Tuberculosis screening in dialysis patients--is the tuberculin test effective?

AIM: Patients with end-stage renal disease are at increased risk for tuberculosis (TB). The Centers for Disease Control and Prevention (CDC) has recommended annual skin testing for TB, with tuberculin-purified protein derivative (PPD), in patients with chronic renal failure. The aim of this study was to identify the incidence and prevalence oftuberculin positivity and assess the utility of the tuberculin test in an inner city dialysis population. METHODS: All patients on chronic hemodialysis at a center affiliated to the University of Chicago, who were tuberculin-tested between 1997 and 2000 or had previously documented PPD positivity precluding retesting, were included. Demographics, comorbidity, and tuberculin and anergy reactivity were recorded. A positive PPD was an induration of > 10 mm in response to 5 tuberculin units of PPD, and anergy an induration of < 2 mm in response to the anergy antigens (Candida and Mumps), at 48 h. PPD-positive patients were compared with PPD-negative patients; Fisher's exact test and t-test were used, p < 0.05 was considered significant. RESULTS: Of 131 patients at the dialysis center, 118 were studied. The remaining 13 refused consent to PPD testing. 41 (35%) were PPD-positive, 77 (65%) were negative. Of the 77 PPD-negative patients, 62 (81%) were anergic. None of the PPD-positive patients had clinical or radiographic signs of active TB. Only 20 patients received INH prophylaxis, the others refused or had contraindications to therapy. The conversion rate ranged from 3 - 8% per year. Demographics, nutritional parameters, comorbidity and adequacy of dialysis did not help predict PPD positivity. CONCLUSION: There is a high prevalence of PPD positivity and anergy among dialysis patients. As the diagnostic utility of the time-tested PPD test is unclear in an anergic dialysis population, the need for a high index of suspicion for active tuberculosis and timely diagnostic work up should be reinforced and not replaced by total dependence on the tuberculin test.

Intraabdominal vancomycin-resistant enterococcus infections: the new threat.

GOALS: To determine the clinical course and outcome in patients with intraabdominal vancomycin-resistant enterococcus infections (VRE-A) and to identify probable risk factors for VRE-A. BACKGROUND: Vancomycin-resistant enterococcus is one of the most notable nosocomial emerging pathogens. The incidence is increasing, especially in the abdominal surgery setting. STUDY: A comparative study of patients with VRE-A and VRE infection in other sites (VRE-O) who were hospitalized for over 1 year. Fisher exact test and Student t test were used; a two-tailed p value of less than 0.05 was considered to be significant. RESULTS: Of 89 nine patients with VRE, six had VRE-A, 24 had VRE-O, and 59 had VRE colonization. The VRE-A group was comprised of one patient with an inoperable Klatskin tumor and biliary sepsis, one with acquired immune deficiency syndrome and an infected pancreatic pseudocyst, two with fecal peritonitis, and two with biliary sepsis after surgery for common bile duct stones. All six patients with VRE-A had recent surgery before VRE isolation, as compared with three in the VRE-O group (p = 0.0001). Despite adequate treatment with intravenous chloramphenicol, resulting in eradication of VRE in all six VRE-A cases, the mortality rate remained high at 50%. CONCLUSIONS: Vancomycin-resistant enterococcus should be recognized as an emerging nosocomial pathogen that causes potentially fatal intraabdominal infections in the postsurgical setting. However, the impact of treatment on ultimate outcome needs further evaluation.

Clostridium difficile and vancomycin-resistant enterococcus: the new nosocomial alliance.

OBJECTIVES: The aims of this study were to determine the frequency of the association between Clostridium difficile (C. difficile) and vancomycin-resistant Enterococcus (VRE) and delineate the role of C. difficile coinfection as a predictor of VRE infection versus colonization and adverse outcome. METHODS: Patients with both C. difficile colitis and VRE (CD/VRE) were compared to patients with VRE alone with regard to demographics, comorbidity, prior antibiotic therapy, and coinfection with methicillin-resistant Staphylococcus aureus and funguria. C. difficile as a predictor of VRE infection (VRE-I) versus colonization (VRE-C) and adverse outcome was also studied. RESULTS: Eighty-nine patients with VRE infection or colonization were studied. This included 31 cases of VRE-I and 58 VRE-C. C. difficile was isolated in 17 (19.1%) of patients; of these C. difficile was isolated before VRE in 9 patients and after VRE in 8. The two groups did not differ in age, residence, or comorbidity. C. difficile coinfection was not predictive of VRE-I versus VRE-C, nor was it associated with increased length of stay or mortality. However, the mortality rates in both groups was high, around 30%. A significant association was noted between the use of vancomycin and metronidazole (before the isolation of VRE) and C. difficile coinfection (p = 0.03 and p = 0.001, respectively). A high incidence of nosocomial coinfection with methicillin-resistant Staphylococcus aureus, funguria, and gram-negative sepsis was noted in both groups; the association with funguria was statistically significant (p = 0.029). CONCLUSIONS: In conclusion, C. difficile coinfection is common in patients with VRE infection or colonization and is significantly associated with other nosocomial dilemmas like funguria. This may result in the emergence of highly virulent pathogens including vancomycin-resistant C. difficile, posing new challenges in the management of nosocomial diarrheas.

Systemic lupus erythematosus in males: a retrospective study with a review of the literature.

OBJECTIVE: To delineate the clinical pattern of a cohort of male patients with systemic lupus erythematosus (SLE) and compare it with previously reported data. DESIGN: Retrospective review of hospital records. SUBJECTS: Male patients (n = 11) who were diagnosed with SLE and admitted to a 500-bed university hospital between 1990 and 1998. Eight of the men were African-American and three were Latino. The mean age was 36 years (range, 29-46). METHODS: Clinical and laboratory data were collected according to a well-established protocol. Imaging and invasive studies (including aspirations and biopsies) were also recorded. RESULTS: Nine of the patients (82%) had renal involvement, with five needing dialysis within a year of presentation. Five patients had neurologic involvement: two presented with psychosis and three with seizures. Eight patients had hematologic involvement, and seven had serosal and articular involvement. Cutaneous lesions (discoid lupus) were noted in only one patient. A majority of the patients were noncompliant and were lost to follow-up; therefore, ultimate outcome could not be clearly delineated. CONCLUSION: Renal, serosal, neurologic, articular, and hematologic involvement occurred frequently in our sample of male patients with SLE. The most striking finding was the high frequency of renal involvement with poor prognosis. A high index of suspicion for SLE in males may permit earlier diagnosis and may dictate the need for more aggressive therapy.