Mucormycosis in a transplanted kidney.

Mucormycosis of the transplanted kidney has so far been reported in only 9 patients, with a high mortality rate. Here, we report a rare case of isolated mucormycosis of the transplant kidney with successful outcome.

Mycobacterium xenopi infection after heart transplantation: an unreported pathogen.

Mycobacterial infections are a well-known, potentially serious, albeit infrequent complication of solid-organ transplantation. Nontuberculous mycobacteria generally account for less than 50% of all such isolates in this patient population. Mycobacterium xenopi, an environmentally ubiquitous organism and common contaminant of hospital hot water systems, is a particularly uncommon isolate after transplantation and has never been reported in heart allograft recipients. We report the occurrence of cavitary M. xenopi infection in an immunocompromised heart transplant recipient in which all the diagnostic criteria of the American Thoracic Society were met. To our knowledge, this is the first such case in a heart transplant recipient described in the literature. Despite therapy, to which the isolates were sensitive in vitro, the patient developed extensive lung cavitation and nodules and succumbed 5 months later to allograft rejection, chronic allograft vasculopathy, and pneumonia.

Fungemia observations of peripheral tissue clearance in humans.

Patients with fungemia, mainly due to Candida albicans, had cultures repeated from arterial and venous sites to determine yeast cell clearance during fungemia. Of the 48 patients, 37 had repeat positive cultures (36 arterial and venous samples; one venous culture). Additionally, 24 patients had arterial and venous samples cultured quantitatively. An average of 9.1 colony forming units (CFU) ml-1 was isolated from arterial samples and 5.5 CFU ml-1 from venous samples (60% of arterial, P < 0.01). This suggest that arterial fungal densities exceed venous densities and that peripheral tissues clear 40% of yeasts.

AIDS and changing patterns of mortality.

We compared changes in all-causes mortality rates, 1986 versus 1980, among members 25 to 44 years of age of demographically defined groups with high AIDS cumulative incidence to the changes among same-age, same-sex members of groups with low AIDS cumulative incidence. Among nonwhite men ages 25-44 residing in northeastern New Jersey (NJ) counties, AIDS cumulative incidence was 1,409 cases per 100,000; all-causes mortality was 413.8 deaths per 100,000 per year in 1980 and increased 74% to 726.6 deaths per 100,000 per year by 1986. In contrast, among white men ages 25-44 residing in other NJ counties, AIDS cumulative incidence was 75 cases per 100,000; all-causes mortality fell slightly from 192.6 deaths per 100,000 per year in 1980 to 189.2 deaths per 100,000 per year in 1986. Among nonwhite women ages 25-44 residing in northeastern NJ counties, AIDS cumulative incidence was 435 cases per 100,000; all-causes mortality was 162.07 deaths per 100,000 per year in 1980 and increased 70% to 276.3 deaths per 100,000 per year by 1986. Among white women ages 25-44 residing in other NJ counties, AIDS cumulative incidence was 9.1 cases per 100,000; all-causes mortality was 90.5 deaths per 100,000 per year in 1980 and fell slightly to 83.0 deaths per 100,000 per year in 1986. A substantial portion of the increased mortality of the groups with high AIDS cumulative incidence resulted from causes that have not been associated with HIV infection.

Cumulative AIDS incidence and altered pneumonia mortality.

We grouped New Jersey residents according to age, sex, race, and residence-specific cumulative incidence of AIDS since the onset of the AIDS epidemic: less than 15, 15-99, 100-499, and greater than or equal to 500 cases per 100,000 people, respectively. We determined mortality from bacterial and viral pneumonias (International Classification of Diseases [ICD] 480.0-486.9) from underlying cause of death files. Between 1980 and 1986, pneumonia mortality increased from 15.1 deaths per 100,000 per year (95% confidence interval [CI] 10.4, 19.7) to 25.0 deaths per 100,000 per year (95% CI 19.2, 30.8), an increase of 10.0 deaths per 100,000 per year (95% CI 2.6, 17.3), among those 25-44 years of age in the highest cumulative incidence group for AIDS. Increases in other population subgroups were approximately proportional to each subgroup's AIDS cumulative incidence. In particular, pneumonia mortality did not increase among those 25-44 years of age in groups with low cumulative incidence of AIDS. Deficiency of cell-mediated immunity, a diagnosis commonly applied in AIDS cases, was listed as a secondary diagnosis in 14% of the pneumonia deaths of persons 25-44 years of age in 1986 and in none of those in 1980.

Cumulative AIDS incidence and altered mortality from mycobacterial disease: New Jersey.

Changes in mycobacterial disease mortality between 1980 and 1986 were examined among New Jersey residents aged 25 to 44 using single cause of death data. The demographic group with the highest cumulative incidence of acquired immune deficiency syndrome (AIDS) (non-white residents of the four urban counties adjacent to New York City) sustained an increase of 10.1 deaths/100,000 men/yr and 3.1 deaths/100,000 women/yr. Groups with lower cumulative incidence of AIDS sustained smaller increases in mycobacterial disease mortality. The group with the lowest cumulative incidence of AIDS (white residents outside the four urban counties adjacent to New York City) sustained the smallest increase in tuberculosis (TB) mortality. Using single cause of death data, it was not possible to identify a relationship between increased extrapulmonary TB deaths and AIDS cumulative incidence, but such a relationship was identifiable from multiple cause of death data. Of 30 mycobacterial disease deaths of all ages with cellular immune deficiency as a contributory diagnosis on the death certificate, 21 (70%) were known to the state's AIDS registry as AIDS cases and four more (13%) were known to the registry as having human immunodeficiency virus (HIV) disease not meeting the full clinical criteria for AIDS. Young populations with a high cumulative incidence of AIDS have experienced substantially increased mortality from mycobacterial diseases. The association of mycobacterial disease mortality with HIV disease may be underestimated from AIDS registry data and from searches of single cause of death data for mycobacterial disease deaths.

Cumulative AIDS incidence and altered mortality from bacterial infections.

To determine whether populations with high cumulative incidence of acquired immunodeficiency syndrome (AIDS) experienced increased deaths from sepsis, central nervous system abscess, or endocarditis, New Jersey AIDS patients were grouped according to their age, sex, race, and residence-specific cumulative incidence of AIDS since the onset of the AIDS epidemic. Between 1980 and 1986, among 25-44 year olds in the highest cumulative incidence group for AIDS, sepsis mortality increased from 3.3 to 15.2 deaths/100,000/year, an increase of 11.9 deaths/100,000/year (95% confidence interval (6.9, 17.0) deaths/100,000/year); mortality from central nervous system abscesses increased from zero to 1.7 (0.1, 3.2) deaths/100,000/year; and mortality from endocarditis increased from 0.8 deaths/100,000/year to 2.4 deaths/100,000/year, an increase of 1.6 (-0.5, 3.7) deaths/100,000/year. Age-matched New Jersey patient populations with low cumulative incidence of AIDS did not sustain a similar increase. The HIV disease-associated increase in sepsis mortality among young populations represents a new component of the substantial increase in U.S. sepsis mortality that occurred over the last two decades, but was previously limited to older populations.

Diagnosis of Mycobacterium bacteremia in patients with acquired immunodeficiency syndrome by direct examination of blood films.

Thirty acquired immunodeficiency syndrome patients with mycobacterial bacteremia documented by Du Pont Isolator (Du Pont Co., Wilmington, Del.) blood cultures underwent microscopic examination of buffy coat blood smears. Of 30 patients, 14 were culture positive for Mycobacterium avium-Mycobacterium intracellulare complex and 1 was positive for M. tuberculosis. Of 15 culture-positive patients, 13 had identifiable organisms on Kinyoun- or auramine-stained direct blood smears.

Brain lesions in patients with acquired immunodeficiency syndrome.

Infections involving the brain have become a major complication in patients with acquired immunodeficiency syndrome. We have reviewed 48 cases of central nervous system lesions in patients with acquired immunodeficiency syndrome. and its related complex. All patients had computed tomographic scans with contrast performed; 31 of 48 were intravenous drug abusers. Computed tomographic abnormalities found included 21 patients with multiple ring-enhancing lesions, 13 with single ring-enhancing lesions, 11 with single hypodense lesions, and three with multiple hypodense lesions. Twenty-five patients had a positive serologic reaction for Toxoplasma. Sixteen patients had brain tissues examined. Of the 16 patients, six had cerebral Toxoplasma (one with concomitant Mycobacterium tuberculosis), and ten had diagnoses other than toxoplasmosis (three of whom had a positive serologic reaction for Toxoplasma). Two patients had M tuberculosis; one patient had Nocardia asteroides with Salmonella enteritidis. Of the remaining seven patients, three had encephalitis of unknown cause, two had inconclusive tissue diagnoses, one had progressive multifocal leukoencephalopathy, and one had vasculitis. In the population of intravenous drug users, brain lesions from diseases other than toxoplasmosis may be just as prevalent. Attempts to obtain a diagnosis from brain tissue is highly recommended to permit the design of effective and specific therapy for those diseases amenable to therapy.

Evidence for destruction of lung tissues during Pneumocystis carinii infection.

Five cases of Pneumocystis carinii infection with evidence of lung tissue destruction that occurred in patients with the acquired immunodeficiency syndrome were reviewed. None of the patients had a history of cigarette smoking, but all five had either cavitarylike lesions in the lungs or had pneumothorax at the time of presentation to the hospital. All patients had P carinii identified in specimens obtained either from bronchial washings or from open-lung biopsy. In four of the five patients, no other pathogens were involved in the lungs, while the fifth patient had concomitant cytomegalovirus infection. Findings on chest roentgenograms included large thin-walled cavitarylike lesions, multiple cavitary lesions, or pneumothorax. These presentations of the infection have not been previously described, and the mechanisms for lung tissue damage are as yet unknown. Cavitary lung disease found on chest roentgenograms in patients should not exclude the diagnosis of P carinii pneumonia, and patients with the acquired immunodeficiency syndrome presenting with pneumothorax should have the possibility of P carinii infection included in the differential diagnosis.

Central nervous system tuberculosis with the acquired immunodeficiency syndrome and its related complex.

Central nervous system tuberculosis occurred in three patients with the acquired immunodeficiency syndrome (AIDS) and seven patients with AIDS-related complex who were evaluated for 48 months. Nine patients were intravenous drug abusers and one was Haitian. Five patients had cerebral-ring-enhancing lesions and three had hypodense areas. The clinical spectrum included meningitis in two patients, multiple cerebral abscesses in one, and tuberculomas in four. All Mycobacterium tuberculosis isolates were sensitive to standard antituberculous drugs. All patients received treatment with isoniazid, rifampin, and pyrazinamide; six patients also received streptomycin. Three patients with AIDS died of opportunistic infection preceded by central nervous system tuberculosis. Among the patients with the AIDS-related complex, three improved with treatment, three were lost to follow-up, and one died. Tuberculosis should be considered in the differential diagnosis of central nervous system mass lesions in intravenous drug abusers with AIDS or AIDS-related complex. Because patients with tuberculosis can be cured, biopsy of accessible brain mass lesions should be mandatory. Preventive therapy may be indicated in drug abusers without disease.

Yield of bone marrow culture in the diagnosis of infectious diseases in patients with acquired immunodeficiency syndrome.

The yield in cultures of bone marrow aspirations or biopsies was determined in 50 patients with acquired immunodeficiency syndrome. Most patients were febrile and had no identifiable source of infection. Concurrent stool, urine, and blood samples were also cultured. The bone marrow aspiration and biopsy procedures produced no complications and enabled a microbiological diagnosis to be made in 42% of the cases. Granuloma formation was not seen in any of the infected bone marrow specimens despite the fact that mycobacteria were seen in abundance in some. Bone marrow culture is a valuable low-morbidity invasive procedure in the evaluation of febrile patients with acquired immunodeficiency syndrome.

Bacteremia and fungemia in patients with acquired immune deficiency syndrome.

Patients with acquired immune deficiency syndrome (AIDS) are known to have identifiable host defense deficiencies, especially deficiencies in cell-mediated immunity. They are at increased risk for developing infections of the bloodstream caused by Cryptococcus neoformans and Salmonella species. However, bacteremias caused by other enteric gram-negative rods and Pseudomonas aeruginosa are found less frequently in patients with AIDS than in patients without AIDS (P less than 0.001 and P less than 0.01, respectively). The findings of specific organisms in blood is consistent with the known types of host defense deficiencies in these patients.

Cryptococcal infections in patients with acquired immune deficiency syndrome.

Cryptococcus neoformans is a major pathogen in patients with acquired immune deficiency syndrome and was found to infect 13.3 percent of such patients seen at two medical centers. Serum cryptococcal antigen levels were as high as 1:2,000,000 and, despite therapy, often remained elevated. Antigen titers in the cerebrospinal fluid generally declined at an expected rate in the survivors. The significance of high antigen titers in the blood after a prolonged course of therapy with amphotericin B and 5-flucytosine is unknown.