A patient with penicillin-resistant viridans group streptococcal endocarditis and unusual reactions to vancomycin.

There is a paucity of data regarding the treatment of endocarditis caused by penicillin-resistant viridans group streptococci (PR-VGS). We report a 16-year-old girl who had native-valve endocarditis due to PR-VGS which was identified as Streptococcus mitis. She also had unusual reactions to vancomycin. Eighteen hours after initiation of 50 mg/kg/day vancomycin, she developed a maculopapular rash, then at 48 hours she developed an intermittent high fever and a progressive decrease in peripheral leukocytes and platelets. She developed hypotension on Day 8. Her serum C-reactive protein and procalcitonin levels were high. All reactions improved after vancomycin was discontinued and oral prednisolone was started. This unusual combination of reactions to vancomycin was likely caused by immune and nonimmune mechanisms. Her endocarditis was successfully treated with cefotaxime 200 mg/kg/ day for 4 weeks.

Skin diseases during floods in Thailand.

BACKGROUND: Floods are natural disasters that occur occasionally in Thailand. The most common form skin diseases due to floods are infectious dermatoses especially superficial fungal infection. However the microbiologic evidences have not been evaluated. OBJECTIVE: To evaluate the most common skin diseases during floods and identify the organism that causes skin maceration at web space(s) of toes (Hong Kong foot). MATERIAL AND METHOD: Patients who complained of skin problems were evaluated at the temporary outpatient clinic during October 2006. Skin specimens from all patients who had itches and skin maceration at web space(s) of toes were cultured. RESULTS: Ninety-six patients were evaluated (38 males and 58 females). Eczema was the most prevalent dermatosis, which accounted for 34.5% of the total skin problems and the great majority of these cases were irritant contact dermatitis. Sixteen cases presented with itch and skin maceration at web space(s) of toes. All of them were colonized with various microorganisms. Gram-negative bacilli were the most prevalent ones and were found in 14 out of 16 specimens. Fungal culture was positive in only two specimens. CONCLUSION: Eczema is the most common dermatosis during floods. Skin maceration at web space(s) of toes, which were thought to be fungal infection, are chronic irritant dermatitis with secondary bacterial colonization. Only a few cases were fungal infection. Microbiologic investigation should be done in these patients. Unfortunately, it is not practical in such a situation. Topical medications that have the combination of antiinflammatory, antibacterial and antifungal properties are the most suitable medications.

Invasive fungal infection in Ramathibodi Hospital: a ten-year autopsy review.

OBJECTIVE: Determine the clinicopathological findings in autopsy cases with invasive fungal infection. MATERIAL AND METHOD: The autopsy and medical records with invasive fungal infection in Ramathibodi Hospital between January 1997 and December 2006 were analyzed. The criterions for the diagnosis of invasive fungal infection were the evidence of fungal elements from histopathological section. The age, gender underlying predisposing risk factors for the disease, clinical manifestations, extent of systemic organ involvement documented morphologically at autopsy, and fungal culture were analyzed RESULTS: There were 155 autopsy cases (73 male, 82 female; mean age 45.3 years, range 3 months to 87 years) with the diagnosis of invasive fungal infection. The common clinical presentations were fever (55.5%), and dyspnea (26.5%). The invasive fungal infection was associated with hematologic malignancy in 31%. The common mycoses were aspergillosis and candidiasis, which were observed in 88 and 80 cases, respectively. There were 32 cases (20.6%) of mixed fungal infection. Cultures from autopsy materials were positive for fungus in 80 cases out of 99 cases (80.8%). The most frequent site of fungal infection was in the lungs (74.8%), followed by gastrointestinal tract (28.4%), and brain (26.5%). Invasive fungal infection was diagnosed intravitally in 63.9% of total cases. CONCLUSION: A diagnosis of invasive fungal infection requires a high index of suspicion, especially in immunocompromised patients who presented with prolonged fever Clinical specimens must be sent for histopathology and fungal culture for a definite diagnosis and an appropriate management. Therefore, the physician should inform the laboratory if invasive fungal infection is suspected because special media are necessary for the best recovery of fungi. In addition, the present study underscores the significance of autopsy as a diagnostic method and means of medical quality control.

Detection of heterogeneous, intermediate-vancomycin-resistant Staphylococcus aureus (hVISA) using low-concentration vancomycin disks.

Heterogeneous, intermediate-vancomycin-resistant Staphylococcus aureus (hVISA) represents a threat of an incurable infection since the first report in 1997. The method used to detect hVISA isolates is a population analysis profile (PAP); however, it is impractical for routine laboratory analysis. We therefore tested a simple, reliable and inexpensive method for the detection of hVISA. Eighteen isolates of hVISA and 22 of vancomycin-sensitive S. aureus (VSSA) were included. The organisms were tested by the disk diffusion method, using 15-microg vancomycin disks on four different media: Mueller-Hinton agar (MHA), MHA plus 2% NaCI (MHAS), Brain Heart Infusion agar (BHA), and BHA plus 2% NaCl (BHAS). In addition, two different inoculum sizes, bacterial suspensions adjusted to 0.5 and 2.0 McFarland, were tested. The inhibition zone was read independently by three medical technologists after incubation at 37 degrees C for 24 and 48 hours. The use of MHAS with an inoculum size of 2.0 McFarland and 48-hour incubation period yielded the highest sensitivity (94.4%), specificity (81.8%), positive predictive value (80.9%), and negative predictive value (94.7%). The disk diffusion test with 15-microg vancomycin disk is simple and may be used as a screening method for the detection of hVISA.