Cryptococcal meningitis: diagnostic value of cryptococcal antigen in cerebrospinal fluid.

In three previously reported cases of cryptococcal meningitis, the only laboratory evidence for this diagnosis was the presence of cryptococcal antigen in the cerebrospinal fluid (CSF). Three additional patients had chronic meningitis and repeatedly negative CSF cultures and had cryptococcal antigen demonstrated in the CSF. In our patients, the diagnosis was further supported by the complete recovery after amphotericin B therapy in two and the demonstration of Cryptococcus neoformans in the meninges at autopsy in the third. In certain patients with chronic meningitis, the detection of cryptococcal antigen in the CSF may be the only means of establishing a diagnosis during life. In such patients, if cryptococcal antigen is present in the CSF in a titer of larger than or equal to 1:8, antifungal therapy should be initiated, pending results of other diagnostic studies.

Ceftriaxone treatment of skin and soft tissue infections in a once daily regimen.

A randomized trial to compare the efficacy and safety of 1 g of ceftriaxone daily and 3 to 4 g of cefazolin daily was conducted in 84 hospitalized adults with skin and soft tissue infections. A variety of infections including bacteriologically proven cellulitis, suppurative diabetic foot ulcer, soft tissue abscess, and other miscellaneous infections were treated. Side effects were minimal. Colonization with various microorganisms was observed during therapy with both agents. Clinical cure with or without surgery was achieved in 81 percent (34) of 42 patients treated with ceftriaxone and 77 percent (32) of 42 patients treated with cefazolin. The major difference between antibiotics was the rate of failure in infections caused by multiple organisms: five failures among 13 patients treated with cefazolin compared with no failures among 12 patients treated with ceftriaxone. Ceftriaxone appears to be an effective agent when given once daily as therapy for many serious skin and soft tissue infections.

Multiple pulmonary arteriovenous fistulas demonstrated by dynamic radionuclide pulmonary perfusion scanning.

Dynamic radionuclide perfusion scintigraphy performed with 99mTc-labeled microspheres was instrumental in establishing the diagnosis of multiple, small-vessel, pulmonary arteriovenous fistulas in a 14-month-old patient with cyanosis. Computer analysis of the sequential distribution of tagged microspheres in the pulmonary parenchyma normally demonstrates a curve that rises rapidly to a plateau as the particles microembolize. In the case reported here, the pulmonary flow curve rose rapidly to a maximum and then fell within 2 sec to a plateau of less than 50% of the maximum count, indicating that a large proportion of the microsophers passed through the pulmonary circulation. Conventional pulmonary contrast angiography did not demonstrate any intracardiac shunting but did confirm the presence of multiple pulmonary arteriovenous fistulas.

Time-dependent image quality using 99mTc-pyrophosphate.

Technetium-99m-labeled pyrophosphate has proved to be a useful skeletal-imaging agent. In this study, specific areas of the skeleton were imaged at times ranging from 1/2 to 6 1/2 hr after injection of 99mTc-pyrophosphate. Count ratios between abnormal and normal bone with respect to adjacent soft tissue were obtained for selected regions of interest on computer-stored scintillation camera images. The results show that image quality improves most rapidly from 1/2 to 2 hr, but further modest gain in quality does occur on views recorded between 2 and 6 hr. All lesions detected on the later images were also observed on the early ones and the ratios of uptake between abnormal and normal bone from computer-processed scintillation camera images did not change appreciably with time after the 1/2-hr images. Our results confirm the clinical impression that overall image quality is better on views obtained at least 3 hr after injection. Further delays in imaging beyond 3-4 hr after injection probably will not result in any appreciable gain in diagnostic accuracy.

Clinical features of tiaprofenic acid (surgam) associated cystitis and a study of risk factors for its development.

A case-control study was performed to describe the clinical course and identify risk factors predisposing to the development of tiaprofenic acid associated cystitis. Cases were identified from reports to the Australian Adverse Drug Reactions Advisory Committee and a two-year (1995-1996) national surveillance programme. Definition of a case was onset of symptoms of cystitis while taking tiaprofenic acid with pyuria (>10 WBC/microl) and/or hematuria (>10 RBC/microl), and no evidence of urinary tract infection. Definitions of "prescriber-matched" and "unmatched" controls were those who had been prescribed tiaprofenic acid by the same prescriber within 12 months of the case without developing cystitis or were identified from the databases of local pharmacies of the cases respectively. 81 of 109 identified cases and 109 of 184 potential controls completed a standardised interviewer-administered questionnaire. Median time between the commencement of tiaprofenic acid and symptom onset was 6. 3 months (range 0.1-47.1 months). Median interval between presentation to doctor and drug cessation was 3.0 months (range 0-24. 5 months). In half the patients, symptoms resolved within 14 days of ceasing therapy. Increasing age was a risk factor for the development of tiaprofenic-acid associated cystitis, age >70 years-odds ratio 3.2 (95% confidence interval 1.3-7.9) compared with age <55 years. Patients taking aspirin had a reduced risk (odds ratio 0.3, 95% confidence interval 0.1-0.9). Dose and amount of fluid consumed per day were not related to the risk of cystitis. Earlier recognition of tiaprofenic acid associated cystitis can potentially reduce the morbidity related to this condition. Apart from an increased risk among older patients, it is likely that this condition represents a drug reaction that cannot be predicted from clinical variables.

Ofloxacin versus cephalexin in the treatment of skin, skin structure, and soft-tissue infections in adults.

A multicenter study was conducted to compare the safety and efficacy of oral ofloxacin with that of cephalexin in microbiologic eradication of skin and skin-structure pathogens and the clinical treatment of skin and skin-structure infections. The subjects, 335 adult patients with acute localized infections of the skin, skin structure, or soft tissue, were randomly assigned to receive 400 mg of ofloxacin orally every 12 hours or 500 mg of cephalexin orally every six hours for 10 days. At admission, 398 aerobic pathogens were isolated, the most common being Staphylococcus aureus (160 isolates), Streptococcus pyogenes (49), coagulase-negative staphylococci (30), Staphylococcus epidermidis (25), and Pseudomonas aeruginosa (10). Of 317 isolates tested against ofloxacin, 96% were susceptible, and of 325 tested against cephalexin, 85% were susceptible (P less than 0.001). Microbiologic and clinical outcome were evaluated in 73 ofloxacin-treated patients and in 65 cephalexin-treated patients. The causative pathogens were eradicated in 95% of the ofloxacin group and in 92% of the cephalexin group. In the ofloxacin group, 75% were clinically cured and 23% improved, and in the cephalexin group, 74% and 23%, respectively. Drug-related adverse experiences were reported by 14% of the 161 ofloxacin-treated patients and by 11% of the 162 cephalexin-treated patients; gastrointestinal disturbances were reported by 8% and 7% and nervous system effects by 6% and 1%, respectively (P less than 0.05). It is concluded that both ofloxacin and cephalexin are safe and effective in the treatment of skin and soft-tissue infections.

Prospective, randomized comparison of the efficacy and safety of netilmicin-clindamycin and tobramycin-clindamycin in the treatment of serious systemic infections.

Fifty-three patients with documented or suspected mixed flora infections were randomly assigned to receive either netilmicin or tobramycin in combination with clindamycin. Data from 36 patients with 43 documented infections yielding 102 clinical isolates were evaluated for efficacy. In the 18 patients receiving netilmicin-clindamycin, 90% of the infections responded favorably and 96% of the pathogens were eliminated. In the 18 patients receiving tobramycin-clindamycin, 81% of the infections resolved and 88.5% of the pathogens were eliminated. Forty-nine patients were included in the safety analysis. The incidence of nephrotoxicity was similar in both groups (netilmicin, 20%; tobramycin, 21%). Auditory toxicity occurred less frequently in the netilmicin-clindamycin group (4.5%) than in the tobramycin-clindamycin group (21.7%). These results demonstrate that both the netilmicin-clindamycin and the tobramycin-clindamycin combinations are comparable in efficacy and in potential for causing nephrotoxicity. In this study, however, netilmicin was considerably less ototoxic than tobramycin.

Isolated vasculitis of the bladder.

We describe a case of isolated vasculitis involving the bladder that presented with severe irritative voiding and hematuria. This case presented a diagnostic problem, because malignancy was suspected, but not confirmed by biopsies. Once the vasculitis was diagnosed, secondary systemic causes were excluded, and successful treatment was subsequently undertaken using systemic steroids. It is important to differentiate this rare pathologic entity from the much more frequent tumors of the bladder because the treatment is medical rather than surgical.

Pelvic lipomatosis with cystitis cystica, cystitis glandularis and adenocarcinoma of the bladder: first reported case.

Pelvic lipomatosis is a rare disease which may cause obstructive uropathy. It has been reported with cystitis cystica and cystitis glandularis. Cystitis cystica and cystitis glandularis have been reported previously as progressing to adenocarcinoma of the bladder. The first reported case of pelvic lipomatosis, cystitis cystica, cystitis glandularis and adenocarcinoma of the bladder is presented and the literature reviewed.

Inhaled atropine in asthma.

Ten adult asthmatics inhaled atropine and isoproterenol to determine the site of action in the airways and relative effectiveness of the two drugs. The two agents were equal in their effect on lung volumes and airway resistance but isoproterenol produced significantly better flows. Atropine was shown to be an effective bronchodilator with a predominant site of action in large airways. The authors believe atropine and atropine derivatives deserve ongoing investigation, especially regarding potential side effects of retarding mucociliary clearance and the clinical significance of apparent failure to dilate small airways.

Respiratory failure in cancer patients.

A review of 180 cancer patients requiring mechanical ventilation disclosed that 26% survived to extubation, and 13% and 7% were alive at two and six months, respectively. Mortality was related to several factors individually and the cumulative number of organ systems dysfunctioning in a given patient. Compared with general intensive care patients, those with respiratory failure and neoplastic disease demonstrated a high incidence of drug-induced pulmonary disease, hematologic abnormalities, pneumothorax, and infections with multiple and unusual organisms--all of which alter the approach to management. Although the long-term survival was poor, immediate survival was comparable with that of many groups of patients with respiratory failure.

Smoke inhalation in firemen.

Thirty firemen were studied with pulmonary function tests immediately after a severe smoke exposure and then one and a half and 18 months later in order to evaluate acute and chronic changes in their spirometry. The results were compared with predicted values and with those from a group of closely matched control subjects. We found no significant differences between the acute post-exposure spirometry values and those recorded at six weeks and 18 months later. A trend toward an increased rate of volume loss in the FVC and FEV1 was noted which is similar to other published observations. However, we did find a significant decrement in FVC compared with predicted value, and in FVC and FEV1 compared with control subjects. This is further evidence that firemen may develop lung disease related to their occupational exposure.

Prostatic cancer: role of color Doppler imaging in transrectal sonography.

OBJECTIVE: The aim of this study was to assess the roles of transrectal color Doppler and gray-scale sonography in revealing prostatic cancer, using biopsy as the reference standard. SUBJECTS AND METHODS: Two hundred fifty-six patients referred for urologic studies underwent transrectal sonography using gray-scale and color Doppler scanning. All abnormal areas shown on gray-scale or color Doppler sonography or both were targeted and biopsies were performed. The patients also underwent random sextant biopsies. All biopsies were individually correlated with histopathologic findings and all results were analyzed. RESULTS: Cancer was found on biopsy in 100 patients (39%), and equivocal sonographic results or prostatic intraepithelial neoplasia was found in 22 other patients (9%). In 16 of the patients in whom cancer was detected, the tumors were correctly revealed only with color Doppler sonography. These 16 patients had a mean Gleason score of 6.4 (range, 5-8). Biopsy findings in these 16 patients showed eight patients with extensive lesions, three with moderate lesions, and five with minimal lesions. However, in nine other patients with cancer (9% of cancers detected), both gray-scale and color Doppler sonography failed to reveal lesions that were found on sextant biopsy. An analysis showed that, although highly sensitive, color Doppler sonography was somewhat less specific than gray-scale sonography. CONCLUSION: Color Doppler sonography should become a routine part of transrectal sonography of the prostate gland to improve detection and targeting of lesions. The practice of performing random sextant biopsies should also continue.

The management of testicular cancer in Victoria, 1988-1993. Urology Study Committee of the Victorian Co-operative Oncology Group.

OBJECTIVES: To evaluate the patterns of care and management of testicular cancer in Victoria. DESIGN AND SETTING: Retrospective analysis of all cases of testicular cancer in Victoria from 1988 to 1993 identified through the Victorian Cancer Registry. MAIN OUTCOME MEASURES: Description of patient characteristics, staging investigations, initial management, and outcome. RESULTS: 667 eligible cases of testicular cancer were identified and questionnaires were returned for 633 of these patients (94.9% response rate). There were 357 (56.4%) patients with pure seminoma; 271 (42.8%) with non-seminomatous germ cell tumours, 3 (0.5%) with stromal tumours, and 2 (0.3%) with other tumours. The median age was 32 years (range, 0-80 years). Preoperative marker levels were not available for 8% of patients, and initial staging was considered inadequate in 6%. Surveillance programs used for patients with Stage I disease were considered inadequate in most. Relative survival at five years was 99% for patients with seminoma and 91% for non-seminoma. CONCLUSIONS: There was considerable variation in the investigation, treatment, and follow-up of these patients, which is likely to have resulted in unnecessary morbidity. Clinical practice guidelines should be developed and implemented to promote optimal management.