A Behçet-like disease presenting as ulcerative stomatitis and scarring pustular lesions of the face.

Behçet's disease is a complex multisystem disease of unknown origin. It presents clinically as oral, pharyngeal, and genital ulcerations, uveitis, and inflammatory papulopustules. Diagnosis is made clinically since laboratory and histologic observations are not specific. We present a patient who, despite the absence of eye and genital lesions, seems best viewed as having Behçet's disease.

Occult Streptococcus pyogenes in cellulitis: demonstration by immunofluorescence.

A 23-year-old man developed cellulitis and ascending lymphangitis of the right leg. Blood cultures and skin saline aspirates were sterile. Gram stain of the aspirate did not show any bacteria. Direct and indirect immunofluorescent staining with polyclonal and monoclonal antibodies to Streptococcus pyogenes revealed streptococci in the reticular dermis. The cellulitis resolved following treatment with intravenous cefazoline.

Detection of antibiotic-induced platelet dysfunction in whole blood using flow cytometry.

Using flow cytometry and activation-dependent monoclonal antibodies, we have developed a technique based on forward angle-light scatter (FALS) and immunofluorescence that simultaneously detects human platelet activation, secretion, and aggregation in whole blood. To detect the effects of cefotetan and latamoxef, both of which contain an N-MTT side chain, and of free N-MTT and cefoxitin, which does not contain the N-MTT side chain, on platelet activation and secretion, platelets were stained by the indirect method using a murine-produced platelet specific activation-dependent monoclonal antibody, S12, and a goat anti-mouse IgG fluorescein-conjugated antibody. S12 binds to a 140kd alpha granule membrane protein (GMP-140) that is expressed during secretion. Single parameter, 256 channel, log integrated green fluorescence histograms were generated, and negative and positive fluorescent populations were defined. Latamoxef and cefotetan reduced the number of platelets expressing S12 by more than 43%. In contrast, cefoxitin reduced the number of platelets expressing S12 by only 13.5%. The inhibition of GMP-140 expression per platelet was calculated by converting the log data to linear fluorescence intensity. Latamoxef and cefotetan inhibited expression of GMP-140 by 88% and 87% respectively. Free N-MTT inhibited its expression by 68%. In contrast cefoxitin reduced GMP-140 expression per platelet by only 45%.

Inhibition of platelet aggregation by moxalactam and free N-methylthiotetrazole.

The effects of moxalactam and free N-methylthiotetrazole (N-MTT) in vitro on platelet aggregation induced by adenosine diphosphate (ADP), arachidonic acid, collagen, epinephrine, or ristocetin were determined. Moxalactam at concentrations of 1.9 mM and 5.7 mM inhibited platelet aggregation induced by ADP, arachidonic acid, epinephrine, and ristocetin. Although the aggregatory activity of collagen was not inhibited with 1.9 mM moxalactam, an increase in the concentration of moxalactam to 5.7 mM significantly inhibited collagen-induced platelet aggregation. Inhibition of platelet aggregation by free N-MTT was also concentration dependent. The lowest concentration of N-MTT used in this study, 5.7 mM, inhibited platelet aggregation induced by both arachidonic acid and ristocetin. At a concentration of 28 mM, N-MTT inhibited aggregation induced by ADP, collagen, epinephrine, and ristocetin, but not by arachidonic acid. At 57 mM N-MTT, almost complete inhibition of platelet aggregation occurred for all five agonists tested.

Pharmacokinetics of imipenem-cilastatin in patients with renal insufficiency undergoing continuous ambulatory peritoneal dialysis.

In six patients with end-stage renal disease, a single bolus of imipenem-cilastatin (500 mg each) was given either intravenously or intraperitoneally in a randomized crossover protocol such that each patient received the drug by both routes at a 2- to 3-week interval. Drug levels in plasma and the peritoneal dialysis fluid were analyzed at frequent intervals, and various pharmacokinetic variables were calculated for a one-compartment open model. Data obtained in the present study suggest that while no significant difference in peak plasma levels or volume of distribution were noted, the following variables were significantly different for imipenem as compared with cilastatin: elimination half-life, total plasma clearance, area under the concentration-time curve, and percent drug excretion in the peritoneal dialysis fluid. The elimination half-life of imipenem (3.28 h) or cilastatin (8.84 h) in our patients was in the same range as observed in patients with minimal renal function undergoing hemodialysis. The dose of imipenem-cilastatin should be reduced appropriately in patients with end-stage renal disease undergoing peritoneal dialysis.

Rupture of a pulmonary artery mycotic aneurysm associated with candidal endocarditis.

Candidal endocarditis can develop if candidemia occurs during Swan-Ganz catheterization. Candida endocarditis may persist for many months and is fatal unless the infected valve is resected. Herein is reported the first case of rupture of a mycotic pulmonary artery aneurysm caused by chronic candidal endocarditis. The endocarditis followed Swan-Ganz catheterization and aneurysm progressed despite appropriate medical and surgical therapy.

Cefotetan-induced disulfiram-type reactions and hypoprothrombinemia.

A double-blind, placebo-controlled study in eight healthy male volunteers was conducted to study possible disulfiram-type reactions and hypoprothrombinemia associated with cefotetan administration. Three doses of cefotetan (2 g) or of placebo were administered at 12-h intervals. Ethanol (0.5 g/kg of total body weight) was ingested 1 h after the third dose. Blood ethanol, serum acetaldehyde, and prothrombin times were measured throughout the study. Heart rate, blood pressure, and clinical signs as well as symptoms suggestive of a disulfiram-type reaction were also noted. Five of eight volunteers that received cefotetan showed significant flushing. A significant increase in heart rate also was noted. No change in mean arterial pressure was observed during the cefotetan phase, and no one experienced nausea or vomiting. No statistical differences were observed between phases with respect to ethanol area under the time-concentration curve, elimination rate, or serum acetaldehyde concentrations. A slight but statistically significant increase in prothrombin time also was observed with cefotetan. This study suggests that patients receiving cefotetan might be at risk to develop disulfiram-type reactions and hypoprothrombinemia.

Empirical use of imipenem as the sole antibiotic in the treatment of serious infections.

Seventy-three patients with eighty-five infections were treated with imipenem as the sole antimicrobial agent. Some of these infections were caused by pseudomonads and enterococci resistant to other cephalosporins. The vast majority of the Gram-positive and the Gram-negative bacteria that were isolated had a minimal inhibitory concentration (MIC) of less than 1 mg/l, and all MICs for initial isolates were below the levels of imipenem that were achieved in plasma and other body fluids with a dose of 500 mg every 6 h. The outcomes of 67 infectious episodes were satisfactory, four outcomes were failures and 14 were not evaluable. During the two years of this study, only a few strains of Staphylococcus epidermidis and of Pseudomonas aeruginosa emerged which were resistant to imipenem.

Treatment of skin and soft tissue infections with imipenem/cilastatin.

Ninety-eight adult patients with skin and soft tissue infections caused by a variety of bacterial pathogens were treated with imipenem/cilastatin (71), cefazolin (21), or moxalactam (six) at three medical centers. Favorable clinical responses were observed in 87 of the 90 evaluable cases (97 percent). Most etiologic pathogens were eradicated during treatment including five of seven which demonstrated in vitro resistance to the therapeutic agent. Strains that persisted during treatment were not associated with therapeutic failure except in one cefazolin-treated patient who was infected with Bacteroides fragilis. All three drugs were well tolerated and no specific patterns of adverse reactions were observed.

Pathogenesis and treatment of endocarditis.

The rabbit model has been invaluable for in vivo studies in the pathogenesis and treatment of bacterial endocarditis. Both of the features of the mature bacterial vegetations in this rabbit model, i.e., absence of phagocytosis and decreased metabolic activity, provide evidence to support the concept that a rapidly bactericidal antimicrobial agent provides the optimal approach to the successful treatment of endocarditis. Imipenem, a carbapenem with a very broad spectrum of in vitro activity, has been shown to be rapidly bactericidal in animals and highly effective in the treatment of experimental bacterial endocarditis. In addition, twenty-six patients with endocarditis, caused largely by Staphylococcus aureus, have been successfully treated with imipenem/cilastatin.

Infectious antecedent of immunoblastic lymphoma. Progressive immunosuppression in a patient with lymphogranuloma venereum.

Angioimmunoblastic lymphadenopathy is a nonmalignant disease of unknown etiology often progressing to immunoblastic lymphoma. Immunologic deficiency is evident in these patients as well as in those with various infections found in association with the acquired immune deficiency syndrome (AIDS). This report describes a previously healthy young woman in whom angioimmunoblastic lymphadenopathy developed in association with lymphogranuloma venereum, with progressive loss of immunologic competence. This deterioration paralleled the evolution of angioimmunoblastic lymphadenopathy into a rapidly fatal immunoblastic lymphoma.

Autoimmune mechanisms in the pathogenesis of rheumatic fever.

The etiologic agent of acute rheumatic fever is the group A streptococcus; however, its role in the pathogenesis of this disease is not well understood. Epidemiologic and immunologic evidence suggests that there is a population at risk and that the nature of the host response to streptococcal antigens and the physicochemical nature of the streptococcal antigens all play a significant role in determining the natural history of the disease process. Furthermore, the genetic control of the interaction of the host with the streptococci is clearly involved in a set of events--as yet obscure--that result in acute rheumatic fever. Neither antibody-mediated nor cell-mediated hypersensitivity reactions have been demonstrated in vivo or in vitro that wholly reproduce the characteristics of this disease. Additional studies of the regulation of the immune response and of human immunogenetics are essential for gaining further insight into the pathogenesis of acute rheumatic fever.

Infection with Cryptococcus neoformans var. gattii leading to a pulmonary cryptococcoma and meningitis.

A patient who lived in Ohio, U.S.A., developed a large pulmonary cryptococcoma and meningitis as the result of infection with Cryptococcus neoformans var. gattii, an organism of subtropical and tropical distribution. He had no obvious predisposing illness or condition associated with increased susceptibility to cryptococcosis. Although he was found to have cutaneous anergy, his lymphocytes showed significant transformation responses in vitro when cultured both with mitogens and with killed cryptococci. The meningitis responded to intrathecal amphotericin B. The cryptococcoma, however, did not resolve in response to vigorous antifungal therapy during a period of more than 4 months. Eventually, the cryptococcoma was surgically removed. This case is unusual both for the finding of C. neoformans var. gattii outside its apparent endemic area as well as for the clinical features of the disease.

Ceftizoxime elimination kinetics in continuous ambulatory peritoneal dialysis.

We investigated the kinetics of ceftizoxime, a beta-lactamase stable cephalosporin, in eight subjects undergoing continuous ambulatory peritoneal dialysis (CAPD). A single 500-mg or 1-gm dose was injected IV, or a 500-mg dose was given intraperitoneally in the CAPD fluid during a 6-hr dwell time. The ceftizoxime (500 mg) serum kinetic parameters were as follows: peak concentrations, 21 to 46 mg/l; volume of distribution, 0.27 l/kg; elimination rate constant, 0.0784 hr-1; plasma clearance, 1.66 l/kg hr-1; and t1/2, 10.2 hr. The t1/2 after 1 gm was 12 hr. Dialysate ceftizoxime concentrations rose rapidly between 0.25 and 2 hr and slowly over the next 4 hr, but only 4.04 +/- 1.8 and 7.4 +/- 2.9 mg ceftizoxime/hr was eliminated by the peritoneal route over a 6-hr dwell time after 500 mg or 1 gm IV. This represents only 4% to 5% of the dose. After intraperitoneal instillation, the antibiotic appeared in the serum within 15 min in all four subjects, and the peak serum concentrations ranged from 12 to 19.8 mg/l (mean +/- SD = 16.4 +/- 3.3) between 5 and 6 hr. Approximately 78% of ceftizoxime was absorbed from the peritoneal dialysis fluid during a single 6-hr dwell time. Rate constant for absorption, ka, was 0.3959 hr-1 and absorption t1/2 was 1.75 hr (as calculated by the residual equation). These data suggest that ceftizoxime has bidirectional exchange characteristics through the peritoneal membrane. Instillation of ceftizoxime in CAPD fluid alone may permit rapid absorption to reach therapeutic serum concentrations.

T lymphocyte abnormalities in disseminated histoplasmosis.

Disseminated histoplasmosis is associated with depression of T cell-mediated immunity and in some cases anergy. In this report, two patients with disseminated disease are described. Both had a depression of T cell-mediated immunity as well as other abnormalities of immune response. In one, a patient with relapse, a marked depression in the ratio of T helper to T suppressor cells was noted. Neither patient had any predisposing condition known to be associated with disseminated disease.

A randomized study comparing clinical efficacy and safety of thienamycin formamidine (MK0787)/renal dipeptidase inhibitor (MK0791) and cefazolin.

Twenty-one hospitalized patients with infectious diseases were randomly assigned to receive either thienamycin formamidine/renal dipeptidase inhibitor or cefazolin. Infections treated included septicaemia, pneumonia, osteomyelitis, pyelonephritis, cellulitis and cutaneous abscesses. All eleven patients treated with thienamycin formamidine/renal dipeptidase inhibitor responded well to therapy. One of the ten patients treated with cefazolin developed a superinfection with Pseudomonas aeruginosa. Side effects detected were minor in both groups.

Occurrence and expression of imipemide (N-formimidoyl thienamycin) resistance in clinical isolates of coagulase-negative staphylococci.

More than 500 clinical isolates were screened for resistance to a number of antibiotics, including imipemide (N-formimidoyl thienamycin [MK0787]). Of the 25 coagulase-negative staphylococcal isolates present in the screening sample, almost one-third showed one of two patterns of imipemide resistance. One pattern apparently involves constitutive expression of drug resistance, whereas the other pattern seems to result from an inducible resistance having an apparent induction threshold higher than the minimal inhibitory concentration of imipemide. The mechanism(s) responsible for this imipemide resistance is unclear, but may be distinct from the more common staphylococcal mechanisms of resistance to beta-lactam antibiotics. Only two of the patients from whom imipemide-resistant staphylococci were cultured had actually been treated with the antibiotic.

Treatment of serious infections with moxalactam.

In 93 hospitalized patients, 111 bacterial infections were treated with moxalactam. Eighty-three infections responded well to therapy, nine infections failed to respond to therapy or relapsed, and nine infections showed superinfection with resistant bacteria. The great majority of bacteria isolated had mean inhibitory concentrations below levels readily achieved in plasma, cerebrospinal fluid, bile, abscess fluid, and peritoneal fluid. Among the commonly identified bacteria, only Pseudomonas aeruginosa, enterococci, and Staphylococcus epidermidis had variable sensitivity to moxalactam.

Osteomyelitis caused by viridans streptococci.

A 34-year-old man without known underlying disease was seen with osteomyelitis of the proximal shaft of the left femur. At operation, only viridans streptococci were isolated. The patient responded to a combination of intravenous penicillin G potassium and gentamicin sulfate therapy. To our knowledge, this is the first reported case of osteomyelitis of a long bone produced by hematogenous seeding by viridans streptococci.