William A. Agger

Clinical Features of Clostridial Bacteremia: A Review from a Rural Area

Blood samples, which were obtained from patients who lived in a rural area with approximately 500 acute-care hospital beds, were cultured from 1990 through 1997. We retrospectively reviewed the blood cultures that yielded Clostridium species (74 [0.12%] of 63,296 cultures). These were obtained from 46 different hospitalized patients (incidents per hospital, 0.03%). The source of the Clostridium species was a gastrointestinal site in 24 patients (52.2%). The most frequently identified Clostridium species was Clostridium perfringens (in 10 [21.7%] of patients), followed by Clostridium septicum (in 9 [19.6%]). Thirty-one patients (67.4%) were aged > or =65 years, 13 patients (28.3%) had diabetes mellitus, and underlying malignancy was present in 22 patients (47.8%). The mortality rate of patients whose condition had been managed surgically was 33%; for those patients whose conditions required medical management, the mortality rate was 58%. Clostridium bacteremia in these patients usually had a gastrointestinal source, it often occurred in patients with serious underlying medical conditions, and it rarely was the result of traumatic farm accidents.

Exophiala jeanselmei Infection in a Heart Transplant Recipient Successfully Treated with Oral Terbinafine

An immunosuppressed heart transplant recipient developed Exophiala jeanselmei infection on the second toe. After unsuccessful treatment with different antifungal drugs, the infection responded to a high-dose regimen of oral terbinafine (an antifungal agent not yet approved in the United States for use against the dematiaceous fungi) and warm packs. This is, to our knowledge, the only known case of successful terbinafine treatment of E. jeanselmei infection.

Use of optical mapping to sort uropathogenic Escherichia coli strains into distinct subgroups

Optical maps were generated for 33 uropathogenic Escherichia coli (UPEC) isolates. For individual genomes, the NcoI restriction fragments aligned into a unique chromosome map for each individual isolate, which was then compared with the in silico restriction maps of all of the sequenced E. coli and Shigella strains. All of the UPEC isolates clustered separately from the Shigella strains as well as the laboratory and enterohaemorrhagic E. coli strains. Moreover, the individual strains appeared to cluster into distinct subgroups based on the dendrogram analyses. Phylogenetic grouping of these 33 strains showed that 32/33 were the B2 subgroup and 1/33 was subgroup A. To further characterize the similarities and differences among the 33 isolates, pathogenicity island (PAI), haemolysin and virulence gene comparisons were performed. A strong correlation was observed between individual subgroups and virulence factor genes as well as haemolysis activity. Furthermore, there was considerable conservation of sequenced-strain PAIs in the specific subgroups. Strains with different antibiotic-resistance patterns also appeared to sort into separate subgroups. Thus, the optical maps distinguished the UPEC strains from other E. coli strains and further subdivided the strains into distinct subgroups. This optical mapping procedure holds promise as an alternative way to subgroup all E. coli strains, including those involved in infections outside of the intestinal tract and epidemic strains with distinct patterns of antibiotic resistance.

Milkers' Nodules Complicated by Erythema Multiforme and Graft-versus-Host Disease after Allogeneic Hematopoietic Stem Cell Transplantation for Multiple Myeloma

We describe a case of cow-transmitted parapoxvirus infection--also known as milkers nodules--after a hematopoietic stem cell transplantation for multiple myeloma. The infection was complicated by erythema multiforme and acute exacerbation of graft-versus-host disease. Parapoxvirus was confirmed by electron microscopy. The natural history of milkers nodules in immunocompetent hosts is described and compared to that in our immunocompromised patient.

Clinical Comparison of Borreliacidal-Antibody Test With Indirect Immunofluorescence and Enzyme-Linked Linked Immunosorbent Assays for Diagnosis of Lyme Disease

OBJECTIVEnTo compare the clinical results with the borreliacidal-antibody test (BAT) and two standard screening serologic tests for Lyme disease (LD)-the indirect immunofluorescence assay (IFA) and the enzyme-linked immunosorbent assay (ELISA).nnnDESIGNnThe medical records of patients from an endemic LD area, who had been serologically tested during the summer of 1992, were retrospectively categorized by clinical diagnoses without results of serologic tests. Serologic testing, which included control serum samples from patients from a nonendemic LD area, was performed in a blinded fashion, and the results were compared with the clinical categories.nnnMATERIAL AND METHODSnMedical records of 307 patients who had been serologically tested for LD were reviewed. We found untreated, active LD in 43 patients (early-localized LD, 21; early-disseminated LD, 14; and late-disseminated LD, 8) and treated LD in 33. Non-LD cases were categorized into acute or chronic conditions of unknown or known cause.nnnRESULTSnOverall, the BAT had a sensitivity of 11% in active LD and did not correlate with results of other conventional surface antibody assays. The IFA and ELISA were more sensitive (67 to 93%), but false-positive results frequently were noted (20 to 40%) in acute and chronic non-LD inflammatory conditions. The specificity of the BAT, IFA, and ELISA in the control group was 96%, 93%, and 97%, respectively.nnnCONCLUSIONnUntil the sensitivity, as measured by prospective clinical studies, is improved without loss of specificity, the BAT should not be used clinically for the diagnosis of LD. Suspected cases of LD with atypical clinical manifestations should have positive ELISA and IFA results confirmed with a standardized immunoblot assay.

Acromioclavicular Septic Arthritis and Sternoclavicular Septic Arthritis with Contiguous Pyomyositis

Acromioclavicular (AC) and sternoclavicular (SC) septic arthritis with contiguous pyomyositis are rare, especially in immunocompetent individuals. We report a case of septic AC joint with pyomyositis of the deltoid and supraspinatus muscles and a separate case with septic SC joint with pyomysitis of the sternocleidomastoid muscle. Both patients had similar presentations of infections with Staphylococcus aureus and were successfully treated with surgical incision and drainage followed by prolonged antibiotic therapy.

Successful Treatment of Brainstem Blastomycosis with Fluconazole

The lipid formulation of amphotericin B is the initial drug of choice for central nervous system blastomycosis, but it is costly and associated with significant toxicity. This case report details a patient with primary pulmonary blastomycosis with dissemination to the skin, one joint, and the brainstem that was successfully treated solely with high-dose fluconazole.

Intracellular patterns of sialophorin expression define a new molecular classification of breast cancer and represent new targets for therapy

Background:Sialophorin is a transmembrane sialoglycoprotein. Normally, the molecule is only produced by white blood cells where it regulates functions such as intercellular adhesion, intracellular signalling, apoptosis, migration and proliferation.Methods:Normal breast tissue and primary breast tumours were analysed by immunohistochemistry for sialophorin expression. The sialophorin-positive breast cancer cell line MCF7 was engineered to stably express either non-targeted or sialophorin-targeted small interfering RNA (siRNA). Assays were then performed in vitro to assess apoptosis, intracellular adhesion, transendothelial migration and cytotoxicity. An orthotopic mouse model assayed ability to produce tumours in vivo.Results:Normal breast epithelial cells exhibit expression of the N-terminal domain of sialophorin in the cytoplasm but not the nucleus. The majority of these normal cells are also negative for expression of the C-terminal domain. In contrast, malignant breast epithelial cells exhibit N-terminal expression both in the cytoplasm and nucleus and the majority express the C-terminus in the nucleus. Using differential patterns of intracellular expression of the N and C termini of sialophorin, we define six subtypes of breast cancer that are independent of histological and receptor status classification. Targeting sialophorin with siRNA resulted in the MCF7 breast cancer cell line exhibiting increased homotypic adhesion, decreased transendothelial migration, increased susceptibility to apoptosis, increased vulnerability to lysis by natural killer cells and decreased ability to produce tumours in mice.Conclusion:Our results indicate that intracellular patterns of sialophorin expression define a new molecular classification of breast cancer and that sialophorin represents a novel therapeutic target.

The Clinical Presentation of Subcutaneous Phaeohyphomycosis: A Case Series from Yetebon, Ethiopia

Subcutaneous phaeohyphomycosis is a chronic fungal infection usually found on the lower extremity and feet of agricultural workers in the tropics. It can present with various skin manifestations, verrucous to nodular plaques, and is caused by multiple species of fungi. Laboratory confirmation requires skin samples for pathology and fungal cultures. Cure, often difficult in resource-poor countries, requires months of antifungal therapy. We describe the cases of three men from Ethiopia who were seen and are being treated by American doctors who traveled there on a medical mission.

Reflexive Culture for Diagnosis of Group A Streptococcal Pharyngitis Remains of Questionable Value

TO THE EDITOR—We read with interest the article by Dingle et al [1], which reported clinical features of patients with sore throat and negative rapid antigen detection tests (RADTs) but positive reflexive cultures for group A streptococci (GAS). Before we accept their conclusion that the recommendations of the Infectious Diseases Society of America [2] be called into serious question, we suggest a critical review of their study. Treatment of GAS pharyngitis, as the authors state, decreases contagiousness and also reduces pain symptoms by about 1 day [3]. However, the primary reason to treat GAS pharyngitis is to prevent its suppurative and nonsuppurative complications. Among 1023 RADT-negative, GAS culture–positive cases, the authors found 29 cases of peritonsillar abscesses, 28 of which were diagnosed at presentation. The remaining case was diagnosed 1 day following initial presentation, when there would have been insufficient time for reflexive culture results to have translated into enough antibiotic therapy to prevent the complication. Therefore, it appears that none of the tonsillar abscess diagnoses were aided by culture, nor would their treatment have been different: drainage and antibiotics.