Candidal sinusitis and diabetic ketoacidosis. A brief report.

A 55-year-old man presented with diabetic ketoacidosis and pansinusitis due to infection with Candida albicans. The infection responded to local drainage procedures, the administration of amphotericin B (2 g), and aggressive medical therapy of the ketoacidosis. Sinusitis due to C albicans is rare but may be more frequently seen in the immunocompromised host. Unlike those infections caused by Mucor or Aspergillus species, sinusitis due to C albicans may respond to local drainage and amphotericin B therapy.

The utility of Osler's nodes in the diagnosis of infective endocarditis.

The etiology of Osler's nodes remains controversial. We describe a patient with endocarditis in whom Streptococcus sanguis was grown from the biopsy of such a lesion. Bacterial embolic events are likely to be the major pathogenetic event in the development of Osler's nodes, and recognition of the etiology of infective endocarditis may be found through biopsy of them.

Homeless individuals and drug-resistant tuberculosis in south Texas.

Drug-resistant tuberculosis was found in 21 percent of homeless individuals in New York City between 1982 and 1987. To see if this relationship existed in south Texas, we evaluated all admissions to a Texas Health Department facility with culture-proven tuberculosis. Four hundred forty-three patients were admitted between September 1987 and October 1990. Twenty-six, (5.9 percent) of these patients were identified as homeless. Alcoholism, tobacco abuse, divorce, and unemployment were common demographic characteristics. Six male patients and one female patient (27 percent) had Mycobacterium tuberculosis resistant to one or more antituberculosis drugs. Five were Hispanic, one was white, and one was black. The six male patients had resistance to only one drug, either rifampin or ethambutol. The female patient had resistance to streptomycin, isoniazid, and rifampin. These findings illustrate that drug-resistant tuberculosis exists among homeless individuals in south Texas. As the number of homeless people increases, physicians need to recognize that pulmonary tuberculosis is a frequent infection in this population and that the causal mycobacteria may well be resistant to one or more antituberculosis agents.

Clinical value of paired sputum and transtracheal aspirates in the initial management of pneumonia.

One hundred young adults with acute pneumonia were prospectively studied to determine the impact of the transtracheal aspiration (TTA) Gram stain on immediate management. Sputum and TTA interpretations by staff and housestaff were compared. After a management plan was elected based on sputum Gram stain interpretation, the TTA was evaluated and the final plan chosen. A change in treatment after the TTA was available occurred in eight cases, and this was an appropriate change in only five. The putative pathogen as identified by TTA culture was correctly predicted after sputum Gram stain interpretation in 36 to 62 percent of cases and after TTA interpretation in 37 to 62 percent. This indicates significant observer variation but not superiority of one type of specimen over the other. In most cases, paired sputum and TTA Gram stain were both read correctly or incorrectly. When differences occurred, sputum interpretations were as likely to be correct as were TTA interpretations. The TTA Gram stain offered no advantage over sputum Gram stain in the initial management of acute pneumonia in this young adult military population.

Tuberculosis in Korea. The relationship between prior therapy and drug resistance.

A review of 121 culture-positive cases of pulmonary tuberculosis from 1979 to 1984, including both Korean and American patients, at the major US military hospital in Korea indicated that most antituberculosis drug resistance occurred in patients with a history of previous antituberculosis therapy. The 98 patients without previous therapy who were not household contacts of a known resistant case had low rates of drug resistance (7 percent to isoniazid, 5 percent to streptomycin, 2 percent to p-aminosalicylic acid, and none to rifampin or ethambutol). All were sensitive to at least two of the drugs in the commonly prescribed regimen of isoniazid, rifampin, and ethambutol. In contrast, both patients who were household contacts of a known resistant case and 11 (52 percent) of the 21 patients with previous therapy had drug-resistant organisms. Our data support the use of isoniazid as preventive therapy for those who develop tuberculin reactivity while in Korea, in the absence of close contact with a known resistant case. Our data also suggest that the regimen of isoniazid, rifampin, and ethambutol is appropriate initial therapy for active disease acquired in Korea, provided that an adequate history excluding these risk factors can be obtained.

Pulmonary tuberculosis in diabetics.

Pulmonary tuberculosis is found predominantly in the lung apices. In diabetics it has been suggested that tuberculosis tended to occur predominantly in the lower lobes. A retrospective chart review was performed of all patients with a diagnosis of diabetes and pulmonary tuberculosis admitted to a health care facility to determine the presenting chest roentgenographic location of tuberculosis. Multiple lobe involvement was the predominant chest roentgenographic finding in both diabetics and nondiabetics with pulmonary tuberculosis. Since tuberculosis and diabetes frequently coexist in the population at risk for tuberculosis, clinicians should suspect tuberculosis in the diabetic with an abnormality on chest roentgenogram. Aggressive diagnostic measures and specific chemotherapy should be given and monitored to treat pulmonary tuberculosis.

Tuberculosis. Cause of death in antibiotic era.

A five-year review (1979 to 1983) of 41 patients with active tuberculosis at the time of death was performed to determine the cause of death. Twenty deaths (49 percent) were directly attributed to tuberculosis. Overwhelming tuberculous disease was the cause of death for seven patients, and among them the majority had strikingly low serum levels of albumin. Ten patients died of either massive hemoptysis or respiratory failure. Only two patients died due to progressive drug-resistant disease in an area where drug resistance is common. The majority of patients (21/41; 51 percent) died of common medical problems unrelated to tuberculosis. Eleven patients died from cardiopulmonary disease (five pulmonary emboli, one respiratory failure due to chronic obstructive pulmonary disease, two acute myocardial infarctions, and two primary dysrhythmias). Three deaths were the result of gastrointestinal bleeding, and three patients died as a result of bacterial superinfection. Our data indicate that patients still die of tuberculosis in the era of effective antituberculosis therapy. It is imperative that clinicians are aware that pulmonary emboli, arteriosclerotic heart disease, bacterial superinfection, and gastrointestinal bleeding cause approximately 50 percent of the deaths among patients who have tuberculosis and that prompt recognition and treatment of those diseases might decrease the mortality from tuberculosis.

The lack of utility of the latex agglutination test for detection of Candida antigen in the diagnosis of systemic candidiasis.

The Ramco latex agglutination test in the diagnosis of systemic candidiasis was utilized for 11 serum samples from 10 patients with systemic candidiasis, 21 serum samples from patients colonized with Candida species, and 20 control serum samples from patients with stable medical problems and no evidence of Candida albicans infection. This study was double-blind and the results of the latex agglutination test did not influence the decision for antifungal therapy. Nine of 10 patients with systemic candidiasis had positive titers (greater than or equal to 1:4); however, these were determined only 1 to 5 days before culture positivity. Nine of 21 (43%) of colonized patients were falsely positive (greater than or equal to 1:4) and all of the control samples were negative. The Ramco latex agglutination test was unreliable and inconsistent in this small sample group to establish an early diagnosis of systemic candidiasis.

Fungemia due to Torulopsis glabrata.

Torulopsis glabrata is a yeast ordinarily considered nonpathogenic. Systemic infection with this yeast occurs in patients who are debilitated, immunosuppressed, diabetic, or receiving multiple antibiotics. We have presented a case of fungemia due to T glabrata in a previously healthy person. The predisposing condition resulting in debility and predisposition to fungemia was major vascular surgery. Treatment with amphotericin B eradicated the fungemia.

Bubonic plague.

A 19-year-old man, recently returned from a 10-day military exercise in central California, had acute onset of shaking chills, headache, and bilateral inguinal adenopathy after having been bitten by insects on his lower extremities. He had exquisitely tender inguinal and femoral nodes bilaterally. Needle aspirate from an inguinal node grew Yersinia pestis. The patient was treated with streptomycin and chloramphenicol and did well.

Osler's nodes and the recognition of infective endocarditis: a lesion of diagnostic importance.

Osler's nodes are classic lesions strongly associated with infective endocarditis. Osler's original description placed them as a frequent finding (70%) in cases of endocarditis. Recent literature, however, has infrequently described these lesions, which in general are no longer found to be useful. We review the clinical syndromes of infective endocarditis and their association with these lesions. We also review the pathogenesis of the lesion that currently supports the embolic nature of Osler's nodes. Osler's nodes are helpful clues if they appear in patients with infective endocarditis, and biopsy and culture of the lesion may provide an etiologic diagnosis.

Bacteremia due to Pasteurella multocida.

Pasteurella multocida should be considered as a possible etiologic agent in any infection that is the result of an animal bite or scratch. Because of its opportunistic capability, it should be included among the possible pathogens in bacteremia, particularly in any patient with immunosuppression or liver cirrhosis, especially if there is a history of animal exposure.

Anticoagulation in prosthetic valve endocarditis.

We reviewed the experience with infective endocarditis at some major US Army Medical Centers. One hundred patients were studied, comparing 82 patients who had native valve endocarditis (NVE) with 18 patients who had prosthetic valve endocarditis (PVE). Among patients with PVE, four had porcine valves and 14 had synthetic. None of the patients with NVE had received anticoagulants; 14 of 18 patients with PVE had received anticoagulants. The major causes of death were central nervous system hemorrhage, congestive heart failure, uncontrolled infection, and embolic phenomena. The principal cause of death in patients with PVE was CNS hemorrhage. Of the patients with PVE, 36% had symptomatic cerebral hemorrhage while receiving anticoagulants and 80% of them died.

The lion of the union: the pelvic wound of Joshua Lawrence Chamberlain.

PURPOSE: Major General Joshua Lawrence Chamberlain is a true American hero. His medical history and war wounds provide a rare snapshot of Civil War era medicine. In particular the most devastating injury was a rifle shot through the pelvis rupturing the bladder and urethra. We describe this injury and how it affected his life to provide insight into late 19th century urological care. MATERIALS AND METHODS: All available references, including biographies, letters, surgical reports, military documents and prior medical summaries, were reviewed regarding Chamberlain's urological history. RESULTS: While leading the Union charge to Petersburg, Virginia on June 18, 1864, Chamberlain was struck with a minié ball anteriorly below the right greater trochanter. The ball coursed obliquely upward disrupting the bladder and urethra, and embedded behind the left acetabulum. An unprecedented wound exploration in the field hospital was performed to extract the bullet and "reconnect severed urinary organs." Hope for recovery was nonexistent as urine was seen exiting the lower wound postoperatively. This genitourinary injury required 4 subsequent repairs during Chamberlain's lifetime and ultimately left him with a draining urethrocutaneous fistula at the penoscrotal junction. CONCLUSIONS: Survival from catastrophic Civil War wounds was rare, especially from "gut wounds" which had a mortality rate of greater than 90%. Chamberlain not only survived but thrived with his sense of duty carrying him back to the battlefield and beyond. He was plagued during his life with recurrent cystitis and epididymo-orchitis, which in an era without antibiotics was especially miserable. Urosepsis is listed as the cause of death on his death certificate and whether this was true is debatable. However, even if this wound did not cause his death, it surely contributed to it.