Characteristics of candidaemia with Candida-albicans compared with non-albicans Candida species and predictors of mortality.

Candidaemia due to non-albicans Candida species is increasing in frequency. We describe 272 episodes of candidaemia, define parameters associated with Candida albicans and other Candida species, and analyse predictors associated with mortality. Patients with C. albicans (55%) had the highest fatality rate and frequently received immunosuppressive therapy, while patients with Candida parapsilosis (16%) had the lowest fatality and complication rates. Candida tropicalis (16%) was associated with youth, severe neutropenia, acute leukaemia or bone marrow transplantation, Candida glabrata (10%) was associated with old age and chronic disease, and Candida krusei (2%) was associated with prior fluconazole therapy. The overall fatality rate was 36%, and predictors of death by multi-variate analysis were shock, impaired performance status, low serum albumin and congestive heart failure. Isolation of non-albicans Candida species, prior surgery and catheter removal were protective factors. When shock was excluded from analysis, antifungal therapy was shown to be protective. Unlike previous concerns, infection with Candida species other than C. albicans has not been shown to result in an increased fatality rate.

Ecthyma gangrenosum without bacteremia. Report of six cases and review of the literature.

We encountered six patients with ecthyma gangrenosum due to Pseudomonas aeruginosa who, uncharacteristically, had no evidence of bacteremia prior to the institution of antibiotic therapy. Seven similar cases have previously been reported in the English-language medical literature. These 13 patients resembled those with classic ecthyma gangrenosum accompanied by Pseudomonas septicemia in being immunocompromised and neutropenic and having skin lesions at similar sites. The most striking difference between these two groups of patients was a significantly lower mortality rate for the nonbacteremic patients. These findings suggest that ecthyma gangrenosum can occur as a primary skin lesion in the absence of bacteremia. Patients with this particular subtype of infection appear to have a better prognosis than those having a preceding bacteremia.

Inadvertent sulfonylurea-induced hypoglycemia. A dangerous, but preventable condition.

Two patients with severe hypoglycemia due to inadvertent use of oral hypoglycemic agents are described. Unintentional substitution of tablets with sulfonylurea drugs was related in both cases to a similarity in shape and color of the pills. In one case glyburide was interchanged with an artificial sweetener, while in the other case chlorpropamide was dispensed by a pharmacist instead of quinidine bisulfate. To our knowledge, 20 similar cases have been reported in the medical literature. Most of them were attributed to sound-alike trade names of drugs. Inadvertent sulfonylurea-induced hypoglycemia has to be included in the differential diagnosis of severe unexplained hypoglycemia. This dangerous condition can be prevented by instructing patients to carefully identify their drugs, introducing typed prescription forms using generic names, and avoiding similar names and appearance of pills.

Shigella bacteremia in adults. A report of five cases and review of the literature.

Shigella bacteremia is rare, occurring mainly in children. We describe five adult patients with Shigella bacteremia and review data on 22 cases reported in the English-language medical literature. Eighteen (67%) of 27 patients had either an underlying condition or were aged older than 65 years. Most patients had clinical signs of acute febrile gastroenteritis. However, in six patients, the organism was not isolated from stool. Species isolated from blood included Shigella flexneri in 11 patients, Shigella sonnei in eight, and Shigella boydii and Shigella dysenteriae in one patient each. Isolation of the bacterium from blood only was associated with a high mortality rate, in contrast to its isolation both from blood and stool. It is suggested that blood cultures should be obtained from elderly or immunocompromised patients with acute febrile gastroenteritis to detect shigellemia as well as bacteremia caused by other enteric pathogens, such as Salmonella or Campylobacter.

Unintentional weight loss. A retrospective analysis of 154 cases.

Unintentional weight loss (UWL) was documented in 154 patients (2.8%) admitted to an internal medicine department during a two-year period. A retrospective analysis of the clinical charts showed that more than one third (36.3%) were found to have a neoplasm, involving preponderantly the gastrointestinal tract. Patients with neoplasia were older and more frequently had abnormal physical findings and significantly lower values of serum albumin as well as higher values of alkaline phosphatase than other patients. Despite extensive investigations, in 36 patients (23.3%) UWL remained unexplained even after prolonged follow-up periods. The remaining 62 patients had a variety of disorders, preponderantly gastrointestinal tract (26 patients) and psychiatric (16 patients) diseases. Endocrinologic disorders such as diabetes mellitus and hyperthyroidism were relatively uncommon (3.8%). Unintentional weight loss is a relatively common problem in clinical practice. Familiarity with the spectrum of disorders associated with UWL as well as selected clinical and laboratory values may help in the initial examination of these patients.

Human cryptosporidiosis: spectrum of disease. Report of six cases and review of the literature.

Although once regarded exclusively as an animal parasite, Cryptosporidium has emerged during the last decade as a cause of diarrhea in humans. Of the 43 cases of human cryptosporidiosis reported, 27 patients in whom either humoral or cell-mediated immune defects were present had chronic protracted diarrhea that was almost invariably unresponsive to therapy and culminated in death. In contrast, 16 patients with intact immune systems had either self-limited disease or were asymptomatic. Animal exposure was almost exclusively recorded in the latter group. During the last six months at University of Texas M. D. Anderson Hospital and Tumor Institute, Houston, gastrointestinal (GI) tract cryptosporidiosis developed in six homosexual men with acquired immune deficiency syndrome (AIDS). The diagnosis of cryptosporidiosis was established histologically in five patients. In four, cryptosporidial oocysts were detected in the stool. In addition to extensive GI tract cryptosporidiosis, two patients had biliary tract involvement. Multiple chemotherapeutic agents failed to control the disease, and five patients eventually died. Cryptosporidiosis should be considered in the differential diagnosis of diarrhea, in animal handlers or in the severely compromised patient, especially one with AIDS, who has chronic protracted diarrhea.

Bacteremia in adult diabetic patients.

OBJECTIVE: To compare the microbiology, sources, complications, and outcome of bacteremia in diabetic and nondiabetic patients. RESEARCH DESIGN AND METHODS: A prospective study was conducted of all episodes of bacteremia in hospitalized diabetic and nondiabetic patients. The study consisted of patients greater than or equal to 18 yr of age with bacteremia detected within a 19-mo interval. RESULTS: We compared 124 episodes of bacteremia in 119 diabetic patients to 508 episodes in 480 nondiabetic patients. Diabetic patients were older than nondiabetic patients (median age 74 vs. 68 yr, P = 0.0001). In patients with an indwelling urinary catheter and bacteremic urinary tract infection, the percentage of Klebsiella in diabetic patients was 60% (6 of 10) and in nondiabetic patients was 17% (4 of 23, P = 0.04). In patients without an obvious source of bacteremia, the percentage of staphylococcal isolates in diabetic patients was 29% (10 of 35) and in nondiabetic patients was 14% (24 of 176, P = 0.04). Staphylococci were a common cause of bacteremic infections of the extremities in diabetic patients (12 of 19, 63%) and nondiabetic patients (20 of 50, 40%). Septic shock was the only complication that was more common in diabetic patients. The mortality in diabetic and nondiabetic patients was 28 and 29%, respectively. CONCLUSIONS: Our results represent elderly patients with non-insulin-dependent diabetes mellitus. In this group, empirical treatment for suspected bacteremic urinary tract infection in patients with a urinary catheter should include coverage for Klebsiella. Empiric treatment for suspected bacteremia of unknown origin or caused by infection of the extremities should include an antistaphylococcal drug. The prognosis of bacteremia in diabetic and nondiabetic patients was similar.

Tuberculosis mimicking cancer--a reminder.

The charts of 26 patients who were referred with a presumptive diagnosis of neoplasms and who were ultimately found to have only tuberculosis were reviewed. Twenty-one patients (81 percent) were born in the United States, and only three patients had a history of exposure to tuberculosis. Most patients had few symptoms, and the average duration of symptoms was 2.8 +/- 1.5 months. Classic symptoms of tuberculosis, like fever, hemoptysis, and weight loss, were uncommon. Chest roentgenographic abnormalities were present in 62 percent of the patients. Although some of the patients had undergone nondiagnostic biopsy procedures before referral, none had had skin tests for tuberculosis. Underlying conditions were found in eight patients, and alcoholism was the most common. Laboratory abnormalities were rare with the exception of increased platelet counts, which were found in eight patients. The most common form of tuberculosis was pulmonary (14 patients) followed by lymphadenitis (nine patients). Tuberculosis remains an elusive disease even in countries with advanced medical technology. In some cases, its presentation may suggest the presence of malignancy.

Excess mortality in women with hospital-acquired bloodstream infection.

PURPOSE: We examined the outcomes of bloodstream infection in men and in women and whether any sex-related differences were explained by underlying disorders, severity of disease, or clinical management. SUBJECTS AND METHODS: Using a prospectively collected database, we compared in-hospital mortality in men and women. We used multivariable logistic regression analysis to test whether sex-related differences could be due to potential confounders. RESULTS: Of 4250 patients with bloodstream infections, 1750 (41%) had hospital-acquired infections. The overall case fatality was 31% (625 of 2032) in women and 29% (631 of 2218, P = 0.1) in men. However, 43% (325/758) of the women with hospital-acquired infections died, compared with 33% (327/992) of the men (P = 0.0001). In a multivariate analysis, female sex was associated with greater mortality in patients with hospital-acquired infections (odds ratio = 1.7; 95% confidence interval: 1.1 to 2.6). The excess mortality in women was mainly seen in patients with major underlying disorders (fatality rate of 45% [234 of 525] in women vs. 32% in men [234 of 743, P = 0.0001). CONCLUSIONS: Mortality in women with hospital-acquired bloodstream infections is substantially greater than in men. The excess mortality was concentrated in women with severe underlying disorders, suggesting that sepsis might have accentuated differences in the outcome of underlying disorders in women.

Ethambutol-induced thrombocytopenia.

Extreme thrombocytopenia, purpura, and melena developed in a 71-year-old woman four days after ethambutol administration was started. The macrophage inhibition factor test was positive for ethambutol, and the thrombocytopenia subsided shortly after discontinuation of the drug therapy. The sequence of events in this patient suggests that, although previously unreported, thrombocytopenia should be added to the list of side effects of ethambutol.

Seroepidemiologic study of toxocariasis and strongyloidiasis in institutionalized mentally retarded adults.

Serologic surveys for Toxocara canis and Strongyloides sp., as well as stool examinations for intestinal parasites, were conducted in a home for mentally retarded adults. Evidence of parasitic infection was found in 30 (28.3%) of 106 residents; nine (8.5%) had positive toxocaral serology (enzyme-linked immunosorbent assay[ELISA]), 1 (0.9%) had positive serology for Stronglyoides sp. (ELISA), and 21 (19.8%) had parasites in stool (including Stronglyoides stercoralis in the patient with positive serology). Most of the residents with positive toxocaral serology lived in the same apartment and used to play with dogs. Parameters found to be significantly associated with positive toxocaral serology were pica behavior and eosinophilia (P less than 0.05). Mental retardation requiring institutionalization appears to be a risk factor for toxocariasis and other parasitic infections in adults as it is for children.

Prognostic significance of the neutrophil count in immunocompetent patients with bacteraemia.

To examine the prevalence of neutropaenia in immunocompetent, bacteraemic patients, and whether it carries an independent risk for mortality, we surveyed 2096 bacteraemic patients without malignant diseases, and who were not receiving cytotoxic drugs. The granulocyte count on the day of the first positive blood culture was < 1 x 10(9) cells/l in 33 patients (1.7%, group 1); 1.0-4.0 x 10(9) cells/l in 154 patients (7.9%, group 2); 4.0-8.0 x 10(9) cells/l in 564 patients (29%, group 3); 8.0-20.0 x 10(9) cells/l in 1034 patients (53%, group 4); and > 20.0 x 10(9) cells/l in 163 patients (8.4%, group 5). The mortality rates in the five groups were 39.4%, 18.8%, 18.1%, 25.7% and 25.8%, respectively (p = 0.0001). The main pathogens in group 1 were Staphylococcus aureus in 25% of patients and Pseudomonas sp. in 23%. Mortality in group 1 patients was higher than in the other patients (odds ratio 1.4, 95% CI 1.1-1.9]. Mortality was also significantly higher in group 2 patients with high blood urea nitrogen. The percentage of neutropaenia, septic patients without known risk factors for neutropaenia is small, but their mortality is high. Overall mortality in patients with relative neutropaenia (1.0-4.0 x 10(9) cells/l) is low, but a subgroup of patients with high blood urea nitrogen is at considerable risk for a fatal outcome. High leucocyte counts are also a marker of increased risk for mortality, but this association is not an independent prognostic factor.

Value of transrectal ultrasonography for diagnosis and treatment of prostatic abscess.

A new diagnostic and therapeutic application of transrectal ultrasonography (TR-US) is described. TR-US demonstrated one or more well-defined hypoechogenic areas in the prostate gland of 6 patients who presented with clinical signs of urinary tract infection and had only partial response to antibiotic therapy. The presence of a collection of pus in the prostate was confirmed in 4 of 6 patients by transperineal aspiration guided by TR-US, and by prostatic massage or transurethral prostatectomy in the other 2 patients. Ultrasonography also confirmed the resolution of abscesses in 5 patients.

Aquarium-borne Mycobacterium marinum skin infection. Report of a case and review of the literature.

A 33-year-old fish fancier developed a protracted skin infection that ultimately was found to be caused by Mycobacterium marinum. The organism was isolated from the lesion as well as from infected fish taken from his home aquarium. The lesion resolved after a six-week course of oral sulfamethoxazole and trimethoprim. Forty-four additional cases of culture-proved M marinum skin infections acquired from aquariums and reported in the English-language literature are reviewed. Almost universally, the lesions remained circumscribed and were either single nodular (14 patients) or multiple sporotrichoid (31 patients). Diagnosis was supported by acid-fast smears (15 patients) and isolation of the organism from skin lesions (43 patients) or from fish (two cases). In vitro studies, as well as clinical outcomes, suggest sulfamethoxazole-trimethoprim or ethambutol hydrochloride plus rifampin to be the drugs of choice.

Correlation between candiduria and departmental antibiotic use.

The incidence of candiduria is increasing in teaching hospitals. We examined the hypothesis that this trend was correlated with the amount of departmental antibiotic consumption. In the setting of a large teaching hospital in Israel, the correlation coefficient between departmental intravenous antibiotic consumption (expressed as daily defined dose (DDD)/1000 patient-days) and the incidence of candiduria per 1000 patient-days was 0.47 (P=0.03). For broad-spectrum antibiotics, the corresponding correlation coefficient was 0.66 (P=0.001). The strongest correlation with candiduria was shown for the use of meropenem (r=0.79, P<0.001) and ceftazidime (r=0.66, P=0.001). This is the first time that departmental habits of antibiotic use have been shown to be strongly correlated with the incidence of candiduria in hospitalized patients. These results add an important new dimension to the strategy of restricting broad-spectrum antibiotics.

Bacteraemia caused by hospital-type micro-organisms during hospital stay.

A sharp transition between community-type and hospital-type pathogens at the second or third day of hospital stay is often assumed. This study aimed to test whether such a threshold phenomenon exists for bloodstream infections and to examine the relationship between the proportion of infections caused by hospital-type pathogens and length of stay in the hospital. Blood stream infections were studied in a referral and a university hospital in west Denmark, and a university hospital in central Israel during three study periods (1994-1996, 1992-1995, 1989-1995 in the three hospitals respectively). No threshold effect at 2-3 days stay in the hospital could be demonstrated. However the percentage of Pseudomonas aeruginosa bloodstream infections increased constantly in the three hospitals from 1%, 1% and 7% during the first 2 days to 7%, 4%, and 14% during the third week of hospital stay (P<0.01 for all three comparisons-chi(2)for linear trends). For Candida sp. the increase was from 0%, 2%, 1% during the first 2 days to 3%, 4%, and 9% during the third week, P<0.05. Methicillin-resistant Staphylococcus aureus in Israel increased from 26% of the total number of S. aureus during the first 2 days to 69% during the third week, P<0.0001. For penicillin-resistant S. aureus in Denmark, the percentages were 84% and 100%, P<0.05.The percentage of infections caused by hospital-type pathogens increased almost linearly during the first 3 weeks of hospital stay, with no threshold effect. This trend should be taken into account when prescribing empirical therapy for nosocomial infections.

Oral ofloxacin as treatment of malignant external otitis: a study of 17 cases.

Seventeen patients with malignant external otitis were treated with oral ofloxacin. Their mean age was 69 years. Seven of the patients were diabetic. Pseudomonas aeruginosa, sensitive to ofloxacin (Kirby-Bauer method, inhibition zone greater than or equal to 22 mm), was isolated from the external auditory canal in all patients. Ofloxacin (200 mg b.i.d.) was given to the patients for 12 to 39 days. Two patients also received additional parenteral antibiotic therapy. Subjective and objective improvement occurred in all patients during treatment, and complete resolution was documented in all patients, with one exception. Only one patient suffered recurrence 2 weeks after discontinuation of antimicrobial therapy. The results of our study suggest that oral ofloxacin is an effective treatment for malignant external otitis caused by Pseudomonas aeruginosa.

Pelger-Huët anomaly mimicking 'shift to the left'.

A case report is presented of an 83-year-old male patient with respiratory distress, body temperature of 38.5 degrees C, bilateral white infiltrates on chest X-ray and ECG showing acute myocardial infarction. Clinical evaluation led to the suspicion of severe infection accompanying lung congestion due to the infarction, mostly because his white blood cell differential count showed a persistent severe 'shift to the left'. Re-examination of his blood smear showed that the 'shift to the left' did not consist of band forms but of a 'Pelger-Huet' anomaly of the granulocytes. Recognition of this anomaly in the light of rapid clinical and radiological improvement precluded the administration of antibiotics for the diagnosis of severe infection with pulmonary involvement, which responded to diuretic therapy alone.