Subcutaneous phaeohyphomycosis caused by Lasiodiplodia theobromae and successfully treated surgically.

While visiting Jamaica, a 50-year-old woman stumbled on an outdoor wooden staircase and sustained an injury to the right leg. The wound was cleaned topically and the patient was given antibacterial therapy. Five weeks later, in Canada, she presented with an ulcer at the injury site. An excisional biopsy showed copious broad, septate, melanized fungal filaments penetrating into tissue. Culture yielded a nonsporulating melanized mycelium. The isolate was strongly inhibited by cycloheximide and benomyl but grew at 37 degrees C. After 16 weeks cultivation on modified Leonian's agar at 25 degrees C, it developed pycnidia characteristic of Lasiodiplodia theobromae, a common tropical phytopathogen mainly known previously as a rare agent of keratitis and onychomycosis in humans. The patient was not given antifungal chemotherapy, and the ulcer, which had been broadly excised in the biopsy procedure, ultimately resolved after treatment with saline compresses. The six-month follow-up showed no sign of infection. This case, interpreted in light of previously reported cases, shows that on rare occasions L. theobromae is able to act as an agent of subcutaneous phaeohyphomycosis and that, when this occurs, debridement alone may be sufficient to eradicate it.

Evaluation of Roche Amplicor PCR assay for Mycobacterium tuberculosis.

The Roche Amplicor Mycobacterium tuberculosis PCR test (RMtb-PCR) was compared with mycobacterial culture, with the BACTEC 460 system and inoculation on Lowenstein-Jensen media. Results were interpreted with an adjusted "gold standard" incorporating clinical diagnosis. A total of 1,480 clinical specimens from 1,155 patients, including tissues and fluids, as well as 141 specimens which demonstrated a positive growth index on the BACTEC 460 system were assessed. The sensitivity, specificity, and positive and negative predictive values of RMtb-PCR compared with the adjusted gold standard for clinical specimens were 79, 99, 93, and 98%, respectively. In smear-positive specimens, the sensitivity of RMtb-PCR was 98% versus 53% for smear-negative specimens. When RMtb-PCR was performed two times per week, PCR results were available an average of 21 days before the culture results. For specimens demonstrating a positive growth index on the BACTEC 460 system, RMtb-PCR had a sensitivity and specificity of 98 and 100%, respectively. This study demonstrates the value of a commercial nucleic acid amplification kit for rapid diagnosis of M. tuberculosis, particularly in smear-positive specimens or BACTEC culture-positive specimens.

Piperacillin versus cefazolin given perioperatively to high-risk patients who undergo open cholecystectomy: a double-blind, randomized trial.

OBJECTIVE: To study the efficacy, microbiologic features and toxicity of prophylactic cefazolin versus prophylactic piperacillin in high-risk patients who undergo open cholecystectomy. DESIGN: Double-blind randomized trial with follow-up for 6 weeks postoperatively. SETTING: An 850-bed community hospital, located in a major Canadian city. Patients admitted to hospital who satisfied published criteria for being at high-risk for infection after open cholecystectomy were entered into the protocol, and those who satisfied the criteria and provided consent were entered into the study. Eighty-one patients were randomly assigned by computer to receive either piperacillin or cefazolin as the prophylactic agent. INTERVENTIONS: Open cholecystectomy. MAIN OUTCOME: Provides detailed information on the organisms found in the biliary tree in patients with acute cholecystitis, assesses the in-vitro activity of cefazolin versus piperacillin against the isolated organisms, expecting that piperacillin would be much more active against isolated anaerobes and gram-negative bacteria. RESULTS: Bactobilia was documented in 42% of patients in the cefazolin group and 29% of patients in the piperacillin group. Piperacillin was active in vitro against 94% of all isolates versus 56% for cefazolin (p < 0.005, McNemar's test). Adverse effects and toxicities in both the piperacillin and cefazolin group were low and were not serious. CONCLUSIONS: Both piperacillin and cefazolin are safe and effective prophylactic antimicrobials for high-risk patients who undergo open cholecystectomy. However, piperacillin had a much wider spectrum of in-vitro activity against the isolated pathogens, especially Enterococcus sp., Enterobacter cloacae and the anaerobes.

Normally saprobic cryptococci isolated from Cryptococcus neoformans infections.

We report two cases in which Cryptococcus laurentii was isolated from surgically resected pulmonary lesions but the cryptococcal cells is tissue reacted positively with a specific fluorescent antibody (FA) conjugate for Cryptococcus neoformans. Both patients had no apparent host defense defects. In both cases, multiple cryptococcal isolates were obtained from tissue, and yeastlike cells consistent with C. neoformans were seen in direct histology. The isolates were identified by assimilation patterns and standard procedures including phenoloxidase reactions. Since C. laurentii was consistently isolated by using stringent procedures, it was considered unlikely that the fungus represented surgical or laboratory contamination. Its presence may be the result of dual infection not detected by FA, but other possible explanations exist. The results show the value of the FA test in diagnostic mycology and call into question previous reports of cryptococci other than C. neoformans as agents of infection.

Evidence for the occurrence of the same strain of Campylobacter pylori in the stomach and dental plaque.

Restriction endonuclease analysis with HindIII, HaeIII, and BglII endonucleases of DNA extracted from each of eight colonies of Campylobacter pylori subcultured from a stomach biopsy and from each of eight colonies subcultured from dental plaque of the same patient indicated that at least three strains were present in the dental plaque but only one strain was present in the biopsy. One of the dental strains had restriction patterns indistinguishable from those of the biopsy isolate, providing evidence that both sites were infected with the same strain of C. pylori.

Examination of human stomach biopsies, saliva, and dental plaque for Campylobacter pylori.

To examine possible sources of Campylobacter pylori and to determine the routes by which it is transmitted to the human stomach, samples of dental plaque and saliva from 71 patients undergoing endoscopy in addition to stomach biopsies were collected and cultured on selective noninhibitory Skirrow medium. A total of 29 (40.8%) of the stomach biopsies yielded C. pylori. None of the saliva samples and only one of the dental plaque samples was found positive for C. pylori, and thus neither saliva nor dental plaque could be implicated as a significant reservoir of this organism.

Comparison of selective and nonselective media for recovery of Campylobacter pylori from antral biopsies.

Antral biopsy specimens from patients with acid peptic disease were cultured in parallel on Skirrow medium (SM) and sheep blood agar (SBA) for Campylobacter pylori. In institution 1, 23 of 88 (26.1%) endoscopies were positive on SBA compared with 37 of 88 (42.0%) on SM (P = 0.0001). In institution 2, 29 of 49 (59.2%) endoscopies were positive for C. pylori on SBA and 27 of 49 (55.1%) were positive on SM (P = 0.50). The addition of SM optimizes the recovery of C. pylori from antral biopsy specimens.

Expanded clinical spectrum of infections caused by Proteus penneri.

Strains of Proteus penneri from seven abdominal wounds (after bowel resection), five urine samples, and eight other sites were isolated in mixed cultures. Seven urine isolates were in pure cultures. All infections were nosocomially acquired, indicating that complete identification of P. penneri in the clinical laboratory is warranted.

Campylobacter pyloridis is associated with acid-peptic disease in Toronto.

Campylobacter pyloridis has been associated with acid-peptic disease in centres outside Canada. The authors conducted a pilot study to see if this association existed in Toronto. Patients in whom esophagogastroscopy was indicated on clinical grounds were arbitrarily selected for determination of the presence of C. pyloridis. Included in the study were 100 patients who underwent 105 endoscopies. In 75 patients (80 endoscopies) there was some form of acid-peptic disease (inflammation or ulceration of stomach or duodenum). Of those with acid-peptic disease, 34% had C. pyloridis compared with 4% among patients without acid-peptic disease (p less than 0.01). Men with acid-peptic disease were more likely to harbour C. pyloridis than women (48% versus 16%, p less than 0.01). The organisms were curved gram-negative rods that appeared as small colonies after 4 days of incubation under microaerobic conditions. They were strongly urease positive. There was considerable heterogeneity of endoscopic diagnoses. Future clinical studies of C. pyloridis need careful endoscopic and histologic classification.

Susceptibilities of 45 clinical isolates of Proteus penneri.

Patterns of susceptibility of 45 Proteus penneri clinical isolates to 14 antimicrobial agents were evaluated by a macrobroth dilution method. All strains were highly susceptible to ceftizoxime, ceftazidime, moxalactam, cefoxitin, gentamicin, tobramycin, netilmicin, and, with few exceptions, to amikacin, piperacillin, and cefoperazone. Most strains were susceptible to cefotaxime and ceftriaxone. All strains were resistant to cefazolin and cefsulodin.

Proteus penneri and urinary calculi formation.

The clinical significance of Proteus penneri, a newly described species, is unknown. A case report is presented, which is to the best of our knowledge the first description of this organism causing a urinary tract infection and bladder calculi.

An outbreak of Staphylococcus epidermidis septicemia.

During 45 wk from August 1980 to June 1981, the catheter sepsis rate increased from a prior 2 to 34% (23 of 68 patients on intravenous hyperalimentation). The causative organism was Staphylococcus epidermidis, grown on blood cultures in 21 of the 23 patients and on the catheter-tips of all 23. Routine cultures of the catheter-tips of the 45 patients who received intravenous hyperalimentation during this period with no evidence of catheter sepsis grew S. epidermidis on three catheter-tips (6.7%), possibly contamination during catheter removal. Sepsis resolved within 24 hr after catheter removal, with no antibiotics given for the sepsis. The organism had identical antibiograms on the blood and catheter-tip cultures in each patient, but antibiograms varied between patients. In these complex patients undergoing multiple medical events, the intravenous hyperalimentation nurse recorded that iv tubing in septic patients had leaked solution at the attachment to the catheter hub, and a review of nursing notes on charts of patients who had been on intravenous hyperalimentation revealed that a leak had been noted in the patients who subsequently had catheter sepsis. The leak was due to a manufacturing defect resulting in a decrease in diameter of the plastic connection of the iv tubing, which produced a loose attachment to the hub. The problem was remedied by switching to a Luer-lok attachment. However, in July 1982, two patients had separation of the Luer due to a manufacturing defect in the threads, followed by a catheter sepsis. Sepsis from the local contamination was not manifest until 5.4 +/- 2.7 days later. Quality control by manufacturers is emphasized.

Growth of common bacteria and Candida albicans in 10% soybean oil emulsion.

Bacterial and fungal growth in 10% soybean oil emulsion (Intralipid) and 5% fibrin hydrolysate in 5% dextrose was studied at 4, 25 and 37 degrees C. Staphylococcus aureus, Streptococcus pyogenes, Str. fecalis, Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli and Candida albicans were grown in broth at 37 degrees C, diluted in saline and inoculated into each of the two preparations as well as a mixture of the two. Growth was measured at 24, 48 and 72 hours. In 10% soybean emulsion, all bacteria except S. pyogenes multiplied, but in fibrin hydrolysate-dextrose solution the only organism of those studied to grow was S. aureus. In the hydrolysate-dextrose-lipid mixture, all organisms multiplied except S. pyogenes and P. aeruginosa. C. albicans grew in all solutions tested. While at 4 degrees C, organisms did not multiply. The fibrin hydrolysate-dextrose solutions given by infusion into a central vein for hyperalimentation have been shown to support predominantly fungal growth, and contamination of the solution and ultimately of the indwelling catheter is a constant hazard. Because both bacteria and C. albicans grew equally well in 10% soybean oil emulsion, its use as a caloric source when infused into a central vein may increase the occurrence of sepsis. When this emulsion is used to provide essential fatty acids or calories, it should be given via a peripheral vein, so that a central catheter will not be contaminated.