Pott's puffy tumor: a complication of intranasal cocaine abuse.

The increasing intranasal abuse of cocaine has been associated with numerous medical problems. Among the most common complications are chronic sinusitis and septal perforation, although myocardial infarction and death also have been reported. We describe the development of Pott's puffy tumor in a patient who chronically abused cocaine. Pott's puffy tumor, a subperiosteal abscess of the frontal bone associated with frontal osteomyelitis, is a rare complication of frontal sinusitis. This case report underscores the dangers of cocaine abuse and describes yet another potentially serious sequela.

Prevalence of antibody to hepatitis B virus in foreign-born hospital employees.

Hepatitis B surface and core antibodies were measured in 512 community hospital employees at increased risk for developing infection with hepatitis B virus. Antibody was detected in 140 (27 percent) participants. Multivariate logistic regression analysis indicated that seropositivity was strongly associated with the prevalence of hepatitis B in an employee's country of birth and with age. These results suggest that reported differences among hospitals in hepatitis B seropositivity may in part be a reflection of the national origin of its employees. These data also indicate that each hospital should assess its own risk for hepatitis B infection and that prevaccination serologic testing is particularly worthwhile in hospitals having large numbers of foreign-born employees.

Nonresponse to hepatitis B vaccine in homosexual men.

Of 479 homosexual men immunized with three 20-microgram doses of the hepatitis B vaccine, approximately 15% failed to develop protective titers of antibody to the surface antigen of hepatitis B virus (greater than 10 sample ratio units [SRU]). We revaccinated 34 nonresponders with an additional three doses of vaccine and compared their immunologic status with that of 14 control men who had responded to initial vaccination. Most men (15 of 19) who had measurable antibody to hepatitis B surface antigen (SRU, 2.1-9.9) after initial vaccination responded to revaccination, whereas ten of the remaining 15 nonresponders (SRU, less than 2.1) did not. No single immunologic measure distinguished ultimate responders from nonresponders; however, the initial responders differed from delayed responders and nonresponders by having higher numbers of total lymphocytes, B, T, and T helper and suppressor cells.

Antibody to human lymphotropic virus type III: immunologic status of homosexual contacts of patients with the acquired immunodeficiency syndrome and the acquired immunodeficiency-related complex.

Twenty homosexual men who reported having sexual contact with homosexual men who had the acquired immunodeficiency syndrome (AIDS) or the AIDS-related complex were examined to determine their clinical status, immunologic profiles, and the presence of antibody to the human T-cell lymphotropic virus type III (HTLV-III). Of the 20, eight men had one or more signs or symptoms of the AIDS-related complex and 12 were asymptomatic. Antibodies to HTLV-III were present in 14 (70%) of 20 of the sexual contacts as compared with four (10%) of 40 healthy homosexuals without known contact with a patient who had AIDS (P less than .0001). Seropositive contacts had significantly higher mean counts of suppressor lymphocytes and lower helper: suppressor ratios (P less than .05 and .005, respectively) and higher serum levels of IgG than seronegative contacts (P less than .05). It was not possible to determine significant differences in sexual practices, drug use, length of relationship, or numbers of different sexual partners between symptomatic and asymptomatic contacts or between seropositive and seronegative contacts in this study.

Sequential clinical and immunologic abnormalities in hemophiliacs.

We examined 35 patients with hemophilia to determine if there was an association between impaired cell-mediated immunity and the amount of factor concentrate use. There was a significant negative relationship between the logarithm of the helper-suppressor ratio and the logarithm of concentrate use determined over the previous one year, five years, and total lifetime. Similarly, the presence of splenomegaly was significantly associated with the logarithm of concentrate use for each time interval. Hypergammaglobulinemia, anergy, and lymphadenopathy were present in a high proportion of patients. Repeated study of 30 of these patients at eight to 14 months showed no significant changes in their T-cell subsets. At follow-up, 16 patients had lymphadenopathy with or without splenomegaly and four had splenomegaly alone. No significant associations between concentrate use during the study period and changes in T-cell subsets or clinical condition were found.

IgG antibody to purified protein derivative by enzyme-linked immunosorbent assay in the diagnosis of pulmonary tuberculosis.

We studied the diagnostic utility of an enzyme-linked immunosorbent assay (ELISA) in hospitalized patients with suspected pulmonary tuberculosis (TB). A positive culture for M. tuberculosis identified active disease, and 3 negative cultures and smears defined the negative group. IgG antibody activity was determined by adding a 1:1,000 dilution of serum to plates coated with PPD antigen. Alkaline phosphatase labeled anti-IgG was added, color developed, and an optical density index (ODI) was determined. Twenty-one patients with M. tuberculosis TB had a mean ODI of 0.27, which was higher than 99 patients without TB, ODI 0.10 (p less than 0.001). An ODI of 0.15 or greater was established as a positive ELISA test. For patients with M. tuberculosis TB, the ELISA had a sensitivity of 67 and a specificity of 79%. The first smear had a sensitivity of 57 and a specificity of 99%. With the first smear and the ELISA test results, a combined sensitivity of 86% was achieved. When both ELISA and the first smear were negative (101 cases), active TB caused by M. tuberculosis was found in only three patients (3.0%).

Ophthalmologic findings in acquired immune deficiency syndrome (AIDS).

Forty-one homosexually active men had ophthalmologic and immunologic evaluations. Four of eight with acquired immune deficiency syndrome (AIDS) had abnormal ocular findings that included cotton-wool spots, retinal hemorrhages, cytomegalovirus, retinitis and conjunctivitis due to cytomegalovirus, and keratoconjunctivitis sicca. The other four patients with AIDS and 33 homosexual male controls had normal ocular examinations. Patients with AIDS and abnormal eye findings had a notably lower total leukocyte count, absolute lymphocyte count, percentage T-helper lymphocytes, helper-suppressor lymphocyte ratio, hematocrit level, and platelet count than patients with AIDS and normal results on eye examination or controls. All patients with AIDS and abnormal eye examination results died; the four other patients with AIDS and normal eye findings remain alive. These observations suggest that ophthalmologic abnormalities are common in patients with AIDS, are associated with severe immunoregulatory abnormalities, and carry a poor prognosis.

The spectrum of immunologic abnormalities and clinical findings in homosexually active men.

Clinical and laboratory evaluations of 181 men were performed; the population studied included 131 homosexual or bisexual men (who were stratified into one of three groups on the basis of symptomatology and abnormal findings on physical examination), 39 heterosexual men (who served as controls), and 11 men with acquired immunodeficiency syndrome (AIDS). The presence of specific symptoms and/or lymphadenopathy in homosexual men was associated with perturbation of immunoregulation. A large percentage of asymptomatic, homosexually active men had abnormalities in lymphocyte numbers, subpopulations, and subclasses. Symptomatic individuals had clinical findings, immunologic alterations, and abnormalities of hematopoiesis similar to those found in patients with AIDS. These data suggest that clinical evaluation in conjunction with laboratory studies may serve to identify individuals at increased risk of developing AIDS.

Acquired immunodeficiency syndrome in a patient with multiple risk factors.

To our knowledge, we report the first case of a homosexually active man with severe hemophilia A in whom acquired immunodeficiency syndrome (AIDS) developed. Alterations in cell-mediated immunoregulation and development of AIDS have been described in both healthy homosexually active men and heterosexual men with hemophilia A. Patients with multiple risks may be more likely to have AIDS develop. Physicians should be aware of the risk factors associated with AIDS; persons with multiple predisposing factors require intensive examination and close follow-up.

The enzyme-linked immunosorbent assay method for IgG antibody to purified protein derivative in cerebrospinal fluid of patients with tuberculous meningitis.

Three patients with culture-proven Mycobacterium tuberculosis meningitis were studied. Analysis of cerebrospinal fluid with an enzyme-linked immunosorbent assay (ELISA) method measuring IgG antibody to purified protein derivative rapidly yielded positive results, whereas results of acid-fast smears were negative and cultures took several weeks before growth appeared. We did serial studies of cerebrospinal fluid and sera from one patient. Initially, greater amounts of IgG antibody to purified protein derivative were present in the cerebrospinal fluid than in the serum. The antibody level in the cerebrospinal fluid paralleled the patient's clinical course, cerebrospinal fluid cell count, protein level, and glucose level. Cerebrospinal fluid samples from 33 hospitalized control patients were negative for antibody to purified protein derivative. The ELISA method measuring IgG antibody to purified protein derivative should be evaluated as a means of early diagnosis and management of patients with suspected tuberculous meningitis.

Use of an enzyme-linked immunosorbent assay technique in the differential diagnosis of active pulmonary tuberculosis in humans.

Sera from patients with active pulmonary tuberculosis and pulmonary diseases frequently mimicking tuberculosis were assayed for immunoglobulin G antibody activity to purified protein derivative (PPD) by an enzyme-linked immunosorbent assay. A method of standardization was developed to limit assay variation. Patients with active pulmonary tuberculosis had a significantly greater mean level of antibody than had patients with atypical tuberculosis (P = 0.005), sarcoidosis (P = 0.0001), histoplasmosis (P = 0.004), blastomycosis (P = 0.008), or cryptococcosis (P = 0.017), patients who had received bacille Calmette-Guérin vaccination (P = 0.003) or who had a history of treated tuberculosis (P = 0.003), and PPD skin test-positive and skin test-negative control subjects (P = 0.001). This technique may have potential use as a rapid diagnostic aid in evaluating patients with suspected active pulmonary tuberculosis.

Infective endocarditis caused by Paecilomyces varioti.

The first reported case of Paecilomyces varioti endocarditis occurring on a porcine heterograft prosthesis is presented and the clinical and pathological features described in the four previously reported cases of prosthetic valvular endocarditis caused by this organism are reviewed. In each case, infection became apparent more than two months after cardiac surgery. Three of the four patients with infected aortic prosthesis developed outflow obstruction secondary to valvular vegetations. All patients died regardless of medical or surgical intervention. Appropriate therapy remains unknown.

Bleeding in patients with activated partial thromboplastin time inhibitors.

We present a case in which an activated partial thromboplastin time (aPTT) inhibitor may have significantly contributed to prolonged bleeding in a patient and review five similar cases. The possibility of an aPTT inhibitor should be considered in the evaluation of patients with unexplained prolongation of PTT and PT. Such patients may develop significant bleeding even in the absence of other hematologic abnormalities.

Polymicrobial septicemia associated with rhabdomyolysis, myoglobinuria, and acute renal failure.

Myoglobinuria and renal failure resulting from bacterial infection have only rarely been reported. To our knowledge, we describe the first reported case of polymicrobial septicemia resulting in rhabdomyolysis and myoglobinuric renal failure. Renal failure secondary to myoglobinuria has an excellent prognosis; in our patient, recovery was complete. The frequency of rhabdomyolysis, myoglobinuria, and renal failure in septicemia is unknown and can only be determined by an increased awareness of this potential complication of septicemia.