Septic thrombosis of the cavernous sinuses.

Septic thrombosis of the cavernous sinuses (or cavernous sinus thrombophlebitis [CST]) is a dramatic and potentially lethal illness, which is still occasionally seen by clinicians. Before the availability of antimicrobial agents, mortality from CST was near 100%, but it markedly decreased to approximately 20% to 30% during the antibiotic era. Nevertheless, the threat of death and serious morbidity continues to necessitate early recognition, diagnosis, and treatment of CST to minimize risks to the patient. Accordingly, we reviewed the salient clinical features of this illness, with emphasis on newer aspects of diagnosis and treatment.

Trichosporon asahii, a non-Candida yeast that caused fatal septic shock in a patient without cancer or neutropenia.

Trichosporon asahii (formerly Trichosporon beigelii) is an emerging fungal pathogen seen particularly in immunologically compromised patients. There are now approximately 100 reported cases of hematogenously disseminated infections with this life-threatening yeast, and no effective antifungal therapy is available. The present case is unusual because the patient did not have neutropenia or evidence of a malignancy.

Spinal epidural lipomatosis in a human immunodeficiency virus-positive patient receiving steroids and protease inhibitor therapy.

We describe a patient who became cushingoid as a result of receiving steroid therapy for thrombocytopenia purpura and who then developed spinal epidural lipomatosis 4 months after he started receiving ritonavir as part of his therapy for human immunodeficiency virus infection. We believe that ritonavir may have contributed to the development of epidural lipomatosis and that clinicians should be aware of this possible association.

Non-surgical management of post-cesarean endomyometritis associated with myometrial gas formation.

We present a case of post-cesarean delivery, nonclostridial endomyometritis in which uterine (myometrial) gas formation raised concern for myonecrosis and need for hysterectomy. The patient fully recovered without surgery. Myometrial gas formation in this setting and in an otherwise stable patient may be an insufficient reason for hysterectomy.

Toxoplasmosis of the spinal cord in a patient with AIDS: case report and review.

We present the case of a patient whose acute myelopathy almost completely resolved with empirical therapy for toxoplasmosis, and we review thirteen previously reported cases of myelopathy thought to have been caused by Toxoplasma gondii in patients with AIDS. The most common symptoms and abnormal physical findings were motor loss (usually paraparesis), bilateral sensory loss, urinary bladder dysfunction, and local pain. The majority of patients had magnetic resonance images that showed abnormalities of the spinal cord and brain in association with positive serology for Toxoplasma. Therapy for toxoplasmosis, when administered soon after the onset of symptoms, has resulted in clinical and radiographic improvement in the conditions of patients with toxoplasmosis.

Evaluation of the variety of plasmid profiles in S epidermidis isolates from hospital patients and staff.

Plasmid profiling was used to determine the variability of normal flora isolates of Staphylococcus epidermidis in order to evaluate the usefulness of plasmid profiling for identifying pathogens. Fifteen hospital staff members and patients repeatedly had cultures taken from the hands and nares, and multiple isolates were examined for plasmid profiles. S epidermidis isolated from the nares of 15 neonates were also examined. The total number of isolates examined for plasmid profiles was 726. Repetition of profiles was common among the different isolates from a single sampling (one swab). The frequency of re-isolating similar profiles on different days varied from 7% to 13%. Simultaneous isolation of similar profiles from nares and hands on the same individual varied from 0% to 11%, the percentage being lower for personnel. Isolation of the same plasmid profile from different individuals occurred only twice and resulted in an assignment probability of Pa = 0.002 for isolates obtained from different individuals. Significantly more isolates from nares contained plasmids (97%) compared with isolates from hands (89%). Patients who had two or more isolates of coagulase-negative staphylococci with similar profiles were judged, clinically, to have infections in 12 of 13 cases. However, the likelihood of re-isolating an S epidermidis strain with a similar plasmid profile twice from the same person at different times was sufficiently high to prevent plasmid profiling from being used as an absolute criterion for infection.

Epidemic Shiga bacillus dysentery in Central Africa.

An outbreak of dysentery began late in 1979 in Central Africa and spread to involve a major portion of Zaire as well as Rwanda and Burundi. We traveled to a mission hospital in northeast Zaire during the epidemic and isolated Shigella dysenteriae, type 1, from most of the patients studied. All isolates were resistant to ampicillin, tetracycline, chloramphenicol, sulfathiazole, and streptomycin but sensitive to trimethoprim-sulfamethoxazole. Antimicrobial resistance was transferable to Escherichia coli, and at least three plasmids were identified in the donor Shigella isolates by using agarose gel electrophoresis. One was coded for ampicillin, tetracycline, and chloramphenicol resistance while a second conferred resistance to ampicillin and chloramphenicol but not tetracycline. A third large plasmid of approximately 120 megadaltons could not be transferred to E. coli recipients. All S. dysenteriae isolates yielded identical kinetic growth curves when analyzed on the Abbot MS-2 Research System. This is the most extensive outbreak of dysentery caused by S. dysenteriae reported since the Central American epidemic of 1969, and the first epidemic caused by a strain resistant to ampicillin.

Inciting and etiologic agents of colitis.

Since 1979, 3,115 stool samples were tested for detection of Clostridium difficile and its cytotoxin; these were obtained from patients who had drug-related diarrhea. Presumed or proven colitis due to C. difficile was diagnosed in 130 patients. Drugs implicated most commonly as causing or associated with the onset of enterocolitis due to C. difficile were ampicillin (38 episodes), cephalosporins (71), clindamycin (36), and the aminoglycosides (45). The hamster model of colitis was employed to explore the role of other inducing agents. Altering the usual diet of hamsters to one with a higher protein content decreased the time to death due to C. difficile cecitis following the administration of cefazolin (10 mg). Several cathartics also were studied for their effect on the lethality of antibiotic-induced cecitis. Daily administrations of castor oil (0.5 ml per day) and vegetable oil (1.0 ml per day) improved survival against lethal doses of clindamycin. Milk of magnesia or mineral oil provided no protection. Four patients with C. difficile colitis induced by therapy with cytotoxic drugs also were identified. Methotrexate induced cecitis when administered orally and daily to hamsters, and C. difficile and its cytotoxin were identified in the hamsters' stools. Death due to methotrexate-induced cecitis was prevented by daily administration of folinic acid or vancomycin. These data demonstrate that a variety of antibiotics, antineoplastic agents, cathartics, and diet changes can induce C. difficile colitis in humans and hamsters.

Acute erosive reactive arthritis associated with Campylobacter jejuni-induced colitis.

A case of acute erosive, reactive arthritis following Campylobacter jejuni-induced ulcerative colitis is presented. This is the 12th such case reported in the literature and the first in which destructive lesions of periarticular bone are demonstrated. A review of the literature suggests that reactive arthritis associated with C. jejuni infection is similar to that following other invasive types of bacterial diarrhea and is often associated with HLA-B27 lymphocyte antigen.

Endophthalmitis caused by Moraxella nonliquefaciens.

We report the first case of endophthalmitis caused by Moraxella nonliquefaciens. Most likely, entry followed minor trauma from a contact lens, with the marked invasiveness of the organism resulting from the patient's immunocompromised state. This case, in addition, serves to illustrate the advantage of genetic transformation assay to differentiate the species of this group of organisms.

The gallium scan: problems and misuse in examination of patients with suspected infection.

Gallium citrate Ga 67 (67Ga) has been used for almost ten years as a means of detecting inflammatory lesions in febrile patients. We have reviewed 80 cases from Milwaukee County General Hospital (1977 through 1979) in which 67Ga scanning was performed to detect inflammatory lesions in patients by suspected infection. Fifty scans also were available for review by the nuclear medicine staff. We found the sensitivity of 67Ga scans at our institution to be 90%, but specificity to be only 64%. In five (6%) of the cases, 67Ga scanning was the most important means of establishing a diagnosis. Of the 50 scans available for review, only 26 scans (52%) were interpreted in the same way as the original reading. Twenty-two (27%) of all scans in retrospect should not have been ordered, either because of the fever was gone and the patient's condition was improving or the diagnosis was already made. We conclude that 67Ga scans can be useful to detect inflammatory lesions but that they are frequently used inappropriately by physicians at our hospital, they are difficult to interpret, and the specificity is lower than the sensitivity.

Evaluation of modified Stuart's medium in Culturettes for transport of Neisseria gonorrhoeae.

A prospective study compared rates of isolation of Neisseria Gonorrhoeae after immediate plating of clinical specimens onto Thayer-Martin medium with isolation rates after initial transport in modified Stuart's medium (MST) contained in Culturettes. Of 75 specimens positive for Neisseria gonorrhoeae after immediate plating onto Thayer-Martin medium, 65 (87%) were also positive after being held in MST medium for < or = 8 hr. Twenty (95%) of 21 clinical specimens remained positive after being held in MST medium for < or = 3 hr. However, the rates of isolation of N. gonorrhoeae were significantly reduced after transport for 24 and 48 hr; 60% and 27% of specimens, respectively, yielded N. gonorrhoeae-positive cultures after these intervals. Therefore, it is concluded the MST medium in Culturettes is an acceptable transport medium for specimens containing N. gonorrhoeae when transport time prior to inoculation of growth medium is < or = 3 hr.

Evaluation of eight cephalosporins in hamster colitis model.

Eight commonly used cephalosporins were evaluated in the hamster colitis mode. They were all found to cause hemorrhagic cecitis and death within 10 days of being given as subcutaneous or oral challenges. Necropsy findings were indistinguishable from clindamycin-induced cecitis. Bacteria-free cecal filtrate obtained from hamsters dying of cephalosporin-induced cecitis contained toxin similar or identical to hat produced by Clostridium difficile isolated from the cecum of a hamster. Daily oral administration of poorly absorbed cephalosporins protected hamsters from clindamycin-induced cecitis and death as long as the cephalosporins were continued. The absorbable cephalosporins were ineffective in protecting hamsters from clindamycin-induced cecitis. This difference probably relates to the lower concentrations of absorbable cephalosporins maintained in the ceca of the hamsters. The possible correlation of these findings to human cases of cephalosporin-induced pseudomembranous colitis is discussed.