Malignant metastatic deposits in an immunocompromised patient-could this be tuberculosis?

We report the case of a 50-year-old female renal transplant patient who developed disseminated deposits initially diagnosed as metastatic malignancy of unknown primary. She declined a tissue diagnosis but subsequently developed recurrent sepsis and symptomatic unilateral pleural effusion. Mycobacterium tuberculosis was cultured from pleural fluid. Following introduction of anti-tuberculous medications, her symptoms improved rapidly and the progression of her disseminated deposits stabilized. Tuberculosis is well-known to be associated with immunocompromised patients. It is a curable disease and should remain an important differential diagnosis for transplant patients who develop suspicious malignant metastatic lesions.

Fever in the returning traveller: the importance of sensitivity.

We report the case of a 28-year-old man, presenting with episodes of fever and rigours, having recently returned from Cameroon and Uganda. Initial investigations for malaria were negative, and the patient was sent home without a clear diagnosis. Subsequent review of the blood film revealed the presence of Plasmodium ovale. This case highlights the importance of repeated and careful inspection of blood films, given the relatively low sensitivity of rapid diagnostic tests in P. ovale infection. It also illustrates the importance of the travel history in the diagnosis of malaria.

Review of 26 years' hospital admissions for chickenpox in North London.

The epidemiology of chickenpox admissions to an Infectious Diseases Unit was studied over 26 years. Risk factors, markers of disease severity, and complications were analysed in patients admitted during the last 5 years. Some 613 patients were admitted with chickenpox over three 5-year periods between 1968 and 1993. There was a 2.23-fold increase in the number of adults admitted from home between the first and last period. Patients of European origin showed a three-fold increase. The mean age of adults rose from 26.2 to 34.3 years. Some 23% of adults had varicella pneumonitis. Smokers were six times more susceptible to pneumonitis than were non-smokers. Adult asthmatics were not at increased risk, whereas 42% of asthmatic children had chest complications. Seventeen of the 18 immunocompromised patients had a relatively uncomplicated course. Of the children, 32% had secondary skin infections, with no excess complications among those with eczema. Thrombocytopenia and elevated aspartate transaminases were four times and twice, more frequent in adults than children, respectively. These features occurred mostly in males. The male-to-female admission ratio was 2:1 in adults, and 1.2:1 in children. Males in both age groups showed a trend to more severe disease and more primary complications than did females. Our data showed an increase in adult chickenpox admissions. We have identified asthma as a risk factor for pulmonary complications in children, but not adults, and male gender as an independent risk factor for severe chickenpox.

Malaria at Christmas: risks of prophylaxis versus risks of malaria.

PIP: A large increase in the number of falciparum malaria cases imported into the UK was reported to the malaria reference laboratory in the first quarter of 1998. Contributory factors were unusually heavy rains in east Africa and a reduction in the use of the most effective antimalarial drug, mefloquine. There was also an increase in the number of cases of severe malaria in the UK. During December 1997 and January 1998, the Hospital for Tropical Diseases, London, treated 5 patients for severe malaria and gave advice on 20 more patients with malaria who had been admitted to intensive care units throughout England. 4 of the severe cases treated at the hospital are reported. In 3 of those 4 cases, incorrect, misleading, or inadequate advice was given by health care professionals. Media coverage of the adverse effects of antimalarial drugs has contributed to confusion about prophylactic regimens among both health care professionals and the public. The incidence of falciparum malaria among travellers who do not take prophylactic drugs is about 0.6% in east Africa and 3.5% in west Africa over a 2-week travel period. Travellers need to take measures to avoid being bitten by mosquitoes and should be taught to promptly seek medical help if they develop a fever while abroad or after they return. Moreover, using any one of the recommended prophylactic regimens is better than not using a potent regimen or no prophylaxis at all. Mefloquine is 90% protective against malaria in sub-Saharan Africa. While the efficacy of proguanil and chloroquine in 1987 was about 70% in west Africa and 50% in east Africa, those levels are now probably lower. The side effects of antimalarial drugs are discussed.^ieng

A comparison between single-dose fosfomycin trometamol (Monuril) and a 5-day course of trimethoprim in the treatment of uncomplicated lower urinary tract infection in women.

This study is a comparison of the microbiological and clinical efficacy of single-dose fosfomycin trometamol therapy and a 5 day course of trimethoprim in the treatment of uncomplicated urinary tract infection in female patients. Urine dip-slide samples were obtained from 547 female patients aged 18-65 by 22 General Practitioners (GPs) participating in the study from 21 centres in the UK. All patients were diagnosed as having a urinary tract infection by their GP on the basis of history and clinical examination. Patients were randomised to receive either single dose fosfomycin trometamol or a 5 day course of trimethoprim in a 2:1 ratio. Patients who had significant bacteriuria (> or = 10(5) c.f.u/ml) at the first visit (300) were included in the microbiological analysis. The two commonest urinary pathogens isolated were Escherichia coli and Staphylococcus saprophyticus. Trimethoprim resistance was more frequent amongst E. coli isolates whereas fosfomycin trometamol resistance was more common amongst S. saprophyticus isolates. Microbiological cure was demonstrated in 83.3% of the trimethoprim treated group and 83% of the fosfomycin trometamol treated group. Persistence of the infecting bacteria was seen in 17% of each treatment arm.

Molecular epidemiology of varicella-zoster virus in East London, England, between 1971 and 1995.

The molecular epidemiology of varicella-zoster virus in London, England, between 1971 and 1995 was examined by using two informative polymorphic markers, variable repeat region R5 and a BglI restriction site in gene 54. Viruses from 105 cases of chickenpox and 144 of zoster were typed. Two alleles of R5, A and B, were found at prevalences of 89 and 6%, respectively. No difference in allele frequency between the zoster and chickenpox cases was found, and no change in the frequencies of these alleles was observed to occur over time. By contrast, a BglI restriction site (BglI+) was found with increasing frequency over time among cases of varicella (P < 0.005) and, to a lesser extent, cases of zoster. The BglI+ polymorphism was strongly associated (P < 0.0005) with zoster in subjects who had immigrated to the United Kingdom from countries with low adult immunity to varicella (LAIV). Sixty-three percent of the subjects with zoster who had emigrated from countries with LAIV carried the BglI+ virus, in contrast to 10% of adults who had grown up in countries with high adult immunity to varicella. The significance of these data, in view of the changing epidemiology of chickenpox, is discussed.

Primary pericardial mesothelioma presenting as tuberculous pericarditis.

Ante-mortem diagnosis of primary pericardial mesothelioma is very rare. We report a case which presented clinically as tuberculous constrictive pericarditis. The patient underwent pericardial resection with an immediate haemodynamic benefit, although the malignant process progressed, and he died 14 weeks later.