Cryptococcosis and tuberculosis co-infection at a university hospital in Taiwan, 1993-2006.

BACKGROUND: The human immunodeficiency virus (HIV) epidemic and increasing use of immunosuppressive agents have increased the prevalence of both cryptococcosis and tuberculosis (TB). However, the status of co-infection with both pathogens remains unknown. METHODS: This study retrospectively reviewed patient records of cryptococcosis and TB co-infection from 1993 to 2006. The temporal sequence of co-infection was defined as either concurrent or sequential. Data collected included patient demographics, HIV status, co-morbidities, clinical manifestations, treatment strategies, and outcome at 1-year follow-up. RESULTS: There were 23 patients with cryptococcosis and TB co-infection, representing 5.4% of cryptococcosis or 0.6% of TB cases. Eleven (48%) patients were HIV-infected, and no underlying disease or immunocompromised state could be identified in six (26%) patients. Twelve (52%) patients presented with concurrent infection, but diagnosis of co-infection could be achieved simultaneously in only three (13%). Constitutional symptoms, particularly fever and weight loss, were the most common presenting symptoms, developing in more than two-thirds of the patients. The majority (83%) of the patients made a good recovery following dual antifungal and anti-TB therapy. There were three mortalities at the 1-year follow-up, which might be attributable to a delay in diagnosis and treatment of co-infection. The outcomes of HIV-infected and non-HIV-infected patients were not significantly different. CONCLUSIONS: Cryptococcosis and TB co-infection, although rare, develops in both immunocompromised and healthy individuals. Early diagnosis and treatment may improve patient prognosis. There should be a high index of suspicion in order to achieve a timely diagnosis in a TB endemic area.

Disseminated Cryptococcus neoformans var. grubii infections in intensive care units.

A retrospective study of clinical characteristics, outcome and prognostic factors of patients with cryptococcosis was undertaken in intensive care units (ICUs) of a medical centre for the period 2000-2005. Twenty-six patients with Cryptococcus neoformans var. grubii infection were identified (16 males, median age 58 years). The most frequent underlying diseases were liver cirrhosis (38.5%), diabetes mellitus (26.9%) and HIV infection (19.2%). The most frequently identified sites of infection were blood (61.5%), cerebrospinal fluid (38.5%) and airways (34.6%). The mean Acute Physiologic and Chronic Health Evaluation II score at ICU admission was 22.46. The ICU mortality rate in these patients was 73.1% (19/26) and there were a further two mortalities recorded after discharge from ICU, reaching a total mortality rate of 80.8% (21/26). Patients with ICU survival >2 weeks had lower rates of HIV infection (P=0.004), less use of inotropic agents during ICU stay (P<0.001) and lower white blood cell counts (P=0.01). After adjusting for clinical variables in the multivariate Cox regression model, diabetes and cryptococcal infection after ICU admission were independent predictors of good long-term prognosis (P=0.015) and HIV infectious status was associated with poor outcome (P=0.012).

The role of chest radiography in the suspicion for and diagnosis of pulmonary tuberculosis in intensive care units.

BACKGROUND: The role of chest radiography (CXR) in the clinical diagnosis and suspicion of pulmonary tuberculosis (PTB) remains uncertain in the intensive care unit (ICU) setting. DESIGN: This case-control study compared the radiographic findings between ICU patients with and without co-existing PTB to define any predictive patterns for the diagnosis of PTB. Further analysis aimed to elucidate the impact of CXR on the clinical suspicion of PTB. RESULTS: Eighty-nine (89) patients with PTB and an equal number of matched controls were evaluated. Consolidation was the most frequent radiographic pattern. There were no specific predictors for diagnosing PTB in the ICU. Of 89 patients, 55 (62.9%) had a delay in clinical suspicion of PTB. The time from ICU admission to TB diagnosis was significantly delayed in the group without clinical suspicion (30.7 vs. 5.3 days, P < 0.001). In multivariate analysis, a history of PTB was significantly associated with the clinical suspicion of PTB (OR 7.94, P = 0.012), but CXR patterns were not. CONCLUSION: CXR does not contribute as much as expected in the clinical diagnosis and suspicion of PTB in the ICU setting.

The pilin O-glycosylation pathway of pathogenic Neisseria is a general system that glycosylates AniA, an outer membrane nitrite reductase.

O-Glycosylation is emerging as a common posttranslational modification of surface exposed proteins in bacterial mucosal pathogens. In pathogenic Neisseria an O-glycosylation pathway modifies a single abundant protein, pilin, the subunit protein that forms pili. Here, we identify an additional outer membrane glycoprotein in pathogenic Neisseria, the nitrite reductase AniA, that is glycosylated in its C-terminal repeat region by the pilin glycosylation pathway. To our knowledge, this is the first report of a general O-glycosylation pathway in a prokaryote. We also show that AniA displays polymorphisms in residues that map to the surface of the protein. A frame-shift mutation abolishes AniA expression in 34% of Neisseria meningitidis strains surveyed, however, all Neisseria gonorrhoeae strains examined are predicted to express AniA, implying a crucial role for AniA in gonococcal biology.

The phase-variable allele of the pilus glycosylation gene pglA is not strongly associated with strains of Neisseria gonorrhoeae isolated from patients with disseminated gonococcal infection.

The Neisseria gonorrhoeae pglA gene has two alleles, one of which is phase variable. A previous study reported that all disseminated gonococcal infection (DGI) isolates contained the phase-variable allele and proposed a causal link. In the present study of 81 strains no absolute correlation between DGI and the phase-variable pglA allele was observed.

Pulmonary tuberculosis in allogeneic hematopoietic stem cell transplantation.

Pulmonary tuberculosis (TB) is an endemic infectious disease in Taiwan. A retrospective study was conducted to define clinical manifestations and outcomes of patients with pulmonary TB among hematopoietic stem cell transplantation (HSCT) recipients. We identified eight out of 350 HSCT recipients as having pulmonary TB over a 6-year period. The relative risk of having pulmonary TB after HSCT was 13.1-fold higher than in the general population. There was a trend toward increased risk of having pulmonary TB in allogeneic HSCT as compared to autologous HSCT (4.8 +/- 1.8% vs 0, P = 0.067). All the eight patients with pulmonary TB received allogeneic HSCT and most (seven of eight patients) developed the infection during treatment for GVHD. Computed tomography of the chest was normal in one patient, with the rest showing either interstitial (two patients) or alveolar infiltrates (five patients) at the onset of pulmonary TB. The four fatal cases had an obviously shorter duration between HSCT and onset of infection. Our data suggest that pulmonary TB in HSCT recipients is not uncommon in this endemic area. Therefore, an effective strategy of prophylactic treatment for candidates and recipients of allogeneic HSCT, who may have latent pulmonary TB infection, must be developed.

Clinical and microbiological characteristics of bacteremia caused by Acinetobacter lwoffii.

A retrospective study was conducted to analyze the clinical features and pathogenic roles of bacteremia caused by Acinetobacter lwoffii during a 4-year period. Acinetobacter lwoffii (formerly Acinetobacter calcoaceticus var. lwoffii) is recognized as normal flora of the skin, oropharynx and perineum of healthy individuals. There are few reports of Acinetobacter lwoffii bacteremia associated with indwelling catheters in humans, particularly in immunocompromised hosts. The records of 18 patients with Acinetobacter lwoffii bacteremia whose underlying conditions included cancer (11 patients), systemic lupus erythematosus (n=1), chronic obstructive pulmonary disease (n = 2) and other diseases (n = 4), all but one of whom had indwelling catheters during the bacteremic episode, were examined. The clinical syndromes were classified as probable catheter-related bacteremia (n = 14), definite catheter-related bacteremia (n = 2), primary bacteremia (n = 1) or biliary tract infection (n = 1). The infections improved after removal of the catheter and/or appropriate antimicrobial therapy. One death was attributable to the bacteremic event. The results of this study show that indwelling catheter-related Acinetobacter lwoffii bacteremia in immunocompromised hosts appears to be associated with a low risk of mortality.

Disseminated cytomegalovirus disease in a patient with systemic lupus erythematosus not undergoing immunosuppressive therapy.

We describe a case of cytomegalovirus (CMV) infection in a 25-year-old woman with a 3-year history of systemic lupus erythematosus (SLE) with persistently high disease activity, who had not received immunosuppressive therapy. Disseminated CMV infection presented with upper gastrointestinal bleeding, high fever, respiratory distress, leukopenia, and thrombocytopenia. The CMV infection was successfully treated with combined antiviral and immunoglobulin therapy, and the SLE activity decreased concomitantly. CMV disease is closely related to host immunosuppression, primarily T-lymphocyte dysfunction. This case should highlight the relationship between clinically significant CMV disease and compromised immunity in patients with active SLE who are not receiving immunosuppressive therapy.