Septic monoarthritis of the first carpo-metacarpal joint caused by Mycobacterium kansasii.

A case of septic carpal monoarthritis due to Mycobacterium kansasii developing 16 months after accidental inoculation in a healthy laboratory technician is reported. No predisposing factor such as immunosuppression, preexisting degenerative, inflammatory arthritis or cortisone injection was present. Treatment with antituberculous oral medication alone resulted in resolution of the disease. Synovectomy was unnecessary. Ten years after the initial causative event, the patient remains free of symptoms.

Fatal primary infection due to human herpesvirus 6 variant A in a renal transplant recipient.

We describe a fatal primary human herpesvirus 6 (HHV-6) variant A infection in a kidney transplanted adult woman. On day 20 post transplantation (TX), after rejection therapy, the patient presented an acute hemophagocytic syndrome with hepatitis and central nervous system involvement. HHV-6 IgG and IgM antibodies seroconversion was demonstrated. HHV-6 variant A was the sole pathogen detected by nested PCR and/or culture in blood, bone marrow aspiration, liver biopsy, cerebrospinal fluid and bronchoalveolar lavage. The graft was HHV-6 seropositive and the patient was not transfused before day 28 post TX, suggesting that the virus was transmitted by the graft. Despite immunoglobulins, ganciclovir and foscarnet therapy, the HHV-6 infection progressed and led to severe aplasia. The patient developed Aspergillus fumigatus pneumonia and died from fulminant candidemia. This case demonstrated for the first time that HHV-6 variant A primary infection can cause life-threatening disseminated infection in immunosuppressed patients.

Erythromycin prophylaxis for Legionnaire's disease in immunosuppressed patients in a contaminated hospital environment.

Between January 1 and June 30, 1983, immunosuppressive drugs were administered in 20 renal transplant recipients undergoing 23 rejection episodes and in 3 patients with renal failure secondary to systemic disease. Legionella pneumophila, serogroup 1, pneumonia was diagnosed on 12/26 (47%) occasions. In an attempt to decrease this high rate, a program of erythromycin prophylaxis was instituted for every new patient who received immunosuppressive chemotherapy until eradication of the organism from the water supply could be realized. From July 1, 1983 to April 30, 1984, erythromycin prophylaxis (1.5-3 g/day by mouth) was administered during 39 episodes of high-dose immunosuppression (20 kidney graft recipients and 4 patients with systemic diseases); no cases of Legionnaire's disease were recorded. During the same period, erythromycin prophylaxis was withheld from 9 other high-dose immunosuppression episodes (7 kidney graft recipients and one patient with sarcoidosis); 5 cases of Legionnaire's disease occurred (56%) in this group. We conclude that erythromycin effectively protects immunocompromised patients in an environment contaminated with L pneumophila.

Endotracheally administered antibiotics for gram-negative bronchopneumonia.

Sisomicin or a placebo was administered endotracheally to two groups of 18 and 20 unconscious patients, respectively, who had tracheostomies or endotracheal tubes in place and developed a severe gram-negative broncho-pneumonia. In addition, the patients received systemically a combination of sisomicin and carbenicillin. A favorable clinical response was obtained in 14 (77 percent) of the 18 patients who were treated with sisomicin and in nine (45 percent) of the 20 patients who received the placebo (P less than 0.05). Endotracheal therapy with sisomicin was well tolerated and resulted in high levels of sisomicin and in elevated bactericidal activity within the bronchial secretions. Endotracheally administered amino-glycosides might be an important adjunct to systemically administered antibiotics in the management of severe gram-negative bronchopneumonia.

Penetration of aminoglycosides in uninfected pleural exudates and in pleural empyemas.

The concentrations of gentamicin, netilmicin, and amikacin were determined after one single intravenous injection in uninfected pleural fluid after thoracotomy and in purulent pleural empyemas. The mean peak concentrations in the pleural fluid after the injection of gentamicin (1.5 mg/kg), netilmicin (2.0 mg/kg), and amikacin (7.5 mg/kg) were 2.9 +/- 0.3 mg/L, 3.7 +/- 0.8 mg/L, and 11.0 +/- 3.1 mg/L, respectively. The pleural penetration of the drugs was very high (from 80.0 to 99.1 percent). By contrast, gentamicin and netilmicin were not detectable in empyema pus; in this exudate the mean peak level of amikacin was 5.7 +/- 2.2 mg/L, with the penetration of this drug being 31.0 percent. The concentrations of parenterally administered aminoglycosides are substantially lower in empyema pus than in sterile pleural fluid. The possibility of poor pleural penetration of some aminoglycosides, as well as the presence of local conditions in pleural empyema unfavorable to the bioactivity of these drugs, must be kept in mind when treating pleural infections.

Amikacin concentrations in uninfected postthoracotomy pleural fluid and in serum after intravenous and intrapleural injection.

The pharmacokinetics of amikacin after intravenous (IV) and intrapleural injection was compared in 25 patients with pleural drainage after lung resection. In ten patients 7.5 mg/kg of the drug was injected IV; the mean peak concentrations were 31.2 +/- 2.3 micrograms/ml in the serum and 13.3 +/- 3.8 micrograms/ml in the pleural fluid. The penetration of amikacin in the pleural space was 80 percent. After the intrapleural injection of the same dose of amikacin in 15 patients, the pleural fluid concentrations of the drug were extremely high and well sustained during eight hours; however, serum concentrations reached maximal values of 14.1 +/- 4.7 micrograms/ml, indicating a substantial diffusion of amikacin from the pleural space to the blood. In the case of treatment of pleural infections by local injection of aminoglycosides, the serum concentrations must be kept in mind to avoid systemic intoxication from these drugs.

Synergistic necrotizing cellulitis after pneumonectomy.

Synergistic necrotizing cellulitis is a rapidly progressive infection of subcutaneous tissues and muscles. We report a rare case of synergistic necrotizing cellulitis of the chest wall occurring after a pneumonectomy in a patient without any predisposing factors. Despite rapid and aggressive treatment, the patient died in acute respiratory failure 28 h after the first signs of sepsis.

Mycoplasma hominis infection of perihepatic hematomas in a liver transplant recipient.

We report the case of a recipient of liver transplantation in whom postoperative perihepatic hematomas were infected by Mycoplasma hominis. Etiologic diagnosis was delayed because this organism is a rare cause of postoperative infection and usually does not grow on standard bacteriologic media. The role of M. hominis in postoperative infections and the diagnostic problems of this organism are discussed.

Diagnosis and treatment of bacterial meningitis.

In the clinical approach of bacterial meningitis, the following points are stressed. Rapid identification of the germ, pending the results of the cultures. Various laboratory procedures are reviewed such as the Gram stain, the counterimmunoelectrophoresis, lactate determination and limulus assay of the CSF. Because of the local impaired host defences as well as the poor penetration and partial bioinactivation of most of the antibiotics in the CSF, large doses of the drugs are necessary to ensure sufficient levels and bactericidal titers. Specific antimicrobial therapy of meningitis is reviewed, with an emphasis on the third generation cephalosporins which appears to be the key to the treatment of Gram negative infections.

Group B streptococcus arthritis.

Serious infections with group B streptococcus (streptococcus agalactiae) are rare in adults. A 81-year-old patient with cirrhosis who developed a septic arthritis due to this germ, is described. Only eleven cases of group B streptococcal arthritis have been previously reported.

Q fever endocarditis: relapse five years after successful valve replacement for a first unrecognized episode.

A 59-yr-old man presented with mitral endocarditis and negative blood cultures. Antibodies to phase 2 and phase 1 antigens of Coxiella burneti were detected and a diagnosis of Q fever endocarditis was made. Five years earlier, this patient had been successfully treated by aortic valve replacement for a first episode of endocarditis with negative blood cultures. Giemsa and Machiavello stains of the native aortic valve were made retrospectively and showed coccobacilli highly suggestive of Coxiella organisms. It is concluded that the first episode was Q fever endocarditis and that the failure to recognize this aetiology at that time, and the absence of adequate medical therapy, is the cause of the present episode.

Salmonella endarteritis, about two cases and their management.

Mycotic aneurysms due to Salmonella are a classical but uncommon complication of Salmonella infections. We report two cases of such aneurysms, the first one having developed two successive aneurysms of the iliac arteries due to Salmonella typhimurium. The literature on Salmonella endarteritis is briefly reviewed. The importance of an aggressive surgical approach of the mycotic aneurysm, with removal of all infected material and extra-anatomic bypass through contaminated tissue is emphasized. The role of antibiotic treatment is also discussed.

Mediastinitis caused by Aspergillus fumigatus with ruptured aortic pseudoaneurysm in a heart transplant recipient: case study.

The case of a heart transplant recipient with a ruptured aortic pseudoaneurysm caused by an Aspergillus fumigatus mediastinitis is reported. Contamination of surgical fields occurring by air seeding during surgery appears to be the most probable source of infection. Subtle infectious signs of the wound and subacute course are remarkable features of this case.

Microbiological specimen collection in the emergency room.

The first step in the accurate diagnosis of infectious diseases is to provide the laboratory with adequate specimens for microbiological examination. The sample must be representative of the disease process: samples collected on body surfaces, harbouring saprophytic germ are less reliable than aspiration of closed body areas. A sufficient quantity of infectious material, preferably sampled with a syringe aspiration than with a swab, must be transported rapidly to the laboratory. Finally, close collaboration between the clinician and the microbiologist is essential for appropriate collection of selected specimens and corrected interpretation of the bacteriological results. Gram-stained smear examination of the samples is extremely useful and can provide immediate information for initiation of rational empiric antibiotic treatment. The indications for blood cultures sampling are reviewed. Number of blood cultures and volume of blood per culture are important. Screening of the sputum to discard samples too contaminated by the saliva is mandatory: if only screened samples are considered, a sputum Gram stain is a reliable guide to empiric therapy. Gram stain is also essential in the examination of the cerebrospinal fluid as well as is the detection of bacterial antigens. Cytological and chemical characteristics of this exudate are useful in differentiating bacterial meningitis from other diseases but there is considerable overlap between the laboratory parameters of bacterial meningitis and infections of other etiologies.

[Septic shock. Clinical review of 72 cases (author's transl)]. / Le choc toxi-infectieux. Revue clinique de 72 observations

The authors present a series of 72 observations of septic shock. The overall hospital mortality is 51%. Aggravating factors with worst prognosis are a cirrhosis (90% mortality) and wrong antibiotics before shock occurred (88% mortality). Some therapeutic acts (cannulae, venous catheter, urinary catheter, immuno-depressing treatment) increase penetration of gram positive germs of hostipal origin. The germs account for 30% of cases, the most frequent being staphylococcus. Among gram-negative organisms, one finds colibacilli, pseudomonas and last klebsiella. Usual entrance site was respiratory (33%). On clinical grounds we found equal frequency of "warm" shock with vasodilatation (mortality 30%) and "cold" shock (mortality 67%). A certain degree of renal failure sometimes necessitating dialysis is the rule. Intravascular disseminated coagulation occurred 3 times out of 46; 13 had hemorrhage. Finally acid-base disorders were usually of the metabolic acidosis type with respiratory alkalosis. Treatment consists in restauring volemia with abundant perfusions under control of central venous and arterial pressures and diuresis. Antibiotherapy, bactericidal and with wide spectre or specific for the suspected germ, must be immediately started. Importance of surgical debridement when required is evidenced by the low mortality of those cases (2 deaths out of 12). We use steroids systematically at high dosage, intravenous. Vasoactive or tonicardiac drugs are used selectively. Their efficiency and that of steroids are not prooved. Finally a review of the literature concerning the physiopathology and treatment of septic shock and its complications is presented.

A first case of Streptococcus bovis bacteremia and peritonitis from endometrial cancer origin.

BACKGROUND: The most important clinical infections caused by Streptococcus Bovis are bacteremia and endocarditis. Usually, Streptococcus Bovis bacteremia has been described in association with bowel pathology. CASE REPORT: A 67-year-old woman with an history of endometrial cancer Ic was admitted with the suspicion of peritonitis at examination. At exploratory laparotomy, a total hysterectomy was performed and the abdomen was drained. Histology revealed an uterine adenocarcinoma staged IIIa with intramyometrial cocci accumulation. Streptococcus Bovis was isolated from the peritoneal fluid cultures and three haemocultures. CONCLUSION: Because we excluded bowel pathology and endocarditis, this is the first case of Streptococcus Bovis bacteremia from endometrial cancer origin.

[Thoracic empyema. Focus on bacteriology and therapy]. / L'empyème thoracique. Mise au point bactériologique et thérapeutique.

Treatment of empyema thoracis is a difficult one, especially when it occurs in a large residual pleural cavity or with a bronchopleural fistula. Sixty three patients have been studied: 39 post-surgical cases (pneumonectomy 21, lobectomy 14, therapeutic pneumothorax 4) and 24 cases without previous surgical procedure. Bacteriologic findings were as follows: 19% of the cultures were negative; Staphylococcus aureus has been isolated in 43% of the positive cultures, Gram negative bacilli in 40%, anaerobic germs in 21.5% and Streptococcus pneumoniae in one case. In 55 patients (87%) initial treatment was pleural drainage and local irrigations associated with systemic antibiotherapy. Enzymatic debridement with streptokinase was necessary in 25 patients (40%) and intrapleural antibiotherapy in 19 patients (30%). Twenty two patients needed subsequent surgical treatment: 12 pleural debridements, 2 pleuropneumonectomies and 12 open-window thoracostomies were performed. Fourty three patients were cured; 11 died (7 related to the primary disorder) and 8 developed chronic infections. Effective pleural drainage must always be the first treatment in empyema thoracis. When this fails, surgical treatment is imperative. Pleural debridement is the procedure of choice when there is no residual pleural cavity and when the lung can be reexpanded. Pleuropneumonectomy must be reserved to extensive pulmonary destructions. Open-window thoracostomy is the best technique when large residual pleural space or bronchopleural fistula occurs (e.g. after pneumonectomy), and after the failure of all other treatments.

Treatment of bone and joint infections: recommendations of a Belgian panel.

A multidisciplinary panel of Belgian specialists describes the overall therapeutic approach for bone and joint infections. Classification, general methods of investigation, therapeutic options, special circumstances, the role of aminoglycosides and of glycopeptides are described. The possibility of home treatment is discussed, as well as some pharmaco-economic insights.

[Prosthesis-related infections]. / Infections de prothéses.

Long-term prosthetic devices are rapidly recovered by host proteins which increase bacterial adhesion. The bacteria can also produce extracellular polysaccharide material, which in combination of host proteins, produce a biofilm. This one decreases the host defense mechanisms, antibiotics penetration and efficacy, increasing infectivity of the pathogens. Most often, the device is contaminated in the perioperative period by commensal flora. It can also be infected by hematogenous seeding or by contiguous infection. Various clinical presentations of infected devices are described depending on the type of prosthesis, its anatomical localisation and the time elapsed since insertion. Postoperative acute sepsis, insidious infectious signs or isolated device malfunction without signs of infection have all been described. The prosthetic infection rate is low, but when it occurs, the consequences are catastrophic. Excepted in some selected cases, the classical treatment combines the removal of the prosthesis and a long-term appropriate antibiotic therapy. If infection is suspected, it's crucial to establish the diagnosis accurately often by using invasive diagnostic methods (CT-scan guided biopsy, etc.) to obtain adequate samples which detailed microbiological analysis should be carefully interpreted.

[Fulminant erysipelas]. / Erysipèle fulminant.

An apparent resurgence of invasive and life-threatening group A streptococcal infections in young and previously healthy hosts is reported in several countries. We report a case of fatal necrotizing fasciitis and review the spectrum of these clinical syndromes, including the invasive soft tissue infections. This changing pattern of infection could be explained by an increased incidence of some serotypes of group A Streptococcus carrying specific virulence factors, such as pyrogenic exotoxins.