Retrospective study of hospitalized patients with chronic leg ulcers in Hawaii.

The authors describe 226 patients with chronic leg ulcers at a community hospital over a 14-year period. Most leg ulcers were ischemic or venous in origin and located below the ankle. Fifty-five percent of patients were diabetic and the majority of patients were hypertensive. The cases required prolonged hospitalization for systemic antibiotics and vascular surgery. Only 2.3% of patients required above the knee amputation, and 7% needed below-the-knee amputation.

Head and neck cellulitis in hospitalized adults.

INTRODUCTION: Our purpose was to review the clinical features of head and neck cellulitis in hospitalized patients. MATERIAL AND METHODS: A retrospective review was undertaken of 147 cases of head and neck cellulitis seen over a 15-year period at a community Hawaiian hospital. RESULTS: Otologic cellulitis was mainly related to otitis externa, caused by Pseudomonas aeruginosa, although some cases had infected pierced ears or ear cysts. Cervical cellulitis was associated with malignancy, dental infection, or lymphadenitis; these patients often had positive blood cultures. Facial cellulitis was almost always caused by Staphylococci and Streptococci, usually preceded by dental infections, traumatic abscesses, or sinusitis. All study patients recovered completely, except for one patient who developed cavernous vein thrombosis and oculomotor palsy. Seventy-five percent of the patients recovered with parenteral antibiotics alone; the other patients required abscess drainage and/or other surgical procedures, especially if neck infection was present. CONCLUSION: Although head and neck cellulitis cases have grave potential consequences, most patients do very well with proper antibiotics and appropriate surgical drainage.

Eosinophilic pleural effusions.

We present 2 cases of eosinophilic pleural effusion (EPE) seen recently at Straub Hospital. One occurred in a patient with pneumococcal empyema; the 2nd patient had 2 episodes of EPE secondary to malignant histiocytic lymphoma. Eosinophilic pleural effusion (EPE) is defined as having eosinophils exceeding 10% of the pleural fluid WBC differential. EPE is usually exudative, typically accounting for 1% to 8% of all pleural effusions. Up to 30% to 35% of EPE are idiopathic, while other frequent causes include air in the pleural space (30%), and pulmonary infections (10%). Collagen vascular diseases, tuberculosis and malignancies are common causes of EPE. Although spontaneous resolution and a favorable prognosis predominates in this entity, prudent clinical follow-up is advised. Since the first documented case of eosinophilic pleural effusion in 1984 by Harmsen, clinicians have attempted to determine its significance. This condition is defined as pleural effusion with greater than 10% of the WBC differential eosinophils. We saw 2 cases of EPE at Straub Hospital during 1988.

Bacterial endocarditis at a small community hospital.

Clinical features, microbiology, and predisposing factors are described in 56 patients with bacterial endocarditis (BE) treated over a 12-year period at a small community hospital in Hawaii. The average age of patients was 52.0 years. The mean duration of symptoms was 28.8 days (range 1 to 240 days). Streptococci was the most frequently identified causative organism, present in 61% of the cases. Gram-negative bacilli were isolated from six patients (11%). Fourteen patients (25%) required cardiac surgery; the most common condition leading to surgery was severe valvular insufficiency, followed by congestive heart failure and recurrent embolism. Eighty-two percent of the patients in the series survived. The leading causes of death were congestive heart failure and cerebrovascular accidents.

HTLV-III infection. A clinical approach to diagnosis and treatment of the 'AIDS virus'.

The retrovirus human T cell lymphotropic virus type III (HTLV-III) can cause no symptoms at all, a syndrome of vague symptoms such as fever and fatigue, or full-blown acquired immune deficiency syndrome (AIDS). Serologic tests for antibodies to HTLV-III are available for identifying the virus; tests for T lymphocyte subset numbers and function and white cell count are also helpful. Management of patients with the virus depends on clinical presentation: Patients who are asymptomatic carriers need only reassurance and follow-up, patients with mild illness need symptomatic treatment and monitoring, and patients with full-blown AIDS need increasing levels of physical and emotional supportive care. Through early diagnosis, treatment when needed, and patient education, primary care physicians can be instrumental in curtailing the spread of HTLV-III infection.

Nosocomial Ewingella americana bacteremia in an intensive care unit.

Between Dec 8, 1982, and Jan 29, 1983, four cases of primary bacteremia with Ewingella americana occurred in the intensive care unit of a community hospital. The patients developed high fever and leukocytosis, which gradually resolved after institution of antibiotic therapy. All infected patients had undergone either cardiovascular or peripheral vascular surgery. Epidemiologic investigation revealed that the probable source for the Ewingella outbreak was contamination of the ice bath used to cool syringes for cardiac output determinations. The nosocomial outbreak was terminated by the introduction of a closed cardiac output injectate delivery system.

Colonization of human wounds by Escherichia vulneris and Escherichia hermannii.

In this report we present clinical descriptions of 12 Hawaiian patients from whom Escherichia vulneris or E. hermannii strains were isolated. All but two patients had soft-tissue infections with multiple bacteria, particularly Staphylococcus aureus. The other two had purulent conjunctivitis associated with S. aureus and infected malignant peritonitis with multiple organisms, respectively. In none of the cases were the Escherichia spp. found in abundant quantities or considered pathogenic. In preliminary animal pathogenicity studies, 12 strains each of E. vulneris and E. hermannii failed to cause serious symptoms in 4-week-old mice when 10(7) cells were injected intraperitoneally. When 10(6) cells were used, none of these bacterial strains injected into mouse soft tissue was capable of producing persistent wound infections. Susceptibility studies of 40 strains of these bacteria to 20 different antimicrobial agents showed that they were susceptible to third-generation cephalosporins as well as to most other cephalosporins, aminoglycosides, trimethoprim, and sulfamethoxazole-trimethoprim; these strains were only marginally susceptible or resistant to penicillin, tetracycline, chloramphenicol, and nitrofurantoin.

Polymicrobial bacteremia caused by Ewingella americana (family Enterobacteriaceae) and an unusual Pseudomonas species.

Ewingella americana and a Pseudomonas species were isolated from three sets of blood cultures from a 41-year-old patient after coronary bypass surgery. This is the first well-described case of bacteremia due to E. americana. Based on data from 31 strains, a detailed description of E. americana is given.

Actinomyces and an unidentified ameba associated with an intrauterine device.

PIP: A case report is presented of an asymptomatic 29-year-old Hawaiian patient with an IUD who had Actinomyces and an unidentified ameba in a Papanicolaou smear and in whom both organisms disappeared upon removal of the IUD. The patient presented for a routine pelvic examination as part of an employment physical. She denied any significant gastrointestinal or vaginal symptoms as well as any history of foreign travel. The patient reported that she had worn the same IUD for 9 years and that it had caused her no discomfort. A pelvic examination revealed a friable, papular cervix. The Papanicolaou smear revealed the presence of both amebae and colonies of Actinomyces. The findings were confirmed by the Armed Forces Institute of Pathology, which reported an intense, acute and chronic inflammatory reaction marked by the presence of amebae and Actinomyces species colonies. The patient returned 4 months later for a repeat pelvic examination and removal of her IUD. At that time a cervical smear showed only amebae. The patient was seen again 3 months following the IUD removal. She reported that her vaginal discharge had decreased. A repeat Papanicolaou smear was completely normal. Faulkner and Ory have reported a 5-fold increase of pelvic inflammatory disease among IUD users compared to nonusers. Among pelvic infections found to be associated with IUD users is genital actinomycosis. Many of these patients are asymptomatic with only cytologic evidence of Actinomyces, but these patients can progress to pelvic inflammation and abscess formation. Reports have recently described the presence of amebic trophozoites in IUD users. The main purpose in reporting this case is to alert the tropical medicine specialist to this entity. Amebic colonization appears to respond completely to IUD removal, and there is no need for additional medical or surgical treatment.^ieng

Comparative study of prophylactic antibiotics in cardiac surgery. Clindamycin versus cephalothin.

A randomized, prospective study of the relative effectiveness of clindamycin versus cephalothin was performed in 263 adult patients having cardiac surgery from September, 1977, to August, 1978. There were no statistically significant differences in frequency of postoperative infections in these two antibiotic groups. Wound infection developed in 6.5 percent of the cephalothin group and 3.2 percent of the clindamycin group. Urinary tract infection developed in 5.6 percent of the clindamycin group and 2.1 percent of the cephalothin group. Four bacteremic episodes occurred in the clindamycin-treated patients, and one episode of bacteremia occurred in a cephalothin-treated patient. No cases of endocarditis occurred during the study. Clindamycin deserved consideration as an alternative prophylactic agent to cephalothin for cardiac surgery.