Cystic echinococcosis: late rupture and complication of a stable pulmonary cyst.

Cystic echinococcosis is observed worldwide. Traditional management includes an invasive surgical approach with adjunctive chemotherapy. It has been suggested that observation alone may be appropriate in asymptomatic individuals with stable cysts. A case involving a 38-year-old Peruvian man with an asymptomatic bronchogenic cyst (suspected to be due to echinococcus, but never definitely diagnosed) is presented. The cyst was first noted in 1998, and was followed for 10 years during which time he remained asymptomatic with minimal radiographic change. One year later, in 2009, he presented with acute rupture of the cyst causing empyema. The patient required thoracotomy, decortication and resection of the ruptured cyst. Final pathology showed Echinococcus organisms. The patient responded well to treatment with albendazole and praziquantel, and became completely asymptomatic within six months. The present case demonstrates that echinococcal cysts may be at risk of spontaneous rupture, even after many years of clinical stability, thus supporting the case for resection of asymptomatic cysts suspected of being echinococcal at the time of diagnosis. In addition, the case illustrates that medical therapy with albendazole and praziquantel, in conjunction with surgical drainage, can be successful in the treatment of echinococcal empyema.

Subcutaneous phaeohyphomycosis caused by Lasiodiplodia theobromae and successfully treated surgically.

While visiting Jamaica, a 50-year-old woman stumbled on an outdoor wooden staircase and sustained an injury to the right leg. The wound was cleaned topically and the patient was given antibacterial therapy. Five weeks later, in Canada, she presented with an ulcer at the injury site. An excisional biopsy showed copious broad, septate, melanized fungal filaments penetrating into tissue. Culture yielded a nonsporulating melanized mycelium. The isolate was strongly inhibited by cycloheximide and benomyl but grew at 37 degrees C. After 16 weeks cultivation on modified Leonian's agar at 25 degrees C, it developed pycnidia characteristic of Lasiodiplodia theobromae, a common tropical phytopathogen mainly known previously as a rare agent of keratitis and onychomycosis in humans. The patient was not given antifungal chemotherapy, and the ulcer, which had been broadly excised in the biopsy procedure, ultimately resolved after treatment with saline compresses. The six-month follow-up showed no sign of infection. This case, interpreted in light of previously reported cases, shows that on rare occasions L. theobromae is able to act as an agent of subcutaneous phaeohyphomycosis and that, when this occurs, debridement alone may be sufficient to eradicate it.

Piperacillin versus cefazolin given perioperatively to high-risk patients who undergo open cholecystectomy: a double-blind, randomized trial.

OBJECTIVE: To study the efficacy, microbiologic features and toxicity of prophylactic cefazolin versus prophylactic piperacillin in high-risk patients who undergo open cholecystectomy. DESIGN: Double-blind randomized trial with follow-up for 6 weeks postoperatively. SETTING: An 850-bed community hospital, located in a major Canadian city. Patients admitted to hospital who satisfied published criteria for being at high-risk for infection after open cholecystectomy were entered into the protocol, and those who satisfied the criteria and provided consent were entered into the study. Eighty-one patients were randomly assigned by computer to receive either piperacillin or cefazolin as the prophylactic agent. INTERVENTIONS: Open cholecystectomy. MAIN OUTCOME: Provides detailed information on the organisms found in the biliary tree in patients with acute cholecystitis, assesses the in-vitro activity of cefazolin versus piperacillin against the isolated organisms, expecting that piperacillin would be much more active against isolated anaerobes and gram-negative bacteria. RESULTS: Bactobilia was documented in 42% of patients in the cefazolin group and 29% of patients in the piperacillin group. Piperacillin was active in vitro against 94% of all isolates versus 56% for cefazolin (p < 0.005, McNemar's test). Adverse effects and toxicities in both the piperacillin and cefazolin group were low and were not serious. CONCLUSIONS: Both piperacillin and cefazolin are safe and effective prophylactic antimicrobials for high-risk patients who undergo open cholecystectomy. However, piperacillin had a much wider spectrum of in-vitro activity against the isolated pathogens, especially Enterococcus sp., Enterobacter cloacae and the anaerobes.

Microorganisms in the Stomach During Vertical Banded Gastroplasty.

Vertical banded gastroplasty involves the cutting of a stapled window against an Ewald tube Passed perorally, and creation of a vertical staple-line partition. The channel at the window is banded by a polypropylene mesh collar. A study of the gastric rings removed at this operation found that the bacterial colonization rate was 46.8%, so that the potential for infection of the collar exists. The actual significance of this finding is unknown.

Selection of antibiotic coverage in vascular patients undergoing cystoscopy.

Bacteremic seeding of prosthetic vascular grafts represents a cause for graft infection; transurethral procedures account for one source of bacteremia. Therefore, a prospective study of 200 patients undergoing cystoscopy was conducted to identify the incidence of bacteruria and factors associated with it, organisms involved and their antibiotic sensitivities. Positive cultures were found in 21%. The incidence was 64% in in-patients and 8% in out-patients. Positive cultures were found in 12% of patients who received antibiotics and 29% who did not. Four percent showed signs of bacteremia. The cultures identified both Gram positive and negative organisms; multiple organisms grew in 22%. Gram negative organisms were more common in in-patients. Candida grew in 8%. The Gram positive organisms were sensitive to ampicillin (92%), sulfatrimethoprim (75%) and cefazolin (60%); Gram negative to aminoglycosides (100%) and cefazolin (92%). In view of the unpredictable and multiple organisms, it is recommended that pre-cystoscopy cultures be performed and specific antibiotic coverage be based on the sensitivities.

Evidence for the occurrence of the same strain of Campylobacter pylori in the stomach and dental plaque.

Restriction endonuclease analysis with HindIII, HaeIII, and BglII endonucleases of DNA extracted from each of eight colonies of Campylobacter pylori subcultured from a stomach biopsy and from each of eight colonies subcultured from dental plaque of the same patient indicated that at least three strains were present in the dental plaque but only one strain was present in the biopsy. One of the dental strains had restriction patterns indistinguishable from those of the biopsy isolate, providing evidence that both sites were infected with the same strain of C. pylori.

Examination of human stomach biopsies, saliva, and dental plaque for Campylobacter pylori.

To examine possible sources of Campylobacter pylori and to determine the routes by which it is transmitted to the human stomach, samples of dental plaque and saliva from 71 patients undergoing endoscopy in addition to stomach biopsies were collected and cultured on selective noninhibitory Skirrow medium. A total of 29 (40.8%) of the stomach biopsies yielded C. pylori. None of the saliva samples and only one of the dental plaque samples was found positive for C. pylori, and thus neither saliva nor dental plaque could be implicated as a significant reservoir of this organism.

Modern management of cervical scrofula.

From 1970 to 1984, 32 patients were treated for tuberculous (TB) masses, which measured 1.2-5.5 cm. The posterior triangle was involved in 19 patients, anterior triangle in 7, and more than one triangle in 6 (3 bilateral). A superficial node was excised for diagnosis. Acid-fast bacilli were identified on the smear of 18 patients. Caseation necrosis was present in 27 specimens, sarcoidosis in four, nonspecific lymphadenitis in one; all cultures grew Mycobacterium tuberculosis. A chest x-ray showed no active TB. Chemotherapy was given for 9-18 months (9 months when only one node was diseased and 18 months with extensive nodal involvement). Follow-up examinations in all patients (greater than 3 years, mean 8.6 years) has revealed no recurrence. The need to excise all cervical TB nodes, chronically inflamed and often fused to important structures, was eliminated by adequate chemotherapy.

Comparison of selective and nonselective media for recovery of Campylobacter pylori from antral biopsies.

Antral biopsy specimens from patients with acid peptic disease were cultured in parallel on Skirrow medium (SM) and sheep blood agar (SBA) for Campylobacter pylori. In institution 1, 23 of 88 (26.1%) endoscopies were positive on SBA compared with 37 of 88 (42.0%) on SM (P = 0.0001). In institution 2, 29 of 49 (59.2%) endoscopies were positive for C. pylori on SBA and 27 of 49 (55.1%) were positive on SM (P = 0.50). The addition of SM optimizes the recovery of C. pylori from antral biopsy specimens.

Campylobacter pyloridis is associated with acid-peptic disease in Toronto.

Campylobacter pyloridis has been associated with acid-peptic disease in centres outside Canada. The authors conducted a pilot study to see if this association existed in Toronto. Patients in whom esophagogastroscopy was indicated on clinical grounds were arbitrarily selected for determination of the presence of C. pyloridis. Included in the study were 100 patients who underwent 105 endoscopies. In 75 patients (80 endoscopies) there was some form of acid-peptic disease (inflammation or ulceration of stomach or duodenum). Of those with acid-peptic disease, 34% had C. pyloridis compared with 4% among patients without acid-peptic disease (p less than 0.01). Men with acid-peptic disease were more likely to harbour C. pyloridis than women (48% versus 16%, p less than 0.01). The organisms were curved gram-negative rods that appeared as small colonies after 4 days of incubation under microaerobic conditions. They were strongly urease positive. There was considerable heterogeneity of endoscopic diagnoses. Future clinical studies of C. pyloridis need careful endoscopic and histologic classification.

Intraoperative bacterial contamination of vascular grafts: a prospective study.

The establishment of graft infection depends on host response, an appropriate field and bacterial contamination. Intraoperative bacterial contamination of prosthetic graft material was studied prospectively in 77 patients. Vascular reconstruction was indicated for abdominal aortic aneurysm (15%), claudication (42%), rest pain (25%) and ulceration or gangrene (18%). In 78% of cases the procedure was elective. Staphylococcus epidermidis was isolated in 80% of cultures; mixed flora were more frequent in patients with rest pain (60%) and ulceration or gangrene (45%) than in those with aneurysms (22%) or claudication (16%). Grafts became contaminated in 56% of cases using standard techniques; this was lowered to 35% when the surgeon changed gloves before preclotting the graft. There was no significant difference with respect to the surgeon who performed the operation, the indication for operation, primary versus secondary repair or the use of skin barriers. One patient (1.3%) had an established graft infection. It is concluded that the incidence of contamination is high but may be decreased by glove changing.

Proteus penneri and urinary calculi formation.

The clinical significance of Proteus penneri, a newly described species, is unknown. A case report is presented, which is to the best of our knowledge the first description of this organism causing a urinary tract infection and bladder calculi.

Treatment of tuberculous masses in the neck.

Tuberculous cervical lymphadenitis was diagnosed in 23 patients from 1970 to 1980; 21 of them were immigrants. The masses ranged in diameter from 1.5 to 5.5 cm. The posterior triangle was involved in 11 patients, the anterior triangle in 7 and both triangles in 5 (3 bilateral). Excisional node biopsy was performed in all. Acid-fast bacilli were identified on the smear in only 12 patients. Caseation necrosis was present in 19 specimens; the other 4 were comparable with sarcoidosis. However, all cultures grew Mycobacterium tuberculosis, which was corroborated in all by guinea-pig inoculation. No chest roentgenograms showed active pulmonary tuberculosis. Chemotherapy was given for 12 to 18 months. In three patients masses continued to enlarge for 5 months after initiation of chemotherapy, but then regressed and disappeared completely within 12 months. No recurrences were present in any patients (follow-up more than 2.5 years, mean 5.4 years).