Plague pneumonia disease caused by Yersinia pestis.

Plague is a zoonotic infection caused by Yersina pesits, a pleomorphic, gram-negative non-spore-forming coccobacillus that is more accurately classified as a subspecies of Y pseudotuberculosis. Animal reservoirs include rodents, rabbits, and occasionally larger animals. Cats become ill and have spread pneumonic disease to man. Dogs may be a significant sentinel animal as well as a reservoir, although do not usually become ill. Flea bites commonly spread disease to man. Person to person spread has not been a recent feature until the purported outbreak of plague and plague pneumonia in India in 1994. Other factors that increase risk of infection in endemic areas are occupation-veterinarians and assistants, pet ownership, direct animal-reservoir contact especially during the hunting season, living in households with an index case, and, mild winters, cool moist springs, and early summers. Clinical presentations include subclinical plague (positive serology without disease); plague pharyngitis; pestis minor (abortive bubonic plague); bubonic plague; septicemic plague; pneumonic plague; and plague meningitis. Most prominent of plague's differential diagnosis are Reye's syndrome, other causes of lymphadenitis, bacterial pneumonias, tularemia, and acute surgical abdomen. Treatment has reduced mortality from 40-90% to 5-18%. The drug of choice (except for plague meningitis) is streptomycin, with tetracyclines being alternatives. Parenteral cholamphenicol is the treatment of choice for plague meningitis. A tetracycline should be administered as chemoprophylaxis to all contacts over the age of 8 years. Plague vaccine is available, but is only partially protective.

Synovial sarcoma of the suboccipital region of the neck.

A synovial sarcoma (SS) is an uncommon malignant soft-tissue tumor, which in spite of its name does not arise from synovial tissue. It is so named because of its histologic similarity to synovium. An SS originates from mesenchyme, not from synoviocytes and usually manifests as a biphasic tumor with both malignant-epithelial and spindle-cell components. Monophasic epithelial and spindle-cell presentations may cause a diagnostic dilemma. Diagnosis should include immunocytochemistry using cytokeratin and/or epithelial membrane antigen; vimentin further helps to eliminate any histologic confusion. These tumors are most commonly found in the extremities. When located near a joint, invasion occurs only by secondary extension. Rarely are SSs found in the neck, especially in the posterior aspect, as reported here.

Subcapital fracture complicating fixation of an intertrochanteric fracture from osteomyelitis.

Subcapital fractures after open reduction and internal fixation of intertrochanteric hip fractures have not previously been attributed to osteomyelitis. We report a unique case of a 63-year-old man with isolated subclinical osteomyelitis of the femoral neck causing ischemic necrosis and subcapital fracture after sliding screw plate fixation of an ipsilateral intertrochanteric fracture.

Neisseria sicca endocarditis with embolic phenomena.

Two patients with poor oral hygiene developed Neisseria sicca endocarditis, one after probable intravenous drug abuse and Staphylococcus aureus endocarditis and the other after a periodontal surgical procedure. Both experienced significant embolic phenomena and both required 6 or more weeks of intravenous antibiotic therapy. The diagnosis of N. sicca endocarditis must be considered when this organism is isolated from blood cultures in patients with emboli.

Squamous cell carcinoma of the nail bed.

Squamous cell carcinoma of the nail bed is an unusual malignancy of low virulence that is often misdiagnosed as a benign condition. Early diagnosis by biopsy, especially in patients with histories of repeated trauma, chronic infection, or exposure to irradiation or other predisposing factors, may lead to treatment and prevent the tumor from metastasizing.

In vitro activity of ampicillin/sulbactam against enterococci determined by the time-kill method.

Time-kill studies demonstrated that at clinically achievable serum concentrations, ampicillin/sulbactam was equivalent in activity to ampicillin alone against non-beta-lactamase producing isolates of Enterococcus faecalis and Enterococcus faecium. Sulbactam possessed no antibacterial activity against these organisms. It is not yet known if the activity of ampicillin will be increased with the addition of sulbactam when tested against beta-lactamase-producing enterococci.

Achromobacter xylosoxidans (Alcaligenes xylosoxidans subsp. xylosoxidans) meningitis associated with a gunshot wound.

The microbiological and clinical features of a case of Achromobacter xylosoxidans (Alcaligenes xylosoxidans subsp. xylosoxidans) meningitis associated with a gunshot wound are described. To our knowledge, this is the third confirmed case report of meningitis caused by this organism.

Quantitative antimicrobial susceptibility test for Streptococcus pneumoniae using inoculum supplemented with whole defibrinated sheep blood.

The National Committee for Clinical Laboratory Standards recommends the use of lysed horse blood-supplemented Mueller-Hinton broth for determining the quantitative antimicrobial susceptibility of Streptococcus pneumoniae. This procedure may be difficult for laboratories using previously prepared or commercial MIC systems. Therefore, a study was undertaken to determine whether previously prepared microdilution trays containing Mueller-Hinton broth without blood could be used for determining the antimicrobial susceptibility of S. pneumoniae by adding whole defibrinated sheep blood to the bacterial suspension used to inoculate the trays. The presence of alpha-hemolysis was used as an indicator of bacterial growth. One hundred isolates of S. pneumoniae selected to represent a distribution of susceptibility patterns were tested by the National Committee for Clinical Laboratory Standards method and the sheep blood-supplemented-inoculum method. Greater than 94% agreement between the two methods was achieved. The sheep-blood-supplemented-inoculum procedure was highly reproducible and easy to perform and provides an acceptable alternative for determining the MICs for S. pneumoniae for laboratories using previously prepared or commercial microdilution systems.

Two fatal cases of type E adult food-borne botulism with early symptoms and terminal neurologic signs.

Type E botulism, one of the least common forms of botulinal intoxication on the East Coast of the United States, is described for two elderly patients with chronic underlying disease. Both patients consumed tainted kapchunka, a salted, ungutted whitefish. Gastrointestinal symptoms and signs were prominent, but neurologic complaints, although noted soon after the consumption of the fish in one patient, did not progress until late in the course of the patient's illness. One patient exhibited both urinary retention, which was reported mainly in one outbreak of type E botulism (M.G. Koenig, A. Spickard, M.A. Cardella, and D.E. Rogers, Medicine [Baltimore] 43:517-545, 1964), and muscular fasciculations, which have been rarely reported.

Evaluation of the BIOGRAM antimicrobial susceptibility test system.

BIOGRAM is an antimicrobial susceptibility test system for the determination of MICs from the standard disk diffusion test zone diameters. The system was challenged with 511 recent clinical isolates of members of the family Enterobacteriaceae, nonfermentative gram-negative bacteria, staphylococci, and enterococci. Results were compared with those obtained with the broth microdilution method. Appropriate control organisms were included with each test series. A total of 10,085 organism-drug combinations were evaluated. BIOGRAM demonstrated an overall correlation of 95.9% with the reference broth microdilution method.

Collaborative evaluation of the UniScept qualitative antimicrobial susceptibility test.

The UniScept system (Analytab Products, Plainview, N.Y.) is a commercially prepared microdilution antimicrobial susceptibility test for the determination of qualitative susceptibility results for gram-negative and gram-positive bacteria. The system showed excellent correlation with the reference agar diffusion approach for organisms from clinical specimens and with stock and reference cultures. Intra- and interlaboratory reproducibility was high.

Disseminated Strongyloides stercoralis: a fatal case eluding diagnosis.

We have described a patient who died of disseminated strongyloidiasis as a result of steroid therapy, despite an extensive diagnostic evaluation in the face of eosinophilia, but before any immunosuppressive therapy. This death might have been prevented by presumptive treatment after work-up but before immunosuppressive therapy, and repeat diagnostic evaluation after antistrongyloides therapy and during immunosuppressive therapy.

Streptococcus MG-intermedius (S milleri) hepatic abscesses in two patients with regional enteritis.

Two patients with relatively quiescent regional enteritis had liver abscesses caused by S MG-intermedius. The occurrence of two such cases in a single hospital in the space of a few weeks, while possibly coincidental, suggests that infections with this organism, particularly hepatic abscesses, may be more common in patients with regional enteritis than previously realized.

Shigella enterocolitis and acute renal failure.

Although acute renal failure secondary to infections is relatively common in adult patients, uremia requiring dialysis has not previously been reported in an adult patient with shigella enterocolitis. Our patient, infected with S flexneri, had severe renal failure without any evidence of sepsis, rhabdomyolysis, or the hemolytic-uremic syndrome. Antibiotic therapy with trimethoprim-sulfamethoxazole appeared to play a role in his eventual recovery.

Quantitative culture of intravenous catheters and other intravascular inserts.

Quantitative cultures were done on 149 intravenous catheters and 40 additional intravascular inserts. Intradermal and intravascular segments of the insert were cultured separately. The inserts were immersed in broth and flushed. The number of colony-forming units (cfu) per insert was estimated by surface culture of serial dilution of the broth. Nonquantitative culture of undiluted broth was also done. Since all inserts associated with bacteremia had at least 10(3) cfu, inserts greater than 10(3) cfu were considered infected. Staphylococcus epidermidis was more likely than more virulent organisms to colonize an insert without causing bacteremia. The inserts in one bacteremic patient were infected from a distant bloodstream focus; however, in the majority of patients, quantitative intradermal cultures suggested that the insertion site was the portal of entry. In bacteremic patients, either a positive quantitative or a nonquantitative culture identified an infected insert. However, only 33% of positive nonquantitative insert cultures from nonbacteremic patients were confirmed by quantitative insert culture.