Eyelid Molluscum Contagiosum: A Sign of Advanced HIV Infection.

HIV infection can present with dermatologic pathologies, and molluscum contagiosum in the eyelid is a specific sign often related to advanced HIV. Herein, we present the case of an adult patient with eyelid molluscum contagiosum that had been present for the last five years. Despite previous healthcare evaluation, the patient was not tested for HIV infection until presenting to our healthcare facility. The patient was diagnosed with AIDS. Our case highlights the importance of recognizing indirect signs of immunosuppression and the need to promptly order an HIV test. Additionally, we want to emphasize the importance of raising awareness about routine HIV testing, aiming to reduce the social stigma surrounding this test.

Intestinal spirochetosis: an enigmatic disease.

INTRODUCTION: Intestinal spirochetosis (IS) is a condition in which colonic and appendiceal epithelial cells are colonized by one of two anaerobic spirochetes, either the Brachyspira aalborgi or Brachyspira pilosicoli. There is much debate in the literature as to whether IS is a pathogen or a commensal inhabitant. A recent case of IS at our institution prompted a retrospective database search and review of the literature. METHODS: A pathology database search for IS was performed at Carolinas Medical Center from 2003 through 2007. After patient identification, a retrospective review of the endoscopic record and the pathology report was performed. Pathology slides were reviewed for accuracy and special silver stains and/or immunostains were performed if needed. The following data were collected for each patient when available: age, gender, nationality, HIV status, and other co-morbid conditions when noted. We attempted to determine whether patients were treated for spirochetosis and if so, the treatment regimen used as well as the results. RESULTS: The database search detected 29 patients with biopsies showing IS. Three patients were subsequently removed due to incorrect identification. A total of 26 patients with an average age of 45 years were reviewed. The most common symptoms were abdominal pain, diarrhea, and rectal bleeding. Most patients did not exhibit inflammatory changes despite the presence of spirochetosis. Pathologic examination revealed a relative increase in intra-epithelial lymphocytes in a subset of cases, a non-specific finding. Acute colitis or architectural distortion was not seen in any of the study cases. We were only able to obtain follow-up of two patients after treatment with metronidazole and both responded to therapy. CONCLUSIONS: To date, our study is the largest case series that includes both endoscopic and pathologic descriptions and confirms the "bland" nature of the condition. In <20 % of our patients inflammation was present microscopically and it did not correlate well with endoscopic appearance. Symptoms reported by our patients were similar to those reported in previous studies, although our lack of endoscopic changes was different from one previous paper. There is no established standard of care for the treatment of IS and our study, reflects the enigmatic nature of IS as a disease process. In the absence of rigorous literature, physicians will need to use a logical and pragmatic approach to the evaluation and treatment of IS.

Weil's Disease in an HIV-Infected Patient.

Leptospirosis is a zoonosis caused by the spirochete Leptospira. Most cases of leptospirosis are mild to moderate and self-limited. The course of disease, however, may be complicated by multiorgan dysfunction with liver and kidney failure causing Weil's disease. Leptospirosis is also rare among HIV-infected patients. We report a case of an HIV-infected patient with Weil's disease.

Flock health indicators and Campylobacter spp. in commercial housed broilers reared in Great Britain.

This study investigated the relationship between flock health and Campylobacter infection of housed commercial broilers in Great Britain. Thirty ceca were collected at slaughter from batches of broilers from 789 flocks, at either full or partial depopulation, between December 2003 and March 2006 and examined individually for Campylobacter by direct plating onto selective media. Management and health data were collected from each flock and included information on mortality or culling during rearing, the number of birds rejected for infectious or noninfectious causes at slaughter, the proportion of birds with digital dermatitis (also termed hock burn), and other general characteristics of the flock. Campylobacter spp. were isolated from 280 (35%) flocks. The relationship between bird health and welfare and Campylobacter status of flocks was assessed using random-effects logistic regression models, adjusting for region, month, year, and rearing regime. Campylobacter-positive batches of ceca were associated with higher levels of rejection due to infection (odds ratio [OR], 1.5; 95% confidence interval [CI(95%)], 0.98 to 2.30) and digital dermatitis (OR, 2.08; CI(95%), 1.20 to 3.61). Furthermore, higher levels of these conditions were also associated with the highest-level category of within-flock Campylobacter prevalence (70 to 100%). These results could indicate that improving health and welfare may also reduce Campylobacter in broilers.

Disseminated Paecilomyces lilacinus infection in a patient with AIDS.

We describe a case of disseminated Paecilomyces lilacinus infection occurring in a patient with advanced HIV infection. P lilacinus is a ubiquitous environmental fungus that has been associated with infection in various immunocompromised hosts, in patients with invasive medical devices, and in contact-lens wearers. The clinical features, morphologic characteristics, and response to antifungal therapy in our patient are similar to findings reported in disseminated infection due to Penicillium marneffei, another opportunistic fungal infection in HIV-infected patients. We believe this to be the first report of infection with P lilacinus in a patient with AIDS.

Eosinophilic pneumonia induced by ceftaroline.

PURPOSE: A case of eosinophilic pneumonia in a patient receiving ceftaroline for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is reported. SUMMARY: A 65-year-old woman was admitted to a medical intensive care unit after arriving at the emergency room with complaints of progressively worsening shortness of breath. Her medical history included chronic obstructive pulmonary disease, acute respiratory distress syndrome, recent traumatic brain injury, tobacco use, and alcohol abuse. Within the first few days of hospitalization, the patient was diagnosed with MRSA pneumonia based on microbiological data from bronchoscopy bronchial washings. Her renal function liver enzyme levels were within normal limits. Empirical antibiotic therapy included i.v. vancomycin and meropenem and was narrowed to i.v. linezolid monotherapy based on culture and sensitivity results. After 10 days of treatment with linezolid, the patient was persistently febrile, and cultures remained positive. It was decided to switch therapy to a course of i.v. ceftaroline, an anti-MRSA cephalosporin. On the fifth day of treatment with ceftaroline, the patient developed respiratory decompensation and peripheral eosinophilia of 40%. Bronchoalveolar lavage (BAL) results indicated the presence of pulmonary eosinophilia of 13%. Chest radiographs revealed pulmonary infiltrates, and the computed tomography angiography showed no evidence of pulmonary embolism. Ceftaroline was discontinued, and the patient was started on vancomycin and methylprednisolone. The patient responded to methylprednisolone therapy, with repeat BAL and peripheral blood counts showing resolved eosinophilia. CONCLUSION: A patient with risk factors for respiratory disease developed eosinophilic pneumonia after receiving ceftaroline for the treatment of MRSA pneumonia. Eosinophilia resolved after ceftaroline was discontinued and i.v. methylprednisolone was initiated.

Clostridium difficile colitis: a retrospective study of incidence and severity before and after institution of an alcohol-based hand rub policy.

BACKGROUND: Clostridium difficile-associated diarrhea is a leading cause of hospital-acquired diarrhea. We sought to determine whether the institution of a hospital-wide alcohol-based hand rub (ABHR) policy was associated with an increase in the incidence and/or severity of health care facility-onset, health care facility-associated C difficile diarrhea (CDAD). METHODS: We used a retrospective chart review analysis to compare incidence rates of CDAD before and after implementation of the ABHR policy. We also compared rates of sepsis, colectomy, and death in patients with CDAD before and after implementation of the ABHR policy. RESULTS: The incidence rate of CDAD was 3.98 per 10,000 patient-days after implementation of the ABHR policy, compared with 4.96 per 10,000 patient-days before implementation (P = .0036). The crude mortality rate in patients diagnosed with CDAD was 10.7% after implementation, compared with 13.3% before implementation (P = .275). The rate of sepsis in patients diagnosed with CDAD was 19.6% after implementation, compared with 5.2% before implementation (P < .0001). CONCLUSION: Our data provide no evidence of an increased CDAD rate after implementation of an ABHR policy at our institution. The rate of sepsis in patients diagnosed with CDAD did rise, indicating increased severity of illness in patients with C difficile infection.

Concomitant surgical treatment of dental and valvular heart diseases.

BACKGROUND: Invasive dental procedures are often indicated before cardiac valve surgery. The purpose of this case-control study was to determine the risks and benefits of concomitant dental and thoracic surgery. METHODS: Critically ill cardiac inpatients requiring cardiac valve surgery were referred by the Department of Thoracic and Cardiovascular Surgery to our Oral Medicine consult service. Those requiring dental extractions were considered for dental treatment during the same general anesthetic as the cardiac surgery. These study patients were compared with control patients who had extractions before valve surgery in a different setting. There was no attempt to analyze the impact of this practice on the development of infective endocarditis. All patients received broad-spectrum antibiotics during dental surgery. RESULTS: Twenty-one patients had concomitant oral and cardiac valve surgery. Seventeen patients were in the control group. There were no statistically significant differences between cases and controls in demographics, length of stay, nature of the dental surgery, mean number of teeth removed, oral bleeding, or postoperative infections. One patient in the control group developed prosthetic valve endocarditis versus none in the concomitant surgery group. CONCLUSIONS: This case-control study suggests that concomitant surgical procedures for dental and valvular heart disease can be accomplished without clinically significant oral complications. Given the risk from poor oral health following cardiac valve surgery, this approach should be considered for patients who would benefit by avoiding a second general anesthetic and/or a delay in cardiac surgery, and by having their oral surgery performed in the safest environment.

The impact of grassland management regime on the community structure of selected bacterial groups in soils.

The impact of long-term grassland management regimes on microbial community structure in soils was assessed using multivariate analysis of polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE) banding patterns of selected bacterial groups and PLFA (phospholipid fatty acid) profiling. The management regimes assessed were inorganic nitrogen (N) fertiliser application and soil drainage. PCR-DGGE profiles of the eubacteria, actinomycetes, ammonia oxidisers and pseudomonads were assessed by principal co-ordinate analysis of similarity indices which were generated from binary data using both Dice and Jaccard coefficients. The analysis of binary DGGE data revealed significant impacts of N fertiliser on the eubacterial and actinomycete community structure using the Jaccard coefficient, whilst N fertiliser had a significant impact on the actinomycete community structure only when using similarity indices generated from the Dice coefficient. Soil drainage had a significant impact on the community structures of the actinomycetes and the pseudomonads using both Dice and Jaccard derived similarity indices. Multivariate analysis of principal components derived from PLFA profiling revealed that N fertiliser had a significant impact on the microbial community structure. Although drainage alone was not a significant factor in discriminating between PLFA community profiles of the different treatments, there was a significant interaction with N fertiliser. Analysis of principal component analysis (PCA) loadings revealed that PLFAs i15:0 and i17:0 were partly responsible for the clustering away of the undrained-N fertilised treatment. Although soil management regime influenced some background soil data, correlation analysis using PC1 from PLFA data revealed no significant relationship with soil organic matter, pH, total C and total N. These results provide evidence that grassland management practices impact on the community composition of specific microbial groups in soils.