Mycobacterial infections in patients with chronic renal disease.

In this article, the authors have provided a comprehensive review of TB and MOTT infections in patients on renal dialysis and receiving kidney transplants. Because most published series are small retrospective studies or case reports, there are several uncertainties still involved in the diagnosis and treatment of such patients. Unanswered questions include selection of optimal dosage and duration of therapeutic agents; the best tests for screening and diagnosis, especially in high prevalence areas; and the best management of MOTT infections because of unavailability of highly effective therapy.

Angiostrongylus cantonensis eosinophilic meningitis.

In the past 50 years, Angiostrongylus cantonensis, the most common cause of eosinophilic meningitis, has spread from Southeast Asia to the South Pacific, Africa, India, the Caribbean, and recently, to Australia and North America, mainly carried by cargo ship rats. Humans are accidental, "dead-end" hosts infected by eating larvae from snails, slugs, or contaminated, uncooked vegetables. These larvae migrate to the brain, spinal cord, and nerve roots, causing eosinophilia in both spinal fluid and peripheral blood. Infected patients present with severe headache, vomiting, paresthesias, weakness, and occasionally visual disturbances and extraocular muscular paralysis. Most patients have a full recovery; however, heavy infections can lead to chronic, disabling disease and even death. There is no proven treatment for this disease. In the authors' experience, corticosteroids have been helpful in severe cases to relieve intracranial pressure as well as neurologic symptoms due to inflammatory responses to migrating and eventually dying worms.

Rifampin, a useful drug for nonmycobacterial infections.

Rifampin has clinical efficacy against a wide variety of organisms, including Staphylococcus aureus, Legionella pneumophila, group A Streptococcus, Brucella sp, Haemophilus influenzae, and Neisseria meningitidis, as well as in vitro activity against penicillin-resistant Streptococcus pneumoniae, Neisseria gonorrhoeae, Chlamydia trachomatis, Haemophilus ducreyi, and many gram-negative rods. Rifampin is a useful drug for several types of bacterial infections because of its broad spectrum of activity, excellent tissue penetration, and low side effect profile. In combination with other antibiotics, it may be effective when conventional therapies are not.

Amphotericin B use in a community hospital, with special emphasis on side effects.

The purpose of this study was to analyze the usage of amphotericin B desoxycholate in a small community hospital, with special emphasis on its side effects and need for premedication. We performed a retrospective chart review for patients who received intravenous amphotericin B from January 1993 to May 1996. Temperature elevation, clinical symptoms during infusion, need for premedication, and fluctuations in serum potassium and creatinine values were especially noted. Statistical analysis showed that toxicity indicated by laboratory values (laboratory toxicity) increased with increasing amphotericin B dose, but clinical side-effects decreased with advancing age. Clinical side effects were not associated with total amphotericin B dosage; laboratory toxicity in our study was not more prevalent in elderly patients. The main finding of this study was that most patients tolerate amphotericin B well and only 23% of patients needed premedication. Our fungal cure rate was 83%. New, expensive preparations of amphotericin B should be reserved for the small subset of patients who either are intolerant of amphotericin B desoxycholate or need high doses for systemic fungal infections.

Gastrostomy tube infections in a community hospital.

BACKGROUND: Percutaneous gastric feeding tubes are becoming increasingly more common to provide nutrition in debilitated patients, while they decrease the risk of aspiration associated with nasogastric tubes. METHODS: We reviewed infectious complications of 372 feeding gastrostomy tubes placed in a small urban community hospital over a recent period. RESULTS: In our study there was an infection rate of 4.8%. Four serious infections occurred: two cases of peritonitis and two deep abscesses, but there were no infectious deaths. The most common infecting organisms were staphylococci, gram negative bacteria, and yeast. Most infections required treatment with parenteral antibiotics, prolonging hospitalization. Two of 17 infected tubes required removal. CONCLUSION: Percutaneous gastrostomy tubes can produce life threatening infections and deserve serious attention by ICPs in hospitals, long-term care facilities, and home care services. These tubes should only be inserted if they extend meaningful life in patients. Protocols are needed for the care of gastrostomy tubes, and infections must be treated as early and as aggressively as possible to avoid serious consequences.

Tuboovarian abscess caused by Edwardsiella tarda.

Edwardsiella tarda infections are uncommon and have often been reported in association with pet reptiles. The majority of these infections occur as gastrointestinal disorders in immunocompromised hosts. We believe this to be the first reported American case of tuboovarian abscess caused by this organism in an otherwise healthy woman whose only known exposure was to raw seafood. This patient had fever and lower abdominal pain caused by a severe Edwardsiella tarda pelvic abscess that required surgical drainage and intravenous antibiotics for complete recovery.

Retrospective study of hospitalized patients with chronic leg ulcers in Hawaii.

The authors describe 226 patients with chronic leg ulcers at a community hospital over a 14-year period. Most leg ulcers were ischemic or venous in origin and located below the ankle. Fifty-five percent of patients were diabetic and the majority of patients were hypertensive. The cases required prolonged hospitalization for systemic antibiotics and vascular surgery. Only 2.3% of patients required above the knee amputation, and 7% needed below-the-knee amputation.

Head and neck cellulitis in hospitalized adults.

INTRODUCTION: Our purpose was to review the clinical features of head and neck cellulitis in hospitalized patients. MATERIAL AND METHODS: A retrospective review was undertaken of 147 cases of head and neck cellulitis seen over a 15-year period at a community Hawaiian hospital. RESULTS: Otologic cellulitis was mainly related to otitis externa, caused by Pseudomonas aeruginosa, although some cases had infected pierced ears or ear cysts. Cervical cellulitis was associated with malignancy, dental infection, or lymphadenitis; these patients often had positive blood cultures. Facial cellulitis was almost always caused by Staphylococci and Streptococci, usually preceded by dental infections, traumatic abscesses, or sinusitis. All study patients recovered completely, except for one patient who developed cavernous vein thrombosis and oculomotor palsy. Seventy-five percent of the patients recovered with parenteral antibiotics alone; the other patients required abscess drainage and/or other surgical procedures, especially if neck infection was present. CONCLUSION: Although head and neck cellulitis cases have grave potential consequences, most patients do very well with proper antibiotics and appropriate surgical drainage.

Septic bursitis: experience in a community practice.

We reviewed 47 episodes of septic bursitis occurring in a private community medical practice. Most patients were male (85%), and roughly half (49%) the cases were related to recreational or occupational trauma. About 72% of cases were located in the olecranon bursa, while the remaining cases were prepatellar. Prepatellar bursitis patients were more likely to be hospitalized. Staphylococcus aureus was isolated from 70% of bursal fluid aspirations; other etiologic organisms included gram negative bacteria and Mycobacterium marinum. The majority of patients were able to be treated as outpatients with oral antibiotics. All patients were eventually cured without serious complications.

Eosinophilic pleural effusions.

We present 2 cases of eosinophilic pleural effusion (EPE) seen recently at Straub Hospital. One occurred in a patient with pneumococcal empyema; the 2nd patient had 2 episodes of EPE secondary to malignant histiocytic lymphoma. Eosinophilic pleural effusion (EPE) is defined as having eosinophils exceeding 10% of the pleural fluid WBC differential. EPE is usually exudative, typically accounting for 1% to 8% of all pleural effusions. Up to 30% to 35% of EPE are idiopathic, while other frequent causes include air in the pleural space (30%), and pulmonary infections (10%). Collagen vascular diseases, tuberculosis and malignancies are common causes of EPE. Although spontaneous resolution and a favorable prognosis predominates in this entity, prudent clinical follow-up is advised. Since the first documented case of eosinophilic pleural effusion in 1984 by Harmsen, clinicians have attempted to determine its significance. This condition is defined as pleural effusion with greater than 10% of the WBC differential eosinophils. We saw 2 cases of EPE at Straub Hospital during 1988.

Bacterial endocarditis at a small community hospital.

Clinical features, microbiology, and predisposing factors are described in 56 patients with bacterial endocarditis (BE) treated over a 12-year period at a small community hospital in Hawaii. The average age of patients was 52.0 years. The mean duration of symptoms was 28.8 days (range 1 to 240 days). Streptococci was the most frequently identified causative organism, present in 61% of the cases. Gram-negative bacilli were isolated from six patients (11%). Fourteen patients (25%) required cardiac surgery; the most common condition leading to surgery was severe valvular insufficiency, followed by congestive heart failure and recurrent embolism. Eighty-two percent of the patients in the series survived. The leading causes of death were congestive heart failure and cerebrovascular accidents.

Clinical features of Aeromonas enteritis in Hawaii.

The incidence and clinical features of enteritis associated with Aeromonas in Honolulu were studied. The stool isolation rate was 2.9% for Aeromonas, the third most common bacterial pathogen in this population. Clinical features of Aeromonas-associated enteritis were compared with clinical features of enteritis without an associated bacterial pathogen. Although there was a trend toward more abdominal pain, tenderness, nausea and prolonged illness in patients with Aeromonas, these differences were not statistically significant. In most cases, Aeromonas enteritis is a self-limited illness, indistinguishable from other causes of diarrhoea seen in our clinic.

Vibrio vulnificus infection in Hawaii.

A life-threatening Vibrio vulnificus infection occurred in a 52-year-old Korean woman with hepatic cirrhosis. Four days after ingesting raw crab, the patient presented to the hospital with nausea, vomiting, fever, hypotension, and hemorrhagic blistering of the left foot. Vibrio vulnificus was recovered from both her blood and a foot wound.

Insulin-dependent diabetes mellitus associated with pentamidine.

Insulin-dependent diabetes mellitus occurred following intravenous pentamidine treatment of two AIDS patients with Pneumocystis carinii pneumonia. Both patients also experienced drug-induced nephrotoxicity. Patients receiving pentamidine must be observed for multisystem dysfunction, including the onset of severe diabetes mellitus. Dosage adjustment or alternative therapy should be considered with the onset of toxicity.