Successful treatment of cutaneous zygomycosis with extensive surgical debridement and oral posaconazole in an immunocompetent patient.

We describe a case of successful treatment of cutaneous zygomycosis using a combination of extensive surgical debridement and the oral antifungal agent, posaconazole.

Molecular epidemiology of Scedosporium apiospermum infection determined by PCR amplification of ribosomal intergenic spacer sequences in patients with chronic lung disease.

Respiratory tract colonization with Scedosporium apiospermum in patients with chronic suppurative lung disease is a significant concern for lung transplantation candidates, since Scedosporium infections occurring posttransplantation are usually untreatable. Up to 10% of patients with cystic fibrosis attending our respiratory medicine unit have had Scedosporium organisms isolated from sputum samples. We therefore developed a molecular typing method to examine these isolates. Typing by PCR amplification of ribosomal intergenic spacer sequences demonstrated 20 different types from 52 isolates collected from the respiratory medicine unit and elsewhere in Australia. A single common type was isolated from 11 respiratory medicine unit inpatients. Two other types were isolated from more than one source: one from two respiratory medicine unit inpatients and one from two epidemiologically linked nonhuman sources. Multiple isolates were obtained from nine patients. This method demonstrated persistent carriage of isolates of the same type in one patient for 7 months. Two patients showed carriage of isolates with multiple typing patterns within a 3-month period. The high rate of isolation and the predominance of isolates with a single typing pattern from respiratory medicine unit patients may suggest transmission to patients from a source in the unit. There was no epidemiological evidence of direct patient-to-patient spread, and Scedosporium organisms were not isolated from dust, soil, or air samples from the unit. The source and route of transmission have yet to be determined.

Aspergillus antigen testing in bone marrow transplant recipients.

AIMS: To assess the clinical usefulness of a commercial aspergillus antigen enzyme linked immunosorbent assay (ELISA) in the diagnosis of invasive aspergillosis (IA) in bone marrow transplant recipients, and to compare it with a commercial latex agglutination (LA) test. METHODS: In total, 2026 serum samples from 104 bone marrow transplant recipients were tested. These comprised 67 sera from seven patients who had died with confirmed IA, 268 sera from nine patients who had died with suspected IA, and 1691 sera from 88 patients with no clinical, radiological, or microbiological signs of IA. RESULTS: The ELISA was more sensitive than the LA test. All patients who were ELISA positive were also LA positive, and a positive LA result never preceded a positive ELISA. Twelve of 16 patients with confirmed or suspected IA were ELISA positive on two or more occasions, compared with 10 of 15 who were LA positive. ELISA was positive before LA in five patients (range, 2-14 days), and became positive on the same day in the remainder. Aspergillus antigen was detected by ELISA a median of 15 days before death (range, 4-233). Clinical and/or radiological evidence of IA was noted in all patients, and a positive ELISA was never the sole criterion for introduction of antifungal treatment. Two samples (one from each of two patients without IA) gave false positive results. CONCLUSIONS: The aspergillus ELISA is a specific indicator of invasive aspergillosis if the criterion of two positive samples is required to confirm the diagnosis. However, the test is insufficiently sensitive to diagnose aspergillosis before other symptoms or signs are apparent, and hence is unlikely to lead to earlier initiation of antifungal treatment. It is therefore unsuitable for screening of asymptomatic patients at risk of invasive aspergillosis, but does have a useful role in confirming the diagnosis in symptomatic patients.

Diagnosis of invasive aspergillosis in bone marrow transplant recipients by polymerase chain reaction.

A nested polymerase chain reaction (PCR) test targeting Aspergillus spp. large ribosomal subunit genes was evaluated retrospectively on 175 serum samples from 37 bone marrow transplant recipients, 70% of whom received grafts from unrelated donors. Six patients had proven infection, seven had probable infection, and three had possible infection, using the revised EORTC case definitions. These 16 patients were all PCR positive (57 out of 93 samples tested). Two additional patients who did not fulfil current diagnostic criteria, but in whom invasive aspergillosis (IA) was thought clinically probable, were also PCR positive (five out of nine samples). Invasive aspergillosis was unlikely in the remaining 19 patients, four of whom were PCR positive on a single occasion (four out of 70 samples). Three samples were inhibitory to PCR. Sensitivity of PCR in diagnosing patients with IA was 100%, specificity was 79% and positive predictive value was 80%, using the criterion of a single positive result. If two positive results were required, these values were 81%, 100% and 100% respectively. The median duration of infection documented by PCR was 36 days (range 3-248 days) in 17 out of 18 patients (94%) who did not survive. Positive PCR results predated the institution of antifungal therapy in two-thirds of patients. Four patients became PCR positive during pretransplant conditioning therapy.

Recurrent inflammation in a site of previous necrotising fasciitis during intravenous CMF chemotherapy.

We present the case history of a patient with breast carcinoma who developed repeated inflammation at the site of previous necrotising fasciitis following each cycle of intravenous CMF chemotherapy. This complication has not previously been reported.

Infections in adults undergoing unrelated donor bone marrow transplantation.

This study retrospectively reviews infections over a 7-year period in 60 consecutive adults (median age 25 years) undergoing their first unrelated donor bone marrow transplant (UD-BMT). T-cell depletion was employed in 93%. More than half the patients had one or more severe, potentially life-threatening, infections. There was a high incidence of invasive fungal infections (Aspergillus 17, Candida four), despite the use of itraconazole or amphotericin prophylaxis. Ten Aspergillus infections occurred beyond 100 d. Two patients (11%) with invasive aspergillosis survived. Clustering of infections was noted, with invasive fungal infections significantly associated with bacteraemias (OR 3.73, P=0.06) and multiple viral infections (OR 4.25, P=0.05). There were 21 severe viral infections in 16 patients, with CMV disease occurring in four patients only; viral pneumonitis was predominantly due to 'community respiratory' viruses. Most early bacteraemias (68%) were due to Gram-positive organisms. The majority of episodes of Gram-negative sepsis were caused by non-fastidious non-fermentative bacteria, such as Pseudomonas spp. and Acinetobacter spp., historically regarded as organisms of low pathogenicity. In patients with successful engraftment and minimal graft-versus-host disease, late infections suggestive of continued immune dysfunction (shingles, recurrent lower respiratory infections, Salmonella enteritis and extensive warts) were common.

Molecular approaches for the diagnosis and epidemiological investigation of Aspergillus infection.

Molecular techniques have been applied to the diagnosis of invasive aspergillosis and to investigate the ecology and epidemiology of Aspergillus. Recent advances in diagnosis include the development of PCRs targeting either panfungal or Aspergillus-specific sequences, using whole blood or serum samples. When a sensitive PCR is used, invasive aspergillosis in bone marrow transplant patients can be detected several weeks before antigen tests become positive, and a positive PCR often pre-dates the institution of antifungal therapy. The role of PCR in monitoring response to therapy in immunocompromised patients is unclear. No prospective studies have yet demonstrated that management incorporating PCR alters the poor outcome of invasive aspergillosis in immunocompromised patients. Molecular typing of Aspergillus fumigatus has shown wide geographical dispersal of indistinguishable strains. This, combined with the observation that multiple strains may be isolated from individual colonised patients with cystic fibrosis and from immunocompromised patients with disseminated disease, makes the elucidation of the epidemiology of aspergillosis relatively complex.

Gliosis and ganglion cell death in the developing cat retina during hydrocephalus and after decompression.

Even after surgical decompression, infantile hydrocephalus often results in permanent neurological symptoms, including visual deficits. However, little is known about the cellular changes that may be responsible for these effects. The present study was designed to analyze the retinae of normal, mildly hydrocephalic, severely hydrocephalic and surgically decompressed kittens to determine if changes occur in the density and size of retinal ganglion cells. Hydrocephalus was induced in 10 day old kittens by intra-cisternal injection of kaolin. Kittens were allowed to survive from 7 to 28 days after injection. Animals that were decompressed received ventriculoperitoneal shunts 10-15 days after the induction of hydrocephalus and were sacrificed 10-14 days after shunt placement. The density and area of neuronal and glial cells were determined within a sample area in peripheral nasal retina. Total cell density was significantly increased in mildly and severely hydrocephalic animals but returned to normal following decompression. This change represents a significant increase in the glial population. In addition, there was a significant loss of ganglion cells in both the severely hydrocephalic and the shunted groups. Based on these findings, we conclude that gliosis occurs as a result of cell death in the retina following severe hydrocephalus, and decompression is unable to reverse these effects. Furthermore, gliosis occurs in mild cases of hydrocephalus, and may be an early indication that cellular degeneration will follow.

The nutritional status of Guaymi Indians living in Chiriqui province, Republic of Panamá.

Guaymi Indian children have recently been identified as a population group who are at risk for vitamin A deficiency with numerous cases of xerophthalmia with ocular perforation being reported. A four-day parasitological and nutritional clinic based survey was conducted with 335 Guaymi women and children in the towns of San Felix and Alto Caballero to identify the prevalence of parasitic infections and factors associated with malnutrition. A subsample of 79 children, under 19 years of age, from independent families was constructed for the current analysis. The results of the study indicated that 20% of the children had a plasma vitamin A concentration less than 20 micrograms/dl. Significant associations were identified between ascariasis, age, a food diversity score and vitamin A concentrations. Other indicators of nutritional status were also negatively associated with intestinal parasitic infections, and a modernization index, using multivariate regression analysis. In conclusion, this study identified several factors associated with poor nutritional status that can be used by health officers to identify Guaymi children at risk for malnutrition.

Proliferating cell nuclear antigen in developing and adult rat cardiac muscle cells.

During early development, rat cardiac muscle cells actively proliferate. Shortly after birth, division of cardiac muscle cells ceases, whereas DNA synthesis continues for approximately 2 weeks at a progressively diminishing rate. Little DNA synthesis or cell division occurs in adult cardiocytes. Thus, developing cardiac muscle cells are an ideal system in which to examine the expression of cell cycle-regulated genes during development. We chose to examine proliferating cell nuclear antigen (PCNA), a gene expressed at the G1/S phase boundary of the cell cycle. Northern blots of RNA from cardiac muscle cells from 18-day-old rat fetuses and from day 0, 5, and 14 neonatal as well as adult rat hearts revealed that the PCNA mRNA was found in cardiac muscle cells from all ages. However, because it was possible that this was a result of fibroblast PCNA gene expression, we used reverse transcription followed by polymerase chain reaction to see if it was possible to detect the message for PCNA in cardiac muscle cells from all ages. Because of the great sensitivity of this technique, RNA was recovered from 25 isolated adult cardiac muscle cells. Polymerase chain reaction amplification products for PCNA produced from the RNA isolated from these cells conclusively demonstrated that mRNA for this gene, which normally is associated with proliferating cells, is expressed in adult cardiac muscle cells that no longer divide. Furthermore, Western blot analysis demonstrated that the PCNA protein was found only in embryonic and neonatal cells and not in adult rat cardiac muscle cells. Therefore, it might be inferred from these data that PCNA might be regulated at the posttranscriptional level in adult cardiac muscle cells.

Nicotine-induced taste aversion: characterization and preexposure effects in rats.

Rats were trained to drink their 24 hr water intake during a single daily 30 min period. After stabilization, rats were presented with 0.1% (w/v) of sodium saccharin for 30 min. Immediately after removal of the saccharin solution, the animals were injected with saline, mecamylamine hydrochloride or hexamethonium hydrobromide; thirty minutes later, saline or nicotine, 0.05, 0.16, or 0.50 mg/kg were administered. Twenty-four hr later, rats were allowed access to both water and saccharin. Nicotine caused a dose-related decrease in the proportion of fluid consumed as saccharin solution during the 30 min testing situation. Neither mecamylamine nor hexamethonium alone decreased saccharin preference; however, 3 mg/kg of mecamylamine blocked the decrease of saccharin preference induced by nicotine. Preexposure of drug-naive rats to 0.5 mg/kg of nicotine for 2 or 4 days abolished the nicotine-induced taste aversions to saccharin when tested one day, or one week, after conditioning.

An improved drug infusion pump for injecting nanoliter volumes subcortically in awake rats.

A new drug infusion pump capable of injecting nanoliter volumes of drug solution into the brains of awake rats has been constructed which incorporates a new "turntable" commutator and a compact tubing compressor mechanism requiring no gears. Injector cannulas inserted into guide cannulas permanently mounted in the rat's skull are connected to the drug pump by spring-protected, PE 10 tubing. Drug solutions are delivered when the pump rollers compress the drug-filled PE 10 tubing. An additional animal-activated switch and motorized mechanism rotates the drug pump in response to the animal's movements so that the PE 10 drug reservoir is not twisted. Testing the drug pump's performance in vivo with injections of 14C-nicotine into the caudate nucleus shows that drug delivery is both reliable and reproducible.