Syphilis resembling human papilloma virus associated oropharyngeal cancer: case report and literature review of recent incidence trends.

BACKGROUND: The yearly incidence of syphilis has risen markedly in Japan and worldwide. There has also been an increased incidence of human papilloma virus associated oropharyngeal cancer, which presents with clinical features similar to those of syphilis. OBJECTIVE: A case of syphilis with clinical manifestation resembling that of human papilloma virus associated oropharyngeal cancer is reported, along with a literature review of similar cases. METHODS: Clinical case reports and review of previous literature. CONCLUSION: Syphilis may cause irregular mucosal lesions of the oropharynx and cystic lymphadenopathy. It is difficult to diagnose syphilis only by examining pathological specimens, without clinical information such as Treponema pallidum antibody findings. It is necessary to correctly understand the characteristics of syphilis and human papilloma virus associated oropharyngeal cancer to ensure prompt diagnosis and treatment.

Arterial catheter-related bloodstream infection: incidence, pathogenesis, risk factors and prevention.

BACKGROUND: Arterial catheters are essential in critical care for haemodynamic and blood gas monitoring. The risk of infection remains ill defined. AIMS: To delineate the incidence, pathogenesis and risk factors for arterial catheter-related bloodstream infection (BSI). METHODS: Arterial catheters in two randomized trials in 1998-2000 were studied prospectively. One trial studied the effect of a 1% chlorhexidine-75% alcohol solution for cutaneous antisepsis for intravascular catheters, and the other trial studied the efficacy of a chlorhexidine-impregnated sponge dressing, both for prevention of catheter-related BSI. At catheter removal, skin of the insertion site, catheter segments, hub and infusate were cultured quantitatively in all cases. Catheter-related BSI was confirmed by concordance between isolates from the catheter and from blood cultures by restriction-fragment DNA subtyping. Risk factors for arterial catheter-related BSI were determined using univariate analysis. FINDINGS: Of 834 arterial catheters studied (3273 catheter-days), 109 (13%) were colonized and 11 caused bacteraemia (1.3%, 3.4 per 1000 catheter-days). The majority of catheter-related BSIs were acquired extraluminally from skin of the insertion site (63%). The risk of arterial catheter-related BSI was comparable with that for short-term non-cuffed central venous catheters (2.7%, 5.9 per 1000 CVC-days). CONCLUSION: In patients in intensive care with cryptogenic sepsis or bacteraemia, arterial catheter-related BSI must also be suspected and excluded. The most common route of infection is extraluminal; as such, novel technologies shown to prevent bloodstream infection with CVCs, such as chlorhexidine for cutaneous antisepsis and chlorhexidine-impregnated dressings, may also be of benefit with arterial catheters.

Infections in the neutropenic patient--new views of an old problem.

Infection in the neutropenic patient has remained a major clinical challenge for over three decades. While diagnostic and therapeutic interventions have improved greatly during this period, increases in the number of patients with neutropenia, changes in the etiologic agents involved, and growing antibiotic resistance have continued to be problematic. The evolving etiology of infections in this patient population is reviewed by Dr. Donowitz. Presently accepted antibiotic regimens and practices are discussed, along with ongoing controversies. In Section II, Drs. Maki and Crnich discuss line-related infection, which is a major infectious source in the neutropenic. Defining true line-related bloodstream infection remains a challenge despite the fact that various methods to do so exist. Means of prevention of line related infection, diagnosis, and therapy are reviewed. Fungal infection continues to perplex the infectious disease clinician and hematologist/oncologist. Diagnosis is difficult, and many fungal infections will lead to increased mortality even with rapid diagnosis and therapy. In Section III, Dr. Pappas reviews the major fungal etiologies of infection in the neutropenic patient and the new anti-fungals that are available to treat them. Finally, Dr. Rolston reviews the possibility of outpatient management of neutropenic fever. Recognizing that neutropenics represent a heterogeneous group of patients, identification of who can be treated as an outpatient and with what antibiotics are discussed.

Acute appendicitis: comparison of helical CT diagnosis focused technique with oral contrast material versus nonfocused technique with oral and intravenous contrast material.

PURPOSE: To compare the diagnostic accuracy of focused helical computed tomography (CT) with orally administered contrast material with that of nonfocused helical CT with orally and intravenously administered contrast material. MATERIALS AND METHODS: After receiving oral contrast material, 228 patients with clinically suspected appendicitis underwent focused appendiceal CT (5-mm section thickness, 15-cm coverage in the right lower quadrant). Immediately thereafter, helical CT of the entire abdomen and pelvis was performed following intravenous administration of contrast material (abdomen, 7-mm section thickness; pelvis, 5-mm section thickness). Studies were separated and independently interpreted by three observers who were blinded to patient names. Diagnoses were established by means of surgical and/or clinical follow-up findings. RESULTS: Fifty-one (22.4%) of 228 patients had acute appendicitis. Readers diagnosed appendicitis with 83.3%, 73.8%, and 71.4% sensitivity and 93.0%, 92.3%, and 97.9% specificity with focused nonenhanced appendiceal CT. Readers diagnosed appendicitis with 92.9%, 92.9%, and 88.1% sensitivity and 93.7%, 95.1%, and 96.5% specificity with nonfocused enhanced CT. Summary areas under the receiver operating characteristic curve estimates for focused nonenhanced and nonfocused enhanced CT were 0.916 and 0.964, respectively; the differences were statistically significant (P <.05) for two of three readers. All readers demonstrated higher sensitivities for detecting the inflamed appendix with nonfocused enhanced CT. Appendicitis was missed with focused CT in two patients whose inflamed appendix was not included in the imaging of the right lower quadrant. All readers were significantly more confident in diagnosing alternative conditions with nonfocused enhanced CT. CONCLUSION: Diagnostic accuracy of helical CT for acute appendicitis improved significantly with use of intravenous contrast material.

A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates.

UNLABELLED: Neonates who require a central venous catheter (CVC) for prolonged vascular access experience high rates of catheter-related bloodstream infection (CRBSI). PURPOSE: A multicenter randomized clinical trial was undertaken to ascertain the efficacy of a novel chlorhexidine-impregnated dressing (Biopatch Antimicrobial Dressing) on the CVC sites of neonates for the prevention of catheter tip colonization, CRBSI, and bloodstream infection (BSI) without a source. Setting. Six level III neonatal intensive care units. Patients Studied. Neonates admitted to study units who would require a CVC for at least 48 hours. METHODS: Eligible infants were randomized before catheter placement to 1 of the 2 catheter site antisepsis regimens: 1) 10% povidone-iodine (PI) skin scrub, or 2) a 70% alcohol scrub followed by placement of a chlorhexidine-impregnated disk over the catheter insertion site. A transparent polyurethane dressing (Bioclusive Transparent Dressing) was used to cover the insertion site in both study groups. Primary study outcomes evaluated were catheter tip colonization, CRBSI, and BSI without an identified source. RESULTS: Seven hundred five neonates were enrolled in the trial, 335 randomized to receive the chlorhexidine dressing and 370 to skin disinfection with PI (controls). Neonates randomized to the antimicrobial dressing group were less likely to have colonized CVC tips than control neonates (15.0% vs 24.0%, relative risk [RR]: 0.6 95% confidence interval [CI]: 0.5-0.9). Rates of CRBSI (3.8% vs 3.2%, RR: 1.2, CI: 0.5-2.7) and BSI without a source (15.2% vs 14.3%, RR: 1.1, CI: 0.8-1.5) did not differ between the 2 groups. Localized contact dermatitis from the antimicrobial dressing, requiring crossover into the PI treatment group, occurred in 15 (15.3%) of 98 exposed neonates weighing

Reality check: should we use vancomycin for the prophylaxis of intravascular catheter-associated infections?

The use of intravascular catheters is associated with increased risk of bloodstream infections, principally caused by coagulase-negative staphylococci. This "Reality Check" session, held at the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections, focused on the question of whether, and in what manner, vancomycin should be used for the prophylaxis of these infections

Engineering out the risk for infection with urinary catheters.

Catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection. Each year, more than 1 million patients in U.S. acute-care hospitals and extended-care facilities acquire such an infection; the risk with short-term catheterization is 5% per day. CAUTI is the second most common cause of nosocomial bloodstream infection, and studies suggest that patients with CAUTI have an increased institutional death rate, unrelated to the development of urosepsis. Novel urinary catheters impregnated with nitrofurazone or minocycline and rifampin or coated with a silver alloy-hydrogel exhibit antiinfective surface activity that significantly reduces the risk of CAUTI for short-term catheterizations not exceeding 2-3 weeks.

Clustered pulmonary nodules: highly suggestive of benign disease.

Thirty-one adult patients with a cluster of small, noncalcified, pulmonary nodules identified on chest computed tomography (CT) examinations were studied retrospectively. Pathology revealed an infectious/inflammatory etiology in all cases in which a surgical resection of the involved lung was performed. None of the patients in our study group showed evidence of malignancy in the region of a cluster of pulmonary nodules over the follow-up period. The authors conclude that an isolated cluster of small pulmonary nodules is strongly suggestive of benign disease. Although exceptions may rarely occur, most cases represent incidental infectious or inflammatory disease.

Pulmonary arteriovenous malformations: three-dimensional gadolinium-enhanced MR angiography-initial experience.

PURPOSE: To determine whether three-dimensional gadolinium-enhanced magnetic resonance (MR) angiography could be used to identify pulmonary arteriovenous malformations (PAVMs) and to accurately identify the size and number of feeding arteries. MATERIALS AND METHODS: Eight patients suspected of having PAVM were examined with three-dimensional MR angiography at 1.5 T. Images were reviewed by a single radiologist blinded to conventional angiographic findings who evaluated each image for the size, number, and location of PAVMs, as well as for the size and number of feeding arteries. Five patients underwent conventional angiography with embolization therapy, and one patient underwent lobectomy. Two patients did not undergo either surgery or angiography. RESULTS: Three-dimensional MR angiography revealed nine (90%) of 10 PAVMs that were confirmed at conventional angiography (n = 9) or examination of a surgical specimen (n = 1). The single PAVM that was not identified prospectively at MR angiography was small (3-4 mm) and peripheral. Two additional PAVMs were identified in the two patients who did not undergo surgery or angiography. CONCLUSION: Three-dimensional MR angiography is a promising technique for use in the diagnosis of PAVM, although small (<5-mm) PAVMs may be more difficult to identify with the technique. The technique is a particularly useful means of noninvasively demonstrating the size and number of feeding arteries prior to treatment.

Central venous device-related infection and thrombosis in patients treated with moderate dose continuous-infusion interleukin-2.

BACKGROUND: This study was performed to determine the incidence of central venous device-related blood stream infection and thrombosis in patients treated with moderate dose continuous-infusion interleukin-2 (IL-2). METHODS: The records of 160 consecutive patients treated at the University of Wisconsin Hospital and Clinics, between June 1990 and June 1997, with moderate dose continuous-infusion IL-2 (IL-2 [1.5-3.0 x 10(6) U/m(2)/day] Hoffman-LaRoche, Nutley, NJ or IL-2 [4.5 x 10(6) U/m(2)/day] Chiron Corporation, Berkley, CA) were reviewed retrospectively. The majority of patients had metastatic melanoma (78 patients) or renal cell carcinoma (70 patients). All of the patients had a surgically implanted central venous device placed before starting IL-2 therapy; 89% of these were cuffed Hickman catheters. Eighty-four patients received 1 mg of warfarin per day as prophylaxis against device-related thrombosis; none received periinsertion prophylactic antibiotics. RESULTS: Twenty-one patients (13%) developed central venous device-related bloodstream infection (DRBSI) during the study period, a rate of 2 DRBSI per 1000 device-days. DRBSIs were associated with the type of immunotherapy given with IL-2 (P = 0.01) and with thrombosis (odds ratio, 4.1; 95% confidence interval, 1.5-11.4; P = 0.008) but not with patient gender, type of cancer, duration of the central device, or site of device placement. Twenty-six patients (16%) developed central venous device-related thrombosis (DRT) during immunotherapy. Low dose warfarin did not appear to prevent thrombosis. Device-related thrombosis was associated with DRBSI but not with patient gender, type of cancer, type of device, duration or location of device, or concomitant immunotherapy. CONCLUSIONS: Central venous DRBSI and DRT are significant complications that can occur during moderate dose continuous-infusion IL-2 therapy. The risk of DRBSI appears lower than the risk reported with high dose IL-2 therapy by previous investigators. The risk of DRT appears to be higher than the risk reported for patients with similar devices but not given IL-2. Low dose warfarin did not prevent DRT when started after device placement.

Distribution of thrombi in acute lower extremity deep venous thrombosis: implications for sonography and CT and MR venography.

OBJECTIVE: Our objective was to determine the typical distribution of thrombi in acute lower extremity deep venous thrombosis as a means of evaluating the validity of imaging techniques that only include the common femoral and popliteal veins, but not the superficial femoral vein. MATERIALS AND METHODS: The results of 2704 lower extremity venous sonograms, obtained in 2026 consecutive patients over a 4-year interval, were reviewed retrospectively. The distribution of acute deep venous thromboses across various lower extremity venous segments was analyzed for this population, which consisted of both symptomatic and asymptomatic patients. RESULTS: Of 2704 lower extremities studied with duplex sonography, acute deep venous thrombosis was identified in 269 (9.9%). Of these 269 cases, acute deep venous thrombosis was isolated to the superficial femoral vein in 60 (22.3%). The remaining 209 cases (77.7%) showed thrombus that extended into the common femoral or popliteal veins (or both). CONCLUSION: An abbreviated imaging study that evaluates only the common femoral and popliteal veins would fail to identify more than 20% of lower extremity acute deep venous thromboses in a population like ours. Although evaluation of the superficial femoral vein requires additional time and resources, evaluation of this segment may prevent a substantial number of thrombi from being missed.

Injected periurethral collagen for postprostatectomy urinary incontinence: MR and CT appearance.

BACKGROUND: Urinary incontinence, a disturbing complication of radical prostatectomy, is often treated with periurethral collagen injections to increase urethral closure and resistance to urinary outflow. METHODS: Using magnetic resonance imaging and computed tomography, we studied the appearance of glutaraldehyde cross-lined bovine collagen endoscopically injected into the periurethral tissues in four men who developed urinary incontinence after radical prostatectomy. Collagen was also scanned in vitro to verify its magnetic resonance appearance. RESULTS: Collagen deposits appear as well-circumscribed nodules of low to intermediate signal intensity on both T1- and T2-weighted images in the periurethral tissues or in the base of the subjacent penile bulb (base of corpus spongiosum). On contrast-enhanced computed tomography, collagen appears as a hypoattenuating nodular-filling defect within the penile bulb. CONCLUSION: These imaging characteristics should allow differentiation of collagen from locally recurrent prostate carcinoma and avoid inappropriate work-up of benign findings.

Double-blind, randomized trial of scheduled use of a novel barrier cream and an oil-containing lotion for protecting the hands of health care workers.

CONTEXT: Many health care workers suffer severe hand irritation, with cracking and bleeding, as a consequence of frequent handwashing and glove use. Integumentary breakdown has major implications for nosocomial infection control and promotes the spread of bloodborne viruses. The potential benefits of scheduled use of hand-care agents-lotions or creams-in health care workers has not been established by controlled trial. OBJECTIVE: To compare the value of an oil-containing lotion with a novel barrier skin cream in health care workers with severe hand irritation. DESIGN: Prospective, randomized, double-blind trial. SETTING: University medical center. PARTICIPANTS: Fifty-four health care workers from multiple departments with severe hand irritation, 74% with one or more full-thickness cracks or other integumentary breaks. MAIN OUTCOME MEASURES: Objective and subjective parameters for scaling, cracking, weeping, bleeding, and pain were scored by two blinded investigators weekly for 4 weeks, and the hands of subjects were cultured quantitatively at the onset and after 2 weeks and 4 weeks. RESULTS: Subjects in both groups experienced marked improvement in overall hand condition (each, P <.02), particularly in scaling, cracking, and pain. Persons randomized to use of the oil-containing lotion showed greater improvement (mean score, from 6.5 to 2.7 vs 6.8 to 4. 7, P =.006). In 18 (69%) of 26 persons who used the control lotion, all full-thickness integumentary breaks were healed and pain was totally resolved, compared with 14 (52%) of 27 persons who used the barrier cream (P =.26). Use of the two agents in a scheduled fashion had no effect on the levels or profile of the transient hand flora. However, by the fourth week of use, handwashing frequency was 50% higher in subjects randomized to use the control lotion than it was in subjects randomized to use the barrier cream (17.8 vs 11.7 times per day, P =.04). CONCLUSION: Use of an oil-containing lotion or a barrier cream on a scheduled basis can substantially protect the hands of vulnerable health care workers against drying and chemical irritation, preventing skin breakdown and promoting more frequent handwashing.

Massive rhabdomyolysis and multiple organ dysfunction syndrome caused by leptospirosis.

We report a case of leptospiral infection in a 63-year-old man who acquired the infection while swimming in canals and streams in Hawaii. The patient's course was atypical in that he was anicteric and had no evidence of meningitis when he presented with fever, rapidly progressive and severe rhabdomyolysis, thrombocytopenia, acute renal failure, and respiratory distress syndrome. Although he recovered after a protracted illness, he required major life support, including mechanical ventilation and hemodialysis. Initial antimicrobial therapy was designed to cover major bacterial and atypical pathogens, including leptospires. An in-depth work-up for causes of this catastrophic illness confirmed acute leptospirosis. Although rare, leptospirosis is a potentially lethal infection classically associated with hepatitis, azotemia, and meningitis. Most patients experience self-limited illness, with fever, myalgias, and malaise followed by an immune-mediated aseptic meningitis. A small proportion develop shock and multiple organ dysfunction. Whereas myalgias are ubiquitous in leptospiral infection, and most patients show mildly elevated muscle enzymes, life-threatening rhabdomyolysis is rare. This atypical case is reported to urge clinicians to consider leptospirosis in the evaluation of a patient with cryptogenic sepsis who develops multiple organ dysfunction associated with rhabdomyolysis. Appropriate antimicrobial therapy, with penicillin or doxycycline, can be life-saving.

Patterns of disease spread in metastatic breast carcinoma: influence of estrogen and progesterone receptor status.

BACKGROUND AND PURPOSE: It is widely recognized that tumor hormone receptor status correlates with overall survival in metastatic breast carcinoma; however, the influence of hormone receptors on the pattern of disease spread is not well known. PURPOSE: We set out to determine the common distributions of metastatic disease spread in metastatic breast carcinoma, and to evaluate tumor hormone receptor status as predictor of disease spread. METHODS: Thirty-six patients being imaged for possible metastatic breast carcinoma between 1995 and 1998, in whom the presence or absence of tumor estrogen and progesterone receptors (ER+ or ER- / PR+ or PR-) was known, who underwent both contrast-enhanced MR of the brain and total body skeletal scintigraphy, were studied retrospectively. RESULTS: Of twelve patients with skeletal metastases but no brain metastases, 83% were ER+/PR+. Ten patients had brain metastases but no skeletal involvement, 80% of which were ER-/PR-. Seven patients had no brain or osseous metastases, but had metastatic disease in the chest or abdomen. Eighty-six percent of patients in this group were ER-/PR-. The tumor receptor status was statistically different between these three distribution groups (P = .01). A final group, consisting of seven patients, showed widespread disease, with diffuse metastases to the brain, viscera, and skeleton. In this group, no patients were ER+/PR+. CONCLUSION: There are two major patterns of disease spread in metastatic breast carcinoma, excluding patients with extensive diffuse metastases. Patients with ER+/PR+ tumors tend to develop osseous but not brain metastases. Patients with ER-/PR- tumors tend to develop brain but not osseous metastases. Appreciation of these distributions can aid the radiologist in detecting metastatic lesions, and will help the clinician to estimate the likelihood of metastases to various organ systems, as well as to potentially target therapy.

The relationship between pyuria and infection in patients with indwelling urinary catheters: a prospective study of 761 patients.

BACKGROUND: Pyuria is universally considered as essential for identifying urinary tract infections in noncatheterized patients. The utility of pyuria in the catheterized patient, to identify catheter-associated urinary tract infection (CAUTI), has not been adequately defined. METHODS: We prospectively studied 761 newly catheterized patients in a university hospital; 82 (10.8%) developed nosocomial CAUTI (> 10(3) colony-forming units per milliliter). While catheterized, each patient was seen daily, a quantitative urine culture was obtained, and the urine white blood cell concentration was measured quantitatively using a hemocytometer. RESULTS: The mean urine leukocyte count in patients with CAUTI was significantly higher than in patients without infections (71 vs 4 per microliter; P= .006). Pyuria was most strongly associated with CAUTI caused by gram-negative bacilli (white blood cell count, 121 vs 4 per microliter; P = .03); infection with coagulase-negative staphylococci and enterococci (white blood cell count, 39 vs 4 per microliter; P = .25) or yeasts (white blood cell count, 25 vs 4 per microliter; P = .15) produced much less pyuria. Pyuria with a white blood cell count greater than 10 per microliter (>5 per high-power field in a conventional urinalysis) had a specificity of 90% for predicting CAUTI with greater than 10(5) colony-forming units per milliliter but a sensitivity of only 37%. CONCLUSIONS: In patients with short-term indwelling urinary catheters, pyuria is less strongly correlated with CAUTI than in noncatheterized patients with urinary tract infection. The strongest association is with CAUTI caused by gram-negative bacilli; the association is far weaker for infections caused by gram-positive cocci or yeasts. Most patients with CAUTI are asymptomatic and do not have associated fever. Pyuria should not be used as the sole criterion to obtain a urine culture in a patient with a catheter.