Systemic antifungal agents.

Anti-fungal agents are classified under two major headings, systematic and topical agents. Only systematic anti-fungal agents will be discussed in this chapter. Since the discovery in 1955, amphotericin B has been the cornerstone of anti-fungal treatment. It is active against most species of fungi. However, Candida lusitaniae, Pseudallescheria boydii, and fusarium spp have primary resistance to amphotericin B. Recently, new liposomal preparations of amphotericin B have been developed. They are less nephrotoxic. The azole family of anti-fungal includes two broad classes: the imidazoles (clotrimazote, ketoconazote, miconazole) and the triazoles (flucouazole and itracouazole). Imidazoles are still widely used for the treatment of superficial mycoses and vaginal candidiasis. The systematic triazoles are more slowly metabolized and have less effect on human synthesis than imidazoles, hence they are preferred for systemic therapy. Flucytosine is a fluorinated pyrimidine. Clinically, the principal use of flucytosine is as adjunctive therapy with amphotericin B in the treatment of candidial or cryptococcal diseases, Griseofuluin is derived from penicillium. It is fungistatic in vitro for species of dermatophytes. It is useful for the treatment of tinea capitis and tinea unginum.

Pyomyositis in a renal transplant patient with Kyrle's disease.

Pyomyositis, an endemic disease of tropical origin, is increasingly reported in temperate zones, especially in patients with diabetes mellitus and in the immunocompromised. A 28-year-old renal transplant recipient presented with perforating skin lesions (Kyrle's disease), thigh pain, and swelling associated with fever. A gallium scan of the thigh led to surgical exploration and a diagnosis of pyomyositis. To our knowledge, the association of Kyrle's disease with pyomyositis has not been reported before. The significance of this combination of conditions in our patient remains unexplained.

Disseminated histoplasmosis in a patient from a nonendemic area who has acquired immunodeficiency syndrome.

Disseminated histoplasmosis is a serious opportunistic infection in patients with the acquired immunodeficiency syndrome (AIDS), often seen as the first manifestation of the syndrome. However, cases are reported almost exclusively from patients who live in or have traveled to endemic areas. We describe a case of disseminated histoplasmosis in a black woman with a 50-lb weight loss and marked weakness that occurred over a 6-month period. This case is one of the few in which disseminated histoplasmosis occurred as the first manifestation of AIDS in a patient in a nonendemic area. We believe it to be the first case reported in Michigan in which the patient has no history of prior residence in an endemic area. Disseminated histoplasmosis should be suspected in patients with AIDS and unexplained febrile illness, even in nonendemic areas.

Infected arteriovenous hemodialysis graft presenting as left and right infective endocarditis.

Prosthetic grafts have become an acceptable alternative to the autogenous arteriovenous dialysis fistula. The major drawback in their use for the dialysis patient is infection. We present a case of infected polytetrafluoroethylene arteriovenous fistula (endarteritis) with signs of unilateral splinter hemorrhage, Janeway lesions in the affected limb and septic venous embolization to the lungs. The graft eventually ruptured requiring emergency surgery. Staphylococcus aureus is by far the most common implicated organism. An otherwise non-threatening infection at a fistula site can lead to more serious complications such as infective endocarditis.

Fulminant disseminated toxoplasmosis in an HIV patient.

Disseminated toxoplasmosis in AIDS is a rare condition. We present an unusual case of a fulminant form of disseminated toxoplasmosis in a young male homosexual. He was a 30-year-old HIV-positive (diagnosed 4 months earlier), admitted with a 5-day history of diarrhea, vomiting, fever, and cough. He had been generally healthy except for an 8-week history of weight loss and malaise. On admission, except for a temperature of 37.6 degrees C, the physical examination was normal. He was treated symptomatically. Four days after admission he suddenly became short of breath. Despite intensive management, he continued to deteriorate and expired 6 h later. Postmortem examination revealed disseminated toxoplasmosis involving the heart, lungs, brain, stomach, small intestine, and colon. This is an unusual presentation of disseminated toxoplasmosis because of its rapid course with no prior indication of infection. To our knowledge, such an atypical and rapid downhill course of toxoplasmosis (with minimal clinical and laboratory features) has not been reported previously. Increased awareness of this infection in all HIV patients and its possibly rapid course is needed.

A clinico-epidemiological study of epidemic typhus in Africa.

Epidemic, louse-borne typhus persists in the rugged, mountainous areas of Ethiopia and much of northeastern and central Africa as well as in the rural highlands of Central and South America, where the conditions of living favor the harboring of body lice and where antibiotic treatment and effective louse-control measures are unavailable. The historical significance and current epidemiology of typhus, including the reservoir of Rickettsia prowazekii in flying squirrels in the United States, are reviewed, and the clinical presentation, laboratory findings, and hospital course in the cases of 60 patients admitted with epidemic, louse-borne typhus to the St. Paul's Hospital in Addis Ababa, Ethiopia, are described. Treatment of this disease with oral doxycycline, tetracycline, or chloramphenicol prevents complications and results in prompt resolution of symptoms.

Significance of cryptococcal antigen titers in patients with AIDS.

We have described a patient with AIDS and cryptococcal antigen titers of 1:262,144 in CSF and 1:268,435,456 in serum. Although the prognosis is poor in AIDS patients with high cryptococcal antigen titers, this patient responded well to treatment and has been free of clinical recurrence of cryptococcal infection for 2 years.

Cerebral blood flow SPECT with Tc-99m exametazine correlates in AIDS dementia complex stages. A preliminary report.

Human immunodeficiency virus (HIV) infection is frequently complicated by a variety of disease processes affecting the central nervous system (CNS). One of them is AIDS dementia complex (ADC), which, in the absence of opportunistic infection, is believed to be caused by HIV itself. ADC is characterized by a constellation of cognitive, motor, and behavioral symptoms that progressively get worse. This study was coined to recruit AIDS patients without any opportunistic CNS infection but with signs of CNS abnormality as evidenced by behavioral and subtle motor changes, then to categorize them into five stages, and finally to perform the cerebral blood flow scan using Ceretec. The aim of this study was to correlate the abnormalities of the brain scan with the different stages of ADC. Five patients were analyzed, with dementias ranging from mild to severe according to Price's classification. After confirming the absence of CNS opportunistic infections and AIDS associated malignancies by CT of the brain, the patients underwent psychiatric evaluation and brain scans. The SPECT scans were very sensitive in showing uptake defects in the brain, even in the early stages of ADC. The blood flow defects were more pronounced in the later stages, while the CT scans remained negative except in patients with the most severe dementia.

Group B streptococcal endocarditis of tricuspid valve.

We report three cases of group B streptococcal endocarditis of the tricuspid valve. Two patients were intravenous drug abusers. In the literature review, and including our cases, ten patients had group B streptococcal endocarditis of the tricuspid valve. Half of the patients were intravenous drug abusers. Four of the other patients had underlying conditions. All patients were treated with a penicillin with or without an aminoglycoside. Three patients underwent tricuspid valve surgery. The overall mortality was 20 percent. Both patients who died received medical therapy only.

Sleep patterns in rural elders: demographic, health, and psychobehavioral correlates.

Altered sleep patterns, including changes in bedtime, sleep latency, total sleep time, and arising time, have been reported to occur with increasing age. We examine self-reported sleep patterns in a geographically-defined population (n = 3097) of persons aged 65 years and older. Sleep patterns were characterized according to demographic variables, clinical conditions, and physical, psychological, and social functioning. Sleep latency and total hours of sleep increased with age, and older respondents went to bed earlier. The percentage of respondents who reported feeling rested in the morning decreased with age. Women went to bed later, had longer sleep latency, and fewer hours of sleep than men, and were less likely to report feeling rested than men. Sleep patterns were also related to educational attainment, self-perceived health status, physical functional status, psychotropic drug use, alcohol use, depressive symptoms, life satisfaction, and social and recreational activity level. This population study suggests that sleep problems among the elderly are sometimes associated with treatable health conditions and modifiable behavioral and environmental characteristics.

Hospital-acquired infections among surgical patients in Tikur Anbessa Hospital, Addis Ababa, Ethiopia.

One thousand six surgical patients admitted between April 1983 and January 1984 to a hospital in Addis Ababa were studied for incidence of nosocomial infections. On admission, they were carefully examined clinically to exclude community-acquired infections and to determine any underlying risk factors. All patients were closely followed up for detection of developing nosocomial infections. Specimens collected from patients with clinically diagnosed bacterial infections were processed for culture; isolates were identified and tested for susceptibility to the locally used antimicrobial agents. Nosocomial infections were detected in 165 (16.4%) patients. Wound (59%), urinary tract (26%), and respiratory tract (6%) infections accounted for more than 90% of the infections. Fourteen of 18 deaths were attributed to nosocomial infections. About 72% of the patients were given prophylaxis, which was associated with infection (p less than 0.0005). Operations and other procedures were also associated with infection (p less than 0.0005). Anemia was found as a host risk factor (p less than 0.0005). Approximately 90% of the nosocomial pathogens were gram-negative bacteria, of which 84% were Enterobacteriaceae. They were mostly resistant to the commonly used antibiotics. Our findings should create awareness of the problem in this hospital and possibly in others in Addis Ababa and hence prompt measures for effective control.

Hospital-acquired infections among obstetric and gynaecological patients at Tikur Anbessa Hospital, Addis Ababa.

Seven hundred patients admitted to the wards of the Department of Obstetrics/Gynaecology of Tikur Anbessa Hospital, Addis Ababa, between January and July 1984 were studied for the incidence of nosocomial infections. The overall hospital infection rate was 17.0%, with wound infection at 47% followed by urinary-tract infection at 15%. Over 80% of the bacterial isolates were Gram-negative bacteria, the majority of which were multiply resistant to the commonly used antibacterial drugs. Some hospital risk factors have been identified. The findings are discussed in the light of reports on nosocomial infections from hospitals of developed countries.

The bacteriology of nosocomial infections at Tikur Anbessa Teaching Hospital, Addis Ababa.

Patients admitted to a teaching hospital in Addis Ababa were studied for nosocomial infection. Of 2506 patients, 13% developed clinical infections, with the highest rate among obstetric/gynaecologic patients (17.0%). Wound infection was the most frequent type of nosocomial infection (49%) followed by urinary tract infection (25%). Antibiotic prophylaxis was given to 43% of the patients. Gram-negative bacteria comprised 88% of all isolated strains Enterobacteriaceae; 75% of all isolates were found in over 60% of the infection, Proteus 25%, Escherichia coli 20% and Klebsiella 19%. The most widely used antibiotics were ineffective against 65 to 85% of the Gram-negative strains. Cefotaxime and gentamicin were more effective. Staphylococcus aureus isolates were also similarly resistant, against which cephalothin, lincomycin and gentamicin were the more effective ones. Over 70% of the strains were multiple resistant. The findings underscore the need for a surveillance program and infection control system to reduce the high rate of infection and to institute appropriate guidelines for the use of prophylactic and therapeutic antibiotics.

Single-dose treatment of uncomplicated acute gonococcal urethritis in Ethiopian men: comparison of rosoxacin, spectinomycin, penicillin, and ampicillin.

A total of 140 Ethiopian men with gonococcal urethritis were randomly assigned to treatment with aqueous procaine penicillin G (4.8 X 10(6) units intramuscularly [im] plus 1.0 g of oral probenicid); oral ampicillin (3.5 g plus 1.0 g of oral probenicid); spectinomycin (2.0 g im); or oral rosoxacin (Acrosoxacin; 300 mg). Failure rates were 24%, 19%, zero, and 3%, respectively. Forty-four (31.4%) patients were infected with penicillinase-producing Neisseria gonorrhoeae (PPNG) and were evenly distributed in the treatment groups. All 39 PPNG strains analyzed for plasmid content possessed a 2.6-Mdalton plasmid; 28 (71.8%) had a 3.2-Mdalton beta-lactamase-encoding plasmid, ten (25.6%) had a 4.4-Mdalton plasmid (three with and seven without a 24.5-Mdalton plasmid), and one had only a 24.5-Mdalton plasmid. Two patients were infected with N. gonorrhoeae-possessing plasmids apparently capable of encoding but not producing beta-lactamase. Both spectinomycin and rosoxacin are excellent single-dose treatment regimens for gonococcal urethritis in men. All people receiving these drugs in Ethiopia should be tested serologically for syphilis, however, as eight (11.8%) of 68 men in this study also had active latent syphilis.

Rapid etiological diagnosis of pyogenic meningitis by coagglutination, latex agglutination and immunoosmophoresis of cerebrospinal fluid, serum and urine.

Three rapid diagnostic methods for the detection of bacterial antigen-COA (Coagglutination), LA (latex agglutination) and IEOP (immunoelectroosmophoresis); DM (direct microscopy after Gram staining) and culture of cerebrospinal fluid (CSF) have been compared in 53 bacterial meningitis patients and in 13 controls. Urine samples were assayed for antigens in connection with CSF in 32 for COA, LA, and IEOP. The cause of meningitis was S. pneumoniae in 31, H. influenzae type b in 16 and N. meningitidis in 6 using the methods for diagnosis by LA in 100%, COA in 94%, culture in 89%, IEOP in 81% and DM in 78% of the CSF samples. None of the CSF from controls were positive by any of the methods. LA and COA detected antigen in CSF in all 4 patients on 4th and 5th day of treatment but none of the tests were helpful 7-10 days later. LA was effective in detecting antigen in urine in 10/10 (100%) H. influenzae type b, 17/20 (85%) S. pneumoniae prior to antibiotic treatment. IEOP was helpful in antigen detection better in serum than in urine in 5/6 H. influenzae type b and 9/11 S. pneumoniae meningitis. In general we have found LA and COA as simple, rapid specific and sensitive tests and can be applied even in field situations and that LA can be used for antigen detection in urine and IEOP in serum. A large scale study is needed in order to standardize methods for antigen detection in serum and urine.