Successful medical management of a patient with multiple hepatic abscesses due to Edwardsiella tarda.

Isolation of Edwardsiella tarda in humans has been associated with an asymptomatic carrier state as well as mild, self-limited diarrheal illness. Extraintestinal manifestations have included soft-tissue infections, meningitis, osteomyelitis, cholangitis, and sepsis. Only three cases of patients who had documented hepatic abscess due to E. tarda have been reported in the English-language literature; two patients died, and the third required a laparotomy and drainage. We report what is, to our knowledge, the first autochthonous case of hepatic abscess due to E. tarda in the United States and the first case that was successfully managed with antibiotic therapy alone.

Prostatic abscess due to Histoplasma capsulatum in a patient with the acquired immunodeficiency syndrome.

Disseminated histoplasmosis is a systemic fungal infection that may occur in previously healthy or immunocompromised patients. The condition is being recognized with increasing frequency in persons infected with the human immunodeficiency virus. The most common organs involved include the lung, bone marrow, lymph nodes, liver, adrenals and central nervous system, with genitourinary involvement being exceedingly unusual. We describe a Histoplasma capsulatum prostatic abscess occurring after therapy for pulmonary histoplasmosis in a patient with the acquired immunodeficiency syndrome. The prostate may be a difficult focus from which to eradicate disseminated fungal infection in immunocompromised patients.

Treatment of postoperative infection of ascending aorta and transverse aortic arch, including use of viable omentum and muscle flaps.

Postoperative infection of the ascending aorta and aortic arch in 40 patients was treated by antibiotic therapy alone (4 patients) or by operation and lifelong suppressive antibiotic therapy (36 patients). Complications of infection included antibiotic-resistant infection, infected false aneurysm, rupture of suture line, aortocutaneous fistulas, aortic-right ventricular fistulas, arterial embolus, aortic valve insufficiency, aortobronchial fistula, mediastinal abscess, and chest wall problems. These were treated by a variety of operations including composite valve-graft replacement, graft replacement, patch-graft closure of false aneurysm, simple suture of disrupted suture lines and false aneurysm, and debridement of mediastinum and chest wall. The area of reconstruction was covered, and mediastinal dead space was reduced by mobilization of viable tissue, including local tissue and distant structures such as flaps of muscle and omentum. Thirty-three patients (83%) were early survivors, and 28 patients (70%) were alive and well at last follow-up 4 months to 6.5 years after operation.

Candida osteomyelitis. Report of five cases and review of the literature.

Candida species have emerged as important pathogens in human infection. Although a variety of deep-seated candidal infections have been reported, Candida osteomyelitis has rarely been described. Five patients with Candida osteomyelitis are presented, and the 32 adult cases previously reported are reviewed. Candida osteomyelitis is noted as a simultaneous occurrence or late manifestation of hematogenously disseminated candidiasis. Osteomyelitis may not be prevented by a course of amphotericin B adequate to control the acute episode of disseminated candidiasis, particularly in immunosuppressed patients. Less commonly, Candida osteomyelitis presents as a postoperative wound infection. Like bacterial osteomyelitis, the most common presenting symptom is local pain. The insidious progression of infection, the nonspecificity of laboratory data, and the failure to recognize Candida as a potential pathogen may lead to diagnostic delay. Diagnosis can be made by either open biopsy or closed needle aspiration. Successful therapeutic regimens have employed combinations of antifungal therapy (most often amphotericin B) with surgical debridement when indicated. It is anticipated that osteomyelitis will become a more commonly recognized manifestation of hematogenously disseminated candidiasis.

Successful management of Histoplasma capsulatum infection of an abdominal aortic aneurysm.

A 65-year-old woman with disseminated histoplasmosis underwent resection of an atherosclerotic abdominal aortic aneurysm. Yeast forms of Histoplasma capsulatum were present in the aneurysm. Surgical resection and revascularization with a Dacron graft followed by systemic amphotericin B therapy and chronic ketoconazole suppressive therapy have resulted in a patient without symptoms 15 months postoperatively. It is important to be aware of the potential for artherosclerotic aortic aneurysm involvement by H. capsulatum.

Pyoderma gangrenosum. A possible cause of wound necrosis.

Pyoderma gangrenosum is a destructive cutaneous disorder characterized by painful, rapidly enlarging ulcers with under-mined bluish and purplish red margins. This disease is most frequently found in association with ulcerative colitis. However, in the last three years, four cases of pyoderma gangrenosum precipitated by surgical procedures have occurred, and only one of these patients had ulcerative colitis. All four patients responded to steroid therapy and local wound care. Pyoderma gangrenosum can first be suspected by recognition of the previously described classic lesion. In addition, the absence of significant microbial growth and the lack of a specific etiology ascertained on routine and special staining of biopsy material is suggestive of the diagnosis. Histologic characteristics are entirely nonspecific but can be helpful in ruling out other specific entities. The progressively destructive nature of this process in the face of what would seem to be appropriate therapy for bacterial wound infection requires that pyoderma gangrenosum, as well as other aspects of the differential diagnosis of a persistent ulcerative lesion, such as fungal infection, factitious ulcer, or vasculitis, be considered.

Susceptibility and synergy studies of methicillin-resistant Staphylococcus epidermidis.

Methicillin-resistant Staphylococcus epidermidis is an important cause of cerebrospinal fluid shunt infections and prosthetic valve endocarditis. Agar dilution minimum inhibitory concentrations were determined for 100 strains of methicillin-resistant S. epidermidis which were isolated from clinical specimens. Vancomycin inhibited all 100 strains at /=3.12 mug/ml. Of the five cephalosporins and one cephamycin tested, cefamandole was the most active in vitro, inhibiting 97 strains at /=10(2) kill by the combination over the most effective single antibiotic at 24 h) was demonstrated with vancomycin (1.56 mug/ml) plus cefamandole (6.25 mug/ml) in 14 of 14 strains, vancomycin plus cephalothin (6.25 mug/ml) in 14 of 14 strains, vancomycin plus rifampin (0.008 to 0.012 mug/ml) in 6 of 12 strains, rifampin plus cefamandole in 9 of 12 strains, and rifampin plus cephalothin in 10 of 12 strains. The emergence of populations of bacteria resistant to 0.2 mug of rifampin per ml developed in three of five methicillin-resistant S. epidermidis strains tested. The addition of either vancomycin, cephalothin, or cefamandole to the rifampin prevented the emergence of resistance in these three strains. Clinical trials of synergistic antibiotic combination therapy for serious methicillin-resistant S. epidermidis infections are indicated.

Combined effects of ticarcillin and cefazolin on blood coagulation and platelet function.

Combined intravenous infusions of ticarcillin and cefazolin given to normal volunteers resulted in a functional platelet defect which appeared to be determined primarily by the dose and duration of treatment with the penicillin component. No effect on soluble blood coagulation factors was evident. Acute administration of corticosteroids did not influence the prolonged bleeding times induced by extended ticarcillin infusions.

Anaerobic bacterial meningitis.

Anaerobic meningitis occurred in four patients in whom anaerobic bacteria had not been suspected as a possible cause. The predisposing conditions were typical of those seen in patients previously reported to have this infection and included chronic otitis media with mastoiditis, chronic sinusitis, recent craniotomy and abdominal trauma. Two of the patients had undergone immunosuppression (immunosuppressed patients); a compromised immune system may facilitate the development of anaerobic meningitis in patients with the appropritate underlying conditions. Head and neck neoplasms, head trauma, suppurative pharyngitis and laminectomy wounds are additional situations in which anaerobic meningitis occurs. Anaerobic bacterial meningitis probably occurs more often than is recognized. The cerebrospinal fluid should be transported and cultured anaerobically when meningitis develops in a patient with a predisposing condition.

Combined clinical and laboratory studies with carbenicillin and ticarcillin: use in infections involving anaerobic bacteria.

Eleven patients with serious infections involving anaerobic bacteria were treated with carbenicillin (four patients) or ticarcillin (seven patients). All patients were cured clinically and bacteriologically of their infections. An in vitro study testing 157 recently isolated anaerobic organisms against 11 antibiotics showed chloramphenicol, carbenicillin, and ticarcillin at blood level concentrations to be inhibitory to more anaerobic strains than the other eight antibiotics tested. Ticarcillin and carbenicillin appear to be safe and effective and deserve further consideration for use in the therapy of anaerobic infections.

Agranulocytosis during therapy with orally administered cloxacillin.

Agranulocytosis developed in a patient with staphylococcal osteomyelitis after 35 days of treatment with orally administered cloxacillin. The patient had fever, prostration, pharyngitis, and profound leukopenia, which subsequently abated upon withdrawal of the drug. Cloxacillin should be included in the growing list of drugs capable of producing leukopenia and agranulocytosis.

Disseminated histoplasmosis diagnosed from peripheral blood film.

Demonstration of Histoplasma capsulatum in conventional films of peripheral blood establishes the diagnosis of disseminated histoplasmosis. We describe two new examples of this pnenomenon and tabulate relevant data from 11 similar cases.

Comparison of thrombophlebitis associated with three cephalosporin antibiotics.

A double-blind study with volunteers was performed to determine the incidence and severity of thrombophlebitis associated with cephalothin, cephapirin, cefamandole, and a water control. Although there were no statistical differences in the incidence of thrombophlebitis, cephalothin resulted in significantly more severe thrombophlebitis compared with the other agents.

Influence of cephalosporin antibiotics on blood coagulation and platelet function.

Administration of cephalothin to normal volunteers in maximal doses of 300 mg/kg per day resulted in a combined defect of platelet function and blood coagulation. No such abnormalities were evident after infusion of cefazolin or cephapirin at a maximal dosage of 200 mg/kg per day. The observed thrombocytopathy was similar to but less severe than that induced by carbenicillin or ticarcillin and was not reflected by a prolonged bleeding time test or impaired prothrombin consumption. Moreover, it was not a consistent finding in those persons receiving cephalothin. A separate defect involving blood coagulation appeared to result from delayed fibrinogen-fibrin polymerization and was evidenced by extended values of the activated partial thromboplastin and thrombin time tests. It remains uncertain whether the abnormalities described may constitute clinically important hemostatic disorders in patients with normal renal function receiving large doses of cephalosporin antibiotics.

Study of the effects of ticarcillin on blood coagulation and platelet function.

Ticarcillin is a new semisynthetic penicillin similar to carbenicillin. Since carbenicillin has been shown to inhibit platelet function to such an extent that bleeding may accompany its use, an investigation of the effects of ticarcillin on hemostasis was made. The drug was administered to 17 human volunteers for periods of 3 to 10 days in intravenous doses of 100, 200, or 300 mg/kg per day (7 to 21 g/day). Serial studies of blood coagulation and platelet function indicated that coagulation was unaffected by ticarcillin but that platelet function became defective in all subjects. Abnormal platelet function was evidenced by lengthening of bleeding time (17 of 17 volunteers), depressed adenosine diphosphate-induced platelet aggregation (17 of 17), defective collagen-induced aggregation (15 of 17), and abnormal epinephrine-induced aggregation (10 of 17). Prothrombin consumption, due to reduced platelet procoagulant activity, was significantly decreased with a dose of 300 mg/kg per day. Comparison of results from this study with those from an earlier carbenicillin study revealed that ticarcillin at 300 mg/kg per day produces the same defects in hemostasis as does carbenicillin at 300 mg/kg per day, but that lower doses (100 or 200 mg/kg per day) of ticarcillin result in only a mild defect in platelet function. If the effective dose of ticarcillin is proven to be lower than the doses of carbenicillin currently employed for treatment of certain gram-negative infections, bleeding should not be a frequent complication of ticarcillin administration, when the drug is given to patients with normal renal function.