Necrotizing fasciitis and toxic shock-like syndrome caused by group B streptococcus.

A recent increase in reports of necrotizing fasciitis resulting from group B streptococcus has alerted physicians to a possible concomitant increase of toxic shock-like syndrome. We report the second case of group B streptococcus causing necrotizing fasciitis and toxic shock-like syndrome. A black woman, aged 52 years, with newly diagnosed diabetes mellitus had necrotizing fasciitis type II of the left groin. Hypotension, elevated bilirubin and liver enzymes, and adult respiratory distress syndrome rapidly developed. Because group B streptococcus was isolated from a normally sterile site, the patient's condition met the criteria for toxic shock-like syndrome. Extensive surgical debridement, hyperbaric oxygen therapy, and intravenous antibiotic therapy (including clindamycin) were required for complete recovery. The antitoxin effects of hyperbaric oxygen therapy and clindamycin should be further investigated for the treatment of such patients.

Long-term diuretic therapy in hypertensive patients: effects on serum homocysteine, vitamin B6, vitamin B12, and red blood cell folate concentrations.

BACKGROUND: The effects of chronic diuretic use on serum homocysteine and its metabolic cofactors vitamin B6, vitamin B12, and red blood cell (RBC) folate have not been well studied. METHODS: Blood samples from 17 hypertensive patients receiving long-term diuretic therapy and 17 hypertensive patients not taking diuretics were analyzed for serum homocysteine, vitamin B6, vitamin B12, and RBC folate. RESULTS: The mean serum homocysteine concentration for patients taking diuretics (17.87 +/- 1.72 micromol/L) was significantly higher than the mean serum homocysteine concentration for patients not taking diuretics (10.31 +/- 0.99 micromol/L). The mean RBC folate concentration for patients taking diuretics (281.01 +/- 17.56 ng/mL) was significantly lower than the mean RBC folate concentration for patients not taking diuretics (430.85 +/- 28.58 ng/mL). Serum vitamin B6 and vitamin B12 concentrations were not significantly different between the two groups. CONCLUSIONS: Chronic diuretic use is associated with a significant increase in serum homocysteine concentration, a significant decrease in RBC folate concentration, and no significant change in concentrations of vitamins B6 and B12.

Zidovudine-associated type B lactic acidosis and hepatic steatosis in an HIV-infected patient.

A 34-year-old obese woman with human immunodeficiency virus (HIV) infection diagnosed a year earlier was seen because of nausea, vomiting, and intermittent diarrhea for 3 weeks. Her current medications included zidovudine. Physical examination revealed tachypnea and tender hepatomegaly. Computed tomography of the abdomen showed hepatomegaly with fatty infiltration. Liver enzymes were within normal range except for elevated lactate dehydrogenase (LDH). The serum bicarbonate value was low, with a lactate level three times normal. The tachypnea and dyspnea worsened as lactate concentrations rapidly increased to 15 times normal. Although her Po2 and cardiac index were initially adequate, the patient had acute respiratory failure. She died with multiorgan dysfunction, including hepatic failure, severe lactic acidemia, disseminated intravascular coagulation, and renal failure. Autopsy revealed hepatomegaly and massive steatosis. Physicians should consider lactic acidosis in patients taking zidovudine and having unexplained tachypnea, dyspnea, and low serum bicarbonate concentrations.

Prevalence of folate deficiency and macrocytosis in patients with and without alcohol-related illness.

BACKGROUND: This study was done to determine the prevalence of folate deficiency and macrocytosis in patients admitted to the hospital medicine service with alcohol and nonalcohol-related illnesses. METHODS: Two groups of patients, with and without alcohol-related illnesses, were included. Patients were excluded if they received folate therapy, medications known to alter folate concentrations, or if they had an uncertain diagnosis. Complete blood count and erythrocyte folate concentrations were determined from each patient. A Fisher's Exact Test and odds ratio were used to determine the prevalence of macrocytosis and correlation between folate deficiency and macrocytosis in the alcoholic group, respectively. RESULTS: Of the 36 alcoholic patients, 11.1% were folate deficient, and 33.3% had macrocytosis. Only 2 of 12 patients with macrocytosis were folate deficient. No control patient had macrocytosis or folate deficiency. CONCLUSION: The prevalence of folate deficiency among patients with alcohol-related illness is low. There is no correlation detected between macrocytosis and folate deficiency. Our findings suggest that it may be inappropriate to routinely supplement all alcoholics with folic acid, but certainly a small minority may benefit from it.

Granulocyte colony stimulating factor in the treatment of alcohol abuse, leukopenia, and pneumococcal sepsis.

A 32-year-old woman was admitted with alcoholism, leukopenia, and pneumococcal sepsis (ALPS). Standard treatment consists of antibiotics, vitamin replacement, and intensive care unit support. Even with this treatment, the mortality rate is exceedingly high. In addition to standard therapy, this patient received subcutaneously 300 micrograms granulocyte colony stimulating factor (G-CSF) daily. Initial white blood cell count was 700 microL; by day 4 it had increased to 11,400 microL. She had a prolonged hospital course but was discharged in good condition 6 weeks after admission. G-CSF may be warranted in treating ALPS.

Occupational lead intoxication: report of four cases.

We discuss the cases of four immigrant workers in whom lead intoxication developed via inhalation while they were cutting steel beams removed from a dismantled bridge. They all had toxic lead levels with symptoms and received chelation therapy; the therapy was followed by a decrease in blood lead levels. Rebound increases in their blood lead levels and return of the symptoms necessitated two additional chelation treatments. Prevention is certainly superior to treatment, and these cases underscore the importance of prevention of occupational lead exposure. These workers should have been provided with protective clothing to minimize the accumulation of lead on their skin and hair. This clothing should have been left at the work site to protect the members of the workers' households. They should also have been provided with respiratory protection by the strict use of respirators and by engineering controls. Physicians should be aware of the potential health problems related to lead intoxication.