Rajendra Kapila

Central Nervous System Tuberculosis with the Acquired Immunodeficiency Syndrome and Its Related Complex

Central nervous system tuberculosis occurred in three patients with the acquired immunodeficiency syndrome (AIDS) and seven patients with AIDS-related complex who were evaluated for 48 months. Nine patients were intravenous drug abusers and one was Haitian. Five patients had cerebral-ring-enhancing lesions and three had hypodense areas. The clinical spectrum included meningitis in two patients, multiple cerebral abscesses in one, and tuberculomas in four. All Mycobacterium tuberculosis isolates were sensitive to standard antituberculous drugs. All patients received treatment with isoniazid, rifampin, and pyrazinamide; six patients also received streptomycin. Three patients with AIDS died of opportunistic infection preceded by central nervous system tuberculosis. Among the patients with the AIDS-related complex, three improved with treatment, three were lost to follow-up, and one died. Tuberculosis should be considered in the differential diagnosis of central nervous system mass lesions in intravenous drug abusers with AIDS or AIDS-related complex. Because patients with tuberculosis can be cured, biopsy of accessible brain mass lesions should be mandatory. Preventive therapy may be indicated in drug abusers without disease.

Actinomycetales Infection in the Acquired Immunodeficiency Syndrome

Four parenteral drug abusers with the acquired immunodeficiency syndrome had nonmycobacterial actinomycetales infections. Three patients had nocardiosis and one developed a streptomyces lymphadenitis. There was pericardial involvement in two patients, and two patients died. Presumptive diagnoses were often incorrect, highlighting the risks of empiric therapy in these patients. Four of the nine patients with the acquired immunodeficiency syndrome and nocardia or streptomyces infections whose cases were reported to the Centers for Disease Control also had mycobacterial disease. A common susceptibility to these agents may exist in these immunosuppressed patients.

Necrotizing fasciitis: a deadly infection

Necrotizing fasciitis (NF) is a life‐threatening condition, consisting of a soft‐tissue infection with rapidly progressive, widespread fascial necrosis. NF may be caused by a wide variety of microbes. Indeed, NF may be an infection of one species of bacteria or may be polymicrobial. Prompt diagnosis and treatment are essential. Surgical debridement and antibiotic therapy are the primary treatment options.

Infection after insertion of alloplastic orbital floor implants.

Ten patients developed infections after alloplastic implantation (nine silicone, one gelatin film [Gelfilm] implant) for orbital floor fracture repair. Infection resulted from the following: (1) dental surgery, (2) upper respiratory infection, (3) inferior extrusion of a retained implant into the maxillary sinus with a fistulous tract into the inferior conjunctival fornix, (4) rhinoplasty, (5) snorting cocaine and other drugs, (6) postoperative infection after orbital floor repair, and (7) medial implant migration resulting in chronic dacryocystitis. In all ten patients, implants were removed because of orbital abscess, recurrent infection, or chronic low-grade infections. Microbiologic culture of removed implants disclosed Staphylococcus aureus, S. epidermidis, Serratia marcescens, and Pseudomonas aeruginosa as the offending organisms. The main complication of infection included severe cicatricial ectropion of the lower eyelid in three patients. The final globe position was not adversely affected by implant removal performed from five months to 20 years after insertion. Guidelines for prevention and management of orbital implant infections based on these ten patients are presented.

Diffuse cutaneous leishmaniasis associated with the immune reconstitution inflammatory syndrome

Leishmaniasis is an emerging disease in HIV‐infected persons; visceral leishmaniasis is an AIDS‐defining opportunistic infection. The parasite that causes this infection is usually transmitted by the sandfly and occasionally by nonsterile needles among intravenous drug users. Diffuse cutaneous leishmaniasis (DCL) is a rare anergic variant of leishmanial infection with the characteristic presentation of numerous nonulcerating nodules with an abundant parasite load, lack of visceral involvement, negative reaction to the leishmanin skin test, and a chronic course with incomplete response to treatment and frequent relapses. We report a case of DCL that developed in the context of the immune reconstitution inflammatory syndrome (IRIS) in a man with AIDS following initiation of antiretroviral therapy. We also review DCL to emphasize the importance of recognizing and treating this evolving disease in the growing population of patients on immunorestorative therapy.

Cutaneous and mucocutaneous leishmaniasis: Clinical perspectives

Leishmaniasis is endemic in 98 countries and territories, with 1.2 million new cases per year, making it a worldwide concern. The deadly visceral form is a leading cause of death from tropical parasitic infections, second only to malaria. Leishmaniasis appears to be increasing in many countries because of extended urbanization. The disease reservoir includes small mammals; parasite transmission occurs via bite of the female phlebotomine sandfly. Disease manifestations vary and largely depend upon the Leishmania species acquired. It may be first evident with a range of findings-from a localized cutaneous ulcer to diffuse painless dermal nodules-or, in the mucocutaneous form, ulceration of the oropharynx. In the potentially deadly visceral form, the internal organs and bone marrow are affected.

Cutaneous and mucocutaneous leishmaniasis: Differential diagnosis, diagnosis, histopathology, and management

The diagnosis of leishmaniasis can be challenging because it mimics both infectious and malignant conditions. A misdiagnosis may lead to an unfavorable outcome. Using culture, histologic, and/or polymerase chain reaction study results, a diagnosis of leishmaniasis can be established and treatment initiated. Appropriate management requires an accurate diagnosis, which often includes identification of the specific etiologic species. Different endemic areas have varying sensitivities to the same medication, even within individual species. Species identification may be of practical value, because infections with select species have a substantial risk of visceral involvement. In addition, HIV and otherwise immunocompromised patients with leishmaniasis have a propensity for diffuse cutaneous leishmaniasis. For most New World Leishmania species, parenteral antimonial drugs remain the first line of therapy, while Old World species are easily treated with physical modalities. Historically, live organism vaccination has been used and is effective in preventing leishmaniasis, but results in an inoculation scar and an incubation period that may last for years. A more effective method of vaccination would be welcome.

Rocky Mountain spotted fever

Rocky Mountain spotted fever (RMSF) is an unusual but important dermatological condition to identify without hesitation. The classic triad of headache, fever, and a rash that begins on the extremities and travels proximally to involve the trunk is found in a majority of patients. The cutaneous centripetal pattern is a result of cell to cell migration by the causative organism Rickettsia rickettsii. Such individuals should receive prompt antimicrobial therapy and supportive care to avoid serious and potentially fatal complications.

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.

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.