The relationship of antibody-coated bacteria to clinical syndromes as found in unselected populations with bacteriuria.

In selected patients, detection of antibody-coated bacteria (ACB) in voided urine has correlated with upper urinary tract infection. From unselected patients, we studied 350 consecutive urine specimens submitted to the diagnostic laboratory with colony counts greater than or equal to 10(5)/ml. In 19% (55) among 288 specimens selected for final analysis ACB occurred. There were no substantial differences in the occurrence of ACB by age or sex of patients or by species of bacteria. The relationship of ACB to clinical syndromes was: asymptomatic bacteriuria, 15% (27/178); cystitis, 8% (6/75); acute hemorrhagic cystitis, 67% (4/6); prostatitis, 67% (2/3); and acute pyelonephritis, 62% (16/26). Among seven clinical findings, only structural abnormalities of the upper urinary tract correlated with the presence of ACB. Failure of fever and leukocytosis to correlate with ACB probably reflected the presence of other associated primary medical or surgical conditions.

Pseudomonas maltophilia causing heroin-associated infective endocarditis.

The association of Pseudomonas maltophilia endocarditis in three patients with recent history of intravenous drug abuse is reported. All three patients had abnormal heart valves (two prosthetic and one rheumatic). A prominent characteristic of this uncommon pathogen is its in vitro resistance to the commonly used antimicrobials. Cure was achieved in all three cases. In two cases, synergistic antibiotic combinations were used. In one case, plasmid-mediated resistance to amikacin sulfate (Amikan, British; no comparable US product) emerged during therapy. The two patients with prosthetic valves received combined surgical and antibiotic therapy.

Factitious and fraudulent fever.

The task of elucidating the etiology of fever of undertermined origin remains a major undertaking. Factitious fever is uncommonly considered of major importance in the differential diagnosis of fever of undetermined origin although it is a readily identifiable, syndrome and one that is easily excluded one it has been considered. Early identification may reduce the necessity for prlonged, expensive and potentially hazardous hospitalizations for such patients. A retrospective study identified 2.2 per cent (11 of 506) of all patients whose fever on their charts was coded as fever of undetermined origin as having factitious fever. These patients either created factitious fever by manipulation of the thermometer or fraudulent fever by self-induced means. A review of the literature yielded an additional 70 cases in which fever was either the sole factitious sign or part of a larger, more complex factitious illness. Patients were typically young, female and often associated with the medical profession. Patients with factitious fever differ from those with the stereotyped Munchausen's syndrome and may be difficult to recognize. Signs leading to the recognition of this syndrome are emphasized. Since the nature of the psychiatric illness may vary from patient to patient, early discovery may facilitate psychiatric intervention as such patients may be more amenable to therapy.

Survival of a patient with pancytopenia and disseminated coagulation associated with miliary tuberculosis.

A 56-year-old man with histologically and bacteriologically proved disseminated tuberculosis in association with pancytopenia responded to antituberculosis chemotherapy with bacteriologic cure of his tuberculosis and concomitant resolution of the pancytopenia. This association has been generally believed to have a nearly 100 percent mortality. In addition, the patient developed laboratory evidence of disseminated intravascular coagulation (DIC). The single and simultaneous occurrence of these two hematologic abnormalities is extremely rare. A number of factors possibly relating to the development of pancytopenia and DIC in conjunction with miliary tuberculosis are briefly discussed.

Haemophilus influenzae septic arthritis in adults.

The incidence of Haemophilus influenzae infections appears to be increasing although disease in adults due to this organism remains unusual. Only 16 cases of septic arthritis caused by this agent were found in a review of the literature. Two additional cases are reported and a summary of the clinical characteristics of these patients is presented. In general, females are affected more commonly than males, and blacks more often than whites. Joint involvement may be single or multiple, and associated or underlying conditions are frequent. Treatment with a variety of antimicrobials was generally successful and 87% of the infected joints was restored to pre-infection status. There were no specific characteristics in the clinical presentation which would allow an early precise etiologic diagnosis.

Comparison of the efficacy and safety of ceftibuten and cefaclor in the treatment of pneumonia and bronchiectasis.

In a multicentre, international study of 187 adult patients with bacterial pneumonia or bronchiectasis, the safety and efficacy of a regimen of 200 mg ceftibuten administered twice-daily was compared with cefaclor given in a dosage of 500 mg three times a day. Of the 94 evaluable patients, 66 received ceftibuten and 28 received cefaclor. The overall bacteriological response was similar in the two treatment groups with elimination of the original pathogen in 91% and 89% of the patients receiving ceftibuten and cefaclor, respectively. The overall clinical response mirrored the bacteriological results with a successful clinical outcome in 92% of ceftibuten-treated patients compared with 93% in patients receiving cefaclor. Adverse experiences were, in general, few and mild, being reported in 8% and 17% of patients receiving ceftibuten and cefaclor, respectively.

Slide coagglutination for Salmonella typhi antigens in broths inoculated with feces from typhoid fever patients.

Salmonella typhi antigens D, Vi and d were readily detected, by slide coagglutination, in mannitol selenite (MSB) and dulcitol selenite (DSB), Salmonella enrichment broths 4 hours after inoculation with feces from 60 patients with bacteriologically confirmed typhoid fever. Positive coagglutination also occurred using MSB and DSB inoculated with fecal specimens obtained from 16 patients from whom S. typhi was not cultured. Twelve of these later seroconverted to Salmonella O antigen. None of the MSB or DSB inoculated with feces from 50 healthy control subjects, gave a positive coagglutination test. The coagglutination method appears to have potential as a rapid test for the detection of antigens of S. typhi in MSB and DSB broths inoculated with feces from patients with suspected typhoid fever.

Pulmonary mycobacteriosis and malignancy presumed activation by irradiation.

It has been widely believed that pulmonary tuberculosis may be activated by irradiation. Although mycobacterial infections are not rare in the immunocompromised host, activation of disease by irradiation has not been described in previous reviews of mycobacterial infections associated with malignancy. This report presents a case of a patient in whom activation of pulmonary infection with mycobacteria of the avium-intracellulare complex was believed to be linked to local irradiation for carcinoma of the breast. The differentiation of pulmonary infection from the effects of irradiation in this setting may be difficult and it is important that irradiation not be blamed for changes that may result from an infectious agent.

Unusual infections caused by Pasteurella multocida.

Three cases of infection with Pasteurella multocida included acute epiglottitis, septic arthritis, and pleuropulmonary infection. Human infections with this microorganism are commonly related either to animal contact (eg, wound infections) or to the presence of underlying chronic respiratory tract disease. Although septic arthritis and pleuropulmonary infections have previously been attributed to this pathogen, to our knowledge, this is the first reported case of acute epiglottitis caused by P. multocida.

Response of typhoid fever caused by chloramphenicol-susceptible and chloramphenicol-resistant strains of Salmonella typhi to treatment with trimethoprim-sulfamethoxazole.

Chloramphenicol remains the drug of choice for the treatment of typhoid fever in most areas despite the risks of relapses and toxicity. In a comparison of the efficacy of trimethoprim-sulfamethoxazole (TMP-SMZ) and chloramphenicol against typhoid fever, 60 patients in Indonesia were randomly assigned to receive either TMP-SMZ (320 mg of TMP and 1,600 mg of SMZ daily) or chloramphenicol (2 g daily) for 14 days. TMP-SMZ was significantly more effective in sterilizing the blood, but the two drugs were equally effective with regard to relapse rate, frequency of prolonged fever, and mortality. Use of TMP-SMZ in Vietnam for the treatment of typhoid fever caused by chloramphenicol-resistant Salmonella typhi showed that TMP-SMZ is as effective as ampicillin. Likewise, a review of other published reports suggests that TMP-SMZ has an overall record in the treatment of typhoid fever that is equal to or better than the records of other available drugs. TMP-SMZ has emerged as a satisfactory alternative to chloramphenicol for the treatment of typhoid fever and should be especially useful in areas where chloramphenicol-resistant S. typhi has been isolated.

Detection of Salmonella typhi D, Vi, and d antigens, by slide coagglutination, in urine from patients with typhoid fever.

Salmonella typhi antigens D, Vi, and d were detected in the urine of 59 out of 61 (97%) bacteriologically confirmed typhoid fever patients by slide coagglutination with monovalent antisera coupled to protein A-rich staphylococci. These antigens were also detected in the urine of an additional 22 patients, 16 of whom subsequently demonstrated seroconversion by S. typhi O antibody agglutination, but from whom the bacterium was not isolated. The remaining 13 patients had negative urine coagglutination results, no isolation of S. typhi from blood or stool specimens, and no demonstration of seroconversion. These results suggest that the method of slide coagglutination of urine can be used to screen patients with suspected typhoid fever with a high degree of reliability. The method may also have potential importance in the diagnosis of typhoid when the bacterium is not isolated.

Susceptibility of Pseudomonas maltophilia to antimicrobial agents, singly and in combination.

Pseudomonas maltophilia is resistant to most of the commonly used antimicrobial agents including those active against Pseudomonas aeruginosa. The susceptibility of 14 clinical isolates of P. Maltophilia to 18 antimicrobial agents was determined by broth dilution testing. All organisms were susceptible to trimethoprim-sulfamethoxazole (TMP-SMZ), minocycline, and LY127935. A total of 87 and 79% of the organisms were susceptible in vitro to colistin and chloramphenicol, respectively. With the exception of sisomicin, the organisms were resistant to the aminoglycosides. Of 21 combinations of antimicrobials examined for synergy, only the combination of TMP-SMZ with carbenicillin was consistently (86%) synergistic in vitro. Supplementation of the testing media with calcium and magnesium increased the minimal inhibitory concentrations for the aminoglycosides, the penicillins, and TMP-SMZ against P. maltophilia.

Treatment of systemic sporotrichosis with ketoconazole.

Infections of deep soft tissues with the dimorphic fungus Sporothrix schenckii are uncommon in humans, and therapy has often required toxic drugs. We report our experience in treating 11 patients who had deep-seated sporotrichosis with ketoconazole, a well-tolerated, orally absorbed antifungal agent. Eight infections involved one or more joints, and three involved thoracic, cervical, and widespread cutaneous sites, respectively. For eight patients all evidence of infection resolved during therapy. Sustained remissions (6 months to 5 years) were noted for six patients after the discontinuation of all therapy and for an additional patient 4 years after the initiation of ketoconazole treatment. Durable responses were associated with prolonged treatment with 400-800 mg of ketoconazole daily. Our favorable experience suggests that oral therapy with ketoconazole may benefit other patients with systemic sporotrichosis.