microbiologic information.

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.

The diagnostic enigma of extra-Pulmonary tuberculosis

Abstract The failure to diagnose tuberculosis during life is largely due to the decline in the index of clinical suspicion which has accompanied the reduction in prevalence of tuberculosis and to failure to appreciate changes in the epidemiological pattern of the disease. Ten patients with extra-pulmonary tuberculosis seen in one hospital during a 4-yr period illustrate contemporary diagnostic problems. In each, a diagnosis of tuberculosis was not considered initially because of lack of suspicion and consequent failure to utilize proven and accepted laboratory methods. Along with high index of clinical suspicion, some simple laboratory and diagnostic studies are of immense value. If tuberculin tests are negative in the initial phase, and become positive during the course of an illness with non-specific symptoms, this may indicate a tuberculous etiology. Equally significant is the unexplained rise in alkaline phosphatase resulting from granulomatous involvement of the liver. With modern chemotherapeutic drugs available, tuberculosis is now usually a curable disease. Physicians, therefore, must be aware of the problem of undiagnosed tuberculosis, particularly in elderly patients and must pursue proper investigations so that chemotherapy can be initiated early in the course of the illness.

Rapidly Progressive Necrotizing Fasciitis and Gangrene Due to Clostridium difficile: Case Report

A case of rapidly progressive necrotizing fascitis and gas gangrene due to Clostridium difficile that responded very well to surgical intervention is described.

Coccidioidomycosis and Blastomycosis: Endemic Mycotic Co-Infections in the HIV Patient

Opportunistic fungal infections including aspergillosis species, candida species, and fusarium can be found in HIV-infected patients. Disseminated diseases due to endemic mycoses including histoplasmosis, coccidioidomycosis, and blastomycosis are all being reported among HIV patients who reside in the known endemic areas. However, in the non-endemic areas, or due to the rarity of these pathogens, it might be difficult to recognize these unfamiliar disease presentations. We report a patient with HIV who had dual infections with endemic mycotic infections of coccidioidomycosis and blastomycosis, as he had a brief stay in the endemic area.

Anaerobic Infections of the Pelvis

&NA; In normal nonpregnant women anaerobes predominate in the cervicovaginal flora. The frequency of Bacteroides fragilis isolation ranges up to 16%. In pregnancy anaerobic prevalence falls progressively from the first to the third trimester and increases precipitously immediately after delivery. Anaerobes are often responsible for infections from vulva to ovaries, but the microbial etiology of post‐cesarean section endometritis remains unclear. Risk factors for pelvic infection include cesarean delivery as contrasted with vaginal delivery; among those undergoing cesarean section, risk factors for infection are prolonged labor, prolonged membrane rupture, excessive numbers of vaginal examinations, and perhaps age of less than 17 years. Gonorrhea is also a risk factor for subsequent pelvic infection. The use of an intrauterine contraceptive device is associated with increased risk of pelvic actinomycosis. Anaerobic disease often is associated with a putrid odor and may present as 1 or more pulmonary emboli. Optimal treatment of pelvic anaerobic infections is not yet agreed upon. Clindamycin and chloramphenicol are the 2 documented firstline agents. Penicillin is often effective but a substantial percentage of B fragilis strains resist it; this is also true of carbenicillin. The data on cefoxitin look encouraging, but more data are needed on both the efficacy and the frequency of superinfection.

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.

Modification of an experimental mouse Candida infection by human dialyzable leukocyte extract

Human dialyzable leukocyte extract (10(7) - 10(8) leukocyte equivalents, containing transfer factor) was administered intraperitoneally to CFW mice the day of and 2 days after intravenous infection with Candida albicans. Tissue Candida populations were determined immediately after and 2, 4, 7 and 14 days after infection. Kidney populations were significantly reduced on 27% of the days studied. Similar reduction in C. albicans census was obtained after injection of leukocyte extracts from donors skin test-positive to Candida antigens or donors negative to Candida antigens by skin test and migration inhibition analyses. There was no evidence of a dose-response relationship for leukocyte extract in the range 10(5) - 10(9) leukocyte equivalents. When mice were primed with C. albicans antigen 4 weeks prior to challenge the efficacy of leukocyte extracts was not augmented. There was no evidence that the infection-reducing effects were related to augmented polymorphonuclear leukocyte mobilization, increased mononuclear clearance of C. albicans, or to a direct toxic effect on C. albicans blastospores. These studies suggest that the reduction in Candida populations was non-specific and give further impetus to the use of the dialyzable leukocyte extracts as non-specific supplements to antibiotics in overwhelming or recalcitrant infections in man.

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