Pleural fluid findings in patients with the acquired immunodeficiency syndrome: correlation with concomitant pulmonary disease.

BACKGROUND: We sought to define the spectrum of conditions associated with pleural effusion (PE) in patients with the acquired immunodeficiency syndrome (AIDS) who submitted to diagnostic thoracentesis. METHODS: The medical records of patients with human immunodeficiency virus (HIV) infection and PE studied by thoracentesis over a 5-year period, were reviewed for demographics, clinical presentation, concomitant illnesses, pleural fluid analysis, management, and outcome. RESULTS: Thoracentesis was done in 30 patients, 24 men and 6 women, with an overall mean age of 36 +/- 9 years. Mean CD4 cell count was 157 +/- 249/mm3. The cause of the PE was infectious in 21 (70%) and noninfectious in 9 (30%). Bacterial pneumonia was the most common cause of PE (57%). Streptococcus pneumoniae and Staphylococcus aureus were the major organisms recovered. Mycobacterial infections were present in 3 patients, and Nocardia sp was isolated from 1 patient. Non-Hodgkin's lymphoma (5 cases) was the leading noninfectious cause of PE, followed by Kaposi's sarcoma (3 cases) and adenocarcinoma of the lung (1 case). Twelve of the 30 patients died during hospitalization. CONCLUSION: Pleural effusion is an important problem in patients with advanced HIV infection. It is most frequently associated with bacterial pneumonia. Cytologic and microbiologic examination of the pleural fluid is helpful in determining the cause of PE in this patient population.

Recent trends in the prevalence and distribution of schistosomiasis in the Nile delta region.

In 1983, a survey of 71 villages in the Nile delta demonstrated that the overall prevalence of Schistosoma mansoni and S. haematobium infections was 39% and 5%, respectively. Recent increased availability of praziquantel, combined with Egyptian Ministry of Health-sponsored media efforts to educate the public about schistosomiasis, prompted us to determine the current status of S. mansoni and S. haematobium infections in the delta and evaluate any changes that may have occurred since the previous survey. The same villages that participated in the 1983 survey were resampled in 1990. Stool and urine samples were requested from all occupants over the age of two years in a 5% sample of houses within each village. Stool (Kato) thick smears and urine sediments were read qualitatively at the rural health station. Field-prepared Kato smears and a 20% sample of urine specimens were forwarded to the Ministry of Health Laboratory, where quantitative readings were also performed. Analysis of samples obtained from 17,310 persons revealed that S. mansoni prevalence had decreased to 23% and that S. haematobium prevalence had decreased to 3% (P < 0.001). The highest levels of schistosome infection were found in governates located in the eastern section of the delta. The observed changes in the prevalence of S. mansoni and S. haematobium suggest that control measures are having a favorable impact on schistosomiasis transmission in this region.

Diloxanide furoate for treating asymptomatic Entamoeba histolytica cyst passers: 14 years' experience in the United States.

Diloxanide furoate is used for treating asymptomatic or mildly symptomatic persons who are passing cysts of Entamoeba histolytica. The Centers for Disease Control (Atlanta) released this drug for 4,371 treatment courses from 1977 through 1990. Of the 2,815 report forms (64%) returned, 656 adverse effects were reported for 390 treatment courses (14%); they included flatulence (260), diarrhea or cramping (100), nausea (93), headache (17), disorientation or dizziness (9), and diplopia (4). During 1984-1990 uniform collection of data allowed more detailed analysis of toxicity and efficacy; fewer adverse effects were reported for persons aged 20 months to 10 years than for persons aged greater than 10 years (6 of 206 [3%] vs. 89 of 763 [12%], relative risk = 0.27, 95% confidence interval = 0.12 less than relative risk less than 0.61). Parasitological cures were achieved during 497 (86%) of the 575 treatment courses (52%) administered to asymptomatic persons who were passing cysts, who had received a full 10-day treatment course, and for whom results of a follow-up stool examination (greater than or equal to 14 days post-treatment) were available. Diloxanide furoate is safe and effective for treating asymptomatic persons who are passing E. histolytica cysts and may be particularly well tolerated in children.

A trichinosis outbreak among Southeast Asian refugees.

The number of cases of trichinosis reported to Centers for Disease Control has declined steadily, with an average of only 44 cases per year from 1984 through 1988. This decline was almost entirely due to a reduction in cases acquired from ingestion of fresh commercial pork. However, from July 21 through September 3, 1990, 90 (72%) of 125 Southeast Asian refugees from six states and Canada developed trichinosis after attending or eating pork sausage taken from a wedding held in Des Moines, Iowa, on July 14, 1990. Eating uncooked sausage prepared at home from commercially obtained pork was associated with the development of this illness (odds ratio = 34.0, p less than 0.001). Analysis by amount of pork consumed was significant (Mann-Whitney U rank sum test, p less than 0.001). This outbreak of trichinosis in Iowa is the fourth reported within the last 15 years among the 900,000 Southeast Asian refugees resident in the United States and one of the largest reported outbreaks in US history. The continued presence of Trichinella spiralis in commercial pork emphasizes the need for further education and control measures for persons whose dietary habits place them at risk for developing trichinosis.

Trichinosis surveillance, United States, 1987-1990.

Since the Public Health Service began recording statistics on trichinosis in 1947, the number of cases reported by state health departments each year has declined. In the late 1940s, health departments reported an average of 400 cases and 10-15 deaths each year; from 1982 through 1986, the number declined to an average of 57 cases per year and a total of three deaths for the period. From 1987 through 1990, 206 cases of trichinosis from 22 states, including 14 multiple-case outbreaks, were reported to CDC. In 1990, two large outbreaks associated with commercial pork accounted for 106 cases. In the 192 instances in which a suspect food item was identified, pork was implicated in 144 (75%) cases, walrus meat in 34 (18%), and bear meat in 14 (7%). Sausage, the most frequently implicated pork product, was associated with 128 of the 139 cases for which a form of ingested pork was specified. Before 1990, the proportion of cases of trichinosis attributable to consumption of commercial pork had declined steadily. This decline was probably due to a combination of factors, including laws prohibiting the feeding of garbage to hogs, the increased use of home freezers, and the practice of thoroughly cooking pork. Although the incidence of trichinosis has decreased substantially since national reporting was initiated in 1947, a dramatic increase in 1990, resulting from two large outbreaks, emphasizes the need for further education and control measures.

Trichinella infection in travelers.

To define the incidence of trichinosis associated with foreign travel and characterize the epidemiologic and clinical features of cases acquired abroad, all case report forms submitted to the Centers for Disease Control through state health departments and the National Morbidity Reporting System from 1975 to 1989 were reviewed. Twenty-six cases of travel-associated trichinosis were identified during that period. Most reported cases (73%) occurred between 1982 and 1987. Affected patients were more likely to have traveled to Mexico and Asian countries (65%). Reported high-risk behaviors included consumption of undercooked pork products, use of unsanitary cooking practices, and importation of potentially contaminated meat products into the United States. Trichinosis should be considered in the differential diagnosis of eosinophilia in travelers returning from abroad. Pretravel counseling that includes information concerning the risk of eating improperly prepared meat products may help future travelers minimize the risk of acquiring this illness.

Ultrastructural studies on the effect of tumor necrosis factor on the interaction of neutrophils and Naegleria fowleri.

Naegleria fowleri is the common etiologic agent of primary amebic meningoencephalitis (PAM). We investigated the interaction of human neutrophils with Naegleria trophozoites and examined the effect of neutrophil stimulation by the recombinant human tumor necrosis factor (TNF) on this interaction. As indicated by scanning and transmission electron microscopy, TNF stimulated the adherence of neutrophils to N. fowleri with destruction of the ameba. Neutrophil iodination, an indirect measure of stimulation, increased from 0.81 +/- 0.23 nmol/10(7) cells/hr to 2.41 +/- 0.62 nmol/10(7) cells/hr following the addition of TNF to the neutrophil-N. fowleri mixture (P less than 0.05). This was independent of complement or specific immunoglobulin. Ingestion of neutrophils by Naegleria trophozoites was observed following more prolonged incubation, particularly in the absence of TNF. These findings suggest a role for TNF-mediated destruction of Naegleria trophozoites by neutrophils in host defense, and that ingestion of host neutrophils by Naegleria trophozoites may represent a virulence factor.

Tetracycline pleurodesis for malignant pleural effusions. A 10-year retrospective study.

We retrospectively examined the use of tetracycline pleurodesis for the palliative treatment of malignant pleural effusions. Twenty-five patients (32 procedures) were identified for study. In contrast to higher success rates in prior reports, 13 procedures (40.6%) failed as repeated pleural drainage was required. Only five procedures (15.6%) achieved complete resolution of pleural fluid. In 14 procedures (43.8%) pleural effusions recurred but were not treated. In some of these cases the effusion may have been reduced sufficiently to relieve symptoms, while in others the high short-term mortality rate (29% in 30 days) and the development of loculated effusions (34%) may have led to the decision not to treat. Instillation of a larger dose of tetracycline (greater than or equal to 1 g) was associated with a better outcome. Although adequate pleural drainage and proper technique were used, other factors such as the presence of pleural masses, atelectasis, loculations, and patient performance status were not uniformly controlled. Greater attention to these factors and use of a larger dose of tetracycline (greater than or equal to 1 g) may increase the likelihood of a successful pleural symphysis.