Vancomycin-dependent enterococcal strains: case report and review.

We report, to our knowledge, the first isolation of VDE from a burn unit. Our experience was similar to earlier reports, in that continuous administration of vancomycin and previous VRE isolation preceded the recovery of VDE. Given the increasing prevalence of VRE as a nosocomial pathogen, intensive care units must now be attuned to the emergence of VDE as serious pathogen.

Spread of strain W, a highly drug-resistant strain of Mycobacterium tuberculosis, across the United States.

Strain W, a highly drug-resistant strain of Mycobacterium tuberculosis, was responsible for large nosocomial outbreaks in New York in the early 1990s. To describe the spread of strain W outside New York, we reviewed data from epidemiologic investigations, national tuberculosis surveillance, regional DNA fingerprint laboratories, and the Centers for Disease Control and Prevention Mycobacteriology Laboratory to identify potential cases of tuberculosis due to strain W. From January 1992 through February 1997, 23 cases were diagnosed in nine states and Puerto Rico; 8 were exposed to strain W in New York before their diagnosis; 4 of the 23 transmitted disease to 10 others. Eighty-six contacts of the 23 cases are presumed to be infected with strain W; 11 completed alternative preventive therapy. Strain W tuberculosis cases will occur throughout the United States as persons infected in New York move elsewhere. To help track and contain this strain, health departments should notify the Centers for Disease Control and Prevention of cases of tuberculosis resistant to isoniazid, rifampin, streptomycin, and kanamycin.

Primary intravascular lymphomatosis associated with Mycobacterium marinum.

Intravascular lymphomatosis (i.v.l.) is a rare condition in which neoplastic cells preferentially infiltrate blood vessels of the central nervous system. Nonspecific symptoms associated with i.v.l. include dementia, seizures, and multifocal cerebrovascular events. i.v.l. was discovered at autopsy of a patient whose neurological deficits were predated by a particularly aggressive form of Mycobacterium marinum soft-tissue infection. It is speculated that i.v.l. may have had an occult effect on the patient's cell-mediated immunity that predisposed him to this normally innocuous mycobacteria.

Pulmonary disease due to infection by Mycobacterium avium complex in patients with AIDS.

We reviewed the clinical, radiographic, and histologic features of nine patients with AIDS and pulmonary disease due to Mycobacterium avium complex (MAC). Pulmonary MAC disease was defined by (1) the isolation of MAC from two or more lower respiratory tract specimens or from a single lung biopsy sample, (2) an infiltrate revealed by chest radiography, and (3) the absence of other identified pulmonary pathogens or malignancies. Pulmonary MAC disease was present in five (2.5%) of 200 patients with disseminated MAC infection and in four additional patients without evidence of dissemination, as assessed by blood culture. The median CD4 cell count at the time of presentation was 90/microL. Pulmonary MAC disease was the initial AIDS-defining infection in five patients and presented within a median of 5 months after the initial infection in four patients. Radiographic patterns for these nine patients included consolidating or nodular infiltrates and cavitation. The histopathology of pulmonary MAC disease was characterized by granulomatous inflammation, often associated with necrosis and few evident organisms. The conditions of all patients treated with multidrug regimens clinically improved.

Invasive cavitary pulmonary aspergillosis in patients with cancer: a clinicopathologic study.

We studied the histopathology and clinicopathologic correlates of invasive cavitary pulmonary aspergillosis in 11 immunosuppressed patients with disseminated malignancy. In most patients cavities were produced by separation of necrotic from viable lung, resulting in an intracavitary sequestrum ("lung ball"). Central dissolution of large necrotic areas and suppurative granulomatous aspergillary pneumonia were additional causes of cavities in three patients. In four patients with chronic cavities sequestra had been replaced by intracavitary mycetomas ("fungus balls"). Neutrophils usually were numerous at the interface of the sequestrum and adjacent lung, but were minimally present in three patients with prolonged severe neutropenia. The lack of neutrophils in some patients suggests that factors other than neutrophil-derived proteases may be important in cavity formation. A prominent giant cell reaction was seen in three patients with chronic cavities. Hemoptysis occurred in five patients and massive hemoptysis due to a bronchoarterial fistula caused the death of one patient. The "air-crescent" sign was not observed radiographically in any patient and is therefore considered to be an insensitive marker for lung cavitation in invasive aspergillosis. Persistent intracavitary fungal growth may serve as a reservoir for recurrent fungal invasion in patients with prolonged or repeated episodes of severe neutropenia.

Probable neutropenic enterocolitis in patients with AIDS.

Neutropenic enterocolitis is well documented in patients with leukemia or lymphoma who are recovering from the adverse effects of chemotherapy. We report two cases of probable neutropenic enterocolitis in two patients with AIDS who developed the syndrome during an episode of moderate neutropenia. To the best of our knowledge, this syndrome has not been reported previously in a patient with AIDS. Both of our patients manifested a mild form of enterocolitis that was characterized by fever, abdominal pain, and evidence of colonic edema easily recognized by computed tomography of the abdomen. Both patients were managed successfully with use of conservative measures including discontinuation of use of marrow-suppressive drugs and therapy with broad-spectrum antimicrobial agents. Neutropenic enterocolitis should be considered as a treatable cause of fever and abdominal pain in patients with AIDS.

Emergence of a new opportunistic pathogen, Candida lusitaniae.

Candida lusitaniae has been an infrequently reported opportunistic pathogen. Most previously reported cases of serious infection caused by this organism have proven fatal and were associated with amphotericin resistance of the organism. We report two patients with hematologic malignancies undergoing cytotoxic chemotherapy who developed fungemia with this organism while they were granulocytopenic. The organisms isolated from each patient were fully susceptible and were treated successfully with amphotericin B. When isolated from an immunocompromised host, C. lusitaniae should be considered an opportunistic pathogen and undergo antifungal susceptibility testing. Amphotericin B should be considered the drug of choice, but a poor clinical response may be indicative of a resistant isolate.

'Punch' actinomycosis causing osteomyelitis of the hand.

Osseous actinomycosis usually results from direct invasion of bone from adjacent soft-tissue infection. Involvement of the jaw and vertebral column has been frequently reported, but involvement of the bones of the wrist or hand is rare. A patient with osteomyelitis of the distal right first metacarpal bone due to Actinomyces israelii following a punch injury during fisticuffs is described. Review of similar cases revealed a striking association of this type of infection with punch injuries; hence the term, punch actinomycosis. Analysis of the pus in these infections typically reveals sulfur granules; strict anaerobic conditions must be employed to culture the etiologic agent, A israelii. Management of individual cases should include surgical débridement combined with high-dose parenteral penicillin, followed by long-term penicillin therapy, orally.