Reduction in tuberculin skin-test conversion rate after improved adherence to tuberculosis isolation.

The rate of purified protein derivative (PPD) conversion in workers at our hospital increased to 1.7% in 1991. After implementation of mandatory respiratory isolation of patients with community-acquired pneumonia, the rate dropped to 0.6%. This policy may protect workers in institutions where the majority of patients with pneumonia have risk factors for tuberculosis.

Use of heteroduplex analysis to classify legionellae on the basis of 5S rRNA gene sequences.

Seventeen different species of Legionella, 12 serogroups of Legionella pneumophila, and 2 Legionella-like amoebal pathogens (LLAP1 and Sarcobium lyticum) were examined by heteroduplex analysis of PCR products of the 5S rRNA gene. Eight different banding patterns were identified, indicating that heteroduplex analysis of this gene can be used to classify these bacteria according to base substitutions between species. This classification may have future applications in clinical and epidemiological studies.

Early switch from intravenous to oral antibiotics in hospitalized patients with infections: a 6-month prospective study.

We assessed what percentage of hospitalized patients treated with intravenous antibiotics would be candidates for early switch to oral therapy, and evaluated the clinical outcomes of patients after the switch. All hospitalized patients in whom an intravenous antibiotic was prescribed for treatment of an infection were prospectively screened to identify candidates for switch in therapy. Of the 655 patients treated with intravenous antibiotics, 300 (46%) were candidates for a switch, and the change was implemented in 262 (40%). Of the 171 evaluable patients, the switch was associated with clinical cure in 167 (98%) and failure in 4 (2%). In hospitalized patients with infections, the duration of intravenous antibiotic therapy can be minimized with early switch to oral therapy. This practice is associated with good patient outcome.

Tuberculosis in Kentucky: current recommendations for empiric therapy.

Current guidelines for empiric therapy for pulmonary tuberculosis depend on the presence of INH or INH and rifampin resistance (MDRTB) in the community. The objective of this study was to determine the susceptibility of MTB in Kentucky and to consider which therapeutic modality for empiric therapy should be followed. The total number and rate of pulmonary tuberculosis was analyzed and compared to national trends. Data of susceptibility were analyzed based on INH and rifampin resistance. There were 4753 cases of TB in Kentucky between 1984 and 1994. Data of susceptibility were available from 1989 through 1994. Total number of MTB decreased by 14% in 1994 from 1993 but resistance to INH doubled from 3.2% to 7.6%. MDRTB increased from 1.2% to 3.2%. INH resistance > 4% on initial isolates was recorded in Allen, Bell, Estill, Fleming, Jefferson, Kenton, Knott, Oldham, Rowan, and Wolfe counties. Outbreak of MDRTB was documented in Estill County. There was no HIV infection documented in this group. In the rest of the state, INH resistance was < 4%. In counties with INH resistance < 4%, empiric therapy for TB should include 3 drugs: INH and rifampin for 6 months and PZA added for the first 2 months. In counties with INH resistance > 4%, empiric therapy should include 4 drugs: INH, rifampin, PZA, ethambutol or streptomycin. In Estill County with documented MDRTB, empiric therapy should include 5 to 6 drugs: INH, rifampin, PZA, ethambutol, streptomycin, and amikacin. If INH and rifampin resistance is present, the therapy should include at least 3 drugs to which the organism is sensitive. This regimen should be continued until sputum cultures become negative. Further therapy should be continued with 2 drugs for 1 year. HIV infected patients constitute a separate category and therapy for them should be individualized.

Community-acquired pneumonia in the elderly: association of mortality with lack of fever and leukocytosis.

Elderly patients with community-acquired pneumonia may not have a systemic inflammatory response characterized by fever and leukocytosis. We compared lack of fever and leukocytosis with mortality in elderly patients with community-acquired pneumonia. Patients with fever and leukocytosis (group A, 47 patients) were compared with those without fever and leukocytosis (group B, 17 patients). Comparison of the two groups by unpaired, two-tailed t test showed that lack of fever and leukocytosis correlated with mortality. Hospitalized elderly patients who have community-acquired pneumonia without fever and leukocytosis are seven times more likely to die than those who have these symptoms. Future research in the adjunct use of immune modulators such as granulocyte colony-stimulating factor in these patients should be encouraged.

Pancoast's syndrome secondary to thoracic actinomycosis.

Pancoast's syndrome is almost exclusively caused by a malignant apical lung tumor invading the structures of the thoracic outlet. We report a case of thoracic actinomycosis as a cause of Pancoast's syndrome. A 65 y/o bm presented with a 6 month history of nonproductive cough, weight loss, a left upper lobe infiltrate, and a positive PPD of 20 mm. He failed to improve with triple antituberculous therapy for 3 months with worsening of left upper lobe disease. CT scan of the chest showed a mass lesion of the left upper lobe. Bronchoscopy with BAL and biopsy as well as percutaneous fine needle aspiration failed to reveal a diagnosis. Patient developed Pancoast's syndrome characterized by reflex sympathetic dystrophy with pain, swelling, and numbness of left shoulder, arm, and hand. A thoracoscopic left upper lung biopsy was performed and histologic examination revealed sulfur granules containing filamentous organisms characteristic of Actinomyces species. All sections were negative for malignancy. AFB stain and culture were negative. Patient was clinically cured following a 6-month course of penicillin with resolution of the left upper lobe mass. Although rare, thoracic actinomycosis must be considered in the differential diagnosis of Pancoast's syndrome. This case emphasizes the importance of obtaining a precise etiologic diagnosis before a treatment decision is made.

Hot tub legionellosis.

Legionella pneumophila is the cause of Legionnaires' disease, and Pontiac fever, an influenza-like condition without pneumonia. We present a case of Pontiac fever after exposure to a hot tub contaminated with L pneumophila. A 37 y/o wf presented to the office with acute onset of sore throat, fever, headache, and myalgia. Patient was hospitalized 3 days later because of worsening shortness of air. Chest x-ray was normal. Patient was treated with 2 days of IV erythromycin and was discharged home on oral erythromycin. Her Legionella IFA was 1:16,384. Two days later, she developed chest tightness, pleuritic chest pain, and increasing shortness of air but did not have any cough or sputum production. She was re-hospitalized with a diagnosis of Pontiac fever and treated with IV erythromycin plus oral rifampin. A repeat chest x-ray remained normal. After a detailed epidemiologic history was obtained, it was noted that she became ill after using a hot tub, which her two children also used and they themselves developed a self limited illness. Water from the hot tub was positive for L pneumophila by DFA, culture, and PCR. Patient improved gradually with therapy and was discharged home. This report emphasizes the importance of a complete epidemiologic history in the diagnosis of respiratory infections. It also demonstrates that aquatic environment can be contaminated with Legionella and serve as a source of infection.

A case of concurrent Lyme meningitis with ehrlichiosis.

We report on a case of concurrent Lyme meningitis and ehrlichiosis in a patient with occupational exposure to ticks as a logger. The patient had a febrile Illness with a reticulate erythematous rash on his upper torso, meningoencephalitis, thrombocytopenia, and hepatitis. Acute and convalescent serologies were consistent with a dual infection with Lyme disease and ehrlichiosis. Ixodes scapularis is the tick that is associated with Lyme disease in our area and this tick has also been reported to harbor the species of Ehrlichia that causes human granulocytic ehrlichiosis. Empiric therapy for both Lyme disease and ehrlichiosis should be considered in any patient suspected of having a tick-borne illness and presenting with signs and symptoms compatible with both infections.

Diagnosis of Legionella pneumophila, Mycoplasma pneumoniae, or Chlamydia pneumoniae lower respiratory infection using the polymerase chain reaction on a single throat swab specimen.

Diagnosis of Mycoplasma pneumoniae and Chlamydia pneumoniae lower respiratory infections using DNA amplification by polymerase chain reaction (PCR) on throat swab specimens has been reported. In this study we determined the sensitivity of the detection of Legionella pneumophila in simulated throat swab specimens by PCR. Next, we compared the sensitivity and specificity of a single throat swab PCR with the current tests for diagnosis of Legionella spp., M. pneumoniae, and C. pneumoniae in patients with lower respiratory tract infections. Patients' work-up included: (a) throat swab specimen for Legionella spp., M. pneumoniae, and C. pneumoniae PCR; (b) throat swab specimen for C. pneumoniae culture; (c) sputum specimen for L. pneumophila direct fluorescent antibody and culture; (d) urine specimen for L. pneumophila serogroup 1 antigen detection; and (e) serum specimen for L. pneumophila, M. pneumoniae, and C. pneumoniae acute and convalescent antibody titers. A total of 155 patients with lower respiratory infection were enrolled in this prospective study. Throat swab PCR was positive for Legionella spp. in five of the six patients with legionellosis, indicating the presence of this organism in the oropharynx of patients with Legionnaires disease. Mycoplasma pneumoniae PCR was positive in eight of the nine patients with mycoplasma infection. Chlamydia pneumoniae PCR was positive in the two patients with C. pneumoniae infection. None of the other 138 patients with negative PCR had other positive confirmatory tests for respiratory infection by these three organisms (100% specificity). PCR was able to detect 15 of the 17 infected (88.2%). Results of this investigation indicate that PCR on a single throat swab specimen is a rapid, sensitive, and specific test that may greatly simplify the diagnosis of lower respiratory infection caused by Legionella spp., Mycoplasma pneumoniae, or C. pneumoniae.

Pseudomonas pickettii pneumonia in a diabetic patient.

Pseudomonas pickettii is a nonfermenting gram negative rod closely related to Pseudomonas aeruginosa that rarely causes human disease. We describe a case of P pickettii pneumonia in a 41-year-old diabetic patient. Two months prior to admission, patient was treated for a methicillin resistant Staphylococcus aureus pneumonia. Present illness started 2 days prior to admission with fever, chills, pleuritic chest pain, and productive cough. Chest x-ray showed a right lower lobe infiltrate with effusion. Thoracocentesis of the right chest brought a transudative fluid. P picketii was isolated from pleural fluid and blood. The patient was initially treated with aztreonam and piperacillin and therapy was changed to ampicillin according to sensitivity results. The pneumonia resolved after 10 days of antibiotic therapy. Our case is the first reported case of P pickettii pneumonia. P pickettii has been reported to cause nosocomial bacteremias associated with contaminated intravenous products and airway colonization from contaminated respiratory therapy solution. Our patient most likely had oropharyngeal colonization with P pickettii during his previous hospitalization. His underlying illnesses might have predisposed him to aspiration and development of P pickettii pneumonia. This case emphasizes the central role of the microbiology laboratory in the proper identification and sensitivity reporting in the management of respiratory infections caused by unusual organisms, such as P pickettii.

Early switch from intravenous to oral cephalosporins in the treatment of hospitalized patients with community-acquired pneumonia.

BACKGROUND: Switch therapy is defined as the early transition from intravenous to oral antibiotics during treatment of infection. This study was designed to evaluate the clinical outcome and length of stay of hospitalized patients with community-acquired pneumonia treated with an early switch from intravenous to oral third-generation cephalosporins. METHODS: Patients with a new roentgenographic pulmonary infiltrate and at least two symptoms (cough, fever, or leukocytosis) were enrolled in this study and treated with intravenous ceftizoxime sodium (1 g every 12 hours) or ceftriaxone sodium (1 g every 24 hours). Patients were switched to oral cefixime (400 mg every 24 hours) as soon as they met the following criteria: (1) resolution of fever; (2) improvement of cough and respiratory distress; (3) improvement of leukocytosis; and (4) presence of normal gastrointestinal tract absorption. RESULTS: Of the 120 patients enrolled, 75 (62%) had clinical data evaluated. Long-term follow-up showed that 74 patients (99%) were cured; one patient required readmission for further intravenous therapy. Mean duration of hospital stay was 4 days. CONCLUSIONS: This investigation demonstrated that an early switch to oral cefixime may be reasonable in hospitalized patients with community-acquired pneumonia who have already shown a good clinical and laboratory response to therapy with intravenous third-generation cephalosporins. This approach is clinically effective and minimizes hospital stay.

Clinical significance of mycobacterium other than tuberculosis isolated from respiratory specimens at a university hospital.

BACKGROUND: Mycobacteria other than tuberculosis (MOTT) are ubiquitous and have been recognized to cause pulmonary disease. Because of newer laboratory diagnostic techniques, it has become more frequent to identify MOTT from pulmonary specimens. The objective of this study was to determine the spectrum of MOTT in pulmonary specimens in hospitalized patients and determine their clinical significance. METHODS: A retrospective study of all cases of positive pulmonary specimens cultured for MOTT in patients admitted to University of Louisville Hospital from January 1989 to December 1992 was performed. A determination of whether or not the MOTT caused pulmonary disease was made, using the criteria required by the American Thoracic Society. RESULTS: There were 221 positive pulmonary specimen cultures for mycobacteria, of which 164 were MOTT and 57 were M tuberculosis. Of the MOTT isolates, 82 (50%) were M gordonae; 44 (27%) M avium intracellulare; 18 (11%) M chelonae; 12 (7%) M fortuitum; 2 (1%) M kansasii; 2 (1%); M scrofulaceum; 2 (1%) M xenopi; and 2 (1%) M terrae. From all the MOTT cases, only one met the criteria for MOTT pulmonary disease. The rest were found to be non-pathogens, either colonizers or contaminants. CONCLUSION: Newer laboratory diagnostic techniques are improving isolation and identification of MOTT. Even though reports of positive pulmonary specimens for MOTT are becoming more numerous, MOTT was found to be a rare pulmonary pathogen in our hospital, when strict criteria were used.

Acute miliary blastomycosis in an AIDS patient.

The incidence of blastomycosis in immunocompromised patients with HIV infection is very low when compared to other mycoses. Of the 19 cases of blastomycosis described in HIV-infected patients, only four had a miliary pattern on chest x-ray. A case of acute miliary blastomycosis in an HIV infected patient from Louisville is described.

HIV-negative "AIDS" in Kentucky: a case of idiopathic CD4+ lymphopenia and cryptococcal meningitis.

Here we describe a case of unexplained CD4+ T-lymphocyte depletion and cryptococcal meningitis in a patient without evidence of human immunodeficiency virus (HIV) infection. This newly recognized syndrome has been named idiopathic CD4+ lymphopenia (ICL). When HIV infection is suspected in a patient with an opportunistic infection, a CD4+ lymphocyte count should be obtained, even if the patient's HIV test is negative. Patients with persistently low CD4 counts (< 300 cells/microL, or < 20%) who show no evidence of HIV infection, who have no defined immunodeficiency, and who are not receiving therapy associated with CD4 depletion have disease that meets the definition of ICL, and the case should be reported to the Centers for Disease Control.

Lemierre's syndrome: postanginal sepsis due to anaerobic oropharyngeal infection.

Lemierre's syndrome is an uncommon clinical entity. It consists of oropharyngeal infection and anaerobic bacteremia, followed by jugular vein septic thrombophlebitis with embolization to lungs and other areas. Although it occurs less frequently than in the pre-antibiotic era, it is important that the typical presentation be recognized because of its lethal potential. A case of Lemierre's syndrome in Louisville, Kentucky, is described.