Clinical differences between pulmonary and extrapulmonary tuberculosis: a 5-year retrospective study.

This article describes the clinical, epidemiologic, laboratory, and treatment characteristics of pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) in Eastern North Carolina, a primarily rural area. The database was obtained for 1988-1992 from the University Medical Center of Eastern North Carolina-Pitt County and East Carolina University School of Medicine (the tertiary care referral center for this region). One hundred thirty-eight culture-positive patients were enrolled in the study; 56% were PTB and 44% were EPTB. African-American males constituted 59% of the population. Sixty-nine percent of the patient base were uninsured. There was a bimodal age distribution of < 40 and > 60 years of age. Factors associated with PTB (reported as odds ratios) were white males (2.5), diabetes mellitus (5.4), and cancer (5.1). Factors associated with EPTB (reported as odds ratios) were African-American females, positive human immunodeficiency virus (HIV) serology (8.7), low hematocrit (32.6), and elevated alkaline phosphatase (199). This study emphasizes that in the latest resurgence of tuberculosis, impoverished rural areas, which have been ignored in earlier and present control efforts, are important reservoirs of disease.

Heimlich valve treatment of Pneumocystis carinii-associated pneumothorax.

Two patients were treated for AIDS-associated bilateral pneumothoraces which persisted despite prolonged chest tube drainage. Heimlich flutter valves were used to facilitate the outpatient management of these patients.

Magnetic resonance imaging as an adjunct to sonography in the evaluation of the female pelvis.

Magnetic resonance imaging (MRI) of the pelvis is generally considered to be most beneficial in those cases where the pelvic sonogram is limited or equivocal. All cases that underwent both sonographic and MRI examinations at our institution for the evaluation of the female pelvis in the past two years were retrospectively reviewed. We reviewed the sonographic and MRI reports and the subsequent clinical management in the 41 cases that had both studies to assess whether MRI contributed to the clinical management decision. Both studies were interpreted independently based upon the known clinical and laboratory data available at the time. MRI was obtained in 21 cases because the sonogram was suboptimal or inconclusive. In the other 20 cases it was obtained for additional information, even though the sonogram was diagnostic. Of the 21 inconclusive sonographic studies, MRI established or clarified the diagnosis in all cases. Of the 20 studies where MRI was obtained for additional information, MRI added useful data that helped contribute to the clinical management of 11 patients. MRI is an important adjunct to pelvic sonography. It established, clarified, or added significant data in 78% of cases.

Rocky Mountain spotted fever presenting as thrombotic thrombocytopenic purpura.

A patient presented with findings compatible with thrombotic thrombocytopenic purpura. The diagnosis of Rocky Mountain spotted fever was also considered because the patient was a hunter in a tick-infested area. He was treated for both diagnoses. The patient recovered and a diagnosis of Rocky Mountain spotted fever was confirmed by serologic methods. Clinical symptoms and hematologic parameters of severe Rocky Mountain spotted fever may resemble thrombotic thrombocytopenic purpura, implying that there may be similarities in the pathophysiology of both disorders.

Automated radiographic report generation using barcode technology.

Barcode reporting is a method of automated report preparation made possible by advancing computer technology, which may improve radiographic services and reduce their costs. This reporting method for normal examinations in a hospital-based radiology practice has been well accepted by radiology staff and has encouraged further applications. A free-text barcode system for reporting mammographic examinations subsequently has been developed and has further reduced dependency on transcription services, with little or no increase in radiologist's workload. Most radiologists in the department with the system believe it has had a positive impact on radiographic services, and almost two-thirds of them would consider using this kind of reporting system in a private-practice setting.

Velo-pharyngo-laryngeal myoclonus: evaluation of objective tinnitus and extrathoracic airway obstruction.

Velo-pharyngo-laryngeal myoclonus, the rapid, rhythmic contraction of muscles of the pharynx and larynx, is a rare neurological manifestation of numerous disease processes affecting the cerebellum. In its most common form, palatal myoclonus, this disease frequently presents to the otolaryngologist as objective tinnitus. Impedance audiometry provides a useful means of verifying suspected palatal myoclonic activity through recorded changes in the middle ear pressure, as mediated by muscle activity at the proximal portion of the eustachian tube. A very rare case of velo-pharyngo-laryngeal myoclonic with clonic contraction of the laryngeal adductors and subsequent extrathoracic airway obstruction is presented. Tracheostomy provided immediate symptomatic relief of dyspnea.

Synergistic action of trimethoprim and sulfamethoxazole for Nocardia asteroides: efficacious therapy in five patients.

Eighteen isolates of Nocardia asteroides were tested for in vitro susceptibility to trimethoprim (TMP) and sulfamethoxazole (SMZ) alone and in various combinations using disc and paper strip diffusion tests. TMP-SMZ showed synergistic action for two-thirds of teh nocardia isolates tested. Five patients with Nocardia pneumonia were treated with TMP-SMZ and all were cured. Four of the patients' isolates were tested and all showed synergistic patterns of inhibition with the spaced disc and paper strip methods. The agar diffusion disc and synergy tests of TMP-SMZ appear to correlate with clinical usefulness when the Nocardia are susceptible with large zones of inhibition around the combination TMP-SMZ disc.

Infections in the alcoholic.

Serious infections appear to occur more frequently in alcoholic patients. However, whether this is due to the effects of alcohol per se or to the other frequent complications of alcoholism--nutritional deficiencies, cirrhosis, and poor hygiene--has not been determined. The host factors that may underlie an increased frequency of infection in alcoholics and the clinical infectious syndromes associated with alcoholism are described.

Herpes zoster.

Herpes zoster ("shingles") is usually a benign, self-limited disease. However, it can be debilitating or even fatal. The potentially serious complications of ocular involvement or postherpetic neuralgia and the confusing therapeutic regimens that are often advocated make this a complicated subject. Dissemination is more common in immunosuppressed and elderly febrile patients, and the complications are more serious. Herpes zoster patients may benefit from treatment with vidarabine, currently the only antiviral agent approved for use in this disease. Corticosteroids may be helpful in selected patients.

Genital herpes simplex virus infections: clinical manifestations, course, and complications.

The clinical course and complications of 268 patients with first episodes and 362 with recurrent episodes of genital herpes infection were reviewed. Symptoms of genital herpes were more severe in women than in men. Primary first-episode genital herpes was accompanied by systemic symptoms (67%), local pain and itching (98%), dysuria (63%), and tender adenopathy (80%). Patients presented with several bilaterally distributed postular ulcerative lesions that lasted a mean of 19.0 days. Herpes simplex virus was isolated from the urethra, cervix, and pharynx of 82%, 88%, and 13% of women with first-episode primary genital herpes, and the urethra and pharynx of 28% and 7% of men. Complications included aseptic meningitis (8%), sacral autonomic nervous system dysfunction (2%), development of extragenital lesions (20%), and secondary yeast infections (11%). Recurrent episodes were characterized by small vesicular or ulcerative unilaterally distributed lesions that lasted a mean of 10.1 days. Systemic symptoms were uncommon and 25% of recurrent episodes were asymptomatic. The major concerns of patients were the frequency of recurrences and fear of transmitting infection to partners or infants.

Risk of recurrence after first episodes of genital herpes. Relation to HSV type and antibody response.

To define risk factors associated with recurrent genital herpes-simplex-virus infection caused by either Type 1 or 2 herpesvirus (HSV-1 or HSV-2), we prospectively studied 137 patients with a first symptomatic episode of the disease and 87 with a recurrent episode. First episodes were divided into 78 primary infections (no antibodies to HSV in acute-phase serum) and 59 nonprimary infections (antibodies present). HSV-1 infections were less frequent and less likely to recur than HSV-2 infections. Fifteen per cent of primary first episodes were caused by HSV-1, as compared with 3 per cent of nonprimary first episodes and 2 per cent of recurrent episodes. Moreover, during follow-up of first-episode patients, only 14 per cent of HSV-1 infections recurred, as compared with 60 per cent of HSV-2 infections. Recurrences were more likely to follow an index recurrent episode than an index first episode, whether primary or nonprimary, and were more likely to occur in men than in women. Among patients with primary HSV-2 infections, the probability of recurrence was directly related to the presence and titer of neutralizing antibody to HSV-2 in convalescent-phase serum.

Amikacin penetration into synovial fluid during treatment of septic arthritis.

The concentration of amikacin from simultaneous synovial fluid and serum samples was measured on four separate occasions in a patient treated for Serratia marcescens septic arthritis. Synovial fluid levels were between 12.5 and 24.4 micrograms/ml, with concurrent serum levels of 12.1-21.0 micrograms/ml. Parenterally administered amikacin readily distributed into synovial fluid. Failure to eradicate the patient's Serratia septic arthritis with amikacin and daily arthrocentesis may have been a result of inactivation of the antibiotic arising from acidosis occurring in the synovial fluid.

In vitro evaluation of cefoxitin and cefamandole.

Cefoxitin and cefamandole were evaluated in vitro against 263 organisms. Studies were performed in Mueller-Hinton and nutrient broth and agar employing inoculum sizes of 10(6) and 10(8) organisms per ml. At obtainable serum levels both antibiotics were bactericidal for nearly all strains of Escherichia coli, Klebsiella, Proteus mirabilis, and Staphylococcus aureus but were inactive against Pseudomonas aeruginosa and enterococcus. In agar, cefamandole appeared to be active against most strains of Enterobacter and indole-positive Proteus, whereas cefoxitin was active against indole-positive Proteus but not Enterobacter. Moreover, in broth medium most strains of Enterobacter were not readily inhibited by either antibiotic and only 40 and 73% of indole-positive Proteus were inhibited by 10 mug of cefamandole per ml in Mueller-Hinton and nutrient broth, respectively. However, in both broth media, 10 mug of cefoxitin per ml continued to be inhibitory and bactericidal for most isolates of indole-positive Proteus. Cefoxitin also was bactericidal against four cephalothin-resistant strains of E. coli. These data suggest that cefoxitin broadens the spectrum of existing cephalosporins by enhancing the activity against indole-positive Proteus species as well as some other Enterobacteriaceae. On the other hand, with the exception of strains of Enterobacter aerogenes, the apparent increased in vitro activity of cefamandole was demonstrated in agar and not in broth.

Genital herpetic infection in men and women: clinical course and effect of topical application of adenine arabinoside.

Sixty-three episodes of genital herpetic infection in 55 men and 45 episodes in 42 women were randomly assigned to topical treatment with 3% adenine arabinoside, topical treatment with placebo ointment, or no therapy. In addition, 10 episodes in women who were not randomly assigned to therapy were evaluated and followed. Clinical evaluation and viral cultures were done on day 3, day 8, and weekly thereafter until the lesions had healed. The natural clinical course of genital herpetic infection was defined in patients given placebo or no therapy. Patients with a history of previous genital herpetic infection had significantly less pain, few lesions, and shorter duration of illness and viral shedding than patients who had no history of previous genital infection with Herpesvirus. An unexpected finding was that 87% of women experiencing their first episode of genital herpetic infection had cervical cultures positive for Herpesvirus hominis, whereas only 4% of women with recurrent herpetic infection had a positive cervical culture. Treatment with 3% adenine arabinoside did not influence the course of either primary or recurrent genital infection with Herpesvirus.