[Diagnostic utility of Osler's nodules in infectious endocarditis among parenteral drug users]. / Utilidad diagnóstica de los nódulos de Osler en la endocarditis infecciosa en usuarios de drogas por vía parenteral (UDVP).

BACKGROUND: The objective of study is to describe of clinic, microbiological and histological data of five cases of infective endocarditis (IE) with Osler's nodes in intravenous drug users. PATIENTS Y METHODS: Prospectively, 43 cases of IE in intravenous drugs users was revised. In 4 patients, a aspirate puncture of Osler's node was performed and in one patient a biopsy of Osler's node was done with Gram's stain and culture of specimen. RESULTS: From 43 episodes of IE, 33 were right-side IE, 9 left-side y 1 right and left side. No patients with right-side IE presented Osler's nodes, however five of 10 (50%) patients with left-side endocarditis. In all of cases gram positive cocci were observed in Gram's strain and Staphylococcus aureus growth on culture of lesion with the same antibiotype than isolated from blood culture. One case a cutaneous biopsy was performed, and inflammatory infiltrate with necrosis was found. CONCLUSIONS: The Gram's strain and culture of specimen aspirated from Osler's nodes were of high utility in the diagnosis of IE in intravenous drugs users. The presence of Osler's nodes in a patient with infective endocarditis must be suggest that the location in left-side. These data suggest that Osler's nodes in infective endocarditis by S. aureus in intravenous drugs users was originated by microvascular septic emboli.

Utilidad diagnóstica de los nódulos de osler en la endocarditis infecciosa en usuarios de drogas por vía parenteral (UDVP) / Diagnostic utility of osler's nodes in the infective endocarditis in intravenous drug users

Fundamento: Se describen los datos clínicos, microbiológicos e histológicos de cinco episodios de endocarditis infecciosa (EI) con nódulos de Osler en usuarios de drogas por vía parenteral (UDVP).Pacientes y métodos: Se han estudiado de forma prospectiva 43 casos de EI en UDVP. En 4 pacientes se realizó punción aspiración y en otro biopsia de un nódulo de Osler, con tinción de Gram y cultivo de la muestra. Resultados: De los 43 episodios de EI 33 fueron derechas, 9 izquierdas y 1 mixta. Cinco de los 10 (50 por ciento) pacientes con endocarditis izquierda o mixta presentaron nódulos de Osler, pero no se encontraron en ninguno de los pacientes con EI derecha. En todas las muestras tomadas por punción aspiración se observaron cocos grampositivos en racimos en la tinción de Gram y se obtuvo crecimiento de Staphylococcus aureus con el mismo antibiotipo que los aislados en los hemocultivos. En el único caso en el que se realizo biopsia del nódulo se apreciaba trombos sépticos en la microcirculación. Conclusiones: La tinción de Gram y el cultivo del material aspirado de los nódulos de Osler tiene una alta rentabilidad en el diagnóstico etiológico de la EI en los usuarios a drogras por vía parenteral. La presencia de nódulos de Osler en un paciente con EI nos debe sugerir que la localización es izquierda. Estos datos sugieren que los nódulos de Osler, en la EI por S. aureus en los UDVP se origina como consecuencia de embolismos sépticos microvasculares (AU)

[Infective endocarditis in intravenous drug users. Study of 34 cases]. / Endocarditis infecciosa en usuarios a drogas por vía intravenosa. Estudio de 34 casos.

OBJECTIVE: Infective endocarditis (IE) in injection drug users (IDU) have a special etiologic, epidemiological and clinical characteristics different to IE in the general population. The clinical and evolutive features of a group of IE in IVD are reported. METHODS: A retrospective analysis was made of 34 episodes (24 patients) of IE in IDU in the Catagena Area (Murcia, Sapin). RESULTS: A total 34 episodes, 18 was males (75%) and 6 (25%) females with a age media of 26.1 years (DE, 4.3). Eighty-four percents were infected with human immunodeficiency virus. The location of IE was right-side in 26 (73%), left-side in 7 cases (18%) and right-left in one (2%). Staphylocococcus aureus was isolated in 31 cases (91%), it was meticillin-resistant in 4 cases (13%); Pseudomonas aeruginosa, and Streptococcus equisimilis was isolated in one case each. Fever was present in 33 patients (97%) and more than half were cough, pleuritic chest pain and expectoration. Twenty-five patients with right IE has chest X-ray abnormal, specially nodules-infiltrates pulmonary. Vegetations were not observe in 7 (21%) occasions by transthoracic echocardiography. In six of 8 patients with left-side IE present a cerebri embolisms. Two patients with left IE death (21%). The rate of successful therapy in the right-side IE treated during 2 or 4 weeks were 100%. CONCLUSIONS: The IE in IDU is a entity produced mainly by S. aureus, affect preferentially a right-side cavities and the prognosis is generally good.

Management of adverse reactions to prophylactic trimethoprim-sulfamethoxazole in patients with human immunodeficiency virus infection.

BACKGROUND: In hospitals attended by patients with human immunodeficiency virus infection, adverse reactions are often observed to trimethoprim-sulfamethoxazole, particularly cutaneous reactions. Given the importance of this drug for prophylaxis we have attempted to establish a desensitization or tolerance protocol so that patients can continue the drug without repeated adverse reactions. METHODS: We studied 34 HIV patients with adverse cutaneous reactions to trimethoprim-sulfamethoxazole, slight to moderate in nature but not life-threatening. Skin tests (prick and intradermal) were done in an attempt to rule out a mechanism of hypersensitivity. Subsequently, trimethoprim-sulfamethoxazole was administered orally in increasing doses beginning with trimethoprim, 0.2 mg, and sulfamethoxazole, 1 mg. The same dose was repeated after 12 hours and then doubled every 24 hours until the therapeutic dose was achieved. If adverse reactions appeared we maintained the last dose administered and administered antihistamines until the reactions cleared or improved. RESULTS: None of the patients had positive skin tests (immediate or delayed). Twenty- seven patients were satisfactorily desensitized. After a follow-up of 3 months, 25 patients were still incident-free on trimethoprim-sulfamethoxazole prophylaxis, and 19 returning for check-ups at 6 months could still tolerate the drug well. CONCLUSIONS: Our data indicate that patients with adverse reactions to trimethoprim-sulfamethoxazole can continue prophylactic treatment after oral desensitization.

Asteroid bodies and calcium oxalate crystals: two infrequent findings in fine-needle aspirates of parotid sarcoidosis.

We have studied 3 cases of sarcoidosis involving the parotid gland by means of fine-needle aspiration cytology (FNAC). The main findings were noncaseating granulomas, multinucleated giant cells (MGCs), and lymphocytes. In one case MGCs contained asteroid bodies and in another case we observed calcium oxalate crystals (COCs) over both stromal fragments and MGCs. Although nonpathognomonic for sarcoidosis, these 2 findings may help in the diagnosis of this condition. However, both are easily overlooked and must be borne in mind when viewing noncaseating granulomas. Sarcoid granulomas displaying COC must be differentiated from foreign-body granulomas. The aforementioned cytological findings must be assessed in conjunction with clinical findings. Nevertheless, in most cases the diagnosis of sarcoidosis is made by exclusion.