Gastrointestinal basidiobolomycosis in Arizona: clinical and epidemiological characteristics and review of the literature.

Gastrointestinal basidiobolomycosis (GIB) is an unusual fungal infection that is rarely reported in the medical literature. From April 1994 through May 1999, 7 cases of GIB occurred in Arizona, 4 from December 1998 through May 1999. We reviewed the clinical characteristics of the patients and conducted a case-control study to generate hypotheses about potential risk factors. All patients had histopathologic signs characteristic of basidiobolomycosis. Five patients were male (median age, 52 years; range, 37--59 years) and had a history of diabetes mellitus (in 3 patients), peptic ulcer disease (in 2), or pica (in 1). All patients underwent partial or complete surgical resection of the infected portions of their gastrointestinal tracts, and all received itraconazole postoperatively for a median of 10 months (range, 3--19 months). Potential risk factors included prior ranitidine use and longer residence in Arizona. GIB is a newly emerging infection that causes substantial morbidity and diagnostic confusion. Further studies are needed to better define its risk factors and treatment.

Colonic perforation in unsuspected amebic colitis.

Unsuspected amebic colitis presenting as inflammatory bowel disease, as in our patient, has been previously reported (4, 7, 8). Misdiagnosis, delay in antibiotic treatment, and institution of immunosuppression were the result of failure to identify the parasite in stool specimens and have resulted in suffering, morbidity, mortality, and surgery. In all previously reported cases, routine stool studies failed to identify E. histolytica (4, 7, 8). The correct diagnosis was only established after reviewing the surgical specimen or biopsies obtained endoscopically. Because the erroneous diagnosis of inflammatory bowel disease can lead to disastrous complications, it is imperative to exclude amebic colitis prior to undertaking steroid therapy, especially in patients with a prior history of travel to or residence in areas with endemic E. histolytica (17). We recommend obtaining at least three stool specimens for microscopic examination, as well as testing for serum amebic antibody. Patients should submit fresh stool specimens directly to the laboratory to allow for prompt diagnostic evaluation. Such an approach might lead to the improved diagnosis of amebiasis.

Ventral hernia synthetic mesh repair infected by Mycobacterium fortuitum.

We report the occurrence of a refractory infection caused by the "rapidly growing" nontuberculous mycobacterium, Mycobacterium fortuitum, after incisional hernia repair using synthetic mesh. The patient had previously undergone three herniorrhaphies incorporating polypropylene mesh. Multiple surgical debridements were required, along with complete removal of all the mesh, to eradicate the infection. Prolonged antimicrobial therapy with sulfamethoxazole, an agent active against the patient's isolate, was also used. Although this atypical mycobacterium has been reported to cause a variety of infections, including many types of periprosthetic infections, this case represents successful treatment of M. fortuitum infecting abdominal wall mesh.

Gastrointestinal basidiobolomycosis. Morphologic findings in a cluster of six cases.

We describe the histopathologic features of 6 cases of gastrointestinal basidiobolomycosis examined at 4 Phoenix, AZ, area hospitals during the last 4 years. Resected stomach and intestinal specimens were characterized by marked mural thickening with fibrosis, prominent tissue eosinophil infiltration and palisading granulomatous inflammation around pale fungal hyphae. In 2 cases, there was colonic perforation. Basidiobolus ranarum hyphae (associated with spore-like spherules in 4 cases) were identified within tissue sections; the irregularly branched, thin-walled, occasionally septated hyphae were typically surrounded by a thick eosinophilic cuff (Splendore-Hoeppli phenomenon). Although the histologic features of B ranarum are well described in the skin and subcutaneous tissue, gastrointestinal involvement has presented considerable diagnostic difficulty. Before the occurrence of this cluster of cases, intra-abdominal B ranarum infection has been reported only rarely.

The tetracyclines.

The tetracyclines, among the first of the antibiotics to become available 50 years ago, remain widely used. Tetracyclines have bacteriostatic activity against a wide variety of pathogens that are responsible for many common and some exotic infections. They are particularly valuable in the treatment of atypical pneumonia syndromes, chlamydial genital infections, rickettsial infection (Rocky Mountain spotted fever, typhus, Q fever), Lyme disease, and ehrlichiosis. On the basis of pharmacokinetic considerations, doxycycline is the preferred agent among the tetracycline congeners. Minocycline may have a limited role in the treatment of methicillin-resistant staphylococcal disease in situations in which an oral antimicrobial agent may be appropriate. The tetracyclines are generally contraindicated during pregnancy and childhood because of their association with dental staining and interference with bone growth. Photosensitivity may occur with some tetracyclines, and several drug and food interactions may limit gastrointestinal absorption.

Trimethoprim-sulfamethoxazole.

After 25 years of use in the United States, trimethoprim-sulfamethoxazole (TMP-SMX) is widely prescribed for various indications. By virtue of sequential blockade of microbial folic acid synthesis, the antimicrobial combination has excellent in vitro inhibitory activity against many common respiratory and urinary tract pathogens, as well as many nosocomial infecting strains. In patients infected with the human immunodeficiency virus, TMP-SMX provides prophylactic and therapeutic potency against Pneumocystis carinii but at the risk of frequent side effects. TMP-SMX is also used for treatment of pulmonary and disseminated nocardiosis and some forms of Wegener's granulomatosis, as well as for prophylaxis of spontaneous bacterial peritonitis. Increasing bacterial resistance and concern about occasional severe adverse effects suggest that the usefulness of TMP-SMX may diminish in the future.

Coccidioidal infection of the thyroid.

Infection of the thyroid gland with Coccidioides immitis, the causative agent of coccidioidomycosis, is very rarely recognized antemortem. We report 2 recent cases, one immunosuppressed by corticosteroid treatment of sarcoidosis and the other without any recognized impairment of host defenses. In the first case, thyroid gland involvement was but 1 indication of disseminated infection. In the second case, the patient appeared to have autoimmune thyrotoxicosis without clinical evidence of coccidioidomycosis elsewhere. Although historical autopsy studies have indicated that coccidioidal involvement of the thyroid gland can infrequently occur as part of fatal disseminated infection, to our knowledge only 2 other cases of infection detected during life have been reported. Optimal treatment of this rare complication of coccidioidomycosis is uncertain.

Basidiobolomycosis: an unusual fungal infection mimicking inflammatory bowel disease.

Basidiobolus ranarum is a fungus belonging to the Entomophthoraceae family and is mainly associated with subcutaneous soft tissue infection. The disease is usually characterized by an insidious onset of massive induration of the subcutaneous tissue involving the limbs, trunk, or buttocks. Most cases of basidiobolomycosis have been reported from Africa, South America, and tropical Asia. Visceral involvement is extremely rare. Only 4 cases with involvement of the gastrointestinal tract, including 1 fatal case originating in the United States, have been well documented in the English-language literature. This case report describes the first successfully treated patient residing in the United States who had B. ranarum infection involving the gastrointestinal tract.

Localized soft-tissue infections with Mycobacterium avium/Mycobacterium intracellulare complex in immunocompetent patients: granulomatous tenosynovitis of the hand or wrist.

In immunocompetent patients, Mycobacterium avium/Mycobacterium intracellulare complex (MAC) has been associated with pulmonary infection in adults, cervical lymphadenitis in children, and disseminated infection in children and adults. MAC rarely has been recognized as a cause of localized soft-tissue infection in immunocompetent hosts. Six cases of granulomatous tenosynovitis due to MAC are reported; five cases occurred after local surgical procedures, trauma, or corticosteroid injection. In four cases, cure was achieved with combined medical and surgical intervention. In these six cases and 11 previously reported cases, both males and females were affected equally, usually in the fifth to seventh decades of life, and the distal upper extremity was predominantly involved. Surgical debridement with appropriate culture was critical for diagnosis and management. Antimycobacterial chemotherapy seemed to be a beneficial adjunctive measure in most cases but was clearly necessary for cure in only a few cases.

Detection of JC virus by polymerase chain reaction in cerebrospinal fluid from two patients with progressive multifocal leukoencephalopathy.

The polymerase chain reaction (PCR) was used to identify JC virus (JCV) in the cerebrospinal fluid of two patients with progressive multifocal leukoencephalopathy confirmed by brain biopsy. In addition, JCV viremia was demonstrated by PCR in one case. JCV detection in spinal fluid by PCR may be the first non-invasive technique available for the diagnostic confirmation of progressive multifocal leukoencephalopathy.

Clinicopathologic spectrum of specific cutaneous lesions of disseminated coccidioidomycosis.

BACKGROUND: Disseminated coccidioidomycosis merits greater attention because the number of persons living and traveling in endemic areas is increasing. OBJECTIVE: Our purpose was to study the clinical and histopathologic findings in patients with specific cutaneous disseminated coccidioidomycosis. METHODS: In six patients with specific skin lesions of disseminated coccidioidomycosis, the diagnosis was confirmed by identification of the organism in tissue or by positive results of tissue culturing. RESULTS: Clinical lesions included solitary granulomatous plaques in two patients and multiple papular, nodular, or pustular lesions in four patients, two of whom also had subcutaneous abscesses. Identifying organisms directly in tissue was possible in only 8 of 17 biopsy specimens and in five of six patients. The histopathologic features showed various degrees of three primary patterns: (1) abscess formation with necrosis, (2) epithelial hyperplasia and granuloma formation with microabscesses, and (3) vascular and perivascular proliferative and inflammatory cell reactions at times suggesting vasculitis. Tissue eosinophilia, present in all patients, was striking in two (eosinophilic abscess formation) and notable in another (vascular inflammation with eosinophilia). CONCLUSION: Cutaneous manifestations of disseminated coccidioidomycosis may be more common and varied than usually recognized.

Tetracyclines, chloramphenicol, erythromycin, clindamycin, and metronidazole.

The tetracyclines are effective in the treatment of Chlamydia, Mycoplasma pneumoniae, and rickettsial infections and also can be used for gonococcal infections in patients unable to tolerate penicillin. These drugs may cause gastrointestinal irritation, diarrhea, phototoxic dermatitis, and vestibular damage, and fatal reactions due to hepatotoxicity have occurred in pregnant women. Chloramphenicol has a broad spectrum of bacteriostatic activity, but its association with suppression of the bone marrow and aplastic anemia has relegated it to a historical role. Erythromycin is the drug of choice for the treatment of infections caused by M. pneumoniae, Legionella species, group A beta-hemolytic streptococci, and Streptococcus pneumoniae. The frequency of serious adverse effects associated with the use of erythromycin is low; dose-related epigastric distress may occur. Clindamycin is bactericidal to most nonenterococcal gram-positive aerobic bacteria and many anaerobic microorganisms. Although historically it was a frequent cause of antibiotic-associated diarrhea and colitis, clindamycin is considered an excellent alternative to beta-lactam antibiotics for treatment of many staphylococcal infections, and it has therapeutic utility in anaerobic infections and in several protozoan infections in immunosuppressed patients. Metronidazole is efficacious for treating nonpulmonary anaerobic infections, various parasitic infections (trichomoniasis, amebiasis, and giardiasis), nonspecific vaginitis, and Clostridium difficile-mediated colitis. With use of metronidazole, mild side effects such as epigastric discomfort, diarrhea, reversible neutropenia, and allergic-type cutaneous reactions may occur.

Acute infective endocarditis.

Acute infective endocarditis is an important cardiovascular emergency that can be detected with improved diagnostic techniques. In the last few decades we have witnessed a changing spectrum of microorganisms causing infective endocarditis. Successful treatment of infective endocarditis is enhanced by the combined and cooperative efforts of the internist and the surgeon. In this article, we have discussed the clinical evaluation, laboratory techniques, and noninvasive studies by which proper diagnosis can be made and appropriate antimicrobial therapy instituted. We have also reviewed the indications for surgical intervention. With careful clinical evaluation and proper application of the diagnostic and therapeutic modalities, acute infective endocarditis can often be cured.

Pharmacokinetics of amantadine hydrochloride in subjects with normal and impaired renal function.

Amantadine is useful for the prevention and treatment of influenza A and for the treatment of Parkinson's disease and drug-induced extrapyramidal disorders. We have compared the pharmacokinetics of amantadine in patients with impaired or negligible renal function to that in normal subjects. The half-life of elimination in subjects with normal renal function was 11.8 +/- 2.1 hours (range, 9.7 to 14.5 h). Eight patients with various degrees of renal insufficiency (creatinine clearance from 43.1 to 5.9 mL/min . 1.73 m2) had half-lives of elimination from 18.5 h to 33.8 days. We also studied 10 patients on thrice-weekly hemodialysis. Assuming complete bioavailability of the drug, less than 5% of the dose was removed by each 4-hour hemodialysis. The mean half-life of elimination during chronic hemodialysis was 8.3 days (range, 7.0 to 10.3). We present guidelines for use of amantadine in patients with impaired renal function, including those on maintenance hemodialysis.