Aspergillus valve endocarditis in patients without prior cardiac surgery.

Aspergillus native valve endocarditis in patients who have not had cardiac surgery is uncommon. We report 3 cases and review 58 other adult patients reported in the English-language literature. Sixty-seven percent of the patients had underlying immunosuppression. The clinical features were fever (74%), embolic episodes (69%), a new or changing heart murmur (41%), and sudden visual loss (13%). Patients with mural endocarditis were more often immunosuppressed, especially due to solid organ transplants, but had lower frequency of heart murmurs and embolic episodes. Echocardiography revealed a vegetation in 78% of all the cases in which it was performed. Examination and culture of biopsy material often helped to establish a diagnosis of Aspergillus infection. Twenty-five patients had an antemortem diagnosis. These patients received a mean cumulative amphotericin B dose of 27 mg/kg. Twenty percent (3/15) of patients who received combined surgical and medical therapy survived, compared to none of those who received medical therapy alone (p = 0.08). Patients who survived were not immunosuppressed. We conclude that native valve aspergillus infective endocarditis is uniformly fatal without surgical intervention and antifungal therapy.

MR imaging of spinal infections.

In the appropriate clinical situation, MR imaging is a powerful tool in the diagnosis of spinal infection. Imaging of spinal infections requires the use of a combination of T1-weighted and T2-weighted or STIR sequences. Contrast enhancement is useful and helps to define paraspinal and epidural disease. Knowledge of potential pitfalls with MR imaging and of normal marrow conversion is required. With these points in mind, MR imaging will be beneficial in the care of patients with spinal infections.

Sternotomy infection with Mycoplasma hominis: a cause of "culture negative" wound infection.

Wound infections with Mycoplasma species are unusual; diagnosis may be delayed because of the growth characteristics of this organism. We report Mycoplasma hominis infection of sternotomy wounds in two patients. The first presented with fever and drainage from the incision 1 week after coronary artery bypass grafting. The other patient presented with drainage from the incision three weeks after double-lung transplantation. In both cases, initial cultures were negative, but the typical colonial morphology of M. hominis was subsequently detected. Successful treatment consisted of debridement and long courses of antibiotic therapy; omental flap grafting was eventually required for the second patient. Other published cases were reviewed and compared with the newly reported cases.

Vertebral osteomyelitis and aortic lesions: case report and review.

Coexistence of vertebral osteomyelitis and lesions of the aorta is rare but may be lethal if not diagnosed promptly and treated effectively. We describe a patient who was treated at the Cleveland Clinic Hospital, and we review 69 additional cases reported in the literature. The native aorta was involved in 66 cases; four patients developed infection of prosthetic aortic grafts. The most common aortic lesions associated with vertebral osteomyelitis were mycotic aneurysms, infected aneurysms, and pseudoaneurysms. The wide variety of pathogens involved included salmonellae and other gram-negative bacilli, mycobacteria, gram-positive cocci, and fungi. In some cases infection was polymicrobial. The condition was associated with protean clinical manifestations. Diagnosis was frequently delayed, and mortality was 71%. In some instances surgical procedures at sites of unsuspected aneurysms precipitated life-threatening hemorrhage. Therapy with antimicrobial drugs alone was insufficient. The best results were achieved when specific drug therapy was combined with resection of the infected aorta or aortic graft, thorough debridement, and extraanatomic bypass grafting.

Lymphoproliferative disorders associated with carbamazepine.

Carbamazepine-induced lymphoproliferative disorders are relatively rare. A 32-year-old woman developed cervical lymphadenopathy while taking carbamazepine. Histologic evaluation of the lymph node biopsy specimen demonstrated near-total effacement of the nodal architecture by a population of pleomorphic immunoblasts. The predominant cell population expressed CD3, CD2, CD5, and CD4, while results of testing for CD8 were negative. On the basis of the morphologic and immunohistologic features, a diagnosis of high-grade, non-Hodgkin's lymphoma, T-cell immunoblastic type, was made. Despite the fact that aggressive behavior is usually associated with immunoblastic lymphomas, the patient has done well for 33 months after cessation of carbamazepine in the absence of chemotherapeutic treatment. The clinical features of this patient's illness, therefore, suggest that it is best regarded as a so-called pseudolymphoma.

J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care.

Of 6,504 consecutive patients who underwent isolated coronary bypass grafting in 1985 to 1987, 72 (1.1%) patients experienced sternal wound complications. Ten patients (14%) with wound complications died of multi-system failure. Only the patients with negative cultures fared well; of the bacterial culture categories, polymicrobial infection carried the worst prognosis. Effects of recurring infection were seen throughout the first year. Patients, grouped according to conduits received, experienced these wound complication rates: vein grafts only, 11/1,085 (1.0%); one internal thoracic artery, 38/4,073 (0.9%); and bilateral internal thoracic artery grafts, 23/1,346 (1.7%). There were no significant differences in wound complication rates between primary and reoperation patients or among conduit groups. By logistic regression analysis, the relative risk for patients with diabetes and bilateral internal thoracic artery grafting was 5.00 (95% confidence interval, 2.4 to 10.5). Operation time as a continuous variable increased the relative risk of wound complication 1.47 times per hour (1.3 to 1.7); obesity, 2.90 times (1.8 to 4.8); and blood units as continuous variable, 1.05 times per unit (1.01 to 1.10). Bilateral internal thoracic artery grafting in nondiabetic patients carried no greater risk of wound complication than that in patients with vein grafts only or with one internal thoracic artery graft.

Decreased infections in cardiac transplant recipients on cyclosporine with reduced corticosteroid use.

Fifty patients undergoing orthotopic cardiac transplantation were monitored over 34 months for evidence of infection. Four separate immunosuppressive protocols were used during the course of the study; the most recent protocol (protocol 4) employed significantly lower overall steroid dosages than the earlier protocols (protocols 1,2, and 3). All immunosuppressive regimens used cyclosporine, and azathioprine was added in the last three protocols. Statistical techniques to compare the occurrence of infection in protocols 1,2, and 3 v protocol 4 showed that patients in protocol group 4 (n = 21) had significantly more time free of pneumonia (P = .02) and major infections (P = .04) and marginally more time free of symptomatic cytomegalovirus infection (P = .08) than patients in protocol groups 1, 2, and 3 (n = 29). The median incidence of major infection per month was lower for protocol group 4 (P = .02). The time free of viral infection did not differ significantly between the two groups (P = .75) nor did the median incidence of rejection per month (P = .19). The authors conclude that reduction of steroid dosages in cardiac transplant patients receiving cyclosporine is associated with a significant decrease in the incidence of clinically important infections.

A multivariate analysis of risk factors for pneumonia following cardiac transplantation.

Fifty cardiac transplant recipients were followed over a 34-month period for evidence of pneumonia that developed in twelve patients. Potential risk factors evaluated fell into three categories: demographic (age, sex, race, and underlying cardiac disease); pretransplant status (hospitalized, intubated, pulmonary infiltrate, requirement for antibiotics, or the need for a ventricular assist device); and posttransplant therapy (amount and type of blood products, prolonged endotracheal intubation or reintubation, use of ventricular assist devices, immunosuppressive protocols, lymphocyte subset ratios, and occurrence of rejection, leukopenia, or CMV infection). The Cox proportional hazards model identified posttransplant reintubation (P = 0.009) and the use of protocols employing larger steroid dosages (P = 0.02) as significant risk factors for pneumonia. In a separate analysis, the occurrence of pneumonia was shown to be a significant risk factor for mortality (P = 0.018).

Infections of the cardiac suture line after left ventricular surgery.

PURPOSE: Infections of the cardiac suture line after left ventricular surgery are rare but may be fatal if not diagnosed promptly and treated effectively. In order to alert physicians to this entity, we reviewed data from three patients who presented at the Cleveland Clinic Hospital and from 22 patients in the literature. PATIENTS AND METHODS: The three patients in the current report underwent treatment at the Cleveland Clinic Hospital. Additional cases of infection of the left ventricular suture line were identified by reviewing the English literature pertaining to surgery for left ventricular aneurysms, pseudoaneurysms, and postoperative cardiac infections. RESULTS: Infection presented on average 16 months after surgery with cardiocutaneous fistulae, chest wall masses, hemoptysis or other pleuropulmonary symptoms, or systemic illness with bacteremia resembling endocarditis. Staphylococci and gram-negative bacilli were the most frequent pathogens. Diagnosis was often delayed and mortality was high. Left ventricular false aneurysms were identified in 15 of the 25 patients. Bleeding from sinuses in the chest wall or epigastrium or repeated hemoptysis were important clinical clues. In some instances, ill-advised surgical or instrumental procedures precipitated life-threatening hemorrhage. Treatment with antibiotics alone was insufficient. Excision of all infected sutures and Teflon pledgets and adequate debridement of the infected suture line were required to achieve cures. CONCLUSION: Since infection of the left ventricular suture line has protean clinical manifestations and may present months or years after the initial surgery, a high index of suspicion is of paramount importance in diagnosing the condition. Institution of cardiopulmonary bypass and reoperation through median sternotomy is recommended to achieve a cure.

A multivariate analysis of the risk of cytomegalovirus infection in heart transplant recipients.

Thirty-four consecutive heart transplant recipients were studied over a two-year period for evidence of cytomegalovirus (CMV) infection. Twenty-three episodes of CMV infection were identified; 19 of these occurred within 120 d after transplantation and were statistically analyzed. Fifteen potential risk factors were evaluated, including the following: pretransplant CMV serological status of donor and recipient; recipient's age, sex, race, and cardiac disease; number and type of blood products transfused; type and intensity of immunosuppression; occurrence of rejection; and leukopenia. The Cox proportional hazards model identified both greater than average steroid dosage and positive recipient CMV serology as significant risk factors for CMV infection (P = .014 and .048, respectively). In a separate analysis, however, only greater than average steroid dosage was associated with clinically significant CMV infection (P = .005).

Vertebral osteomyelitis presenting as spinal compression fracture. Six patients with underlying osteoporosis.

Six patients with osteoporosis had vertebral osteomyelitis (VO) with infection of a single vertebra that presented with a collapsed vertebral body, thought to be a simple compression fracture. The resulting delay in correctly diagnosing VO was associated with disabling sequelae in a high proportion of cases. This distinctive presentation accounted for 13% of all hospitalized patients with VO and 2.4% of inpatients with osteoporotic compression fractures during the last five years; it may be more common than suggested by the paucity of published cases. In patients with osteoporosis and vertebral compression fractures, osteomyelitis should be considered when there is severe back pain, persistent unexplained fever, unexplained elevation of the erythrocyte sedimentation rate, or bacteremia without an obvious extravertebral focus of infection, particularly if the patient is immunocompromised. Early biopsy and culture of the collapsed vertebral body will facilitate diagnosis and therapy.

Liver abscess in Crohn's disease. Report of four cases and review of the literature.

Four patients with liver abscesses and Crohn's disease are described, and reports of 14 cases in the English language literature are reviewed. The incidence of liver abscess in patients with Crohn's disease (114-297 per 100,000) appears to be higher than that of liver abscess in the general population (8-16 per 100,000). Frequently the clinical manifestations of liver abscess are mistaken for a reactivation of Crohn's disease, and diagnosis is delayed. In comparison to patients with liver abscess in the general population, patients with Crohn's disease and liver abscess are considerably younger, are more likely to have multiple rather than solitary abscesses, and usually have a predisposing intraabdominal focus of infection, rather than a biliary one. Streptococci, especially Streptococcus milleri, are the most frequent cause of liver abscess in patients with Crohn's disease. Liver scanning should be performed routinely in patients with Crohn's disease in whom a febrile illness cannot be completely explained by bowel disease, or in whom fever does not respond to drainage of intraabdominal abscesses.