[Headaches and aphasia in an immunocompromised patient]. / Kopfschmerzen und Wortfindungsstörungen bei einem immunsupprimierten Patienten.

We report the case of a 81-year-old, immunocompromised Patient, admitted to our hospital with new-onset headaches and word-finding difficulties. The MRI of the brain revealed a temporal mass on the left with marginal contrast-enhancement. During the next days Listeria monocytogenes grew in the bloodcultures so that the diagnosis of a brain-abscess caused by Listeria was established. Due to the localisation, surgical drainage of the abscess was not possible, so that a prolonged antibiotic therapy lasting over 4.5 months was initiated. The MRI after therapy demonstrated no abscess persistence. Listeria mostly cause infections in the immunocompromised, elderly, newborn or pregnant host. Next to bacteraemia without a focus, CNS-invasion with meningitis, meningoencephalitis or less frequent abcess-formation (5-10%) is the most important manifestation.

Serum procalcitonin for discrimination between septic and non-septic arthritis.

BACKGROUND: Early differentiation between septic and non-septic arthritis is difficult. A previous study showed promising diagnostic accuracy of serum Procalcitonin (PCT) in septic arthritis, limited by a low sensitive PCT test kit. OBJECTIVE: To investigate the diagnostic value of PCT in patients with septic and non-septic arthritis using a novel test with low detection limit. METHODS: Forty-two patients, 28 with non-septic and 14 with septic arthritis were prospectively included. For each patient, gram stain, culture and polarization microscopy of synovial fluid was done and PCT, C-reactive protein (CRP), white blood cell count, uric acid and blood cultures were taken. Patients with septic arthritis, patients with non-septic arthritis with and without concomitant infection were compared. RESULTS: Patients with septic arthritis had a significant higher PCT concentration than patients with non-septic arthritis (p<0.0001). At a cut-off of 0.1 (0.25) ng/ml, sensitivity for septic arthritis was 100(93)% and specificity 46(75)%. Specificity rose to 93% after exclusion of patients with non-septic arthritis and concomitant infection. Both sensitivity and specificity for the diagnosis of septic arthritis were higher for PCT than CRP. CONCLUSIONS: Our data suggest that PCT seems to be a highly sensitive and specific marker for septic arthritis, depending on the clinical setting. Further studies are warranted.

Vertebral osteomyelitis caused by Actinobaculum schaalii: a difficult-to-diagnose and potentially invasive uropathogen.

We report the first case of vertebral osteomyelitis caused by Actinobaculum schaalii and review all cases of A. schaalii identified at our institution between 2002 and 2005. A. schaalii causes urinary tract infections - especially in elderly people - occasionally with septic complications.

[Infection with Aeromonas hydrophila after use of leeches (Hirudo medicinalis) in a free microvascular osteo-(myo-)cutaneous flap--suggestions for successful management]. / Aeromonas hydrophila-Infektion nach Therapie mit Hirudo medicinalis bei venöser Stauung nach freiem mikrovaskulären osteo-(myo-)kutanen Gewebetransfer--Empfehlungen zur erfolgreichen Therapie.

Medical leeches (Hirudo medicinalis) are an important therapeutic option in the treatment of venous congestion of flaps. In a case report an infection with Aeromonas hydrophila of a free microvascular osteo-(myo)-cutaneous flap after leech application for venous congestion is described and the current literature reviewed. Infection associated with leech therapy is a documented complication of leech application, with reported incidences ranging from 2.4 to 20 %. In some cases an infection of the wound developed with Aeromonas hydrophila, a Gram-negative rod that lives symbiotically in the intestines of the leech. Because of the risk of graft loss, early diagnosis and immediate initiation of an empirical intravenous antibiotic therapy with Piperacillin/Tacobactam or a third or fourth generation cephalosporins are essential even before results for sensitivity testing are received. An alternative is a short-term preemptive therapy with Cotrimoxazol or Ciprofloxacin during leech application.

[Diagnostics for pulmonary tuberculosis in adults]. / Diagnostik der pulmonalen Tuberkulose beim Erwachsenen.

The incidence of pulmonary tuberculosis (TB) is decreasing in Western Europe. However, TB should not be considered to be a rare disease, particularly in immigrants and in immunocompromised persons (i.e. HIV infection). The clinical presentation is often atypical in immunocompromised persons. In general, the extent of the disease is underestimated by the clinical presentation. X-ray and a sequential investigation of three samples of sputum including microscopy, culture and susceptibility testing for the first-line drugs should be obtained. Tuberculin testing is useful in the diagnosis of latent TB and in screening persons with close contact to patients with active disease. New blood tests based on the detection of interferon-g released by antigen specific T-cells have some advantages compared to tuberculin testing.

[Diagnostic procedures for patients with community acquired pneumonia]. / Diagnostik bei ambulant erworbener Pneumonie.

The diagnosis of community acquired pneumonia (CAP) is based on a patient history with respiratory symptoms and additional symptoms and signs such as fever over more than 4 days, dyspnea and tachypnea and/or a positive lung auscultation. Despite recently developed tests, radiology is a key diagnostic procedure for confirming CAP. Importantly, the first treating physician must judge whether to hospitalize a patient or not. Two major scoring systems allow judgement of severity and short-term prognosis. In general, in patients with mild or moderate pneumonia who can be treated on an ambulatory basis, no specific microbiological diagnosis must be performed. If, for clinical or epidemiological reasons a gram stain is done, it must be obtained from purulent sputum. Recent tests may help in discriminating between viral and bacterial pneumonia (procalcitonin test) or determine the bacteria responsible for acute disease (pneumococcal antigen test using urine).

Course and outcome of Staphylococcus aureus bacteraemia: a retrospective analysis of 308 episodes in a Swiss tertiary-care centre.

Staphylococcus aureus bacteraemia (SAB) is associated with substantial morbidity and mortality worldwide. The charts of adult patients with SAB who were hospitalised in a Swiss tertiary-care centre between 1998 and 2002 were studied retrospectively. In total, 308 episodes of SAB were included: 2% were caused by methicillin-resistant strains; 49% were community-acquired; and 51% were nosocomial. Bacteraemia without focus was the most common type of community-acquired SAB (52%), whereas intravenous catheter-related infection predominated (61%) among nosocomial episodes of SAB. An infectious diseases (ID) specialist was consulted in 82% of all cases; 83% received appropriate antibiotic treatment within 24 h of obtaining blood cultures. Overall hospital-associated mortality was 20%. Community-acquired SAB was associated independently with a higher mortality rate than nosocomial SAB (26% vs. 13%; p 0.009). Independent risk-factors for a fatal outcome were age (p < 0.001), immunosuppression (p 0.007), alcoholism (p < 0.001), haemodialysis (p 0.03), acute renal failure (p < 0.001) and septic shock (p < 0.001). Consultation with an ID specialist was associated with a better outcome in univariate analysis (p < 0.001). Compared with a previous retrospective analysis performed at the same institution between 1980 and 1986, there was a 140% increase in community-acquired SAB, a 60% increase in catheter-related SAB, and a 14% reduction in mortality. In conclusion, mortality in patients with SAB remained high, despite effective antibiotic therapy. Patients with community-acquired SAB were twice as likely to die as patients with nosocomial SAB. Consultation with an ID specialist may reduce mortality in patients with SAB.

Dynamics of serum procalcitonin in patients after major neurosurgery.

Classical markers of infection cannot differentiate reliably between inflammation and infection after neurosurgery. This study investigated the dynamics of serum procalcitonin (PCT) in patients following major neurosurgery. PCT concentrations remained < 0.2 ng/mL during the post-operative course. In contrast, leukocyte and neutrophil counts, as well as C-reactive protein (CRP) levels, increased significantly post-operatively (leukocytes, range 7.1-23.7 x 10(9)/L, p < 0.001; neutrophils, range 70.8-94.5%, p < 0.001; CRP, median 14 mg/L, range 3-95 mg/L, p < 0.001). Analysis of PCT levels using assays with improved sensitivity may be useful in the diagnosis of neurosurgical patients with post-operative fever of unknown origin.

Vertebral osteomyelitis caused by non-tuberculous mycobacteria.

Vertebral osteomyelitis caused by non-tuberculous mycobacteria is a rare disease, with only 31 cases and one nosocomial outbreak reported in the literature (MedLine review between 1965 and December 2003). The clinical features are often indistinguishable from those of pyogenic osteomyelitis. Early diagnosis of such infections is a major challenge because of the slow growth of these microorganisms. No consensus guidelines for the treatment of these infections exist. Prolonged anti-mycobacterial therapy in combination with surgical debridement is recommended.

The integration of alternative treatment modalities in HIV infection--the patient's perspective.

The relationship between professionals representing conventional treatment (CT) and professionals representing non-conventional therapies (alternative therapy (AT) and/or psychotherapy (PT)) is usually characterized by mutual scepticism and mistrust, the overriding fear being that either side will evoke unjustified hopes or will provide false treatment. We investigated whether patients with HIV infection had unrealistic hopes in non-conventional treatment (non-CT), to what extent they use non-CT, and whether perceived benefit and harm differ between the two modes of treatment. We examined a sample of 100 patients with documented HIV-infection in the out-patient department using a self-developed questionnaire, the Hospital Anxiety and Depression Scale (HAD) and data concerning the HIV status. Fifty-six patients used AT and/or PT. Severity of HIV disease did not differ between users and non-users of non-CT. The most important reasons for the use of AT were 'strengthening the body and resistance; supplementing conventional therapy'. Users of non-CT rated the competence of CT lower than non-users in solving medical problems (VAS-scores 0-100: 65.5 +/- 17.6 vs 76.3 +/- 17.7; p = 0.003) and in solving emotional problems (VAS scores 0-100: 35.8 +/- 21.2 vs 48.2 +/- 28.9; p = 0.02). Users of non-CT were significantly more anxious 8.4 +/- 4.8 vs 5.5 +/- 4.6; p = 0.004) and more depressive (5.7 +/- 4.5 vs 3.7 +/- 4.5; p = 0.03) than non-users. Expectations and hopes did not differ between users of AT and non-users: main hopes were a delay of disease progression (76% vs 71%) and an alleviation of symptoms (78% vs 66%).(ABSTRACT TRUNCATED AT 250 WORDS)

Oral hairy leukoplakia in a patient with ulcerative colitis.

A 30-year-old man with ulcerative colitis developed oral hairy leukoplakia (OHL). Serological examination for human immunodeficiency virus (HIV)-1 and HIV-2 infection showed no abnormalities. Biopsy specimen of the lateral tongue showed ballooned prickle cells, and electron microscopy revealed herpes-type viruses. Immunologic investigation of the patient showed a marked decrease in T-helper cells as a result of immunosuppressive regimen. The present report appears to be the first well-documented case of OHL in an HIV-negative patient with ulcerative colitis. OHL may be a marker for severe immunosuppression but is not necessarily associated with HIV infection. Patients with iatrogenic immunosuppression should be monitored for OHL. Concerning the marked decrease in T-helper cells in this case, the presence of OHL may imply the examination of T-lymphocyte subsets in patients such as HIV-infected individuals or in organ transplant recipients.

[Successful treatment of HIV-associated pneumocystis carinii pneumonia with dapsone plus trimethoprim]. / Erfolgreiche Behandlung der HIV-assoziierten Pneumozystis-carinii-Pneumonie mit Dapson plus Trimethoprim.

Standard treatments of HIV-associated Pneumocystis carinii pneumonia (PCP) consist of high dose intravenous or oral cotrimoxazole or intravenous pentamidine. Both treatment modalities are associated with a high incidence of side effects which strengthen the need for alternative therapies. Since April 1987 we have used the combination of dapsone plus trimethoprim (DP+TMP) as primary treatment for PCP in patients who could be managed on an outpatient basis. We report the results of an analysis of the efficacy and toxicity of this treatment in 20 episodes of PCP in 18 patients. PCP was diagnosed by identification of the pathogens in bronchoalveolar lavage specimens. Chest X-ray revealed bilateral involvement in 11 and unilateral in 7 cases and no infiltration in one patient. Treatment over three to four weeks was successful in 14 of 20 PCPs (70%). In six cases (30%) treatment was changed to another regimen after a mean of seven days due to a maculopapular rash (n = 2), haematotoxic side effects (n = 2), persistent fever (n = 1) and for unexplained reasons (n = 1). Less severe side effects not causing a change in treatment were a slight to moderate neutropenia (n = 10), a moderate elevation of liver enzymes (n = 2) and a well tolerated rash (n = 2). The success rate of DP+TMP was in the same range as it is known for the standard regimens, whereas the rate of severe side effects appears to be lower. The results suggest that in AIDS patients DP+TMP may be used as first line treatment of PCP which is not severe enough for hospitalisation.