Clinical manifestations of actinomycosis in Southern Taiwan.

BACKGROUND AND PURPOSE: Actinomycosis is an uncommon and frequently misdiagnosed infection that may present as an acute or indolent process. Even when clinical suspicion is high, the disease is commonly confused with other chronic inflammatory diseases and malignancy. An early diagnosis helps the clinician in deciding treatment and can avoid physical morbidity such as unwarranted surgery. METHODS: We retrospectively evaluated the histopathology and selected clinical information on all cases of actinomycosis that occurred at Kaohsiung Veterans General Hospital in Taiwan from 1993 to 2005. Data on the demographic characteristics, predisposing conditions, clinical presentations, diagnosis and treatment were analyzed. RESULTS: A total 36 cases of actinomycosis were identified and evaluated. The mean age of patients was 52.14 +/- 13.28 years, and the male-to-female ratio was 1:1.1. Only three types of actinomycosis were found in this study: cervicofacial, at an incidence of 31%; thoracic (33%); and pelvic (36%). The clinical manifestations depended upon the region of infection; the most frequent presentations of cervicofacial, thoracic and pelvic actinomycosis were cutaneous soft tissue swelling with drainage sinus formation (55%), hemotypsis (75%) and abnormal vaginal spotting (54%), respectively. The most common initial laboratory abnormalities were normochromic anemia (69%) and leukocytosis (25%). While most patients had no history of a foreign body, all pelvic actinomycotic patients had a history of intrauterine device use. Nineteen patients (53%) had no comorbid conditions and 11 patients (31%) had malignancy. Most patients were initially diagnosed as malignancy (56%). All patients with actinomycosis were diagnosed by histopathologic findings. Twenty two patients (61%) were treated by surgery combined with antibiotics, 11 patients (31%) by surgery only and 3 patients (8%) by antibiotics only. No recurrence or mortality occurred. CONCLUSIONS: Actinomycosis should be included in the differential diagnosis when patients present with chronic drainage sinus, chronic hemoptysis and abnormal vaginal spotting with use of intrauterine devices.

Multidrug-resistant Acinetobacter baumannii in ventilator-associated pneumonia at a medical center in southern Taiwan.

BACKGROUND AND PURPOSE: To evaluate the significance of multidrug-resistant Acinetobacter baumannii (MDRAB)-related ventilator-associated pneumonia at a medical center in southern Taiwan. METHODS: We retrospectively reviewed the medical records of patients with MDRAB isolated from sputum and described the characteristics of these patients. Patients were divided into 2 groups according to their clinical pulmonary infection scores (CPIS), and their host factors and outcomes compared. RESULTS: In the patient group with significant MDRAB-related lung infection, Acute Physiology and Chronic Health Evaluation II scores were significantly higher than in those patients with lower CPIS scores (<6). However, the clinical outcomes, including the duration of hospitalization after isolation of MDRAB and mortality rate, were not different. CONCLUSION: Our investigation showed that significant lung infections with MDRAB isolation did not result in prolonged hospitalization or increased mortality. The initial clinical severity of the group with significant MDRAB-related lung infection was significantly greater than in the other. We propose that MDRAB-related pneumonia should be regarded as a signal of the clinical severity of the patient rather than as a prognostic factor.

Clinical manifestations of eosinophilic meningitis caused by Angiostrongylus cantonensis: 18 years' experience in a medical center in southern Taiwan.

BACKGROUND: With the improvement of public health, eosinophilic meningitis associated with Angiostrongylus cantonensis infection is now seldom reported in Taiwan. Eosinophilic meningitis typically occurred sporadically in children. This study aims to analyze the clinical manifestations and change in the contemporary epidemiology of eosinophilic meningitis in Taiwan. METHODS: This is a retrospective study of patients diagnosed with eosinophilic meningitis at Kaohsiung Veterans General Hospital, from December 1991 to September 2009. The demographic characteristics, clinical presentations, laboratory data, radiographic imaging, and treatment and clinical outcome were analyzed. A PubMed search with the keywords of eosinophilic meningitis, A cantonensis, and Taiwan was performed to retrieve cases of eosinophilic meningitis caused by A cantonensis since 1960. RESULTS: Thirty-seven patients were diagnosed to have eosinophilic meningitis during a period of 18 years. The median age was 32 years (range, 2-80 years). Ninety five percent (35/37) of the patients were adults. The median incubation period was 10.5 days (range, 3-80 days). Most of the patients presented with headache (29, 78%), fever (25, 68%), and 11(30%) had hyperesthesia. Patients with hyperesthesia had longer incubation period (55 vs. 7 days, p=0.004), lower serum immunoglobulin E levels (127.5 vs. 1295 IU/mL, p<0.001), and longer duration between symptom onset and spinal taps (14 vs. 5 days, p=0.011). Three patients presented initially with lymphocytic meningitis, and eosinophilia only appeared on a second lumbar puncture. Magnetic resonance imaging of the brain disclosed leptomeningeal enhancement (17/26, 65%) and increased signal intensity (10/26, 38%) on T2-weighted and fluid-attenuated inversion recovery images. There were eight relapses and two patients died. No sequela was noted except in one 2-year-old toddler, who had weakness of both lower limbs. CONCLUSIONS: The epidemiology of eosinophilic meningitis has changed during the past two decades in Taiwan and occurs mainly in adults in the setting of outbreaks. Hyperesthesia; repeated lumbar puncture in cases with lymphocytic meningitis of uncertain cause; and a detailed history, including food consumption, are important to establish an accurate diagnosis.

Outbreak of Salmonella enteritidis B in a family in southern Taiwan.

BACKGROUND AND PURPOSE: This study describes a Salmonella outbreak in a 9-member family in Southern Taiwan, and emphasizes the risk of Salmonella infection in extreme age. METHODS: Salmonella infection was identified by blood culture, stool swab, and Widal test. A questionnaire was designed for the family to ascertain the underlying disease, symptoms, and history of untreated water and food exposure. RESULTS: Of 9 members in the family, 4 had symptoms of fever, abdominal pain, and watery diarrhea. There was a relationship between Salmonella infection and age, and associated symptoms included fever, nausea, diarrhea, abdominal pain, and weakness. CONCLUSIONS: Salmonella infection tends to occur more frequently in very young or very old people, especially elderly patients with chronic pre-existing comorbidities. Therefore, age is a significant risk factor for this symptomatic disease.

Clinical manifestations of Japanese encephalitis in southern Taiwan.

BACKGROUND AND PURPOSE: Japanese encephalitis virus infection is a sporadic infectious disease in Taiwan. Despite progress in laboratory examinations and imaging studies, diagnosis of Japanese encephalitis remains underestimated. This study was conducted to identify clinical symptoms and laboratory findings that may assist in early identification of this disease. METHODS: This retrospective study included all patients diagnosed with Japanese encephalitis at Kaohsiung Veterans General Hospital from January 2000 through December 2007. Epidemiologic data, predisposing factors, neurological and non-neurological signs and symptoms, laboratory data, and treatment were analyzed. Outcomes and neurological complications were evaluated. RESULTS: Eleven patients had Japanese encephalitis, and 10 had sufficient information for enrolment into the study. Nine patients presented with non-significant constitutional symptoms of fever, nausea, or headache. Other signs and symptoms included rhinorrhea, sore throat, abdominal pain, cough, myalgia, or arthralgia. Eight patients had lymphocytic pleocytosis with elevated protein and borderline low glucose levels in the cerebrospinal fluid. Leptomeningeal enhancement and low density lesions were the most common computed tomography findings. T2 hyperintensity lesions and leptomeningeal enhancement were seen in 5 patients. Two patients presenting with acute flaccid paralysis had high intensity lesions on the thalamus and basal ganglion. There were no correlations between clinical, laboratory, and imaging findings. None of the patients had neurological sequelae. CONCLUSIONS: Presentations, laboratory examination, and clinical signs are not specific for Japanese encephalitis. Sporadic cases are usually seen from May to August, which are associated with monsoon rains. Hence increased awareness of this disease is recommended during these periods.

Comparison of clinical characteristics of amebic liver abscess in human immunodeficiency virus (HIV)-infected and non-HIV-infected patients.

BACKGROUND AND PURPOSE: Amebic liver abscess is an emerging parasitic disease in human immunodeficiency virus (HIV)-infected patients. Clinical characteristics of this disease have rarely been compared between patients with and without HIV infection. METHODS: This retrospective study included 24 patients who had been diagnosed with amebic liver abscess during a 17-year period. The demographics, clinical manifestations, radiographic findings, and outcomes were compared between HIV-infected and non-HIV-infected patients. RESULTS: Among 24 patients with amebic abscess, 8 were HIV-infected and 16 were non-HIV-infected. The mean (+/- standard deviation [SD]) age of HIV-infected patients was 41.0 +/- 11.3 years (range, 27-62 years), which was younger than that of the non-HIV-infected group (58.5 +/- 14.6 years; range, 27-77 years; p=0.01). Compared with non-HIV-infected controls, patients with HIV infection had lower white blood cell counts (median, 17.2 x 10(9)/L vs 10.4 x 10(9)/L; p=0.01), neutrophil/lymphocyte (N/L) ratio (median, 12.1 vs 2.7; p<0.01), total bilirubin (median, 42.7 micromol/L vs 13.7 micromol/L; p=0.02), blood urea nitrogen (median, 7.9 mmol/L vs 4.1 mmol/L; p=0.04), and creatinine (median, 114.9 micromol/L vs 88.4 micromol/L; p<0.01). On multivariate analysis, low N/L ratio remained a significant predictor for HIV infection (odds ratio, 0.49; 95% confidence interval, 0.264-0.912; p=0.024). No significant differences were observed in clinical manifestations, radiographic findings, and indirect hemagglutination titer between the 2 groups. CONCLUSION: HIV-infected patients with amebic liver abscess tended to have a lower N/L ratio than non-HIV-infected comparators.