ST segment elevations: always a marker of acute myocardial infarction?

Chest pain is one of the chief presenting complaints among patients attending Emergency department. The diagnosis of acute myocardial infarction may be a challenge. Various tools such as anamnesis, blood sample (with evaluation of markers of myocardial necrosis), ultrasound techniques and coronary computed tomography could be useful. However, the interpretation of electrocardiograms of these patients may be a real concern. The earliest manifestations of myocardial ischemia typically interest T waves and ST segment. Despite the high sensitivity, ST segment deviation has however poor specificity since it may be observed in many other cardiac and non-cardiac conditions. Therefore, when ST-T abnormalities are detected the physicians should take into account many other parameters (such as risk factors, symptoms and anamnesis) and all the other differential diagnoses. The aim of our review is to overview of the main conditions that may mimic a ST segment Elevation Myocardial Infarction (STEMI).

Medium for selective isolation of Cryptococcus neoformans.

A medium has been developed that permits the selective recovery of Cryptococcus neoformans from heavily contaminated materials. It employs creatinine as a nitrogen source, diphenyl (C(6)H(5)C(6)H(5)) and chloramphenicol as mold and bacterial inhibitors, and Guizotia abyssinica seed extract as a specific color marker. The medium has proved to be effective in the direct isolation of Cryptococcus neoformans from pigeon nests and from the air.

Zygomycosis of the maxillary sinus and palate caused by Basidiobolus haptosporus.

Basidiobolus haptosporus is known to cause subcutaneous zygomycosis in tropical Africa and Asia. We cared for a 49-year-old hyperglycemic, asplenic man who had never traveled outside the United States and who was seen initially for a painless palatal ulcer with cutaneous hypesthesia of the right cheek and upper lip. An invasive process involved the right middle nasal turbinate, maxillary antrum, maxillary division of the trigeminal nerve, and bony palate. Histological examination of biopsy tissue showed necrotizing granulomata with broad, nonseptate hyphae. Basidiobolus haptosporus was cultured from this tissue. Various laboratory studies revealed no immunologic defect and his lesions responded to therapy with amphotericin B. To our knowledge, this represents the first case of zygomycosis caused by B haptosporus in the Americas and the first culture-documented case of invasive mycosis caused by this mold.

Selective pacing sites.

he right ventricular apex (RVA) has always been the most used pacing site, because it is easily accessible and provides a stable lead position with a low dislodgment rate. However, it is well-known that long-term right ventricular apical pacing may have deleterious effects on left ventricular function by inducing a iatrogenic left bundle branch block, which can have strong influences on the left ventricle hemodynamic performances. More specifically, RVA pacing causes abnormal contraction patterns and the consequent dyssynchrony may cause myocardial perfusion defects, histopathological alterations, left ventricular dilation and both systolic and diastolic left ventricular dysfunction. All these long-term changes could account for the higher morbidity and mortality rates observe in patients with chronic RVA pacing compared with atrial pacing. This observation led to the reassessment of traditional approaches and to the research of alternative pacing sites, in order to get to more physiological pattern of ventricular activation and to avoid deleterious effects. Then, attempts were made with: right ventricular outflow tract (RVOT) pacing, direct His bundle pacing (DHBP), parahisian pacing (PHP) and bifocal (RVA + RVOT) pacing. For example, RVOT pacing, especially in its septal portion, is superior to the RVA pacing and it would determine a contraction pattern very similar to the spontaneous one, not only because the septal portions are the first parts to became depolarized, but also for the proximity to the normal conduction system. RVOT is preferable in terms of safety too. DHBP is an attractive alternative to RVA pacing because it leads to a synchronous depolarization of myocardial cells and, therefore, to an efficient ventricular contraction. So it would be the best technique, however the procedure requires longer average implant times and dedicated instruments and it cannot be carried out in patients affected by His bundle pathologies; furthermore, due to the His bundle fibrous area, higher pacing thresholds are required, causing accelerated battery depletion. For all these reasons, PHP could be considered an important alternative to DHBP, to be used on a large scale. Finally, bifocal pacing in CRT candidates, provides better acute hemodynamic performance than RVA pacing, derived from a minor intra- and interventricular dyssynchrony, expressed also by the QRS shortening. Then, bifocal pacing could be taken into account when RVA pacing is likely to be the origin of serious mechanical and electrical dyssynchrony or when CRT is contraindicated or technically impossible. So, whatever chosen as selective pacing site, you must look also at safety, effectiveness and necessary equipment for an optimal pacing site.

Wangiella dermatitidis endocarditis in an intravenous drug user.

Wangiella dermatitidis is an infrequently encountered dematiacious fungus that usually causes localized infections of the skin and subcutaneous tissues. This report presents the first well-documented case of natural valve infection caused by this organism as it occurred in intravenous drug abuser. His course has been complicated by relapsing infection of two aortic prostheses and dissemination to the vertebral spine. Treatment with a combination of amphotericin B, rifampin, and ketoconazole has arrested the progression of his infection. The microbiologic features and existing clinical information regarding this fungus are reviewed and in vitro susceptibility data for the present isolate are presented.

Outbreak of acute pulmonary histoplasmosis in members of a wagon train.

In August 1980, an outbreak of acute pulmonary histoplasmosis occurred among participants in a wagon train as it traveled through eastern Tennessee. Of the 85 people on the train 69 (81 percent) had evidence of infection with Histoplasma capsulatum. Fifty-four people had symptomatic disease. The source of infection was traced to the site of a former winter blackbird roost in Charleston, Tennessee, that had been partially cleared five years earlier to make a park. Fourteen of 25 soil samples from this site were culture-positive for H. capsulatum. This is the first reported outbreak to involve a large migrant group. The outbreak is unusual in that exposure occurred without excavation, construction or tree-cutting at the site.

Skin sensitivity to histolyn, spherulin, and PPD in the People's Republic of China.

One hundred one subjects living in northwest Hunan Province, People's Republic of China (PRC) were tested with histolyn, (Berkeley Biological Laboratories), spherulin (Berkeley Biological Laboratories), and tubersol (PPD 5 tuberculin units, Connaught Laboratories). Age of the tested subjects ranged from 16 to 58 years; 93 subjects were 22 years old or younger. Nine subjects reacted to histolyn with 5.0 mm or more induration, two subjects reacted to spherulin, and 34 subjects reacted to tubersol. One of the spherulin reactors also reacted to both histolyn and tubersol. The feasibility and advisability of doing a large-scale survey throughout the PRC seem clearly supported by this pilot project.

Acute histoplasmosis. Description of an outbreak in northern Louisiana.

An outbreak of acute histoplasmosis occurred in northern Louisiana in September 1977. All six men who cleared a field of bamboo cane known to be a blackbird roosting site were affected. All had clinical and roentgenographic findings of acute pulmonary histoplasmosis, and all recovered. Seroconversion or fourfold rise in antibody to Histoplasma capsulatum yeast--or mycelial-form antigens were demonstrated in five. Immunodiffusion testing showed that all six patients developed H capsulatum M bands, and two developed H bands specific for active infection. The H capsulatum was isolated from the soil in the cane field. This is the first report of an outbreak of histoplasmosis in Louisiana and the first known isolation of H capsulatum from Louisiana soil.

Zygomycosis. Report of four cases with formation of chlamydoconidia in tissue.

The authors describe spheric to ovoid chlamydoconidia and mucoraceous hyphae in tissues from four patients, two with cutaneous and two with pulmonary zygomycosis. The diagnosis in each case was confirmed by immunofluorescence staining and the presence of characteristic hyphae in tissue. It is important that these conidia be recognized, because they can easily be mistaken for other fungi, nematode ova, or other microorganisms in tissue sections, thereby resulting in the potential for misdiagnosis.

Lobomycosis in western Brazil: report of a clinical trial with ketoconazole.

We report a case of chronic lobomycosis, contracted by a rural resident of the westernmost Brazilian state, Acre, and substantiate that western Amazonia is now an endemic area for Loboa loboi. No changes in lesion morphology resulted from a prolonged course of oral therapy with ketoconazole administered in an attempt to prevent the progressive and destructive extension of the disease.

An epidemic of histoplasmosis on the Isthmus of Panama.

Forty-seven men on the Isthmus of Panama were exposed to histoplasmosis in an old bunker inhabited by bats. The resulting epidemic was studied with serial clinical, serological, and radiological examinations. Thirty-seven (78.7%) of the men showed serological evidence of infection and 26 (70.3%) had symptoms. Incubation periods ranged from 4 to 30 days. A general relationship between severity of illness and degree of exposure was noted. The agar gel diffusion test for precipitin antibodies was more sensitive than the complement-fixation test or slide test in detecting infection with Histoplasma capsulatum. Decontamination procedures and environmental studies are described.

Histoplasmosis in Belize, Central America.

After two small outbreaks of histoplasmosis in Belize, an epidemiologic survey was carried out. Forty percent of 141 persons in two groups tested demonstrated a positive histoplasmin reaction. In one study group there was a significant association between visiting caves and histoplasmin positivity. Histoplasma capsulatum was not isolated in 20 soil specimens collected from outbreak-associated caves, but was isolated from 1 of 26 bats collected from the same caves. The presence of histoplasmosis in Belize, C.A. is documented, and this disease should be considered in differential diagnosis in patients, both residents and visitors in Belize, with compatible clinical presentations.

Acremonium recifei as an agent of mycetoma in India.

Acremonium recifei was identified as the causal agent in a case of white grain eumycotic mycetoma of the hand which occurred in South India. The identification was based on the structure of the granules in tissue and on the morphological characteristics of the culture obtained from the granules. This case represents the first documented instance in which A. recifei has been found outside of Latin America.

Lobomycosis as a disease of the Atlantic bottle-nosed dolphin (Tursiops truncatus Montagu, 1821).

Skin lesions on an Atlantic bottlenosed dolphin, captured off the coast of Florida, were investigated and found to be histologically and microbiologically indistinguishable from those caused in humans by Loboa loboi. All attempts to isolate the etiologic agent or to transmit the infection to mice and monkeys ended in failure. Sight records of other suspected dolphin cases of lobomycosis in Florida waters are described along with citations of two previously confirmed and published dolphin infections.

Occurrence of Blastomyces dermatitidis in Israel. First autochthonous Middle Eastern case.

A nodule from the infrapatellar region of the left knee of a patient in Israel was found by fluorescent antibody staining to contain the tissue form cells of Blastomyces dermatitidis. The diagnosis was confirmed by culture and other mycological studies when a second lesion appeared below the right knee. This represents the first autochthonous case of blastomycosis from Israel and the Middle East.

Occurrence of Histoplasma capsulatum Darling, 1906 in Israel, with a review of the current status of histoplasmosis in the Middle East.

The isolation of Histoplasma capsulatum from a bat cave in the Galilee region of Israel is reported along with the discovery of a bat (Myotis myotis) infected by H. capsulatum. Soils collected in avian and chiropteran habitats throughout Israel also yielded the following fungi of medical interest: Arthroderma quadrifidum, A. tuberculatum, Candida parapsilosis, Chrysosporium indicum, C. keratinophilum, C. tropicum, Cryptococcus neoformans, Ctenomyces serratus, Microsporum gypseum, and Petriellidium boydii. All available reports concerning the occurrence of H. capsulatum and histoplasmosis in the Middle East are critically reviewed.

Phaeohyphomycosis in El Salvador caused by Exophiala spinifera.

We identified Exophiala spinifera as the causal agent in a case of subcutaneous phaeohyphomycosis in El Salvador. Identification was based on the morphology of the fungus in tissue and the microscopic features of the culture obtained from the biopsy material. This case is the first of this type to be documented from Central America.

Penicilliosis marneffei in Thailand: report of five human cases.

The first two cases of Penicillium marneffei infection in humans were reported in 1959 and 1973. There had been no additional clinical reports of penicilliosis marneffei, until the five new cases of human infection described in this paper, the first from Thailand. The patients, three of whom died, came from various parts of the country. Their common clinical manifestations were fever and generalized lymphadenopathy, with multiple soft tissue, bone, joint and pulmonary involvement. Pericarditis with effusion was also seen. The diagnosis was established by isolating and identifying a dimorphic Penicillium species that produced a soluble red pigment in its mycelial form. The histopathologic features of the lymph nodes and bone marrow were similar to those of histoplasmosis capsulati. However, the yeast-like tissue form of P. marneffei divides by fission; that of Histoplasma capsulatum by budding. Treatment with amphotericin B was effective when this antifungal antibiotic was administered early in the course of the disease.

First case of subcutaneous zygomycosis caused by Saksenaea vasiformis in India.

The first case of subcutaneous zygomycotic infection caused by Saksenaea vasiformis in a rice mill worker from India is described. The infection, confined to the man's left foot, showed multiple draining sinuses, inflammation, and intermittent low-grade fever following a crushing injury when a log fell on his foot. Histopathologic examination of two biopsy specimens, taken at 3-wk intervals, revealed the presence of broad, sparsely septate, branched, hyaline hyphae characteristic of a zygomycete. When they were grown on a nutritionally deficient medium, two cultures isolated from the biopsied tissues formed numerous, vase-shaped sporangia typical of S. vasiformis. Necrosis of the affected area led to amputation of the fore part of the foot. A split thickness graft was well accepted, and treatment with potassium iodide, following the graft, cured the infection.