Endocarditis. Changing trends in epidemiology, clinical and microbiologic spectrum.

Infective endocarditis refers to infection of the endocardium or heart valves by microbes, resulting in tissue destruction. Clinical presentation is quite variable, and a high level of suspicion is essential for recognition. Diagnosis is dependent on identification of the causative agent in blood cultures. Cultures that are persistently negative indicate the presence of culture-negative endocarditis, and diagnosis is one of exclusion. Treatment of endocarditis consists of high doses of antibiotics active against the infecting organism. Individualized therapy is the key to management.

Palliative percutaneous balloon valvuloplasty in a cyanotic child with tetralogy of Fallot.

We have presented the case of an 8-month-old child who had tetralogy of Fallot with severe pulmonary stenosis and minimal infundibular stenosis. Because of the relatively small annulus (10 mm) and young age of the infant, total correction was deferred, and a percutaneous palliative pulmonary balloon valvuloplasty was done. At the end of the procedure, he had neither cyanosis nor signs of congestive heart failure, and after four months of follow-up, he had only mild cyanosis with activities.

Respiratory infections in ambulatory adults. Choosing the best treatment.

The diagnosis and treatment of respiratory tract infections in ambulatory adults is challenging. The prevalence of these conditions outstrips the medical profession's efficiency and effectiveness in dealing with them. However, selecting diagnostic techniques that identify causative organisms and therapeutic agents targeted to those organisms should lead to a reduction in the morbidity and mortality associated with these illnesses.

Thrombosis and anticoagulation therapy in coronary ectasia.

A 41-year-old man presenting with unstable angina was found to have diffuse coronary ectasia with a partially occluding thrombus in the proximal left anterior descending artery. Anticoagulation with heparin followed by warfarin resulted in relief of angina and resolution of thrombosis at follow-up angiography 3.5 months later. The patient remains well after three years. Nonatherosclerotic ectatic coronary arteries are prone to thrombosis possibly because of spasm, intimal damage, and blood current eddies. We believe that chronic warfarin therapy may be indicated in many patients with coronary ectasia.

Physiologic changes as patients get older.

As the population ages, primary care physicians are treating increasing numbers of elderly patients. Although certain physiologic changes are known to be age-related, they do not occur uniformly in elderly persons, and it may be difficult to distinguish signs of normal aging from those of disease. Thus, individualized care is important, and with thoughtful diligence, primary care physicians can often improve the quality of life for their elderly patients.

Extreme pyrexia during bretylium administration.

Body temperatures exceeding 41.1 degrees C (106 degrees F) occur with relatively few conditions. In the unusual case reported here, the patient's temperature reached 42.3 degrees C (108.2 degrees F) during intravenous administration of bretylium for refractory ventricular fibrillation. The temperature started to drop as soon as the infusion was stopped and was close to normal within four hours. This appears to be the first report of extreme pyrexia resulting from use of this agent.

Fitz-Hugh-Curtis syndrome.

The Fitz-Hugh-Curtis syndrome consists of right upper quadrant abdominal pain, perihepatitis and genital tract infection. Neisseria gonorrhoeae and Chlamydia trachomatis have been identified as causative agents. This syndrome frequently mimics other diseases and typically occurs in sexually active young women. A high index of suspicion is essential for early diagnosis. Laparoscopy may be indicated for diagnosis and for lysis of adhesions.

Epiglottic abscess due to group B Streptococcus. Communication.

A group B Streptococcus caused epiglottitis with abscess formation in an adult with diabetes mellitus. Group B streptococci are being more commonly isolated from adults, and epiglottitis is another infection in which this organism has been implicated.

Giant avascular hepatocellular carcinoma mimicking metastatic tumor.

We have described the radiographic features of a case of solitary giant hepatocellular carcinoma in a noncirrhotic liver. It was angiographically avascular and resembled a massive metastatic tumor. Most hepatocellular carcinomas appear highly vascular on angiography. Hypovascularity may sometimes be encountered in the presence of cirrhosis.