Septic monoarthritis of the first carpo-metacarpal joint caused by Mycobacterium kansasii.

A case of septic carpal monoarthritis due to Mycobacterium kansasii developing 16 months after accidental inoculation in a healthy laboratory technician is reported. No predisposing factor such as immunosuppression, preexisting degenerative, inflammatory arthritis or cortisone injection was present. Treatment with antituberculous oral medication alone resulted in resolution of the disease. Synovectomy was unnecessary. Ten years after the initial causative event, the patient remains free of symptoms.

[Mediastinal mass, pulmonary infiltration, and meningitis]. / Masse médiastinale, infiltrat pulmonaire et méningite.

A 42 year-woman suffering from a non-small cell lung cancer, presenting initially as a mediastinal tumor, is hospitalized for fever, headaches and nausea. An aseptic meningitis is diagnosed. The patient died despite the administration of broad spectrum antibiotics and antituberculous agents. The differential diagnoses are presented.

A first case of Streptococcus bovis bacteremia and peritonitis from endometrial cancer origin.

BACKGROUND: The most important clinical infections caused by Streptococcus Bovis are bacteremia and endocarditis. Usually, Streptococcus Bovis bacteremia has been described in association with bowel pathology. CASE REPORT: A 67-year-old woman with an history of endometrial cancer Ic was admitted with the suspicion of peritonitis at examination. At exploratory laparotomy, a total hysterectomy was performed and the abdomen was drained. Histology revealed an uterine adenocarcinoma staged IIIa with intramyometrial cocci accumulation. Streptococcus Bovis was isolated from the peritoneal fluid cultures and three haemocultures. CONCLUSION: Because we excluded bowel pathology and endocarditis, this is the first case of Streptococcus Bovis bacteremia from endometrial cancer origin.

Fatal primary infection due to human herpesvirus 6 variant A in a renal transplant recipient.

We describe a fatal primary human herpesvirus 6 (HHV-6) variant A infection in a kidney transplanted adult woman. On day 20 post transplantation (TX), after rejection therapy, the patient presented an acute hemophagocytic syndrome with hepatitis and central nervous system involvement. HHV-6 IgG and IgM antibodies seroconversion was demonstrated. HHV-6 variant A was the sole pathogen detected by nested PCR and/or culture in blood, bone marrow aspiration, liver biopsy, cerebrospinal fluid and bronchoalveolar lavage. The graft was HHV-6 seropositive and the patient was not transfused before day 28 post TX, suggesting that the virus was transmitted by the graft. Despite immunoglobulins, ganciclovir and foscarnet therapy, the HHV-6 infection progressed and led to severe aplasia. The patient developed Aspergillus fumigatus pneumonia and died from fulminant candidemia. This case demonstrated for the first time that HHV-6 variant A primary infection can cause life-threatening disseminated infection in immunosuppressed patients.

Ceftazidime- and imipenem-induced endotoxin release during treatment of gram-negative infections.

To determine whether ceftazidime and imipenem, which target two different penicillin-binding proteins, result in different amounts of endotoxin and cytokine release in patients with gram-negative infection, plasma endotoxin, interleukin-6, and tumor necrosis factor alpha were measured during the first 24 h of antibiotic therapy in 27 patients with gram-negative infection who had been randomized to receive either ceftazidime 2 g t.i.d. (n=12) or imipenem/cilastatin 1 g t.i.d. (n=15). The source of infection was the digestive tract (n=13), the urinary tract (n=5), the respiratory tract (n=2), soft tissue (n=2), i.v. line (n=2), or other (n=3). After the first antibiotic injection, a significant increase in the median concentration of plasma interleukin-6 and plasma tumor necrosis factor alpha was noted, without significant differences related to the antibiotic administered. Antibiotic-induced endotoxemia was detectable in nine patients (including 7 with bacteremia). In conclusion, ceftazidime and imipenem had similar effects on endotoxin and cytokine release during the treatment of gram-negative infections.

[Prosthesis-related infections]. / Infections de prothéses.

Long-term prosthetic devices are rapidly recovered by host proteins which increase bacterial adhesion. The bacteria can also produce extracellular polysaccharide material, which in combination of host proteins, produce a biofilm. This one decreases the host defense mechanisms, antibiotics penetration and efficacy, increasing infectivity of the pathogens. Most often, the device is contaminated in the perioperative period by commensal flora. It can also be infected by hematogenous seeding or by contiguous infection. Various clinical presentations of infected devices are described depending on the type of prosthesis, its anatomical localisation and the time elapsed since insertion. Postoperative acute sepsis, insidious infectious signs or isolated device malfunction without signs of infection have all been described. The prosthetic infection rate is low, but when it occurs, the consequences are catastrophic. Excepted in some selected cases, the classical treatment combines the removal of the prosthesis and a long-term appropriate antibiotic therapy. If infection is suspected, it's crucial to establish the diagnosis accurately often by using invasive diagnostic methods (CT-scan guided biopsy, etc.) to obtain adequate samples which detailed microbiological analysis should be carefully interpreted.

Treatment of bone and joint infections: recommendations of a Belgian panel.

A multidisciplinary panel of Belgian specialists describes the overall therapeutic approach for bone and joint infections. Classification, general methods of investigation, therapeutic options, special circumstances, the role of aminoglycosides and of glycopeptides are described. The possibility of home treatment is discussed, as well as some pharmaco-economic insights.

Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial therapy for bacteremia.

Antimicrobial therapy for 428 episodes of bacteremia in an 850-bed university hospital was prospectively evaluated for 1 year to measure the impact of two factors--blood culture results and the therapy chosen by infectious diseases specialists (IDSs)--on quality of treatment and outcome. Initial shock, a simplified acute physiology score of >15, and inappropriateness of the empirical treatment were independently associated with increased mortality. Empirical treatment was appropriate in 63% of the episodes. This proportion reached 78% for the episodes treated by IDSs, compared with 54% for the others (P < .001). After availability of blood culture results, the proportion of appropriate treatments increased to 94%, with 97% for IDS-treated patients and 89% for other patients (P = .008). IDSs more frequently shifted to oral antibiotics and used fewer broad-spectrum drugs. This study underlines the impact of blood culture results and of IDSs on the prescription of appropriate treatment for bacteremia and on the better use of antimicrobial drugs.

Penetration of meropenem in lung, bronchial mucosa, and pleural tissues.

Lung, bronchial mucosa, and pleural tissue samples were obtained from 14 patients undergoing lung surgery 1 to 5 h after administration of 1 g of meropenem. The mean (range) peak concentrations of meropenem were 3.9 (0.2 to 8.2), 6.6 (3.0 to 13.3), and 2.8 (0.6 to 7.8) mg/kg of tissue, respectively, exceeding the MICs at which 90% of isolates are inhibited for most respiratory pathogens.

Tuberculous inguinal and crural lymph nodes.

Non-respiratory forms of tuberculosis are frequently described in immigrants from endemic countries and in immunocompromised patients. Among the extrapulmonary forms of tuberculous disease, peripheral lymph node involvements, generally cervical, are the most common. Interestingly, only a few cases of tuberculous inguinal adenitis have been reported in the literature during the last 15 years. We report 2 cases of isolated inguinal inflammatory lymph-adenitis observed in immigrant immunocompetent women. The diagnosis of tuberculosis was confirmed by culture obtained by needle aspiration of a lymph node. The lesions completely healed after standard antituberculous therapy.

Compassionate use of amphotericin B lipid complex (Abelcet) in life-threatening fungal infections: report of 30 courses.

OBJECTIVE: To report a single-center experience of compassionate use of amphotericin B lipid complex (ABLC) in patients with proven or suspected fungal infection who were or would have been unable to tolerate conventional amphotericin B. METHODS: Twenty-eight patients receiving 30 courses of ABLC for 22 proven invasive mycosis episodes (11 aspergillosis, seven candidosis, four miscellaneous) and eight suspected episodes are described. Seven patients were given ABLC first-line therapy because of conditions precluding the use of amphotericin B deoxycholate (Am B). Twenty-one patients, initially given Am B, were shifted to ABLC because of failure in four, nephrotoxicity of AM B alone or in combination with another drug in 15, and acute side effects in two. The initial dose of ABLC was 5 mg/kg per day; this could be lowered to 3 mg/kg per day or transiently interrupted in cases of impairment of renal function. RESULTS: A mean cumulative dose of 6107 mg (660--16 050) was given over a mean duration of 22 days (4--49). Clinical response rate was 63% (14/22), with mycologic eradication in 37% (9/17) in proven infections. For proven aspergillosis, corresponding rates were 54% (6/11) and 20% (2/10), and in proven candidosis 71% (5/7) and 60% (3/5), respectively. Twenty-one courses were complicated by one or more side effects: fever and chills (11), impairment of renal function requiring a transient reduction of drug dosage (14), hypotension (1). However, for the whole group, creatinine clearance before and after 2, 4 and 6 weeks of treatment remained quite stable. CONCLUSIONS: ABLC, with its low toxicity, enabled us to treat patients who were or would have been unable to tolerate an efficacious dose of Am B. No conclusions about efficacy can be drawn from this small-size, compassionate study. Well-designed studies to compare efficacy and safety of conventional amphotericin B and the various lipidic formulations should be implemented.

Candida albicans septic thrombosis of the right atrium is associated with a central venous catheter.

Right atrial thrombus formation is a rare complication of central venous catheterization in adults. Infection of this thrombus is exceptional. A case of a right atrial thrombus associated with Candida albicans infection is described. Surgical thrombectomy, withdrawal of the catheter, and long-term antiinfectious therapy seem the only appropriate treatment. The literature on this unusual condition is reviewed.

Antibiotic prophylaxis for infectious complications after therapeutic endoscopic retrograde cholangiopancreatography: a randomized, double-blind, placebo-controlled study.

We performed a randomized, double-blind, placebo-controlled trial of antibiotic prophylaxis before diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in 82 uninfected patients with cholestasis due to biliary tree obstruction of single or multiple causes. The patients were assigned to receive piperacillin (4 g) or placebo three times daily; prophylaxis was started just before initial ERCP and was continued until biliary drainage was completely unobstructed (by one or more ERCP procedures); the maximal duration of prophylaxis was 7 days. Nine patients were withdrawn from the study, and five others could not be assessed because of protocol violations. The 68 clinically evaluable patients underwent 81 therapeutic ERCP procedures. Clinical success (defined as an absence of fever, cholangitis, and clinical signs of sepsis during the 48 hours after the last dose of piperacillin or placebo) was documented for 32 (94%) of the 34 patients given piperacillin and for 24 (71%) of the 34 patients given placebo (odds ratio, 6.66; P = .01). Complete biliary drainage influenced clinical outcome favorably (odds ratio, 5.0; P = .02). All seven instances of bacteriologic failure (bacteremia) involved patients in the placebo group (P < .01). We concluded that antimicrobial prophylaxis significantly reduces the incidence of septic complications after therapeutic ERCP among patients presenting with cholestasis.