Extracolonic manifestations of Clostridium difficile infections. Presentation of 2 cases and review of the literature.

Clostridium difficile is most commonly associated with colonic infection. It may, however, also cause disease in a variety of other organ systems. Small bowel involvement is often associated with previous surgical procedures on the small intestine and is associated with a significant mortality rate (4 of 7 patients). When associated with bacteremia, the infection is, as expected, frequently polymicrobial in association with usual colonic flora. The mortality rate among patients with C. difficile bacteremia is 2 of 10 reported patients. Visceral abscess formation involves mainly the spleen, with 1 reported case of pancreatic abscess formation. Frequently these abscesses are only recognized weeks to months after the onset of diarrhea or other colonic symptoms. C. difficile-related reactive arthritis is frequently polyarticular in nature and is not related to the patient's underlying HLA-B27 status. Fever is not universally present. The most commonly involved joints are the knee and wrist (involved in 18 of 36 cases). Reactive arthritis begins an average of 11.3 days after the onset of diarrhea and is a prolonged illness, taking an average of 68 days to resolve. Other entities, such as cellulitis, necrotizing fasciitis, osteomyelitis, and prosthetic device infections, can also occur. Localized skin and bone infections frequently follow traumatic injury, implying the implantation of either environmental or the patient's own C. difficile spores with the subsequent development of clinical infection. It is noteworthy that except for cases involving the small intestine and reactive arthritis, most of the cases of extracolonic C. difficile disease do not appear to be strongly related to previous antibiotic exposure. The reason for this is unclear. We hope that clinicians will become more aware of these extracolonic manifestations of infection, so that they may be recognized and treated promptly and appropriately. Such early diagnosis may also serve to prevent extensive and perhaps unnecessary patient evaluations, thus improving resource utilization and shortening length of hospital stay.

Comparative killing kinetics of methicillin-resistant Staphylococcus aureus by bacitracin or mupirocin.

The in vitro activities of bacitracin and mupirocin were compared for seven different strains of methicillin-resistant Staphylococcus aureus. Six of seven strains showed bacitracin minimum inhibitory concentrations (MICs) of 0.5 to 1.0 units/mL, and all seven had mupirocin MICs of 0.5 to 2 micrograms/mL. Time-kill studies revealed 2.6- to 4.5-log reduction in 24 hours with strains susceptible to bacitracin (4 units/mL) and 0 to 2.2 reduction with mupirocin (16 micrograms/mL). Bacitracin should be considered further for in vivo studies because of enhanced bacteriocidal effect and lower cost.

Tracing the spread of methicillin-resistant Staphylococcus aureus by Southern blot hybridization using gene-specific probes of mec and Tn554.

In a community hospital in Brooklyn, New York, over a 3-year period, 79 methicillin-resistant Staphylococcus aureus (MRSA) isolates from five different case clusters were subtyped by Southern blot hybridization with two previously characterized gene probes, mec and Tn554. Together, the genotyping enabled the hospital infection control team to differentiate simultaneous MRSA clusters in the surgical intensive care unit (type I:A) and the open heart unit (type II:J), document the spread of one strain (type I:A) between roommates, identify an endemic strain (type II:J) from cardiac monitors and medical personnel, and identify an unrelated outbreak strain (type II:NH) in the labor and delivery unit. On the basis of this investigation it is clear that the routine DNA fingerprinting of MRSA in health care facilities, to monitor their spread and identify cases of nosocomial infections, is an important infection control measure.

Space-occupying and life-threatening infections of the head, neck, and thorax.

Infections of the deep structures of the head and neck are polymicrobial, rapidly progressive, and frequently life-threatening. The bacteriology, clinical presentation, and the need for multidisciplinary management of these infections are stressed. In addition, this article discusses selected head and neck infections of immunocompromised hosts and postexposure prophylaxis for serious infections of the pharynx.

Maintaining and enhancing vaccine immunogenicity.

This contribution highlights factors involved with maintaining and enhancing antigen delivery or immunogenicity. Areas discussed include the cold chain, adjuvants, recombinant vectors for antigen delivery, routes for antigen delivery, and edible plant vaccines. It is doubtless that the technological understanding that underlies these advances is about to revolutionize vaccinology in the near future.

The fortuitous diagnosis of cholera in a two-year-old girl.

We are reporting the fortuitous diagnosis of a case of cholera and the unusual failure of the commercial bacteriologic media that led to the unexpected isolation of Vibrio cholerae. The case demonstrates the need for communication between the medical staff and laboratory personnel when an uncommon disease, such as cholera, is suspected. This case also alerts the clinician to the possibility of multiple enteric pathogens coinfecting a traveller.

The pitfalls of transthoracic echocardiography. A case of eustachian valve endocarditis.

A case of infective endocarditis involving the vestigial eustachian valve is presented and the available English medical literature is reviewed. Only 5 prior cases have been reported: 4 of those required transesophageal echocardiography for diagnosis, and the other was found at autopsy. This clinical entity is routinely missed on transthoracic echocardiography. Injection drug use is a common predisposing factor, and Staphylococcus aureus is the most commonly identified organism. This report broadens the differential diagnosis of endovascular infections in injection drug users and highlights the importance of transesophageal echocardiography for diagnosis in selected patients.

Neuroleptic malignant syndrome possibly caused by molindone hydrochloride.

The case of a patient who developed neuroleptic malignant syndrome (NMS) on three separate occasions is presented. Her third bout of this syndrome possibly was caused by molindone hydrochloride. This medication has been reported only once previously to cause NMS. The pharmacology of molindone is reviewed and a complicating factor in this case--the recent onset of hypothyroidism--is discussed together with its implication in the development of the clinical manifestations of this syndrome.

Retropharyngeal space infections in a community hospital.

The emergency physician often has to deal with infectious disease emergencies. The authors have seen four cases of retropharyngeal infection of potentially life-threatening severity in less than 1 year, all were admitted through the emergency department (ED). Reporting these cases is important to increase awareness among emergency physicians of this classic disease entity. The characteristics of the patients are discussed including initial diagnostic approaches and the use of computed tomography (CT) scanning of the neck and mediastinum. One case of retropharyngeal space infection caused by Neisseria meningitidis serotype W-135 is described. This is the first such reported case. The recommendations are that, in the absence of overt focal infection, a non-surgical approach to the treatment of these patients is indicated. This should include suitable neck roentgenograms, CT scanning, and high-dose, intravenous, beta-lactamase-resistant antibiotics.

Diagnosis of probable cocaine-induced cerebral vasculitis by magnetic resonance angiography.

Cocaine-induced cerebral vasculitis is a serious but uncommon clinical entity. We present a case of probable cocaine-induced vasculitis that was unusual in that it was suggested by magnetic resonance angiography. The patient was a 42-year-old woman, who used cocaine both intravenously and intranasally, who was admitted with the acute onset of an illness that resembled bacterial meningitis. Results of the initial standard evaluation were negative, and a diagnosis of cerebral vasculitis was ultimately suggested by magnetic resonance angiography. We believe this to be the first reported case of the diagnosis of cocaine-induced cerebral vasculitis to be suggested by magnetic resonance angiography.

Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis.

Infective endocarditis of the right-side heart valves occurs commonly in injection drug users. Although a variety of hypotheses have been put forward to explain this clinical observation, no single hypothesis is adequate. In this article, basic scientific, clinical, and microbiological data on this topic are presented. It is apparent that no clear unifying mechanism emerges to explain the well-documented clinical predilection for the infection of the right-side heart valves in this population. Further investigation of this topic utilizing large international clinical registries may help to clarify matters further.

Massive hepatic enlargement with fatty change associated with ketoconazole.

Several forms of hepatic toxicity have been described with the antifungal agent ketoconazole. We report a case of massive liver enlargement with fatty infiltration presenting as gastric compression. This occurred in a young woman with AIDS taking ketoconazole as maintenance therapy for cryptococcal meningitis. This is the first reported case of ketoconazole causing fatty change in the liver.

Severe hypomagnesemia associated with pentamidine therapy.

A case of severe hypomagnesemia in a patient with AIDS that manifested as changes in mental status is presented. The hypomagnesemia was due to renal wasting of magnesium, most probably caused by pentamidine-induced renal tubular injury. This entity has been reported once before and should be considered in the differential diagnosis of altered mental status in patients with AIDS.

Fragmentation hemolysis: an unusual indication for valve replacement in native valve infective endocarditis.

Intravascular mechanical fragmentation of erythrocytes is an uncommon occurrence in native valve infective endocarditis. We report a case of fragmentation hemolysis in a patient with tricuspid valve endocarditis due to Staphylococcus aureus. She received transfusion of multiple units of packed red blood cells and ultimately required surgical removal of the affected valve to control the hemolytic process. We believe this to be only the fifth such reported case and the first in which surgical therapy was necessary to control the hemolytic process.

Infective endocarditis of a native valve due to Acinetobacter: case report and review.

A case of community-acquired infective endocarditis of a native valve that was caused by Acinetobacter calcoaceticus subspecies anitratus is presented. The previously reported cases are reviewed, and therapy for this disorder is discussed. The presence of a transient maculopapular rash involving the palms and soles but sparing the face is suggested as a possible early clinical clue to the diagnosis. Native valve endocarditis caused by Acinetobacter species is an acute, aggressive illness that is more likely to be fatal than the prosthetic valve form; of the previously described patients, five of 15 with native valve endocarditis and one of six with prosthetic valve endocarditis died. In the appropriate clinical setting, we recommend therapy with an antimicrobial agent known to be active against Acinetobacter organisms when blood cultures are reported to yield oxidase-negative, gram-negative coccobacilli until the final identification of the microorganism is known.

Emergence of unusual opportunistic pathogens in AIDS: a review.

Opportunistic infections are a major cause of morbidity and death among patients infected with the human immunodeficiency virus (HIV), particularly late in the disease, when immunosuppression is severe. Some pathogens, such as Pneumocystis carinii and Toxoplasma gondii, are extremely common in this population and are readily recognized by clinicians caring for these patients. However, many other organisms occasionally cause conditions that clinically mimic the more commonly encountered pathogens. Clinicians must be alert to the threat posed by these less frequently occurring organisms and of the broader differential diagnosis that must be considered for infections in patients with HIV infection.

Zidovudine-induced hepatitis.

A case of acute hepatitis induced by zidovudine in a 38-year-old patient with AIDS is presented. The mechanism whereby the hepatitis was induced is not known. However, the patient tolerated well an alternative reverse transcriptase inhibitor, 2'3' dideoxyinosine. Physicians caring for patients with AIDS should be aware of this hitherto rarely reported complication.

Aerosolized vancomycin therapy facilitating nursing home placement.

OBJECTIVE: To demonstrate a novel method of eliminating nasopharyngeal colonization by methicillin-resistant Staphylococcus aureus (MRSA) in a debilitated, hospitalized patient. DESIGN: Single-patient, nonblind, nonplacebo, case study. SETTING: Community hospital, Brooklyn, NY. PATIENT: Hospitalized patient with recalcitrant nasopharyngeal MRSA colonization that could not be eliminated by conventional therapeutic interventions. INTERVENTIONS: Aerosolized vancomycin hydrochloride 120 mg q6h administered in room air via face mask together with vancomycin nasal drops, 2 drops to each nostril q6h. MAIN OUTCOME MEASURE: Elimination of MRSA from the nasopharynx of the patient. RESULTS: Successful elimination of MRSA colonization after four days of therapy. CONCLUSIONS: Aerosolized vancomycin in combination with vancomycin nasal drops is beneficial in eliminating nasopharyngeal colonization by MRSA. Clinical trials are warranted to confirm this clinical observation.