Diagnosis of culture-negative female genital tract tuberculosis with peritoneal involvement by polymerase chain reaction.

BACKGROUND: Female genital tract tuberculosis (TB) is a common cause of infertility in developing countries. It is a paucibacillary form of the disease of which smears and cultures are usually negative. CASE: We were able to use polymerase chain reaction (PCR) amplification of Mycobacterium tuberculosis DNA to support a clinical and histologic diagnosis of a typical case of culture negative female genital tract TB. CONCLUSION: PCR may be a useful adjunct to diagnostic efforts in gynecologic tuberculosis.

The effects of estrogen replacement therapy on airway function in postmenopausal, asthmatic women.

BACKGROUND: Data from multiple clinical, epidemiologic, and in vitro studies are conflicting regarding the effect of estrogen replacement therapy (ERT) on airway function in postmenopausal women with asthma. OBJECTIVE: To determine the impact of withdrawal of estrogen administration in postmenopausal, asthmatic women. METHODS: Twenty asthmatic women who were postmenopausal for at least 2 years and undergoing ERT were recruited for this prospective crossover study. Subjects continued taking baseline estrogen for 28 days, stopped taking estrogen for 28 days, and then resumed taking the medication for 14 days. Objective measurements were obtained by recording daily peak flows in the morning and evening and formal spirometry at days 14, 28, 42, 56, and 70. Compliance was measured by evaluating serum estradiol levels at days 28 and 56. Daily use of short-acting beta-agonist bronchodilators was also recorded. RESULTS: Differences in estradiol levels indicated compliance with the medication regimen. The combined day 14 and 28 (taking estrogen) mean percent predicted forced expiratory volume in 1 second (FEV(1)) was 77% compared with the combined day 42 and 56 (not taking estrogen) mean FEV(1) of 78% and the day 70 (taking estrogen again) FEV(1) of 76% (P>.05). Average peak flow measurements were 295.5 L/min for the duration of ERT, 293.9 L/min while not undergoing ERT, and 291.8 L/min when ERT was restarted for the final 2 weeks of the study (P>.05). Use of short-acting beta-agonist bronchodilators did not differ between study periods. CONCLUSION: These data indicate that neither the discontinuation nor reinitiation of ERT in postmenopausal, asthmatic women has any effect on objective measures of airway obstruction.

Group F streptococcal bacteremia complicating a Bartholin's abscess.

BACKGROUND: Group F streptococci are gram-positive cocci typically isolated from wound infections and abscesses. Bacteremia with group F streptococcus is uncommon, and the lower gynecologic tract has not been reported as a source. We report a case of a Bartholin's abscess leading to group F streptococcal bacteremia. CASE: A 31-year-old female noted fever and rigors 30 min after manipulation of a 3-day-old vulvar abscess. An empty Bartholin's gland abscess was found on examination, and blood cultures grew beta-hemolytic group F streptococci. The patient was treated with ampicillin/sulbactam, symptoms improved, and follow-up blood cultures revealed no growth. CONCLUSION: Group F streptococci are known to inhabit various body sites and have a predilection for forming abscesses; however, bacteremia is infrequent. They have occasionally been identified in true infections of the genitourinary tract but only very rarely in Bartholin's abscesses. This case of group F streptococcal bacteremia following self-drainage of a Bartholin's abscess constitutes the first such description in the medical literature.

Development of quinolone-resistant Campylobacter fetus bacteremia in human immunodeficiency virus-infected patients.

Campylobacter fetus subspecies fetus has been recognized as a cause of systemic illness in immunocompromised hosts, including relapsing bacteremia in human immunodeficiency virus (HIV)-infected patients. Acquired resistance to quinolone therapy, while reported for a variety of bacteria, including Campylobacter jejuni, has not been previously documented for C. fetus. Two cases of quinolone-resistant C. fetus bacteremia were detected in HIV-infected patients. Cloning and nucleotide sequencing of the C. fetus gyrA gene in the 2 resistant isolates demonstrated a G-to-T change that led to an Asp-to-Tyr amino acid substitution at a critical residue frequently associated with quinolone resistance. In addition, comparison of the pre- and posttreatment isolates from 1 patient documented outer membrane protein changes temporally linked with the development of resistance. Relapsing C. fetus infections in quinolone-treated HIV-infected patients may be associated with the acquisition of resistance to these agents, and this resistance may be multifactorial.

Adjunctive corticosteroid therapy for tuberculosis: a critical reappraisal of the literature.

An extensive, although largely forgotten, literature addresses the utility of adjunctive corticosteroid therapy in the management of tuberculosis. Corticosteroid therapy probably improves neurological outcomes of, and decreases mortality due to, tuberculous meningitis of moderate severity. Although therapy for tuberculous pericarditis is simplified (with less need for operative intervention) by adjunctive corticosteroid administration and there are fewer deaths, the incidence of subsequent constriction is not changed. The signs and symptoms of typical reactivation tuberculous pneumonia, tuberculous pleurisy, and probably primary tuberculous disease (with lymphadenopathy) seem to decrease rapidly with corticosteroid therapy, although no differences in final outcomes have been observed. Corticosteroid regimens used in most studies varied greatly in duration and dosage and generally caused significant side effects. Corticosteroids do not appear to diminish the efficacy of adequate antimycobacterial therapy. Adjunctive corticosteroid therapy appears to offer significant short-term but (other than for tuberculous meningitis and effusive pericarditis) minimal long-term benefit for patients with tuberculosis.

Spook house sporotrichosis. A point-source outbreak of sporotrichosis associated with hay bale props in a Halloween haunted-house.

While isolated cases of sporotrichosis typically occur following contact with contaminated plant materials, outbreaks are distinctly unusual. A temporal increase in the incidence of sporotrichosis in a dermatology practice at a military installation in southwestern Oklahoma prompted an investigation. Patients with sporotrichosis presenting to a single dermatologist in the winter of 1992-1993 were interviewed, epidemiological data were collected, and fungal cultures were obtained from incriminated hay fields. Five patients presented with cutaneous sporotrichosis during a 5-week period beginning in December 1992. Four patients had maintained hay bales in a Halloween haunted house and the fifth patient had visited the house once. As in 3 previous reports, this outbreak was associated with stored hay or hay bales harvested in the US plains states. Contact with hay should be recognized as a risk factor for infection with Sporothrix schenckii. Outbreaks are possible given adequate intensity of exposure and may be difficult to recognize because of the delayed presentation of clinical illness.

Validation of catheter semiquantitative culture technique for nonstaphylococcal organisms.

The catheter semiquantitative culture roll tip technique has been validated as a discriminator between non-catheter-related bacteremias and catheter-related bacteremias (CRBs) caused by Staphylococcus species. However, this technique has not been specifically validated when used for the evaluation of catheters infected with organisms other than staphylococci. We reviewed catheters that had been submitted for semiquantitative roll tip culture as well as hospital records to determine clinical correlates of infection. Local infection and CRB were defined by standard criteria. Catheter-related sepsis (CRS) was defined as fever, leukocytosis, or hypotension which resolved with catheter removal, without another source of infection. For 195 catheters from 93 patients, gram-negative rods and enterococci were present on 36, fungi were on 25, Corynebacterium species were on 5, Bacillus species were on 3, Staphylococcus species were on 79, and 41 demonstrated no growth. Of 21 episodes of CRB or CRS due to nonstaphylococcal organisms, only 1 (questionable) episode was due to a catheter with < 15 CFU (P < 0.05). Eleven of these 21 episodes of CRB or CRS were due to gram-negative rods and enterococci, of which only the questionable episode was due to a catheter with < 15 CFU. Nine of these 21 episodes of CRB or CRS were due to fungi, none of which were associated with a catheter with < 15 CFU. The data for Staphylococcus species recapitulated published data (none of 21 CRB or CRS episodes were associated with catheters with < 15 CFU) and validated this retrospective technique. The data presented in this study validate the use of the semiquantitative culture technique for the evaluation of catheter-related infections caused by organisms other than staphylococci.

Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era.

Pylephlebitis usually occurs secondary to infection in the region drained by the portal venous system. We describe a case of pylephlebitis at our institution and examine 18 other cases culled from the literature since 1979, reviewing diagnostic and management issues. A precipitating focus of infection (most commonly diverticulitis) was identified in 13 (68%) of the cases. Bacteremia (often polymicrobial) was present in 88% of the patients. The most common blood isolate was Bacteroides fragilis. Overall mortality was 32%, but most of the patients who died had severe sepsis prior to the initiation of antibiotic therapy. In no case was improvement in a patient's clinical status clearly attributable to the use of heparin, but some beneficial effect of anticoagulation could not be ruled out. This report is the first to examine the published experience with pylephlebitis during the era of antibiotics and modern imaging and is also the first to review critically the role of anticoagulation in the management of this disease.

Purulent pericarditis caused by Candida species: case report and review.

Purulent pericarditis caused by Candida species is a rare and often undiagnosed disease. We recently treated a patient in whom purulent pericarditis due to Candida albicans developed following thoracic surgery. The patient survived after receiving a combination of surgical and medical therapy. A literature review revealed 24 additional cases of purulent pericarditis caused by Candida species. Twenty-one of the patients either had undergone thoracic surgery or had had disseminated candidiasis. None of the 12 patients described before 1980 survived, whereas six (46%) of the 13 patients described after 1980 survived. No patient survived without pericardiectomy (five of six survivors) or at least pericardiocentesis (one survivor). All survivors received full courses of amphotericin B therapy. An increased utilization of echocardiography, along with an increased recognition of the patient populations at risk, has been instrumental in early detection and improved outcome of purulent pericarditis. A combination of prolonged amphotericin B therapy and pericardiectomy appears to be the best approach for achieving a cure.

Misidentification of clinical yeast isolates by using the updated Vitek Yeast Biochemical Card.

The Vitek Yeast Biochemical Card (YBC) is widely used as a rapid identification (RI) (within 48 h) system for clinical yeast isolates. We compared the RI results obtained by the YBC technique with matched results obtained with the API 20C system. The RI of germ tube-negative yeasts isolated from 222 clinical specimens was performed with the YBC system, and the results were compared with those of standard identifications obtained by using the API 20C system and morphology, with additional biochemical reactions performed as required. Commonly isolated yeasts (Candida albicans [n = 29], Candida tropicalis [n = 40], Torulopsis [Candida] glabrata [n = 28], Candida parapsilosis [n = 12], and Cryptococcus neoformans [n = 14]) were generally well identified (115 of 123 [93%] identified correctly, with only C. albicans, C. tropicalis, and C. neoformans mis- or unidentified more than once). The RI of less commonly isolated yeasts included in the YBC database, however, was less successful (54 of 99 [55%] correct). The YBC card failed to identify 42% (10 of 24) of Candida krusei isolates, 80% (4 of 5) of Candida lambica isolates, 88% (7 of 8) of Trichosporon beigelii isolates, and 83% (10 of 12) of Cryptococcus isolates (non-C. neoformans species). For most identification failures (79%; 42 of 53) there was no identification by the end of 48 h; the other identification failures (21%; 11 of 53) gave definite but incorrect identifications. Of eight rare clinical yeast isolates not included in the Vitek database, six were correctly, not identified, while two (25%) were falsely assigned a definite RI (one Hansenula fabianii isolate was identified as Rhodotorula glutinis, and one Hansenula isolate [non-Hansenula anomala] was identified as Hansenula anomala). While the Vitek YBC rapidly and adequately identifies common yeast isolates, it fails in the RI of more unusual organisms.

Cytokine induction in human coccidioidomycosis.

To investigate the immune response to human infection with the fungus Coccidioides immitis, we measured cytokine production from peripheral blood mononuclear cells (PBMC) and plastic-adherent monocytes/macrophages (Mphi) isolated from healthy subjects who were skin test positive to spherulin, healthy subjects who were skin test negative, and patients with active coccidioidomycosis. PBMC and Mphi from all these donor groups secreted increased levels of tumor necrosis factor alpha, interleukin-1 beta, and interleukin-6 in response to stimulation with formalin-killed spherules (FKS), as measured by enzyme-linked immunosorbent assays. Viable C. immitis spherules also stimulated PBMC and Mphi from healthy subjects and patients to secrete tumor necrosis factor alpha, interleukin-1 beta, and interleukin-6, although at levels lower than those induced by FKS. The production of these acute inflammatory cytokines may contribute to the immunopathogenesis of active coccidioidomycosis and could account for the toxicity of the FKS vaccine in humans.

Syphilitic pneumonitis in an HIV-infected patient.

Pneumonitis and symptomatic hepatitis are very rare complications of syphilis. Symptomatic hepatitis and subclinical reticulonodular pulmonary infiltrates were observed when an HIV-infected patient presented with secondary syphilis. The Jarisch-Herxheimer reaction included a flare of hepatitis symptoms, resembling cholangitis. In a patient with syphilis, it may be appropriate to delay an aggressive evaluation for suspected pneumonitis or cholangitis pending the outcome of specific antitreponemal therapy.

Coccidioidomycosis: a persistent threat to deployed populations.

The world-wide deployability of aircrew members exposes them to a peculiar array of medical problems. Non-immune populations, upon deployment to endemic areas, may present to the deployed flight surgeon with acute, poorly recognizable syndromes, such as acute coccidioidomycosis. Alternatively, the acquisition of the chronic progressive form of coccidioidomycosis in endemic areas may be a problem for the flight surgeon, who may be faced with a poorly recognizable syndrome which first manifests itself weeks to months after the crewmember's return from deployment. We describe three cases of coccidioidomycosis in service members that highlight the difficulty in the diagnosis of this disease. These cases prompted an epidemiologic survey of recent cases of coccidioidomycosis among Air Force beneficiaries, presented here, to better define the impact of this disease on personnel assigned to endemic areas. A brief discussion of the epidemiologic and clinical features of the disease and of the aeromedical disposition of the aviator is presented.