Yechezkel Sidi

Pacemaker endocarditis. Report of 44 cases and review of the literature.

We conducted a retrospective study to characterize the clinical course, microbiologic spectrum, and risk factors for endocarditis and for associated mortality in a large series of patients with documented pacemaker endocarditis. Using a computerized search through the medical records of 10 major hospitals in Israel from 1982 to 1992, and carefully reviewing the charts, we identified 44 patients with pacemaker endocarditis. The cases were categorized as definite (n = 25), probable (n = 12), or possible (n = 7) infective endocarditis based on strict case definition. Fever and chills were the most common symptoms. Increased ESR, leukocytosis, microscopic hematuria, and anemia were the most common laboratory findings. A relatively high proportion of the patients were diabetic. The most common source of endocarditis was infection acquired by the placement procedure or infection of the pacemaker pouch. Demographic, clinical, and laboratory features were similar to those of endocarditis patients of a similar age range without pacemakers, although the frequency of fever and chills was higher in our patients than in those patients and splenomegaly, vascular embolic phenomena, and new or changing murmurs were rare in our patients. The major pathogens were Staphylococcus aureus and Staphylococcus epidermidis, similar to other series of pacemaker-associated bacteremia and similar to the microbiologic findings of early prosthetic-valve endocarditis. However, this microbiologic profile is different from that of native-valve endocarditis. Although the present series did not show a statistically significant advantage to electrode removal over conservative treatment, when analyzed together with pooled data from other studies, it suggests that the surgical approach is preferable.(ABSTRACT TRUNCATED AT 250 WORDS)

Serological and molecular survey for HTLV-I infection in a high-risk Middle Eastern group

To define the extent of human T-cell leukaemia virus (HTLV-I) infection among a group of Jewish immigrants to Israel with an increased frequency of adult T-cell leukaemia, various serological and molecular screening methods, including enzyme-linked immunosorbent assay (ELISA) for anti-HTLV-I, ELISA for antibody to recombinant HTLV-I p40tax protein, and molecular detection of infection by polymerase chain reaction (PCR) amplification of HTLV-I proviral DNA from peripheral blood mononuclear cell DNA, were used. By HTLV-I ELISA the overall rate of infection was 12% (24 of 208) among immigrants from Khurusan, northeastern Iran; no HTLV-I carriers were detected among 111 unselected Jewish immigrants from other parts of Iran. There was unexplained clustering of HTLV-I infection within a cohort of 32 elderly women of similar geographic origin in a home for old people--14 were seropositive by ELISA and 19 of 29 were positive by PCR. The findings in this newly identified high-risk population suggest that in addition to ELISA, other screening techniques may be required to detect all carriers in high-risk populations.

Epidemiology of travel-related hospitalization.

BACKGROUND Limited information exists on causes of hospitalization in patients returning from the tropics, and most is focused on febrile diseases. We evaluated all causes of post-travel hospitalization in a tertiary care hospital in Israel. METHOD Demographics, diagnoses, and destinations of patients admitted between January 1999 and December 2003 with a history of recent travel were recorded. Demographics and destination of healthy travelers presenting to our pretravel clinic at the same period were recorded. RESULTS Of 211 patients admitted, 71% were males, 8% were immigrants/foreign workers, and febrile diseases accounted for 77% of admissions. The most common diagnoses were malaria in 54 (26%), unidentified febrile disease in 34 (16%), and dengue fever in 27 (13%). New World cutaneous leishmaniasis was the most common cause of admission among nonfebrile patients (18 [9%]). Diarrheal diseases accounted for only 11% of admissions. Regarding destination, 101 (48%) patients had been to Asia, 71 (34%) to Africa, and 43 (20%) to the Americas. Of our healthy traveler population, 59% traveled to Asia, 20% to Africa, and 20% to the Americas. Travel to Africa carried the highest risk of being hospitalized (OR 1.85, 95% CI 1.16-2.97; p = .01). Most (59%) patients returning from Africa had malaria. The principal health problem originating in Asia was dengue fever (27%), and from Latin America, cutaneous leishmaniasis (48%). Males comprised 71% of the patients, and 59% of the healthy traveler population (p < .0001). Males were more likely to acquire malaria (OR 2.15, 95% CI 1.13-4.09; p = .02) and leishmaniasis (OR 3.41, 95% CI 0.97-11.89; p = .05). CONCLUSIONS Febrile diseases were the most common cause for hospitalization, with malaria, unidentified febrile diseases, and dengue fever being the most common. Diseases were destination related; travel to Africa was associated with a higher rate of hospitalization. Malaria and cutaneous leishmaniasis had a substantially male predominance, probably due to risk-taking behavior.

Association of Serum Uric Acid and Cardiovascular Disease in Healthy Adults

Studies in different populations with high risk for cardiovascular disease (CVD) have shown an association between serum uric acid (SUA) and CVD. However, only a few studies have demonstrated such an association in healthy populations. The aim of this study was to investigate the association between SUA and CVD in a cohort of men and women without diabetes or CVD. A retrospective study was conducted, with a mean 4.8-year follow-up. The outcome was the occurrence of a cardiovascular event, defined as the diagnosis of ischemic heart disease, acute coronary syndrome, acute myocardial infarction, or ischemic stroke. Mean SUA levels were 6.2 ± 1.1 mg/dl for men (n = 6,580) and 4.4 ± 1.1 mg/dl for women (n = 2,559). For women, the rate of CVD occurrence was 11.6% for the highest quartile of SUA level, compared with 5.0% to 6.5% for the lower 3 quartiles. For men, the rate of CVD occurrence was 14.0% for the highest quartile of SUA level, compared with 10.8% for the lowest quartile. The hazard ratio for CVD, adjusted for age, serum creatinine level, body mass index, systolic blood pressure, low-density lipoprotein cholesterol level, triglyceride level, plasma fasting glucose, physical activity, cardiovascular family history, use of diuretics, and current smoking, was 1.24 (95% confidence interval 1.08 to 1.41) for women and 1.06 (95% confidence interval 1.00 to 1.13) for men (p for interaction = 0.04). In conclusion, the strong association of SUA levels with CVD in women, compared with the much lesser degree in men, highlights the necessity of stratifying by gender in investigations of cardiovascular risk factors and supports exploration of SUA as a marker of CVD risk in healthy populations.

Rheumatic Manifestations Preceding Adult Acute Leukemia: Characteristics and Implication in Course and Prognosis

The manifestations and outcome of adult patients with acute leukemia (AL) were examined to study the characteristics of the rheumatological prodrome of AL and to find whether it is a marker of a distinct clinical and laboratory course and whether it has any prognostic implication. During a 10-year period, 8/139 (5.8%) of AL patients presented with rheumatic manifestations. The average duration of the arthritis syndrome preceding the diagnosis of AL was 3.25 months. The most common pattern of presentation was a reactive arthritis-like syndrome involving the large joints asymmetrically and associated with low back pain. Distinctive features suggesting a paraneoplastic arthritis were severe pain disproportionate to physical findings, a poor response to conventional antirheumatic treatment, and early significant osteopenia or lytic bone lesions. The epidemiological, clinical and laboratory characteristics of patients with or without rheumatic manifestations were comparable, except for fever on presentation, the presence of transient metabolic derangement following chemotherapy, and the initial average hemoglobin, hematocrit and serum uric acid values. Moreover, the initial outcome of the two groups was similar, as the early mortality rates were comparable (42.8% vs. 45% for patients with or without arthritis, respectively). In conclusion, rheumatic syndrome presentation of adult AL is uncommon, and apparently has no deleterious effects on initial prognosis. A timely diagnosis requires an increased awareness to distinctive features.

Acute Coronary Events Following Cisplatin-Based Chemotherapy

Six patients with no previous signs or symptoms suggestive of coronary artery disease developed acute coronary ischemia/infarction shortly after cis-diamine-dichloroplatinum II (cisplatin) -based chemotherapy. In two patients this was the sole chemotherapeutic agent used. One patient underwent coronary angiography which disclosed no pathology, but following which, while on a calcium channel blocking agent regimen, he had an uneventful course of chemotherapy with cisplatin. Documentation of cisplatin-related vascular events is important in view of the growing number of patients who undergo cisplatin-based chemotherapy.

Native Valve staphylococcus epidermidis Endocarditis: Report of Seven Cases and Review of the Literature

This report describes seven patients from three university hospitals whose native valve infective endocarditis was caused by Staphylococcus epidermidis. The literature on endocarditis caused by S. epidermidis is also reviewed and the clinical features of patients with native valve endocarditis due to this organism are compared with those of patients from a general series of infective endocarditis cases. Compared with infective endocarditis caused by other organisms, S. epidermidis endocarditis tends to occur more frequently in male patients. Patients with S. epidermidis endocarditis exhibit fewer embolic complications and skin manifestations. The frequency of congestive heart failure is lower in this group. The relative indolent course and apparent rarity of native valve S. epidermidis endocarditis necessitate a high index of suspicion for early diagnosis.

Adult T-cell lymphoma in Israeli patients of Iranian origin.

The clinical and laboratory features of four Israeli patients with adult T‐cell lymphoma‐leukemia (ATL) are presented. In three of them evidence for human T‐cell lymphotropic leukemia virus (HTLV‐I) infection was obtained. Interestingly, all of the patients immigrated to Israel from the same regions in Iran. Except for lack of skin involvement, the clinical course was typical for ATL as described worldwide. This is the first report of ATL in an Iranian cohort. This observation suggests that Iranian patients with ATL‐like illness should be studied for the presence of HTLV‐I infection.

Lactic Acidosis and Fatal Myocardial Failure Due to Clozapine

Objective To describe a patient with neutropenic fever complicated by hyperglycemia, lactic acidosis, and fatal myocardial failure associated with clozapine therapy. Case Summary A 37-year-old Ashkenazic Jewish man was admitted for agranulocytosis and fever, which developed after 11 weeks of clozapine monotherapy for drug-resistant schizophrenia. Complete blood counts and a routine serum chemical analysis had been normal before the treatment was initiated, and remained within normal limits during the first 10 weeks of the treatment. On the day of admission, the patient deteriorated rapidly and developed extreme hyperglycemia, severe lactic acidosis, recurrent cardiac arrest, cardiogenic shock, and coma. He died 36 hours later despite intensive treatment. Discussion Clozapine intake induced fatal aganulocytosis, associated with hyperglycemia, lactic acidosis, and heart failure. White blood cell count monitoring was insufficient to predict these adverse effects. Conclusions Clozapine should be avoided in high-risk patients (e.g., the elderly, women, Ashkenazic Jews).

Sexually transmitted brucellosis in humans.

Sexual transmission of brucellosis has rarely been reported in humans. We describe 2 cases of probable sexual transmission of Brucella from husband to wife. In 1 case, orchidoepididimitis existed, whereas in the other case, the presence of Brucella in the semen in the absence of genital symptoms was demonstrated by polymerase chain reaction.