Bacterial endocarditis in a patient with mitral valve prolapse.

Bacterial endocarditis developed following dental manipulation in a child with mitral valve prolapse. Antibiotic prophylaxis is recommended for patients with this cardiac abnormality who undergo procedures that may be associated with bacteremia.

Vertebral osteomyelitis presenting as spinal compression fracture. Six patients with underlying osteoporosis.

Six patients with osteoporosis had vertebral osteomyelitis (VO) with infection of a single vertebra that presented with a collapsed vertebral body, thought to be a simple compression fracture. The resulting delay in correctly diagnosing VO was associated with disabling sequelae in a high proportion of cases. This distinctive presentation accounted for 13% of all hospitalized patients with VO and 2.4% of inpatients with osteoporotic compression fractures during the last five years; it may be more common than suggested by the paucity of published cases. In patients with osteoporosis and vertebral compression fractures, osteomyelitis should be considered when there is severe back pain, persistent unexplained fever, unexplained elevation of the erythrocyte sedimentation rate, or bacteremia without an obvious extravertebral focus of infection, particularly if the patient is immunocompromised. Early biopsy and culture of the collapsed vertebral body will facilitate diagnosis and therapy.

Infective endocarditis caused by slow-growing, fastidious, Gram-negative bacteria.

In a review of endocarditis caused by fastidious, slow-growing gram-negative rods, similarities in the spectrum of disease overshadow differences among cases grouped by specific organisms. Cardiobacterium hominis, Actinobacillus actinomycetemcomitans and Haemophilus species usually seed previously damaged cardiac valves presumably during bacteremia from an upper respiratory site. The clinical presentation resembles that of Streptococcus viridans endocarditis and is usually subacute or chronic. Despite bacteriologic cure, severe CHF and/or systemic embolization frequently develops during or following the course of antibiotics, resulting in significant morbidity and a high mortality rate. This report of nine cases diagnosed at five hospitals in a 7-year period suggests that endocarditis due to these organisms is more common than previously appreciated and frequently goes unrecognized. This is probably due to a lack of attention to the requirements for culture of this group of bacteria with propensity for granular growth in broth. We have proposed specific cultural techniques appropriate to the search for these organisms in patients with apparent culture-negative endocarditis.

Haemophilus influenzae meningitis: the spectrum of disease in adults.

Fifteen cases of Haemophilus influenzae (HI) meningitis in adults occurring of Cleveland during the last 11 years are presented. The majority of patients had factors predisposing to infection such as otitis, pneumonia, diabetes or alcoholism. In addition, 7 of the 15 patients developed meningitis at various intervals following head trauma and neurosurgery, and 3 patients required dural repairs for CSF rhinorrhea. The diagnosis of meningitis may be difficult to establish resulting in delay in appropriate therapy in some cases. Nuchal rigidity was absent frequently; CSF lymphocytosis can be seen initially. The CSF Gram stain may be negative or the pleomorphic nature of the organism on Gram-stain may make distinction from other gram-negative organisms difficult. The majority of patients had meningitis due to non-Type B HI in contrast to previous reports of this illness in children and adults. One of our patients had beta-lactamase producing HI isolated from CSF. We believe that chloramphenicol should be included in the initial empiric therapy for adults with meningitis and gram-negative coccobacillary rods on Gram-stain or negative CSF Gram-stains.

Aspergillus valve endocarditis in patients without prior cardiac surgery.

Aspergillus native valve endocarditis in patients who have not had cardiac surgery is uncommon. We report 3 cases and review 58 other adult patients reported in the English-language literature. Sixty-seven percent of the patients had underlying immunosuppression. The clinical features were fever (74%), embolic episodes (69%), a new or changing heart murmur (41%), and sudden visual loss (13%). Patients with mural endocarditis were more often immunosuppressed, especially due to solid organ transplants, but had lower frequency of heart murmurs and embolic episodes. Echocardiography revealed a vegetation in 78% of all the cases in which it was performed. Examination and culture of biopsy material often helped to establish a diagnosis of Aspergillus infection. Twenty-five patients had an antemortem diagnosis. These patients received a mean cumulative amphotericin B dose of 27 mg/kg. Twenty percent (3/15) of patients who received combined surgical and medical therapy survived, compared to none of those who received medical therapy alone (p = 0.08). Patients who survived were not immunosuppressed. We conclude that native valve aspergillus infective endocarditis is uniformly fatal without surgical intervention and antifungal therapy.

Infections of the cardiac suture line after left ventricular surgery.

PURPOSE: Infections of the cardiac suture line after left ventricular surgery are rare but may be fatal if not diagnosed promptly and treated effectively. In order to alert physicians to this entity, we reviewed data from three patients who presented at the Cleveland Clinic Hospital and from 22 patients in the literature. PATIENTS AND METHODS: The three patients in the current report underwent treatment at the Cleveland Clinic Hospital. Additional cases of infection of the left ventricular suture line were identified by reviewing the English literature pertaining to surgery for left ventricular aneurysms, pseudoaneurysms, and postoperative cardiac infections. RESULTS: Infection presented on average 16 months after surgery with cardiocutaneous fistulae, chest wall masses, hemoptysis or other pleuropulmonary symptoms, or systemic illness with bacteremia resembling endocarditis. Staphylococci and gram-negative bacilli were the most frequent pathogens. Diagnosis was often delayed and mortality was high. Left ventricular false aneurysms were identified in 15 of the 25 patients. Bleeding from sinuses in the chest wall or epigastrium or repeated hemoptysis were important clinical clues. In some instances, ill-advised surgical or instrumental procedures precipitated life-threatening hemorrhage. Treatment with antibiotics alone was insufficient. Excision of all infected sutures and Teflon pledgets and adequate debridement of the infected suture line were required to achieve cures. CONCLUSION: Since infection of the left ventricular suture line has protean clinical manifestations and may present months or years after the initial surgery, a high index of suspicion is of paramount importance in diagnosing the condition. Institution of cardiopulmonary bypass and reoperation through median sternotomy is recommended to achieve a cure.

The fate of cadaver renal allografts contaminated before transplantation.

Through the routine use of cultures from saline slush transport solution and the initial and final organ perfusates, 14 of 81 cadaver allografts (17.3%) were found to have been contaminated before transplantation. Gram negative organisms, cultured from 5 of the 14 contaminated allografts, resulted in the recipient's death on the first encounter with this problem and the loss of two other allografts. Early antibiotic therapy begun even without evidence of overt infection appeared to prevent any further deaths or graft loss in those whose allografts were contaminated and yielded an overall survival comparable to that of uncontaminated allografts. Without such an approach to the study of perfused cadaver allografts and the management of them when found to be contaminated, this type of infection may go undetected and contribute to allograft and patient loss.

A multivariate analysis of risk factors for pneumonia following cardiac transplantation.

Fifty cardiac transplant recipients were followed over a 34-month period for evidence of pneumonia that developed in twelve patients. Potential risk factors evaluated fell into three categories: demographic (age, sex, race, and underlying cardiac disease); pretransplant status (hospitalized, intubated, pulmonary infiltrate, requirement for antibiotics, or the need for a ventricular assist device); and posttransplant therapy (amount and type of blood products, prolonged endotracheal intubation or reintubation, use of ventricular assist devices, immunosuppressive protocols, lymphocyte subset ratios, and occurrence of rejection, leukopenia, or CMV infection). The Cox proportional hazards model identified posttransplant reintubation (P = 0.009) and the use of protocols employing larger steroid dosages (P = 0.02) as significant risk factors for pneumonia. In a separate analysis, the occurrence of pneumonia was shown to be a significant risk factor for mortality (P = 0.018).

Median sternotomy wound infection and anterior mediastinitis caused by bacteroides fragilis.

The first reported case of median sternotomy infection and mediastinitis caused by Bacteroides fragilis is described. Several positive blood cultures led to diagnostic anaerobic cultures of the wound and administration of clindamycin therapy. This anaerobic infection should be suspected whenever Gram smears of exudates show gram-negative bacilli and aerobic cultures are sterile.

Listeria monocytogenes endophthalmitis.

Listeria monocytogenes and a staphylococcus organism caused a catastrophic endophthalmitis in a patient despite appropriate local and systemic antimicrobial chemotherapy. Although L monocytogenes is widespread in nature and has produced a variety of clinical illnesses, it has only one previously been reported to cause endophthalmitis. If appropriate microbiologic techniques are not employed, the organism may go unrecognized as an ocular pathogen.

Idiopathic infarction of intraabdominal lymph nodes. A cause of fever of unknown origin.

Infarcted peribiliary lymph nodes were found at laparotomy in a 56-year-old man who had a fever of unknown origin and transient abdominal pain. Despite thorough clinical and laboratory investigation, a cause was not demonstrated. A review of the reported cases of idiopathic or spontaneous lymph node infarction revealed a clinical presentation characterized by the sudden appearance of a painful mass, often associated with otherwise unexplained fever. Most clinical laboratory test results were negative. Although the pathogenesis is not known, histologic changes in involved lymph nodes are indistinguishable from those produced experimentally by occlusion of the vascular supply of lymph nodes. The histologic differential diagnosis includes lymphoma, metastatic carcinoma, vasculitis, and infection.

J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care.

Of 6,504 consecutive patients who underwent isolated coronary bypass grafting in 1985 to 1987, 72 (1.1%) patients experienced sternal wound complications. Ten patients (14%) with wound complications died of multi-system failure. Only the patients with negative cultures fared well; of the bacterial culture categories, polymicrobial infection carried the worst prognosis. Effects of recurring infection were seen throughout the first year. Patients, grouped according to conduits received, experienced these wound complication rates: vein grafts only, 11/1,085 (1.0%); one internal thoracic artery, 38/4,073 (0.9%); and bilateral internal thoracic artery grafts, 23/1,346 (1.7%). There were no significant differences in wound complication rates between primary and reoperation patients or among conduit groups. By logistic regression analysis, the relative risk for patients with diabetes and bilateral internal thoracic artery grafting was 5.00 (95% confidence interval, 2.4 to 10.5). Operation time as a continuous variable increased the relative risk of wound complication 1.47 times per hour (1.3 to 1.7); obesity, 2.90 times (1.8 to 4.8); and blood units as continuous variable, 1.05 times per unit (1.01 to 1.10). Bilateral internal thoracic artery grafting in nondiabetic patients carried no greater risk of wound complication than that in patients with vein grafts only or with one internal thoracic artery graft.

Gram-hegative bacillemia.

Members of the Klebsiella-Enterobacter-Serratia group now appear to be the most common cuase of gram-negative bacillemia, followed in order of frequency by E. coli, Bacteroides, polymicrobic infection, Pseudomonas aeruginosa, and miscellaneous pathogens. However, E coli continues to be the organism most frequently responsilbe for bacteremia arising from the urinary tract. Although the urinary tract remains the most common portal of entry for gram-negative bacillemia, a wide variety of extraurinary lesions have assumed increased importance in the pathogenesis of this condition. There is marked variability in the clinical course and outcome of gram-negative bacillemia. Grade of underlying disease and grade of illness cuased by infection are major determinants of fatal outcome. When the patient with gram-negative bacillemia has severe illness due to infection, prompt and decisive action is necessary to prevent death. Antimicrobiol drugs are administered on the basis of a presumptive etiologic diagnosis after appropriate smears and cultures are obtained, but before the causal organism is definitively identified or its in vitro susceptibility is determined. The presumptive etiologic diagnosis is based upon knowledge of the anatomic location of the infection, the circujstances involved in its development, and certain clinical clues. Knowledge of the antimicrobial drugs most likely to be effective against the suspected pathogen(s) will provide a rational basis for selection of antimicrobial agents until the results of definitive microbiologic studies are available. Using this approach, the mortality of gram-negative bacillemia arising from the urinary tract has been reduced markedly from the mortality reported in earlier years.

Septicemia in renal transplant recipients.

Thirty-six renal transplant recipients with 47 episodes of septicemia were studied carefully at the bedside, in the laboratory, and, all too frequently, at autopsy. Gram-negative bacilli were the pathogens most commonly responsible, folloed in order of frequency by gram-positive cocci, polymicrobic etiologic agents, Listeria monocytogenes, and fungi. Infections of the transplant site (urinary tract or transplant wounds) caused septicemia in 51% of the cases. Other portals of entry included the lung, the abdomen, the meninges, the endocardium, and miscellaneous sites. The outcome of septicemia was fatal in 36% of the episodes. There was a significantly higher mortality for episodes of septicemia associated with pneumonia, persistent bloodstream infection, leukopenia, metastatic abscesses, clinical shock, and acute respiratory failure. The high mortality of septicemia in renal allograft recipients demands that extremely careful attention be given to subtle clinical clues denoting the onset and predicting the course of the disorder.

Mucormycosis presenting as positional nystagmus and hydrocephalus. Case report.

A case of mucormycosis presenting with signs of positional nystagmus and obstructive hydrocephalus is described. The authors believe that this presentation of Mucor is unique.

Lymphoproliferative disorders associated with carbamazepine.

Carbamazepine-induced lymphoproliferative disorders are relatively rare. A 32-year-old woman developed cervical lymphadenopathy while taking carbamazepine. Histologic evaluation of the lymph node biopsy specimen demonstrated near-total effacement of the nodal architecture by a population of pleomorphic immunoblasts. The predominant cell population expressed CD3, CD2, CD5, and CD4, while results of testing for CD8 were negative. On the basis of the morphologic and immunohistologic features, a diagnosis of high-grade, non-Hodgkin's lymphoma, T-cell immunoblastic type, was made. Despite the fact that aggressive behavior is usually associated with immunoblastic lymphomas, the patient has done well for 33 months after cessation of carbamazepine in the absence of chemotherapeutic treatment. The clinical features of this patient's illness, therefore, suggest that it is best regarded as a so-called pseudolymphoma.

MR imaging of spinal infections.

In the appropriate clinical situation, MR imaging is a powerful tool in the diagnosis of spinal infection. Imaging of spinal infections requires the use of a combination of T1-weighted and T2-weighted or STIR sequences. Contrast enhancement is useful and helps to define paraspinal and epidural disease. Knowledge of potential pitfalls with MR imaging and of normal marrow conversion is required. With these points in mind, MR imaging will be beneficial in the care of patients with spinal infections.

Sternotomy infection with Mycoplasma hominis: a cause of "culture negative" wound infection.

Wound infections with Mycoplasma species are unusual; diagnosis may be delayed because of the growth characteristics of this organism. We report Mycoplasma hominis infection of sternotomy wounds in two patients. The first presented with fever and drainage from the incision 1 week after coronary artery bypass grafting. The other patient presented with drainage from the incision three weeks after double-lung transplantation. In both cases, initial cultures were negative, but the typical colonial morphology of M. hominis was subsequently detected. Successful treatment consisted of debridement and long courses of antibiotic therapy; omental flap grafting was eventually required for the second patient. Other published cases were reviewed and compared with the newly reported cases.

Decreased infections in cardiac transplant recipients on cyclosporine with reduced corticosteroid use.

Fifty patients undergoing orthotopic cardiac transplantation were monitored over 34 months for evidence of infection. Four separate immunosuppressive protocols were used during the course of the study; the most recent protocol (protocol 4) employed significantly lower overall steroid dosages than the earlier protocols (protocols 1,2, and 3). All immunosuppressive regimens used cyclosporine, and azathioprine was added in the last three protocols. Statistical techniques to compare the occurrence of infection in protocols 1,2, and 3 v protocol 4 showed that patients in protocol group 4 (n = 21) had significantly more time free of pneumonia (P = .02) and major infections (P = .04) and marginally more time free of symptomatic cytomegalovirus infection (P = .08) than patients in protocol groups 1, 2, and 3 (n = 29). The median incidence of major infection per month was lower for protocol group 4 (P = .02). The time free of viral infection did not differ significantly between the two groups (P = .75) nor did the median incidence of rejection per month (P = .19). The authors conclude that reduction of steroid dosages in cardiac transplant patients receiving cyclosporine is associated with a significant decrease in the incidence of clinically important infections.