Kawasaki-like syndromes associated with human immunodeficiency virus infection.

Kawasaki disease is an acute febrile vasculitic syndrome of early childhood. It is very rarely seen in adults. Among the adult patients with Kawasaki disease who have been described, a disproportionate number are infected with human immunodeficiency virus (HIV). This suggests that the immunocompromised state may predispose individuals to this syndrome. We report our experience with 2 HIV-positive patients who presented with Kawasaki-like syndromes and review the published literature on HIV-positive patients with similar syndromes.

A randomized trial of povidone-iodine compared with iodine tincture for venipuncture site disinfection: effects on rates of blood culture contamination.

BACKGROUND: Contamination of blood cultures creates problems in their interpretation and unneeded resource utilization. Because skin flora comprise the major group of contaminant species, more effective skin disinfection at the venipuncture site could reduce contamination. SUBJECTS AND METHODS: We performed a randomized trial in adult inpatients at a tertiary care teaching hospital. Antecubital venipuncture sites were randomly disinfected with povidone-iodine or iodine tincture, and blood cultures (two bottles, 10 mL of blood) were drawn by professional phlebotomists. Scoring of contaminant species was restricted to skin flora. Hospital resource utilization was compared among patients with contaminated blood cultures and those with sterile blood cultures. RESULTS: Of the 3,851 blood cultures collected during the study, 120 (3.1%) were contaminated with skin flora. The contamination rate for blood cultures collected after povidone-iodine was 3.8% (74 of 1,947), compared with a rate of 2.4% (46 of 1,904, P = 0.01) after iodine tincture. The difference in mean total hospital costs for patients with contaminated blood cultures and those with sterile blood cultures was $4,100 (95% confidence interval: $740 to $7,400, P = 0.02). CONCLUSIONS: Iodine tincture is superior to povidone-iodine for venipuncture site antisepsis before blood culture sampling. Because of the high costs associated with contaminated blood cultures, hospitals should consider switching from povidone-iodine to iodine tincture. Reduction of the contamination rate may improve the quality of patient care and reduce hospital costs.

Nosocomial penicillin-resistant pneumococcal infections at a Midwestern university hospital.

We analyzed 333 isolates of Streptococcus pneumoniae from adult inpatients over a continuous 30-month period. Twenty-five percent of isolates were resistant to penicillin, and 18% of tested strains were not susceptible to ceftriaxone. For 29 (15%) of 199 evaluable patients, S pneumoniae was isolated from a culture first obtained >48 hours after admission, and chart review satisfied our case definition for nosocomial infection. S pneumoniae isolates were penicillin-resistant in 14 of 29 nosocomial and 34 of 170 community-acquired cases (odds ratio, 3.73; 95% confidence interval, 1.53-9.15; P=.01).

Primary pulmonary botryomycosis: case report and review.

Botryomycosis is an uncommon bacterial disease characterized by the microscopic formation of eosinophilic granules that resemble those of infection by Actinomyces species. The diagnosis of botryomycosis can be made when microscopic inspection and culture of the granules reveal gram-positive cocci or gram-negative bacilli. Botryomycosis is caused by common bacterial pathogens including Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa, yet the host and microbial factors that contribute to the pathobiology remain unknown. Pulmonary botryomycosis can resemble actinomycosis, tuberculosis, or invasive carcinoma by causing a mass lesion with constitutional symptoms. Radiographically, it invades bone and disrupts tissue planes. Successful treatment often requires a combination of both surgical debridement and long-term antimicrobial therapy. We report a case of primary pulmonary botryomycosis and review the literature on this unusual infectious process.

A meta-analysis of extended-interval dosing versus multiple daily dosing of aminoglycosides.

We conducted a meta-analysis of 22 randomized, controlled trials in which extended-interval dosing of aminoglycosides was compared with multiple daily dosing. When we classified intermediate outcomes as successes, we found that patients receiving extended-interval dosing were at significantly reduced risk of clinical treatment failure (risk difference, -3.4%; 95% confidence interval [CI], -6.7% to -0.2%; P = .039) and that there was a trend toward reduced risk of bacteriologic failure (risk difference, -1.7%; 95% CI, -5.4% to +2.1%; P = .38). Reclassification of intermediate outcomes as failures yielded similar results. There was significant heterogeneity among the trials, necessitating cautious interpretation of these outcomes. There were negligible differences in the risk of nephrotoxicity (risk difference, -0.6%; 95% CI, -2.4% to +1.1%; P = .46) and ototoxicity (risk difference, +0.3%; 95% CI, -1.2% to +1.8%; P = .71). We conclude that for many indications, extended-interval dosing of aminoglycosides appears to be as effective as conventional dosing, with similar rates of toxicity. The added convenience of extended-interval dosing makes it an attractive alternative to conventional dosing.

High frequency of pseudobacteremia at a university hospital.

A prospective survey of all positive blood cultures was performed during a 6-month period at a 390-bed, tertiary-care teaching hospital in St Louis, Missouri. Data were collected from the clinical microbiology laboratory, medical records, and physicians caring for patients with positive blood cultures. Of 5,732 blood cultures, 261 (4.6%) were positive, and approximately half of these (51.3%) were categorized as false positive. Positive cultures were significantly more likely to be true positives if obtained from patients with malignancies or if they became positive within the first 48 hours of incubation.

Analysis of catecholamine and vasoactive peptide release in intracranial arterial venous malformations.

Craniotomy for resection of cerebral arterial venous malformation has been associated with postoperative hypertension, which necessitates administration of large doses of antihypertensive medications to control blood pressure. Controlling blood pressure is essential because hypertensive episodes can lead to postoperative cerebral hemorrhage with increases in morbidity and mortality. We measured vasoactive peptide and catecholamine release in 13 patients who underwent resection of an arterial venous malformation and in a control group of 6 patients who presented for clipping of unruptured cerebral aneurysms. Plasma renin activity, angiotensin I and II, vasopressin, aldosterone, epinephrine, and norepinephrine levels were measured intraoperatively and for 36 h postoperatively. Analysis of variance was used to assess sample and group effects. A significant interaction between sample and groups was found for norepinephrine (p < 0.001) and renin (p = 0.002). Our data suggest that elevated plasma renin and norepinephrine levels are in part responsible for postoperative hypertension in patients undergoing resection of arterial venous malformations. Blocking the release of these hormones may help control blood pressure after surgery for removal of arterial venous malformations.

The epidemiology of chest and leg wound infections following cardiothoracic surgery.

The occurrence of wound infections following cardiothoracic surgery has significant implications. However, the epidemiology of all chest and leg wound infections is infrequently described, and the effects on morbidity, mortality, and cost of care remain undefined. We identified 182 superficial and deep chest and leg infections in 163 patients following 1,554 coronary artery bypass graft (CABG), valve, and CABG/valve procedures over 30 months. The overall infection rate was 11.7%; infections of specific sites involved in the 1,554 procedures occurred at the following rates: 3.1%, superficial chest wounds; 2.3%, deep chest wounds; 4.6%, superficial leg wounds; and 2.2%, deep leg wounds. Chest infection rates were similar for all procedures. Multiple infections occurred in 9.8% of patients and were associated with female sex, diabetes, and prolonged surgery (P < .05). Purulent drainage and fever were more common in chest infections; erythema and pain were more common in leg infections (P < .05). Staphylococcus aureus (32.9%), coagulase-negative staphylococci (27.4%), and Enterobacteriaceae (26.0%) were identified most commonly. Enterobacteriaceae were more commonly isolated from leg wounds (P < .05). Adverse outcomes included reexploration (20.9%), flap surgery (12.3%), and death (4.3%). All adverse outcomes were more commonly associated with deep chest infections (P < .05), but superficial chest and leg infections also had a substantial impact on cardiothoracic surgery-related morbidity. Studies are needed to define site-specific risk factors so that the full potential of prevention and control measures can be realized.

Deactivation of macrophage oxidative burst in vitro by different strains of Histoplasma capsulatum.

It was previously reported that Histoplasma capsulatum (Hc) yeast not only failed to stimulate a murine macrophage oxidative burst (OB), but they also blunted or abolished OB stimulation by a subsequent encounter with potent stimuli such as zymosan or phorbol 12-myristate 13-acetate (PMA). The present studies show that macrophage deactivation is proportional to the time of incubation and the dose of Hc yeast that induce the deactivated state. Hc yeast derived from a virulent strain (G217B) are more efficient inducers of macrophage deactivation than similar preparations derived from the avirulent Downs Hc strain. Yeast cells of two other pathogenic fungi, Candida albicans and Cryptococcus neoformans are shown to stimulate rather than deactivate a macrophage OB.

The PapG tip adhesin of P fimbriae protects Escherichia coli from neutrophil bactericidal activity.

Compared with Escherichia coli ORN103, a nonfimbriated K-12 strain, P-fimbriated E. coli ORN103/pPAP5 was found to interact poorly with human neutrophils and resist their bactericidal activity in vitro. PapG, the Gal alpha(1-->4)Gal binding moiety located at the distal end of the P fimbrial filament, appeared to be responsible for this effect because an isogenic PapG- mutant, E. coli ORN103/pPAP24, exhibited binding interactions with neutrophils that were similar to nonfimbriated E. coli ORN103. Although no direct evidence is available, the poor adherence mediated by PapG could be related to its electrostatic properties because the isolated PapG protein had a pI of 5.2, which indicated that in the physiological pH range it possessed a net negative charge. Antibodies against PapG overcame the protective effect of PapG and markedly enhanced the interactions of P-fimbriated E. coli with neutrophils resulting in bacterial killing. When a P-fimbriated clinical E. coli strain or its isogenic PapG- derivative was injected into the peritoneal cavities of mice, a similar number of neutrophils was recruited to the site of injection. After 2 h, the number of P-fimbriated E. coli organisms that survived the neutrophil influx in the mouse peritoneum was approximately four times more than the number of surviving PapG- bacteria. This result demonstrates that the PapG protein, which is strategically located at the distal region of the P-fibrillum structure, protects E. coli from the bactericidal action of neutrophils.

Mast cell phagocytosis of FimH-expressing enterobacteria.

Most studies of mast cells have been directed at their role in the pathophysiology of IgE-mediated allergic reactions with little recognition of their participation in bacterial infections. We report that mast cells can specifically bind FimH, a mannose-binding subunit on type 1 fimbriae expressed by Escherichia coli and other enterobacteria. This interaction triggers mast cell phagocytosis and killing of the bacteria within vacuoles and through the release of superoxide anions. Also, in view of the fact that mast cells have the capacity to release inflammatory mediators and are particularly abundant in the skin, mucosal surfaces, and around blood vessels, we suggest that these cells play an important role in host defense against microbial infection.

Neutrophil activation by nascent FimH subunits of type 1 fimbriae purified from the periplasm of Escherichia coli.

Previous studies of type 1 fimbriae of Escherichia coli have implicated FimH, a minor subunit, as the determinant of its mannose binding property. Structure-function analysis of FimH has not been possible because of the difficulty in obtaining adequate amounts of the subunit from type 1 fimbriae. We have obtained nascent FimH that has not been incorporated into the fimbrial structure from the periplasm of an E. coli strain expressing the cloned fimH gene. Nascently translocated FimH was initially degraded in the periplasm; however, when co-expressed with FimC, a putative fimbrial chaperone, the FimH molecules were stabilized and readily isolated from the periplasmic extract by fractionation on a sodium dodecyl sulfate-polyacrylamide gel followed by electroelution of the FimH band from the gel. The eluted protein was purified to homogeneity by affinity chromatography on a mannose-Sepharose column. Purified FimH displayed the same mannose-inhibitable binding to human neutrophils as type 1 fimbriated bacteria, including triggering an oxidative burst with concomitant release of reactive oxygen metabolites. In addition, inert microspheres coated with FimH, but not those coated with bovine serum albumin, were phagocytosed by neutrophils. These data provide direct evidence that FimH is the determinant on type 1 fimbriae which is responsible for mediating mannose-specific adherence and that isolated FimH is a potent activator of human neutrophils.

Hydroxyethyl starch 200/0.5 reduces infarct volume after embolic stroke in rats.

BACKGROUND AND PURPOSE: We evaluated isovolumic hemodilution with hydroxyethyl starch 200/0.5 in a rat model of focal cerebral ischemia. This compound avoids the unfavorable viscosity and erythrocyte aggregation abnormalities of low molecular weight dextran during administration over a period of several days. METHODS: Sprague-Dawley rats, anesthetized with 0.5-1% halothane and 70% N2O, were subjected to silicon cylinder (treated and control groups) or sham (sham group) embolization of the cerebral circulation. Thirty minutes after embolization, the treated group (n = 5) was infused with 11 ml/kg of 10% hydroxyethyl starch 200/0.5, and the control (n = 5) and sham (n = 4) groups were infused with saline for 1 hour. In the treated group, 7.1 ml/kg of blood was withdrawn. After 24 hours, the animals were reanesthetized, and cerebral blood flow was determined with [14C]iodoantipyrine. Alternative brain slices were either incubated with 2,3,5-triphenyltetrazolium chloride for infarct volume determination or frozen for ischemic volume and cerebral blood flow determination using autoradiography. RESULTS: The hematocrit in the treated group was reduced from (mean +/- SEM) 46 +/- 1% to 35 +/- 2% at 1.5 hours (p < 0.01). Cortical blood flow was within the normal range of 115-185 ml/min/100 g, except for the ischemic cortex in the embolized groups, treated and control. The ischemic and infarct volume of the treated group was reduced by 74% (p < 0.05) and 89% (p < 0.05), respectively, from the control group. The treated and sham ischemic and infarct volumes were not statistically different. CONCLUSIONS: These data suggest that hydroxyethyl starch 200/0.5 could be an effective treatment for ischemic stroke when administered early, because it reduces infarct and ischemic volumes from control values to levels indistinguishable from those of the sham group.

Retrolabyrinthine transtentorial approach to lesions of the anterior cerebellopontine angle.

Various surgical approaches to the cerebellopontine angle have been used for removal of acoustic neuromas. A retrolabyrinthine transtentorial approach has been developed that allows (1) access to the anterior cerebellopontine angle and all portions of the basilar artery, (2) extra dural retraction of the lateral sinus and cerebellum while avoiding the vein of Labbé, and (3) preservation of hearing. This approach allows good exposure of tumor and accurate visualization of cranial nerves. To avoid complications, control of spinal fluid is mandatory and great care must be taken to avoid injury of the cranial nerves. The retrolabyrinthine or translabyrinthine transtentorial approach enables skilled neurosurgeons and neurotologists to gain access to lesions that are located in areas difficult to approach.

The effect of a mannose binding protein on macrophage interactions with Candida albicans.

A soluble mannose binding protein (MBP), obtained from rabbit serum, was found to inhibit phagocytosis of Candida albicans by bone marrow derived, cultured murine macrophages. During in vitro incubation of yeast with lymphocyte-free macrophage populations uptake of the yeast was significantly reduced at MBP concentrations of 5 micrograms/ml. A similar reduction in yeast phagocytosis was produced by dextrose, d-fucose, l-fucose, d-mannose and alpha-methyl-d-mannoside but required saccharide concentrations of 25-50 mg/ml. Inhibition of phagocytosis of the yeast also resulted from pretreatment of either the macrophages or the yeasts with MBP followed by washing. As expected, the addition of mannan to the assay medium blocked the inhibitory effect of MBP for uptake of C. albicans. These findings suggest that both cell bound and soluble mannose receptors may be important modulators of macrophage-Candida interactions.

T-cell chronic lymphocytic leukemia. Unusual morphologic, phenotypic, and karyotypic features in association with light chain amyloidosis.

BACKGROUND: Lymphocytes that display a phenotype of mature B-cells, T-cells, natural killer (NK) cells, or a combination of T-cells and NK cells can be found in patients with lymphoproliferations that manifest as expansions of peripheral blood lymphocytes (PBL). If these PBL expansions exhibit clonality, they can be classified as chronic lymphocytic leukemia (CLL). METHODS/RESULTS: A patient who had two simultaneous, clonal lymphoproliferative disorders manifested as an unusual T-cell CLL in conjunction with systemic light chain amyloidosis is described. Gene rearrangement studies of the PBL of the patient showed clonal rearrangements of both the T-cell receptor beta (T beta) chain and the immunoglobulin genes. Additional immunologic and microscopic studies of the T-cells of the patient showed that they were large, agranular, CD4+ T-cells that also expressed the NK cell marker CD57. Cytogenetics disclosed an unusual karyotype in the PBL. CONCLUSIONS: The pathogenesis of this T-cell CLL and whether it truly represents a malignant disorder, as well as its relation to amyloidosis, is discussed.

Complementary use of computed tomography and magnetic resonance imaging in assessing skull base lesions.

Twenty-six patients underwent computed tomography (CT) and magnetic resonance imaging (MRI) of skull base lesions at the Cleveland Clinic Foundation. CT provided improved bone detail, documenting invasion of the lamina papyracea, orbital floor, fovea ethmoidalis, cribriform plate, pterygoid plates, hard palate, and skull base. MRI defined invasion of the orbit, dura, brain, and cavernous sinus. Improved soft-tissue-tumor interface was evident on MRI. MRI was superior to CT in determining carotid artery involvement. MRI distinguished between tumor and retained secretions in the paranasal sinuses. Combining radiographic tumor staging reliably predicted surgical findings; however, MRI consistently yielded sufficient diagnostic information and the additional expense of performing two imaging procedures may not be justified.