A patient with acquired immunodeficiency syndrome and untreated Encephalitozoon (Septata) intestinalis microsporidiosis leading to small bowel perforation. Response to albendazole.

BACKGROUND: Encephalitozoon (Septata) intestinalis is a common disseminating opportunistic intestinal microsporidian affecting patients with acquired immunodeficiency syndrome. This microsporidian does respond to albendazole therapy. A patient with acquired immunodeficiency syndrome and chronic diarrhea presented to George Washington University Hospital in January of 1996. Despite appropriate surgical specimens, no etiology had been found to explain his cholecystitis, cystitis, and enteritis 3 months previously at another hospital. DESIGN: Tissue specimens were analyzed by light microscopy, using hematoxylin-eosin and the Armed Forces Institute of Pathology Brown-Brenn microsporidia stain, and by transmission electron microscopy. Urine and stool specimens were analyzed by modified chromotrope 2R trichrome and chitin fluorochrome stains and by transmission electron microscopy. RESULTS: At George Washington University Hospital, disseminated E intestinalis was diagnosed from duodenal biopsy, urine, and stool specimens. On the 14th day of oral albendazole therapy, a partial small bowel resection was performed to correct a perforation (air under the diaphragm). There was no enterocyte microsporidian infection at that time, only spores undergoing macrophage digestion. Review of previous specimens showed severe E intestinalis cholecystitis, cystitis, and enteritis. Albendazole was restarted and, after 2 weeks, the patient had negative stool and urine specimens. CONCLUSIONS: Encephalitozoon intestinalis symptomatically targets many organs, including the urinary bladder. To our knowledge, this is the first tissue-documented case of cystitis. Left untreated with albendazole, small bowel infection can lead to perforation and peritonitis.

Adult attachment styles: some thoughts on closeness-distance struggles.

Difficulty with distance regulation is a central source of controversy in couples' relationships. This article describes how attachment theory can contribute to the understanding and treatment of closeness-distance struggles. Discussion focuses on (a) closeness-seeking as a feature of the attachment system, (b) individual differences in adult attachment styles, and (c) the working model that governs how salient interpersonal information is processed and is responded to both emotionally and behaviorally. These elements of the attachment system not only contribute to understanding closeness-distance disturbance but also provide access points for therapeutic intervention.

Visual field testing in the management of cytomegalovirus retinitis.

BACKGROUND: Sequential visual field testing is an extremely helpful adjunct to ophthalmoscopy and fundus photography in the management of cytomegalovirus (CMV) retinitis with the antiviral agents ganciclovir or foscarnet in patients with the acquired immune deficiency syndrome (AIDS). The authors studied the visual field defects found in a series of 110 patients with AIDS and CMV retinitis. METHODS: Ophthalmoscopy and fundus photography were performed on all patients. Visual field analysis was performed with either tangent screen, Goldmann kinetic, or Humphrey automated static perimetry. RESULTS: Of 166 eyes in 110 patients with CMV retinitis, visual field defects were present initially in 92 (55%) eyes of 78 (70%) patients, and ultimately in 97 (53%) eyes of 90 patients in whom follow-up was available. Stabilization of visual field defects was indicative of controlled retinitis. CONCLUSION: Sequential visual field testing will confirm ophthalmoscopic evidence of successful antiviral treatment of CMV retinitis and will corroborate very early progression of previously controlled retinitis.

Disseminated bilateral chorioretinitis due to Histoplasma capsulatum in a patient with the acquired immunodeficiency syndrome.

A 31-year-old white male homosexual was healthy until March 1984, when he developed Pneumocystis carinii pneumonia, which resolved with treatment. In April 1984 he developed fever, followed by hepatosplenomegaly, headaches, blurred vision, pancytopenia and pulmonary infiltrates. On June 11, intracytoplasmic yeast were noted within leukocytes on a peripheral blood smear, and amphotericin B was started. The patient developed progressive respiratory and renal insufficiency and died on June 13, 1984. Autopsy histopathology demonstrated disseminated histoplasmosis and Histoplasma capsulatum was cultured from numerous tissues. Ocular histopathologic examination using special fungal stains and electron microscopy revealed numerous budding yeasts characteristic of Histoplasma capsulatum in the choroid, retina and central retinal vein. Their identification as H. capsulatum was confirmed by immunofluorescent staining.