Herpes simplex virus and recurrent laryngeal nerve paralysis. Report of a case and review of the literature.

A 61-year-old man experienced the abrupt onset of a nonspecific febrile illness followed by the acute development of bilateral vocal cord paralysis. There was no evidence for Guillain-Barré syndrome, multiple sclerosis, brainstem encephalitis, myasthenia gravis, metabolic encephalopathy, poliomyelitis, diphtheria, botulism, tumor, vasculitis, or extrinsic nerve compression. No cause for the fever was ascertained, and the vocal cord paralysis improved sponaneously. Acute and convalescent viral serological studies demonstrated a diagnostic complement-fixation antibody titer rise to herpes simplex virus (HSV) and no rise in titer to influenza A and B, cytomegalovirus, poliomyelitis, or Mycoplasma. This case is similar to several others reported in the literature that suggest a viral neuritis in tenth nerve paralyses in children. The difficulties involved in diagnosing HSV CNS disease before death are discussed, and the medical literature is reviewed for evidence that HSV is the etiological agent in selected cranial neuropathies.

Pneumococcal vaccine strategy. Feasibility of a vaccination program directed at hospitalized and ambulatory patients.

A prospective analysis of patients hospitalized with pneumococcal infection at two Rochester (NY) hospitals was performed during an 18-month period to assess the feasibility of a pneumococcal vaccination program directed at inpatients. Of the 113 patients hospitalized with pneumococcal infection, only nine patients (8%) had previously received pneumococcal vaccine and 76 patients (67%) had been hospitalized at least once in the previous three years. Of the 104 patients who had a source of regular medical care, 100% had made at least one outpatient visit in the previous three years. The association between the acquisition of a serious pneumococcal infection and hospitalization within the previous three years suggests that a vaccination strategy directed at hospitalized high-risk patients would be potentially effective. Also, vaccination of high-risk ambulatory patients remains a viable strategy to prevent serious pneumococcal infection.

Candida fungus balls in the common bile duct. Unusual manifestation of disseminated candidiasis.

Disseminated candidiasis appearing as Candida fungus balls in the common bile duct developed in a patient with acute myelogenous leukemia. The patient had received broad-spectrum antimicrobial therapy for fever of unclear origin and subsequently manifested signs of liver cell dysfunction. A percutaneous transhepatic cholangiogram demonstrated three radiolucent defects in the distal part of the common bile duct, which proved to be fungus balls at operation. The liver was studded with microabscesses that disclosed C albicans on biopsy. The biliary tract fungus balls were removed surgically, and the patient was treated with 2,001 mg of intravenously administered amphotericin B over a 2 1/2-month period. No evidence of Candida infection is evident eight months after completion of therapy.

Promoting completion of health care proxies following hospitalization. A randomized controlled trial in a community hospital.

BACKGROUND: The wider use of written advance directives is popular but problematic. We have shown previously that acute hospitalization in the era of the Patient Self-Determination Act can facilitate directive discussions and documentation. We investigated whether a simple educational intervention following hospitalization would increase patients' execution of durable health care proxies. METHODS: We studied a consecutive series of patients (n = 162) recently discharged from the acute care medical service of a community hospital where they had been interviewed about advance directives. The intervention group was randomized to receive an educational brochure and encouragement to execute durable health care proxies. The primary outcome was the proportion of patients in each group with completed durable health care proxies on file in their primary physicians' offices. RESULTS: Overall, only 20 (12.3%) of 162 patients had documented proxies, 17 of whom (85%) were 65 years of age or older, with no difference between the intervention and control groups (11 [13.3%] of 83 vs nine [11.4%] of 79, respectively). Subgroup analysis of elderly patients also revealed no intervention effect. Univariate analysis revealed three significant predictors of patients' proxy completion: patient age, whether patients had discussed directives in hospital with their physicians, and whether patients' physicians completed proxies for themselves. Multiple logistic regression analysis showed that these three variables interact to predict the probability of patients' executing proxies. CONCLUSIONS: Simple educational interventions, like those mandated by the Patient Self-Determination Act, are unlikely to increase patients' completion of durable healthcare proxies. Multidimensional interventions that target both elderly patients and their personal physicians should be tested in the future. Discussion in hospital about advance directives can be a useful component of such efforts.

Promoting inpatient directives about life-sustaining treatments in a community hospital. Results of a 3-year time-series intervention trial.

BACKGROUND: Hospitalization presents an opportunity for physicians to discuss advance directives with patients and to encourage completion of health care proxies. OBJECTIVE: To prospectively promote discussion and documentation of treatment-specific directives about life-sustaining interventions (cardiopulmonary resuscitation, admission to critical care units, mechanical ventilation, electrical cardioversion, and vasopressor therapy) among unselected medical inpatients in a community teaching hospital. METHODS: We conducted a time-series intervention trial from January 1, 1991, through June 30 1993, divided into three phases. During the education phase, we provided reminders, education, and feedback to attending physicians; during the intervention phase, we promoted a new documentation form for directives to be used by attending physicians; during the control phase, no interventions occurred. We studied consecutive patients (N = 1780) admitted to the hospital acute medical service in each of the following 10 periods: three in the education phase (n = 598), three in the intervention phase (n = 826), and four in the control phase (n = 356). The primary outcome measures were the frequency and content of directives documented by attending physicians in their patients' hospital charts. Secondary outcome measures included physicians' and patients' attitudes about directives, surveyed repeatedly. RESULTS: The proportion of inpatients with directives increased significantly during the intervention phase (62.5% vs 23.6% during the education phase and 25.3% during the control period, P < .001, Pearson chi 2 test). During the final intervention phase, 227 (83.2%) of 273 inpatients had directives documented in the hospital chart. Increases in clinically important ("impact") directives usually involved intensive care, not do-not-resuscitate status. Overall, 366 (86.7%) of 422 physician-attested directives agreed with the treatment preferences of interviewed patients (kappa ranges, 0.53 to 0.79). Physicians' attitudes about and interest in directives improved. CONCLUSIONS: Institutional interventions can facilitate attending physicians' documentation of treatment-specific directives about life-sustaining care for most medical inpatients. More research is needed to confirm the effect of these efforts on quality and cost of hospital care, patients' autonomy, and their eventual execution of durable directives and proxies.

Can we talk? Inpatient discussions about advance directives in a community hospital. Attending physicians' attitudes, their inpatients' wishes, and reported experience.

BACKGROUND: The attitudes of hospitalized patients and their attending physicians about advance directives have not been well studied. We compared these attitudes and explored relationships between them and the frequency of actual directives and directive discussions during hospitalization. METHODS: We conducted scripted interviews with 258 (94.5%) of 273 patients admitted consecutively to the acute medical service of a community teaching hospital in Rochester, NY, and contemporaneously surveyed their attending physicians (n = 68) regarding attitudes about advance directives. Primary outcome measures were patients' willingness to discuss directives, actual physician-patient directive discussions, and patients' preferences for life-sustaining treatments. Also measured were physicians' indications for directive discussions, their reasons not to discuss directives, and their knowledge and attitudes about life-sustaining treatments. RESULTS: Eighty-one percent (172/212) of competent interviewed patients either did (100) or wanted to (72) discuss advance directives in hospital. Forty-one percent of patients chose to forgo cardiopulmonary resuscitation; 24% to 41% refused other life-sustaining interventions (intensive care unit admission, mechanical ventilation, cardioversion, vasopressors). Overall, 90% (246/273) of all patients met at least one of three criteria reported by their physicians as indications for advance directive discussions: age at least 75 years, critical or potentially fatal illness, and patients' desire to discuss directives. Multiple logistic regression revealed that these same variables predicted patients' willingness to discuss cardiopulmonary resuscitation, their preferences to receive or forgo cardiopulmonary resuscitation, and the frequency of physician-patient discussions about these issues. CONCLUSIONS: Most medical inpatients in a community hospital want to, are able to, and meet their own physicians' indications to discuss advance directives. Hospitalization presents an unrealized opportunity for physicians and patients to initiate these discussions.

Grand mal seizures and acute intermittent porphyria. The problem of differential diagnosis and treatment.

A 36-year-old white man had both acute intermittent porphyria and long-standing idiopathic grand mal seizures. Diphenylhydantoin apparently adversely affected both the clinical and biochemical parameters of the acute intermittent porphyria. Comparison of urinary levels of the porphyrin precursors, delta aminolevulinic acid and porphobilinogen, under controlled diet conditions before and after withdrawal of diphenylhydantoin, showed that this drug accounted for approximately one-half of the porphyrin precursor excretion. Significant clinical improvement of the porphyria followed withdrawal of the diphenylhydantoin. Bromides appeared to be approximately as effective as diphenylhydantoin for seizure control in this patient.

A comparison of two methods of processing blood cultures in a community hospital.

Two different methods of processing blood cultures were compared at a community hospital. A day three "blind" subculture and five days of observation for visible growth was used during one year (Phase I), compared with a day five "blind" subculture and seven days of observation for visible growth during the second twelve-month period (Phase II). Phase II was not associated with an increased number of probable pathogens isolated from blood cultures, compared with the earlier "blind" subculture and shorter observation for visible growth used during Phase I. Instead, the later "blind" subculture and longer observation for visible growth yielded a significantly greater number of probable blood culture contaminants. Recommendations for processing of blood cultures developed at referral centers may not be applicable to community hospitals, and the timing of "blind" subcultures and duration of observation for visible growth should be based on the unique patient population characteristics of each hospital.

Nosocomial enterococcal infections: association with use of third-generation cephalosporin antibiotics.

Enterococcal infections consistently account for approximately 10% of all nosocomial infections reported to the Centers for Disease Control. There is concern that an increase in nosocomial enterococcal infection is due to the increased severity of inpatient illnesses and to the widespread use of broad-spectrum beta-lactam antibiotics. Nosocomial enterococcal infections were analyzed at our medium-sized community hospital over a time period spanning 9 years. A significant increase in the infection rate was detected during the latter half of 1986. This increase was due primarily to a disproportionate rise in the incidence of the urinary tract as a site of infection. There were no associated clusters of infection, no predilection for certain patient care areas, and no preceding change in the hospital infection control policies and procedures. Total hospital use of cephalosporins remained stable during the period of increased enterococcal infections, but use of third-generation cephalosporins almost doubled in 1986 compared with the 4 preceding years. Selective pressure of third-generation cephalosporin use appeared to be a factor in the increased incidence of nosocomial enterococcal urinary tract infection.

Comparative effects of glycerol and dextrose on porphyrin precursor excretion in acute intermittent porphyria.

The effects of dietary manipulations on excretion of the porphyrin precursors, delta-aminolevulinic acid (ALA), and porphobilinogen (PBG) were studied in eight patients with acute intermittent porphyria. Three diet periods of 9-17 days comprised each study. In each patient, a "baseline" protein, fat, and carbohydrate intake was kept constant throughout. In addition, during the first diet period each patient received 150 g dextrose; during the second, this was replaced by an isocaloric amount of neutral fat; and during the third, the fat was replaced by 150 g glycerol. In each of the patients, three comparisons of the effect of diet on both ALA and PBG excretion were made: (1) 300 g carbohydrate versus 150 g carbohydrate (dextrose versus fat), (2) 150 g carbohydrate + 150 g glycerol versus 150 g carbohydrate (glycerol versus fat), and (3) 300 g carbohydrate versus 150 g carbohydrate + 150 g glycerol (dextrose versus glycerol). For each of these three diet comparisons, there are sixteen individual comparisons possible for the effect of diet on porphyrin precursor excretion, eight for ALA and eight for PBG. Thus, the mean values for ALA and PBG excretions during each of the diet periods are statistically compared internally within each individual patient. Increasing carbohydrate intake from 150 g to 300 g by isocaloric substitution of dextrose for fat produced a significant (p less than 0.05) decline in eight of the sixteen comparisons of ALA and PBG excretion. Addition of 150 g glycerol by isocaloric substitution for fat caused a significant (p less than 0.05) decline in nine of the sixteen possible comparisons. In the sixteen comparisons of isocaloric dextrose and isocaloric glycerol-substituted diets, dextrose produced significantly (p less than 0.05) lower porphyrin precursor excretion in four cases and glycerol produced significantly (p less than 0.05) lower values in five. One patient showed no significant change on any of the diets. Of the four patients having symptoms believed referrable to porphyria during the study, three reported an improvement in symptoms during the high glycerol intake. The effects of dietary perturbations on porphyrin precursor excretion in acute intermittent porphyria are variable, but glycerol appears to be capable of decreasing the excretions and may prove useful in treating some of these patients.

Legionnaires' lung abscess.

A patient with a clinical course consistent with Legionnaires' disease rapidly developed acute respiratory failure. Sputa and bronchoscopic washings revealed many polymorphonuclear leukocytes but no organisms on gram stain and culture. The diagnosis of Legionnaires' disease was strengthened when the transthoracic aspirate revealed weakly staining gram-negative bacilli with no growth noted on culture. Serologic titers confirmed the diagnosis of Legionnaires' disease. This patient's course was complicated by cavitation which responded to medical therapy with erythromycin. This is the second reported case of Legionnaires' lung abscess.

Longitudinal analysis of endemic gentamicin- and tobramycin-resistant gram-negative bacilli in a community hospital.

The epidemiology of endemic gentamicin- and tobramycin-resistant gram-negative bacilli at a community hospital was analyzed over a one-year period three years following an original analysis at the same hospital. The frequency and distribution of resistant organisms remained stable over the time spanning the two studies. Only 2.8% of all gram-negative bacilli were resistant to gentamicin or tobramycin, and the majority of resistant isolates were non-Enterobacteriaceae. The respiratory and urinary tracts remained the body sites most prone to harbor resistant organisms. Risk analysis using a matched comparison group again revealed prior treatment with an aminoglycoside to be the only significant factor pre-disposing to acquisition of resistant gram-negative bacilli. This analysis indicates that community hospitals may not be important reservoirs of endemic aminoglycoside-resistant gram-negative bacilli, and reconfirms the observation that each hospital must define its own pattern of aminoglycoside resistance and unique risk factors.

Aberrant forms of Escherichia coli in blood cultures: in vitro reproduction of an in vivo observation.

Aberrant filamentous forms of Escherichia coli were observed on direct Gram stain of blood cultures from a patient being treated with the beta-lactam antibiotic cephalexin. After the institution of an alternative antibiotic regimen which included a different cell wall-active agent, E. coli of normal morphology was detected in blood cultures for an additional 48 h. Filamentous forms of E. coli could be reproduced reliably in vitro by incubating the organism in Mueller-Hinton broth containing various concentrations of cephalexin. Both supra- and subinhibitory concentrations of cephalexin resulted in filament formation after 4 h of incubation, whereas 24 h of incubation yielded intact filaments at only a narrow range of subinhibitory concentrations of cephalexin. In vitro comparison of the ability of cephalexin, cephalothin, ampicillin, and gentamicin to cause filamentous forms of E. coli showed that cephalexin and cephalothin produced pure filament formation after 4 h of incubation at subinhibitory concentrations of as low as one-fourth the minimum inhibitory concentration of the antibiotic. Ampicillin was not associated with pure filament formation at concentrations below the minimum inhibitory concentration, and gentamicin produced no filaments at any concentration. The effect of preincubation of E. coli with subinhibitory concentrations of cephalexin on subsequent minimum inhibitory concentrations of ampicillin was examined in an effort to develop an explanation for the persistent sepsis exhibited by the patient. No diminution of the activity of ampicillin by preincubation with cephalexin could be demonstrated. Other possible clinical implications of filamentous forms of gram-negative bacilli are discussed.

Perinephric abscess due to a coagulase-negative Staphylococcus: case report and review of the literature.

Perinephric abscess is an uncommon urinary tract infection that usually is caused by Staphylococcus aureus as a single pathogen or gram-negative bacilli as part of a polymicrobial process. We describe a man who presented with a right perinephric abscess due to coagulase-negative Staphylococcus as the only pathogen. The patient had bilateral nephrolithiasis, and he was treated successfully with percutaneous drainage of the abscess and parenteral antibiotics. Coagulase-negative staphylococci are increasingly reported to cause serious infections. This organism can no longer be routinely dismissed as a contaminant or colonizer. Repeated isolation of coagulase-negative Staphylococcus in the absence of other pathogens must be considered a high risk situation.

Gentamicin and tobramycin resistant gram-negative bacilli in a community hospital.

The incidence and spectrum of resistance to gentamicin and tobramycin among gram-negative bacilli (GNB) isolated in a community hospital over a one-year period were studied. The overall incidence of resistance was 3.7%. Pseudomonads constituted almost half of the resistant organisms. The majority of resistant GNB was isolated from the respiratory and urinary tracts. Acquisition of resistance was correlated with both the total use of gentamicin in the hospital and recent treatment of individual patients with gentamicin plus tobramycin. The overall incidence of resistant isolates (3.7%) and the incidence of resistance for the enterobacteriaceae (1.9%) were lower than rates reported by comparable studies at several university or municipal hospitals.