Fever and multisystem organ failure associated with 17D-204 yellow fever vaccination: a report of four cases.

BACKGROUND: In 1998, the US Centers for Disease Control and Prevention was notified of three patients who developed severe illnesses days after yellow fever vaccination. A similar case occurred in 1996. All four patients were more than 63 years old. METHODS: Vaccine strains of yellow fever virus, isolated from the plasma of two patients and the cerebrospinal fluid of one, were characterised by genomic sequencing. Clinical samples were subjected to neutralisation assays, and an immunohistochemical analysis was done on one sample of liver obtained at biopsy. FINDINGS: The clinical presentations were characterised by fever, myalgia, headache, and confusion, followed by severe multisystemic illnesses. Three patients died. Vaccine-related variants of yellow fever virus were found in plasma and cerebrospinal fluid of one vaccinee. The convalescent serum samples of two vaccinees showed antibody responses of at least 1:10240. Immunohistochemical assay of liver tissue showed yellow fever antigen in the Kuppfer cells of the liver sample. INTERPRETATION: The clinical features, their temporal association with vaccination, recovery of vaccine-related virus, antibody responses, and immunohistochemical assay collectively suggest a possible causal relation between the illnesses and yellow fever vaccination. Yellow fever remains an important cause of illness and death in South America and Africa; hence, vaccination should be maintained until the frequency of these events is quantified.

Toxic shock syndrome originating from the foot.

The most familiar etiology of toxic shock syndrome (TSS) is that of menstruation and tampon use. Nonmenstrual TSS has been described in all types of wounds including postsurgical, respiratory infection, mucous membrane disruption, burns, and vesicular lesions caused by varicella and shingles. A case of TSS occurring in a diabetic male patient with foot blisters is presented. Early recognition by an infectious disease specialist and appropriate medical management led to complete recovery. There have been no reported cases of Staphylococcus aureus TSS originating in the foot to date.

Cryptococcal meningitis in renal transplant patients associated with environmental exposure.

Fungal infections in renal transplant recipients are less common than bacterial infections; however, the morbidity from fungal infections is high. There is limited information in the literature concerning post-transplantation cryptococcal infection due to environmental exposure of patients living in high-risk areas. We report three patients who were diagnosed with cryptococcal meningitis after kidney transplantation. Cryptococcal titers prior to transplant surgery were negative in all three patients. These patients all lived in rural areas and demonstrated evidence of environmental exposure leading to subsequent cryptococcal meningitis. All patients had exposure to pigeon and chicken excreta and, after treatment, two patients are alive and well with excellent allograft function. The third patient has marginal renal function but is currently not on dialysis. Early diagnosis is essential for salvage from these potentially lethal infections. Intense headache was a prominent feature in the clinical presentation of our patients, and should signal the need for early sampling and culture of spinal fluid. Meningismus was not present in any of our patients, even when other systemic symptoms were identified. We recommend a high index of suspicion post-transplantation for all patients who may have environmental or occupational exposure to cryptococcus. If infection is detected quickly and treatment instituted promptly, patient recovery and allograft survival are possible. Long-term therapy with fluconazole, a non-nephrotoxic agent, should permit eradication of the infection with preservation of kidney function.

Clostridium innocuum endocarditis.

Clostridial endocarditis is rare. We describe, to our knowledge, the first case of Clostridium innocuum endocarditis. The fatal case involved the tricuspid and pulmonary valves and was associated with multiple pulmonary emboli. We review the literature, which suggests the varied presentations and outcomes of clostridial endocarditis. Penicillin is the treatment of choice for this disease.

Recognition and treatment of endemic and travel-acquire parasitosis.

The diagnosis of parasitic infections depends on a high level of suspicion after a thorough history and physical examination, mindful of relapsing course of long incubation periods (Table 6). Obvious information that alerts one to the diagnosis include recent travel abroad and in endemic areas of the United States. Within this framework, the most important element in the pursuit of parasitosis is persistence on the part of the physician. Advice from infectious disease specialists and laboratory personnel will increase the probability of finding, identifying, and the treating the underlying process. Serologic tests are helpful in this process. Antigen detection of antibody complexes formation by ELISA technique facilitates specific diagnosis (Table 7). The most important primary care issue is prevention. Treatment with unfamiliar drugs is best pursued with infectious disease consultation because these can have significant toxicities (Table 8). Office announcements reminding patients to ask about travel prophylaxis several months in advance of proposed travel and provision of information concerning endemic parasitoses is recommended.

Group A Streptococcus septicemia and an infected, ruptured abdominal aortic aneurysm associated with pharyngitis.

A 65-year-old man had a 3-day history of sore throat, fever, rigors, back pain, abdominal discomfort, nausea, vomiting, and diarrhea. The patient's daughter had group A streptococcus pharyngitis. The patient was found to have a ruptured abdominal aortic aneurysm. He underwent resection of the aneurysm and right axillary femoro-femoral bypass graft. The patient died 40 hours after admission. Gram stain of the aneurysm showed numerous gram-positive cocci. Group A streptococcus grew from cultures of blood, throat, and aneurysm. The group A streptococcus was M type 3, T type 3 and produced streptococcal pyrogenic exotoxin A. This case is a very rare fatal complication of group A streptococcus pharyngitis.

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.