Tuberculous osteomyelitis masked by concomitant staphylococcal infection.

A systematic and easily reproduced bone protocol was used over a 14-month period to evaluate bone histologically and by mycobacterial culture in patients with chronic osteomyelitis. On examination of 140 bone specimens, we found four patients with unsuspected tuberculous osteomyelitis whose diagnosis was obscured by a concomitant staphylococcal osteomyelitis. Three of the patients had axial skeleton involvement, and one had disease of the femur. No patient had a history of a positive skin test or of tuberculous disease, and none had coexistent pulmonary disease. The underlying granulomatous infection was initially revealed in one patient by histologic examination of bone and in three others only by mycobacterial culture of bone. Concomitant osseous tuberculosis should be excluded in patients with staphylococcal osteomyelitis. Evaluation using a bone protocol with histologic study and culture on Löwenstein-Jensen medium is effective in diagnosing occult osseous tuberculosis.

The detection of airborne Mycobacterium tuberculosis using micropore membrane air sampling and polymerase chain reaction.

STUDY OBJECTIVES: Mycobacterium tuberculosis (MTb) bacilli are carried on airborne droplet nuclei produced by aerosolization that can occur from coughing, talking, or even singing. Because of their prolonged period of suspension, they can be filtered from the air onto a porous medium and readily detected using polymerase chain reaction (PCR). DESIGN: Prospective cohort analysis. SETTING: Samples of circulating air were collected over a 12-month period from within the rooms of 10 hospitalized patients who were under respiratory isolation to rule out MTb infection. A small laboratory pump was used to draw ambient air at a rate of 2 L/min over a 6-h period through a 0.2-microm polycarbonate membrane filter placed near the patient's bed. Analysis of the membrane filters was conducted using PCR. Sputum cultures for MTb were performed simultaneously, and the results of smears stained for acid-fast bacilli (AFB) were noted. MEASUREMENTS AND RESULTS: MTb complex was successfully detected by PCR in six of seven patients in whom sputum MTb cultures were subsequently positive, and in zero of three with subsequently negative sputum cultures. Sampling in one patient with a positive culture, in whom PCR results were negative, was only carried out for 2 h due to pump malfunction. One of the six PCR-positive patients was AFB-smear negative at the time of air sampling. CONCLUSIONS: Our preliminary findings indicate that the technique of Micropore membrane air sampling with PCR analysis has important applications in the epidemiology and diagnosis of MTb.

Transient aplastic anemia caused by parvovirus B19 infection in a heart transplant recipient.

Parvovirus B19 infection in the transplant patient is rarely reported, although cases have occurred in patients with bone marrow, liver, and renal transplants and in children undergoing heart transplantation. We present the first reported case of an orthotopic heart transplant recipient with aplastic crisis caused by parvovirus B19. The infection was diagnosed by bone marrow biopsy, confirmed by serologic studies and polymerase chain reaction, and successfully treated with intravenous immunoglobulin.

Respiratory syncytial virus.

RSV is now understood to be the most significant viral respiratory pathogen of infants and is capable of causing both bronchiolitis and pneumonia. It is a particular risk to hospitalized infants as the virus is easily spread through close contact. The most vulnerable infants are those who suffer with either congenital heart disease or bronchopulmonary dysplasia who easily fall prey to pulmonary complications of infection. Strict environmental control and the use of protective clothing and eyewear should be implemented to decrease the nosocomial spread of RSV. Available diagnostic studies include viral isolation, fluorescent antibody stains, and enzyme immunoassays. Treatment of the disease is usually supportive but hospitalized patients frequently benefit from aerosolized ribavirin therapy. Hopefully, current vaccine trials will be successful and this pathogen will not only be treatable but will also be preventable.

Lyme borreliosis.

Lyme borreliosis is a complex infectious process that primarily involves the skin, heart, joints, and nervous systems. The infectious agent is the spirochete B burgdorferi, which is transmitted by the Ixodes genus of ticks. The clinical presentations of Lyme disease are protean because of the overlap of stages and varied organ system involvement. Furthermore, as previously mentioned, approximately one-third of Lyme patients are unable to recall a tick bite. Lyme borreliosis should be suspected in anyone with a tick bite. The findings of an EM lesion and flu-like symptoms strongly favor the diagnosis of stage 1 disease. Stage 2 evolves weeks to months after a tick bite, with cardiac and neurological findings as well as musculoskeletal pain. Stage 3 primarily manifests itself as arthritis associated with continuing or additional neurologic complications. Serologic studies are currently the most practical laboratory aid in diagnosis, because almost all infected individuals have a positive antibody response to the spirochete. Treatment with antibiotics usually proves successful, although longer courses of therapy may be needed in later stages of the disease, and some patients may not respond.

Capnocytophaga.

Capnocytophaga has been found to cause disease in the normal and the immunocompromised patient. Most often this organism is an opportunist that is difficult to isolate but easy to identify and a unique reminder that uncommon infection may respond to common antibiotics.

Hantavirus: an old bug learns new tricks.

Hantaviruses are a diverse group of RNA arboviruses in the Bunyaviridae family. Although their role as the causative agents of HFRS has been well established, the recent outbreak of a new disease in the Southwest clearly demonstrates the protein clinical manifestations that this pathogen can produce. Furthermore, whereas hantaviruses have been characterized largely as focal agents in the production of geographically delimited diseases, recent trends indicate that endemic areas for the virus are expanding. Outbreaks often occur in clusters as a result of the epizoology of rodent hosts, but isolated cases of hantavirus-related disease also may be observed. Although hantaviruses have proven their pathogenic capability in other areas of the world, it was perceived widely that they were of little consequence to public health in the United States. However, as more is learned about the nature of this truly global infectious agent, its potential danger to mankind becomes increasingly apparent. It is hoped that continued research will elucidate all the facets of hantavirus-induced disease.

Human T-cell lymphotropic virus-type I.

HTLV-I is a retrovirus now identified as the etiologic agent of two diverse disease processes: ATLL, an aggressive T-cell malignancy; and TSP/HAM, a chronic progressive myelopathy. Transmission can occur horizontally through blood transfusions, IV drug abuse and sexual intercourse. Vertical transmission may also occur. Available diagnostic modalities are serologic in nature and include the EIA and the more specific confirmatory assays WIB and RIPA. These studies are thus far suboptimal in terms of sensitivity and specificity, and await refinement. DNA amplification by the polymerase chain reaction seems to hold the most immediate diagnostic promise for the future. AZT apparently is not useful clinically, and current treatment is only palliative in nature. The diverse diseases caused by HTLV-I underscore the insidious nature of the Retroviridae family. These subtle cell-associated pathogens will undoubtedly be shown to play a significant role in other disease processes of uncertain etiology.

BK virus.

BK virus is a human polyoma virus that infects the renal epithelium and remains latent until immunosuppression triggers reactivation. After reactivation, BK virus can be detected in the urine by methods currently available in the clinical laboratory. Correlations can be made between BK viruria and the occurrence of both renal and hepatic pathologies. BK virus is emerging as a significant pathogen in transplant patients. Additionally, the presence of BK virus DNA in primary brain and pancreatic tumors suggests that it may have oncogenic potential. Thus far, attempts to treat BK virus infection have been ineffective, though research has opened new avenues for treatment possibilities. Prevention of BK virus and other latent viral reactivation remains a challenge to viral research.

Management of the transplant recipient with pulmonary infection.

Pneumonia is a common and potentially fatal complication of transplantation. The clinical approach to this problem requires a multipronged attack. Thorough evaluation of the donor and recipient reduces the risk of infection while pointing to likely infectious complications to be anticipated posttransplant. Careful attention to infection control measures with emphasis on handwashing, high efficiency particulate air filtration, and aggressive outbreak investigation minimizes nosocomial pneumonias. Appropriate use of vaccines and prophylactic antimicrobial therapies decreases posttransplant morbidity and mortality. Once pneumonia occurs, a rapid, thorough diagnostic evaluation increases the likelihood of survival for the individual patient and focuses attention on environmental risks that may pose a hazard to the other transplant recipients in the clinician's institution.

The treatment of advanced cardiac allograft rejection.

Severe cardiac allograft rejection remains a serious problem despite the advances of cyclosporine-based immunosuppression. This study analyzes our experience with 202 recipients of cardiac allografts who were treated primarily with cyclosporine and prednisone. Failure of such therapy in 86 patients (43%) resulted in 105 episodes of advanced cardiac allograft rejection as diagnosed by endomyocardial biopsy. Of 101 rejection episodes that were initially treated with intravenous pulse therapy, 48 (48%) were successfully resolved, yet 60% of these successes were associated with major infections. Patients in whom steroid therapy failed or was contra-indicated received intravenous antithymocyte globulin (ATG) or intravenous monoclonal antibody (OKT3). ATG and OKT3 successfully reversed severe rejection in 26 (81%) of 32 and in 13 (93%) of 14 episodes, respectively. Infectious complication rates were 54% and 21%, respectively. Because the majority (87%) of these rejection episodes occurred within the first 30 days after treatment, many of them may have resulted from inadequate immunosuppressive induction therapy. Based on our results, we believe that advanced cardiac allograft rejection may be managed best by individualizing immunosuppressive therapy, thus enhancing prevention, and by adding OKT3 to the regimen when rejection occurs.

Haemophilus parainfluenzae endocarditis in a patient with mitral valve prolapse.

Haemophilus parainfluenzae is a frequent cause of "culture-negative" endocarditis (i.e., endocarditis owing to a fastidious organism which may require longer incubation periods and/or enrichment media for detection compared to traditional pathogens). More cases will probably be identified with improvements in growth and isolation techniques. A case of H. parainfluenzae endocarditis is presented in a patient with mitral valve prolapse, which illustrates the difficulty in diagnosing endocarditis when initial blood cultures are negative. Particularly, it emphasizes the difficulty in selecting appropriate antibiotic therapy since beta-lactamase producing organisms are being isolated with increased frequency. This report is unique in that it documents successful treatment with a cephalosporin and what is, to our knowledge, the third reported case of a beta-lactamase producing H. parainfluenzae causing endocarditis. The authors believe that beta-lactamase stable second or third generation cephalosporins should constitute initial treatment of H. parainfluenzae endocarditis until sensitivity studies become available, since beta-lactamase production by this organism would nullify the effect of the previous agent of choice, ampicillin.

An interesting case presentation: peripartum meningococcal meningitis.

Meningococcal disease during pregnancy is extremely rare. A single reported case occurred more than 20 years ago in England. We present the case of a young woman who just hours after delivery of her baby developed fulminant meningococcal meningitis with its classic findings. Our experience illustrates the importance of early diagnosis and appropriate therapy of meningococcal disease in the gravid as well as in the nongravid population.

Using OKT3 to reverse cardiac allograft rejection.

Acute rejection is the major impediment to long-term patient survival after organ transplantation. Historically, the treatment of cardiac allograft rejection has been use of cytotoxic agents combined with high-dose steroids, resulting in an increased incidence of undesirable side effects. A new agent, OKT3, appears to be capable of reversing acute rejection episodes without significant morbidity. We report 10 cardiac transplant recipients in whom acute rejection was dramatically reversed and clinical symptoms resolved after treatment with OKT3. Side effects were minimal, including febrile episodes, innocuous diarrheal syndromes, mild opportunistic infections, and one hypotensive episode. Critical care nurses administering OKT3 must be cognizant of the risks and benefits of therapy in addition to recognizing potential drug side effects. A nursing care plan was devised to identify nursing diagnoses and intervention related to patient and family education as well as recognition and treatment of the reported adverse effects.

Infections in patients receiving OKT3 monoclonal antibody for cardiac rejection: results of a small clinical trial.

Orthoclone OKT3 (muromonab-CD3), a murine monoclonal antibody that virtually eliminates circulating T cells and inhibits medullary lymphocyte function, has recently been found effective in reversing stubborn severe allograft rejection after heart transplantation. To determine the influence of OKT3 therapy on the development of infections in cardiac allograft recipients, we compared the frequency and severity of infection in 16 patients who underwent treatment for cardiac allograft rejection at our institution from July 1985 through November 1986. these included 11 patients on OKT3 therapy and 5 patients on a conventional immuno-suppressive regimen. With 2 exceptions late in the trial, OKT3 was used only as a rescue therapy, for patients who did not respond to standard adjunctive therapy consisting of high doses of corticosteroids or antithymocyte globulin, or both. The 5 patients who did not receive OKT3 responded to adjunctive therapy and were in general not as ill as the OKT3 recipients. Our protocol specified that patients in both groups be studied during the 6 weeks (42 days) immediately following transplantation. During this period of study, 6 patients in our 11 member OKT3 group experienced 25 infectious processes, 22 of which occurred in only 3 patients and 14 of which were considered life-threatening (2 of the 3 very ill patients died during the study period). These infections were found most often in the gastrointestinal and genitourinary tracts, involved both bacterial and nonbacterial pathogens, and developed about 2 weeks after the initiation of therapy. By comparison, 2 patients in our 5-member non-OKT3 group experienced 3 infectious processes during the study period, and these were not life-threatening. Because of the occurrence in the OKT3 group of 22 of the 25 infections in only 3 patients, these early results were skewed, but a trend was noted towards a higher incidence of bacterial infection in the OKT3 group. A larger and longer-term trial is under way to evaluate the trend.

Nocardia brasiliensis cellulitis in a heart transplant patient.

Three months after undergoing heart transplantation, a 55-year-old man presented with N. brasiliensis cellulitis resulting from a splinter wound acquired during yard work. Surgical débridement was necessary before the infection responded to medical treatment. Although pulmonary nocardiosis is a well-documented complication of immunosuppressive therapy, this is the 1st report of a nocardial infection associated with primary skin involvement in a heart transplant patient.

Exposure of medical students to body fluids.

Three hundred forty-two students at 3 Florida medical schools were surveyed concerning occupational exposures to blood and body fluids during their 3rd-year clerkship. The 16-item questionnaire was anonymously returned by 150 students, and differences among groups were assessed at p < .05. Most of the students complied with universal precautions guidelines (UVPG); 62 reported 101 exposures, including 9 with HIV-positive blood and body fluids. Most of the exposed students knew about the guidelines but regarded the incidents as irrelevant to their safety or supervision training. Noncompliant students reported significantly more exposures than compliant students. Time constraints, inconvenience of using gloves during procedures, and belief that patients were at low HIV risk discouraged adherence to the guidelines. Common practices following exposure were "no action" or "washed area only" without medical follow-up. Medical students' UVPG adherence should be increased by workload modification, user-friendly safety products, and supervised practice training in clinical exposure settings.

Kaposi's sarcoma mimicking cellulitis.

Although Kaposi's sarcoma is not the most common cause of death in AIDS patients, it is often one of the initial opportunistic illnesses associated with human immunodeficiency virus infection. Extensive plaque formation and edema in the lower extremities may take on the appearance of cellulitis, and in dark-skinned persons, the lesions of the neoplasm may not be noticeable. Treatment is palliative; therapy for local effect is appropriate unless lesions are extensive or systemic involvement is present.

Postanginal sepsis. A pain in the neck.

The primary care physician must be on the alert when a patient presents with a sore throat, signs of sepsis, and a rapidly deteriorating condition. Recognition of this distinct clinical presentation should lead to the diagnosis of postanginal sepsis. Once this diagnosis is suspected, therapy with an antibiotic that provides coverage against streptococci and anaerobes should be initiated promptly, and a drainable focus of infection should be excluded.