Direct Tissue PCR and Genotyping for Species Identification in a Case of Laryngeal Blastomycosis.

Otolaryngologic manifestations of infection with Blastomyces species are extremely rare and restricted geographically to recognized endemic regions. Here, we describe a case of laryngeal blastomycosis that presented as slowly progressive dysphonia. While a preliminary diagnosis was made using routine histopathology, a species identification of Blastomyces dermatitidis was made using polymerase chain reaction amplification and rapid genotyping without the need for fungal culture. All symptoms resolved following 1 month of antifungal therapy. Rapid molecular differentiation of B dermatitidis from Blastomyces gilchristii provides important insights into pathogenesis given recent recognition of differences in clinical spectra.

Risk factors for recurrent spontaneous epistaxis.

OBJECTIVE: To identify risk factors associated with spontaneous recurrent epistaxis. PATIENTS AND METHODS: This was a retrospective cohort study assessing patients in the Marshfield Clinic system diagnosed as having epistaxis between January 1, 1991, and January 1, 2011. There were 461 cases with at least 2 episodes of spontaneous epistaxis within 3 years and 912 controls with only 1 episode in the same time frame. More than 50 potential risk factors were investigated, including demographic features, substance use, nasal anatomical abnormalities, nasal infectious and inflammatory processes, medical comorbidities, medications, and laboratory values. A Cox proportional hazards regression modeling approach was used to calculate hazard ratios of epistaxis recurrence. RESULTS: Traditional risk factors for epistaxis, including nasal perforation, nasal septum deviation, rhinitis, sinusitis, and upper respiratory tract infection, did not increase the risk of recurrence. Significant risk factors for recurrent epistaxis included congestive heart failure, diabetes mellitus, hypertension, and a history of anemia. Warfarin use increased the risk of recurrence, independent of international normalized ratio. Aspirin and clopidogrel were not found to increase the risk of recurrence. Few major adverse cardiovascular events were observed within 30 days of the first epistaxis event. CONCLUSION: Congestive heart failure is an underappreciated risk factor for recurrent epistaxis. Hypertension and diabetes mellitus may induce atherosclerotic changes in the nasal vessels, making them friable and more at risk for bleeding. Patients with recurrent epistaxis may also be more susceptible to developing anemia. Physicians should promote antiplatelet and antithrombotic medication adherence despite an increased propensity for recurrent epistaxis to prevent major adverse cardiovascular events.

Examination of antibiotic dosing practices for refractory rhinosinusitis in relation to body weight.

OBJECTIVE: Rhinosinusitis is a common condition that is frequently treated as an infectious disease with antibiotics. In general, antibiotic dosing in adults follows a flat scheme with no regard for body size. Wide variability in body weight raises concern whether this dosing scheme results in efficacious dosing for patients of various sizes. If not, larger patients with chronic rhinosinusitis may have avoidable morbidity from their disease, and surgery may be prematurely recommended. Our goal was to better understand the possible treatment implications of varying body size when prescribing antibiotics for chronic rhinosinusitis. DESIGN: Retrospective chart review. SETTING: Otolaryngology referral center at a multispecialty medical center. PARTICIPANTS: Patients (N = 180) with refractory chronic rhinosinusitis referred to an otolaryngologist for consideration of sinus surgery. METHODS: Main outcome measures included antibiotic usage, dosing, and body size metrics. RESULTS: There was wide variation in patient weight and body mass index. However, treatment guidelines for adults do not recommend dosage adjustments for variation in weight, and there was little variation in dosing strategies for each antibiotic prescribed. Therefore, per kilogram dosing varied widely between patients. Of the 9 antibiotics prescribed for chronic rhinosinusitis, the median per kilogram dose of only 1 antibiotic exceeded the minimum recommended per kilo-gram dose for children. CONCLUSION: In the absence of weight-based guidelines for antibiotic administration, the potential for suboptimal dosing in patients seeking relief for chronic rhinosinusitis or other infectious diseases is great, and further study is needed to examine dosing practices.

PCR analysis of nasal polyps, chronic sinusitis, and hypertrophied turbinates for DNA encoding bacterial 16S rRNA.

BACKGROUND: Nasal polyps are considered to result from chronic inflammation, but the initial or persisting stimulus for the inflammation is not known. A variety of bacteria and fungi have been cultured from nasal polyps, but approximately 35% have sterile cultures. Previously, Mycoplasma pneumoniae-specific DNA was detected in human nasal polyps using polymerase chain reaction (PCR) techniques, suggesting M. pneumoniae as a causative agent in the etiology of nasal polyps. METHODS: In this study, we tested for the presence of bacterial DNA in nasal polyps resected from 40 patients, in nasal mucosa membrane from 9 patients undergoing turbinectomy for hypertrophy, and in sinus mucosa membrane from 6 patients undergoing endoscopic surgery for chronic sinusitis. Tissue DNA was extracted and analyzed by PCR using M. pneumoniae specific primers for DNA that encode the 16S rRNA gene in 41 specimens (31 polyps, 6 turbinates, and 4 sinus), and by consensus sequence-based PCR using broad range primers for most eubacterial DNA encoding the 16S rRNA gene in 38 specimens (26 polyps, 7 turbinates, and 5 sinuses). RESULTS: Only two samples were positive for bacterial DNA encoding 16S rRNA: Streptococcus sp. DNA was isolatedfrom one polyp specimen and Pseudomonas aeruginosa DNA was isolated in one maxillary sinusitis specimen. No evidence of M. pneumoniae-specific DNA encoding 16S rRNA was found in any of the tissues. CONCLUSIONS: This study suggests that chronic bacterial infection is not a major component of nasal polyp etiology.