Tuberculous meningitis in patients with and without human immunodeficiency virus infection.

OBJECTIVE: To characterize the symptoms, signs, laboratory findings, and outcome of culture-proven meningitis due to Mycobacterium tuberculosis in patients with and without human immunodeficiency virus (HIV) infection. DESIGN: Retrospective chart review. SETTING: Urban public general hospital in the United States. PATIENTS: Fifteen patients with and 16 without HIV infection. MEASUREMENTS: Demographics, symptoms, physical exam findings, serum sodium, complete blood cell count, CD4+ cell count, cerebrospinal fluid findings, imaging data, and in-hospital mortality. MAIN RESULTS: Symptoms, signs, chest radiograph appearance, cerebrospinal fluid cell counts and chemistries, and mortality were similar in both groups (p = NS). Median CD4+ cell counts were lower in HIV-infected patients (median 99/mm3, range 7 to 251, versus 384/mm3, range 171 to 724 in those without HIV infection, p = 0.007). Intracerebral mass lesions were more common in the HIV-infected group (60% versus 14% in the uninfected group, p = 0.01), although the presence of a mass did not correlate with focal neurologic deficits, altered level of consciousness, or mortality. CONCLUSION: With the exception of an increased incidence of intracerebral mass lesions in HIV-infected individuals, HIV infection appears to have little impact on the findings and in-hospital mortality of tuberculous meningitis.

Prevalence of neurosyphilis in human immunodeficiency virus-infected patients with latent syphilis.

PURPOSE: A prospective study was done to determine the prevalence of confirmed neurosyphilis (cerebrospinal fluid [CSF] Venereal Disease Research Laboratory [VDRL]-reactive) in human immunodeficiency virus (HIV)-infected patients with latent syphilis (reactive serum rapid plasma reagin [RPR] and microhemagglutination-Treponema pallidum [MHA-TP]). PATIENTS AND METHODS: All HIV-infected patients seen for their first visit at the Los Angeles County/University of Southern California Medical Center AIDS Clinic from June through December 1990 were screened for latent syphilis. Those with reactive serum RPRs and MHA-TPs who had not received recent (within 6 months) therapy for syphilis were offered diagnostic CSF sampling. RESULTS: A total of 312 patients were screened, of whom 71 (22.8%) had reactive serum RPRs and MHA-TPs. Thirty-three of these patients (47%) had diagnostic CSF sampling (26 refused lumbar puncture or were lost to follow-up; 12 had had recent therapy for syphilis and thus did not have CSF sampling). Among the 33 patients who had CSF sampling, 20 (60.6%) had normal CSF profiles (white blood cell count less than 8/mm3; protein less than 0.60 g/L; glucose greater than 2.8 mmol/L) and nonreactive CSF VDRLs. Ten of the 33 patients (30.3%) had abnormal CSF profiles and nonreactive CSF VDRLs, and three of 33 (9.1%) had reactive CSF VDRLs. CONCLUSIONS: Asymptomatic neurosyphilis was found in 9.1% of our patient population undergoing CSF sampling, giving a 1.0% prevalence of CSF VDRL-reactive neurosyphilis in the population we screened. The abnormal CSF findings may have been due to either nonreactive CSF VDRL neurosyphilis, central nervous system infection with HIV, or infection with some unrecognized agent.

Inhibitory effects of the quinolone antibiotics trovafloxacin, ciprofloxacin, and levofloxacin on osteoblastic cells in vitro.

We studied the inhibitory effects of the fluoroquinolones levofloxacin, ciprofloxacin, and trovafloxacin on growth and extracellular matrix mineralization in MC3T3-E1 osteoblast-like cell cultures. Levofloxacin had the least inhibitory effect on cell growth, with a 50% inhibitory concentration of approximately 80 microg/ml at 48 and 72 hours. Ciprofloxacin had an intermediate degree of inhibition, with a 50% inhibitory concentration of 40 microg/ml at 48 and 72 hours. Trovafloxacin exerted a profound inhibitory effect on cell growth, with a 50% inhibitory concentration of 0.5 microg/ml, lower than clinically achievable serum levels. The decreased cell counts with up to 2.5 microg/ml of trovafloxacin and with up to 40 microg/ml of ciprofloxacin were not associated with decreased rates of 5-bromo-2'-deoxyuridine incorporation per cell. Alatrovafloxacin, the L-alanyl-l-alanine prodrug of trovafloxacin, exerted effects on proliferation and 5-bromo-2'-deoxyuridine incorporation similar to those of the parent compound. The quinolones evaluated also inhibited extracellular matrix mineralization by MC3T3-E1 cells. Treatment of confluent cultures with trovafloxacin, ciprofloxacin, or levofloxacin resulted in strong inhibition of calcium deposition, as determined on day 14 by alizarin red staining and biochemical analysis. The effect was apparent with 2.5-5 microg/ml of each of the three antibiotics tested and progressively increased to more than a 90% decline in the calcium/protein ratio with 20-40 microg/ml antibiotic concentration. Further in vivo studies are advocated to evaluate the relevance of the in vitro cytotoxicity reported here to bone healing in orthopaedic patients.

Abscesses secondary to parenteral abuse of drugs. A study of demographic and bacteriological characteristics.

Seventy-seven patients (eighty-six lesions) who had been seen over a fifteen-month period because of an abscess at the site of injection due to parenteral abuse of drugs were identified in a retrospective review. Forty-one patients (forty-five abscesses) had had cultures before antibiotic therapy. Thirty (73 per cent) of the forty-one patients had isolation of a streptococcal species on culture, with microaerophilic streptococci identified in sixteen. Twenty (49 per cent) of the forty-one patients had isolation of a staphylococcal species. Four of the staphylococcal organisms were identified as oxacillin-resistant Staphylococcus aureus. Two patients who had three abscesses each had different organisms in each abscess. Gram-negative bacilli were identified in the cultures of ten (24 per cent) of the forty-one patients; patients who were forty years old or more had a sixfold greater risk of having gram-negative bacilli. Specimens of the abscess had been obtained from thirty-six patients for culture from twelve to seventy-two hours after the first dose of antibiotics had been given. The microbiological findings in these cultures were similar to those in the cultures of specimens obtained from patients before antibiotics had been given. Five (14 per cent) of thirty-five patients who had been tested for the human immunodeficiency virus had a positive result. This finding emphasizes the importance of surveillance for and precautions against the human immunodeficiency virus in people who abuse drugs parenterally.

Management of chronic deep infection following rotator cuff repair.

BACKGROUND: Deep infection of the shoulder following rotator cuff repair is uncommon. There are few reports in the literature regarding the management of such infections. METHODS: We retrospectively reviewed the charts of thirteen patients and recorded the demographic data, clinical and laboratory findings, risk factors, bacteriological findings, and results of surgical management. RESULTS: The average age of the patients was 63.7 years. The interval between the rotator cuff repair and the referral because of infection averaged 9.7 months. An average of 2.4 procedures were performed prior to referral because of infection, and an average of 2.1 procedures were performed at our institution. All patients had pain on presentation, and most had a restricted range of motion. Most patients were afebrile and did not have an elevated white blood-cell count but did have an elevated erythrocyte sedimentation rate. The most common organisms were Staphylococcus epidermidis, Staphylococcus aureus, and Propionibacterium species. At an average of 3.1 years, all patients were free of infection. Using the Simple Shoulder Test, eight patients stated that the shoulder was comfortable with the arm at rest by the side, they could sleep comfortably, and they were able to perform activities below shoulder level. However, most patients had poor overhead function. CONCLUSIONS: Extensive soft-tissue loss or destruction is associated with a worse prognosis. Extensive débridement, often combined with a muscle transfer, and administration of the appropriate antibiotics controlled the infection, although most patients were left with a substantial deficit in overhead function of the shoulder.

Tissue pressures in pyogenic flexor tenosynovitis of the finger. Compartment syndrome and its management.

We investigated 14 patients with pyogenic flexor tenosynovitis for increased tissue pressures in involved digits. All showed raised pressures, in eight to 30 mmHg or more. These levels are consistent with a compartment syndrome. We describe the results of a modified operative technique which includes irrigation of the sheath and the leaving open of a lateral incision. This also allows early active mobilisation of the finger and has given satisfactory early results.

Treatment of chronic osteomyelitis with muscle flaps.

This article discusses a study of 36 patients with chronic osteomyelitis that had local or free muscle flaps. Reconstruction of chronic osteomyelitis requires infection control and assessment of soft tissue and bone. In patients with osteomyelitis with an ununited fracture or nonunion, stabilization of the fracture is needed.

In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos.

In vitro studies of antibiotic elution from polymethylmethacrylate cement comparing Simplex (Howmedica, Rutherford, NJ) with Palacos brands (Richards, Memphis, TN) have shown variable results. This study compares the elution of tobramycin and vancomycin from Simplex and Palacos beads and spacers. Six-millimeter beads and spacers were incubated in phosphate-buffered saline, and the solution was sampled and changed daily until the concentration of antibiotic fell below the minimum inhibitory concentration (MIC) for Staphylococcus aureus. In all groups, the Palacos PMMA beads and spacers showed elution at higher levels and remained above the MIC longer than did the Simplex PMMA beads. Tobramycin had superior elution to vancomycin in all groups. This in vitro study shows that Palacos PMMA has superior elution properties to Simplex PMMA in tobramycin and vancomycin beads and spacers.

Relation of surface area to in vitro elution characteristics of vancomycin-impregnated polymethylmethacrylate spacers.

To study the relationship between surface area and antibiotic elution from antibiotic-impregnated polymethylmethacrylate (PMMA) spacers, a standard block spacer made of vancomycin (4 g) and 40 g of PMMA was compared with two unique spacer designs, the "donut" and "fenestrated." The spacers were incubated in phosphate-buffered saline, which was changed daily, and a microbiologic assay was used to measure the antibiotic activity of the eluates. The donut and fenestrated spacers had 12% and 40% more surface area than the standard spacer, respectively. There was no significant difference, however, in daily elution levels of antibiotic between the donut spacer and the standard spacer. The fenestrated spacer displayed significantly better elution than either the standard or donut spacers, with an average of 20% more antibiotic eluted on any given day.

Culture results and amputation rates in high-pressure paint gun injuries of the hand.

High-pressure paint gun injuries have been well described in the literature, and the use of antibiotics is recommended as part of their management. However, there is no scientific evidence to support the use of antibiotics. In addition, the type of paint injected (water- versus oil-based) has never been investigated to determine the extent of morbidity resulting from these injuries. This study examines the organisms cultured in wounds resulting from these injuries and whether the type of paint injected had an influence on amputation rates. Charts of 35 patients with high-pressure paint gun injuries to their hands were reviewed. The amputation rate was 50% with oil-based paints and 0% with water-based paints. Forty-seven percent of wound cultures were positive, with gram-negative bacteria found in 58% of isolates. Our findings support the use of antibiotics, which should cover both gram-positive and gram-negative organisms.

VUV photoabsorption spectroscopy of sulfur dioxide ice.

In this paper we present the first study of the VUV photoabsorption spectrum of condensed phase SO(2) recorded over the VUV region 120 to 320 nm (10.33 to 3.64 eV). Distinct spectral features were observed that can be used to distinguish between the formation of amorphous and crystalline ice structures. These signatures may then be used to probe the formation of different ice structures as a function of both deposition rate and substrate temperature.

Introduction to adult posttraumatic osteomyelitis of the tibia.

The tibia is the most frequent site of an open fracture, and treatment of adult posttraumatic osteomyelitis of the tibia represents a significant clinical problem that has been recognized for centuries. Ancient modalities such as immobilization and debridement are still mainstays of therapy, and recent developments such as the use of antibiotics and muscle transfer have helped to improve outcome. Osteomyelitis is classified based on the Cierny-Mader system to provide prognostic and therapeutic information. Open fractures can be classified by the Gustilo system, again providing prognostic and therapeutic data. Gustilo Type III fractures have a high likelihood of having infection develop. Treatment principles include immobilization, thorough debridement, control of infection through antibiotic use, control of dead space, and soft tissue coverage.

Compartment syndrome associated with infection of the upper extremity.

Compartment syndrome is a potentially devastating entity associated with a great variety of injuries, but to the authors' knowledge there are no known reports of infection documented as a cause. A retrospective review of 263 patients with upper extremity infections admitted to the orthopaedic infection ward during 1992 was conducted to identify patients with compartment syndrome directly associated with infection. Four patients' clinical presentations fulfilled the criteria: two presented with infection and compartment syndrome, and two developed compartment syndrome 2-12 hours after admission. All four had beta-hemolytic streptococci on initial culture; three of four grew Group A streptococcus. Fasciotomies and serial debridements were necessary. One patient ultimately underwent amputation through the elbow.

Evaluation of neurosyphilis in human immunodeficiency virus-infected individuals.

The diagnosis of neurosyphilis in patients infected with the human immunodeficiency virus (HIV) remains problematic. We examined the use of the Treponema pallidum hemagglutination (TPHA) index and quantitative tests of CSF by means of microhemagglutination-T. pallidum for diagnosis of neurosyphilis in 58 HIV-infected persons with latent syphilis who had not recently received therapy for syphilis. Five patients (9%) had reactive CSF VDRL tests and thus had proven neurosyphilis. For 13 patients (22%), CSF findings were normal and revealed no evidence of neurosyphilis. For 40 patients (69%), abnormal CSF findings were characteristic of neurosyphilis, but their CSF VDRL tests were nonreactive. Twenty-five of the 40 patients with possible neurosyphilis had pleocytosis and elevated CSF levels of protein and/or IgG. Five (12.5%) of these 40 patients had positive TPHA indices that indicated intrathecal antitreponemal antibody production, a finding that provided greater support for the diagnosis of active neurosyphilis. With use of the TPHA index, patients with CSF abnormalities can be better classified in regard to their need for therapy for neurosyphilis.

Delayed primary wound closure in upper extremity soft tissue infections.

Health care costs for inpatient care have been escalating. Homeless and indigent patients may be unable to have access to clean toilet facilities to perform adequate wound care. Evaluation of delayed primary closure of upper extremity soft tissue infections after incision and drainage in 34 patients was done. Patients were discharged at an average of 8.3 days (range, 5-21 days). This is 11 days less than the reported average granulation time for wounds to heal. No patient required readmission for surgery, wound care, or intravenous antibiotics. The authors' institution charges a rate of $2800 per patient day. A potential savings of $1,047,200 was realized.

Limb salvage for chronic tibial osteomyelitis: an outcomes study.

BACKGROUND: The decision to undergo a limb salvage procedure is difficult and multifaceted. This study reviews the outcomes of patients with chronic tibial osteomyelitis who underwent limb salvage and hopes to enhance our understanding of the impact this complex procedure has on the patient's ability to have a functional and fulfilling life. METHODS: Forty-six patients, with at least 18 months follow-up, who had undergone limb salvage for chronic, refractory tibial osteomyelitis were evaluated. A modification of the Limb Extremity Outcomes Instrument was utilized emphasizing inquiries pertaining to quality of life. RESULTS: Thirty-nine (85%) of the 46 patients were able to ambulate independently without pain. All patients younger than 45 years of age had successful outcomes. Thirty-one percent of the patients with a positive smoking history were failures, and 71% of all failures were smokers. CONCLUSION: Limb salvage seems to be a satisfactory option for patients with chronic tibial osteomyelitis. A history of smoking and advanced age may have adverse affects and are relative contraindications.

Acute hematogenous osteomyelitis. An unusual cause of compartment syndrome in a child.

Acute compartment syndrome of the leg developed in a 4-year-old child due to acute hematogenous osteomyelitis of the proximal fibula. Because of its unusual presentation, the diagnosis of osteomyelitis initially was missed. This report suggests that the diagnosis of acute hematogenous osteomyelitis of the proximal part of the fibula should be considered in young children who present with acute compartment syndrome of the leg and who have no history of recent surgery or trauma.