Ramon L. Sandin

Disseminated Mycobacterium bovis after intravesicular bacillus calmette-Gu rin treatments for bladder cancer.

Transitional-cell carcinoma of the bladder is an aggressive and potentially fatal malignancy. In 1990, the US Food and Drug Administration approved the use of intravesicular bacillus CalmetteGuérin (BCG) for the treatment of superficial bladder cancer.1 BCG is a live, attenuated strain of Mycobacterium bovis (M. bovis) that has been used to treat transitional-cell carcinoma since 1976 and has been reported to eradicate disease in more than 70% of patients with in situ and stage I disease.2 The precise mechanism by which BCG acts is unknown, but a local granulomatous inflammation, centered on a T-cell–mediated immunity response, is thought to play a role.3 While the majority of patients tolerate BCG intravesicular treatments well, a number of adverse reactions (eg, fever, hematuria, dysuria, nausea, and malaise) have been reported.4,5 More serious complications include granulomatous prostatitis, pneumonitis, and hepatitis. We report a case of disseminated BCG infection causing pneumonitis that required corticosteroids and antitubercular therapy for cure.

Early identification and control of carbapenemase-producing Klebsiella pneumoniae, originating from contaminated endoscopic equipment

Klebsiella producing carbapenemase is an emerging pathogen. We report transmission of this organism by contaminated endoscopic instruments. Quick identification of source, staff education, contact precautions, and emphasis on hand and environmental hygiene led to case control and prevention of outbreak.

Detection of airborne cytomegalovirus in hospital rooms of immuncompromised patients

Human cytomegalovirus (CMV) is a major pathogen in immunocompromised patients. Transmission in this population is known to occur by fomites, but the potential for airborne spread is unknown. In this study, air from the rooms of two immunosuppressed patients with CMV pneumonia and one patient with latent infection was filtered and examined by a polymerase chain reaction assay. CMV-DNA was easily detected in the rooms of the patients with pneumonia and a weak positive signal was detected in the room of the patient with latent CMV infection. This technique permits the detection of aerosolized CMV-DNA and could possibly be adapted to detect other airborne pathogens.

Infectious complications of cutaneous t-cell lymphoma.

Cutaneous T-cell lymphoma (CTCL) is the most common primary lymphoma of the skin. As with most cancers, survival depends on the stage of disease. Infection is a common complication of CTCL, contributing significant morbidity and mortality. We report a patient with severe, generalized mycosis fungoides (MF) complicated by recurrent skin infections,and we review the infectious complications of patients with CTCL.

Mucormycosis in immunochallenged patients

Mucorales species are deadly opportunistic fungi with a rapidly invasive nature. A rare disease, mucormycosis is most commonly reported in patients with diabetes mellitus, because the favorable carbohydrate-rich environment allows the Mucorales fungi to flourish, especially in the setting of ketoacidosis. However, case reports over the past 20 years show that a growing number of cases of mucormycosis are occurring during treatment following bone marrow transplants (BMT) and hematological malignancies (HM) such as leukemia and lymphoma. This is due to the prolonged treatment of these patients with steroids and immunosuppressive agents. Liposomal amphotericin B treatment and posaconazole are two pharmacologic agents that seem to be effective against mucormycosis, but the inherently rapid onset and course of the disease, in conjunction with the difficulty in correctly identifying it, hinder prompt institution of appropriate antifungal therapy. This review of the literature discusses the clinical presentation, diagnosis, and treatment of mucormycosis among the BMT and HM populations.

Development of daptomycin resistance in a bone marrow transplant patient with vancomycin-resistant Enterococcus durans

Daptomycin has demonstrated antibacterial activity against several antibiotic-resistant strains, including vancomycin-resistant enterococci.1 A paucity of data exists concerning in vivo development of daptomycin resistance of enterococci. We describe an allogeneic bone marrow transplant patient, who was found to have vancomycin-resistant Enterococcus durans bacteremia, which subsequently developed resistance to daptomycin.

Successful voriconazole therapy of disseminated Fusarium solani in the brain of a neutropenic cancer patient

Although Aspergillus remains the most common of the opportunistic molds in patients with hematologic malignancies,disseminated Fusarium infection is increasingly encountered as more aggressive chemotherapeutic regimens and bone marrow transplants lead to prolonged neutropenia.1-11 Most frequently pathogenic to man is F solani, followed by F oxysporum, F verticillioides, and F proliferatum as the next most common12 of a dozen other species that have been documented. Still other species are significant as pathogens of plants and animals. A fatal leukoencephalomalacia of horses is caused by fumonisins that contaminate corn and corn byproducts while in the field.13 The fungus is ubiquitous in the soil and has recently been found in water and wet surfaces within a hospital with known fusarial infections.14 However, some cancer hospital epidemiologists have concluded that the external environment is the more likely source of infection to patients.15 Entry is either airborne or through a breakdown in the skin barrier,10 but central venous catheters should not be underestimated as portals of entry.5,16

Lactobacillus Bacteremia in Febrile Neutropenic Patients in a Cancer Hospital

may cause serious infection in immunosuppressed patients. CliniEmpirical antibiotic therapy for patients with febrile neutropenia cal syndromes associated with L. casei infection include endocardihas resulted in a decrease in the number of cases of bacteremia tis [1, 2], sepsis [3–6], pneumonia [7], meningitis [4], mediastinitis caused by enteric gram-negative bacilli. However, gram-positive [8], liver abscess [9], endometritis [6], amnionitis [5], and urinary organisms have emerged as a major cause of bacteremia in this tract infection [4]. Risk factors for bacteremia include neutropenia, population. We report the occurrence of a microaerophilic, gramprior surgery, malignancy, diabetes, and prior therapy with antimipositive rod, Lactobacillus casei, that caused bacteremia among a crobials inactive against Lactobacillus [5]. Empirical antibiotics significant number of febrile neutropenic patients who were receivsuch as cephalosporins, aminoglycosides, and vancomycin are freing antimicrobials active against this organism. quently used to treat febrile neutropenia but do not eradicate LactoWe reviewed the charts of 22 patients admitted to the H. Lee bacillus [5]. Patel et al. [4] reported that the use of vancomycin Moffitt Cancer Center and Research Institute in Tampa, Florida, in liver transplant recipients promoted colonization of the gastroinbetween January 1988 and June 1996. There were nine males and testinal tract and may constitute a contributing factor in the devel13 females; the mean age was 45.2 years (range, 17–69 years). opment of lactobacillemia. Lactobacillus species are usually susL. casei was isolated from the blood of all patients and from the ceptible to penicillins [1], ampicillin [2], clindamycin [4, 5], and urine of one; the organisms were cultured on both blood agar erythromycin [5], antibiotics that are not commonly used for emincubated at 357C in room air and chocolate agar incubated at 357C pirical therapy for febrile neutropenia. Bayer et al. [3] reported in a 5% CO2 environment. Species identification was performed by that a synergistic effect existed in vitro when penicillin or ampiciluse of the Vitek ANI identification system (bioMérieux Vitek, lin and gentamicin/streptomycin were used in the treatment of Hazelwood, MO). lactobacillemia. Vancomycin, used either alone or in combination Multiple species, notably Escherichia coli, Staphylococcus epiwith gentamicin or streptomycin, did not have antimicrobial activdermidis, or Candida species, were also recovered from the blood ity against Lactobacillus plantarum or L. casei. In another study of 14 study subjects. Lactobacillus bacteremia occurred in 22 paL. casei was found to be resistant to cefoxitin and vancomycin, tients with 10 types of tumors. with synergy between vancomycin and penicillin [2]. Neither A test for independent proportions indicated that bacteremia was L. casei nor Lactobacillus acidophilus was effectively controlled significantly more frequent (9 [6.01%] of 162) among patients by the use of gentamicin alone [2]. with acute myelogenous leukemia (AML) than among all others Lactobacillus becomes a potential pathogen in patients with in the hospital registry (13 [0.1%] of 9,047; t Å 4.1, P Å .0001). cancer when empirical antibiotics used to treat episodes of febrile The underlying malignancy most frequently complicated by bacterneutropenia lack activity against this organism. Capnocytophaga emia was AML (9 [5.4%] of 168), followed by all other leukemias infection, also seen in febrile neutropenic patients with mucositis, (11 [4.4%] of 250) and, rarely, breast cancer (5 [0.33%] of 1,535). similarly requires therapy with penicillin or clindamycin [10]. The The distribution of probable risk factors for lactobacillemia was widespread use of third-generation cephalosporins, aminoglycoas follows: neutropenia, 91% of patients (20 of 22); both mucositis sides, and vancomycin as empirical therapy for febrile neutropenia and neutropenia, 36.4% (8 of 22); and vancomycin therapy, 95.5% facilitates the development of lactobacillus infections. Once dis(21 of 22). Antibiotics frequently used before lactobacillus bactercovered and treated promptly, however, lactobacillus bacteremia emia occurred included vancomycin (95.5% of patients), ceftazareadily responds to treatment with penicillin, clindamycin, or dime (63.8%), tobramycin (63.8%), metronidazole (59.1%), azerythromycin in combination with gentamicin. treonam (45.5%), acyclovir (45.5%), and fluconazole (40.9%). Use

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.

Cutaneous Manifestations of Cryptococcosis

Cutaneous cryptococcosis usually is associated with concurrent systemic infection and actually may develop before clinical manifestations of cryptococcal meningitis become apparent. It is rare for a cryptococcal infection to be localized only to the skin. A case of cutaneous cryptococcosis is described in an immunocompromised patient who initially had a rash and a positive serum cryptococcal antigen titer, but no central nervous system involvement. The papular pustular skin lesions disappeared after 8 weeks of therapy with amphotericin B, which was stopped secondary to progressive azotemia. Less than 2 months after therapy, the skin lesions recurred, again without evidence of systemic disease. Treatment with oral fluconazole resulted in a gradual resolution of the cutaneous lesions. The pathogenesis of cryptococcosis is discussed, with emphasis on the management of cutaneous cryptococcosis.