Exposure of medical students to body fluids.

Three hundred forty-two students at 3 Florida medical schools were surveyed concerning occupational exposures to blood and body fluids during their 3rd-year clerkship. The 16-item questionnaire was anonymously returned by 150 students, and differences among groups were assessed at p < .05. Most of the students complied with universal precautions guidelines (UVPG); 62 reported 101 exposures, including 9 with HIV-positive blood and body fluids. Most of the exposed students knew about the guidelines but regarded the incidents as irrelevant to their safety or supervision training. Noncompliant students reported significantly more exposures than compliant students. Time constraints, inconvenience of using gloves during procedures, and belief that patients were at low HIV risk discouraged adherence to the guidelines. Common practices following exposure were "no action" or "washed area only" without medical follow-up. Medical students' UVPG adherence should be increased by workload modification, user-friendly safety products, and supervised practice training in clinical exposure settings.

The detection of airborne Mycobacterium tuberculosis using micropore membrane air sampling and polymerase chain reaction.

STUDY OBJECTIVES: Mycobacterium tuberculosis (MTb) bacilli are carried on airborne droplet nuclei produced by aerosolization that can occur from coughing, talking, or even singing. Because of their prolonged period of suspension, they can be filtered from the air onto a porous medium and readily detected using polymerase chain reaction (PCR). DESIGN: Prospective cohort analysis. SETTING: Samples of circulating air were collected over a 12-month period from within the rooms of 10 hospitalized patients who were under respiratory isolation to rule out MTb infection. A small laboratory pump was used to draw ambient air at a rate of 2 L/min over a 6-h period through a 0.2-microm polycarbonate membrane filter placed near the patient's bed. Analysis of the membrane filters was conducted using PCR. Sputum cultures for MTb were performed simultaneously, and the results of smears stained for acid-fast bacilli (AFB) were noted. MEASUREMENTS AND RESULTS: MTb complex was successfully detected by PCR in six of seven patients in whom sputum MTb cultures were subsequently positive, and in zero of three with subsequently negative sputum cultures. Sampling in one patient with a positive culture, in whom PCR results were negative, was only carried out for 2 h due to pump malfunction. One of the six PCR-positive patients was AFB-smear negative at the time of air sampling. CONCLUSIONS: Our preliminary findings indicate that the technique of Micropore membrane air sampling with PCR analysis has important applications in the epidemiology and diagnosis of MTb.

Rapidly progressive herpetic retinal necrosis: a blinding disease characteristic of advanced AIDS.

Eleven patients with rapidly progressive herpetic retinal necrosis (RPHRN) complicating AIDS were investigated retrospectively to study the disease spectrum, systemic involvement, and therapy. The mean CD4 cell count was 24/microL. There was a characteristic disease pattern with rapid progression, 82% bilaterality, relative resistance to intravenous antiviral therapy, and 70% retinal detachment. Varicella-zoster virus was the probable cause in 10 patients (detected by polymerase chain reaction in two eyes investigated), and herpes simplex virus was the probable cause in one. Cutaneous zoster occurred previously in 73% but was not concurrent. Seventy-three percent had central nervous system disease, possibly virus-related. RPHRN may be a local herpetic recrudescence in an immune-privileged site with transneural spread. Only four of 20 affected eyes retained useful vision. Poor ocular bioavailability, retinal ischemia, acquired drug resistance, and strain pathogenicity may underlie treatment failure. Acyclovir therapy appears relatively ineffective. Combined intravenous and intravitreal therapy with foscarnet and ganciclovir may be the best current management. Research advances are needed urgently.

Nonfatal gastric mucormycosis in a renal transplant recipient.

Mucormycosis historically has caused substantial morbidity with high mortality in renal transplant patients with disseminated and/or rhinocerebral infection and in patients with gastrointestinal illness regardless of predisposing conditions. We report the first successful treatment of gastric mucormycosis in a renal transplant recipient and review presumed pathogenic mechanisms of mucormycosis in renal transplant recipients as well as historical data.

Maternal death from postpartum necrotizing fasciitis arising in an episiotomy: a case report.

BACKGROUND: Necrotizing fasciitis is a rare condition. We report a fatal case arising from an episiotomy in a previously healthy woman. CASE: A healthy 23-year-old prima gravida white female underwent vaginal delivery with repair of a proctoepisiotomy. Eighty-four hours postpartum, she developed increasing perineal swelling with severe pain. She presented on the 4th postpartum day with edema, erythema localized to the perineum, and vital signs significant only for tachycardia of 120/min. With a leukocytosis of 45,000/mul (87%) neutrophils, she was admitted to the hospital with an initial diagnosis of perineal cellulitis and empirically started on broad-spectrum intravenous antibiotic therapy. The patient's condition continued to deteriorate and she was then transferred to our facility on postpartum day 9 where a team performed two radical debridements of all necrotic tissue. Despite this and a broadened antibiotic coverage, the patient eventually experienced cardiopulmonary arrest and died on postpartum day 12. CONCLUSION: Necrotizing fasciitis must be considered in the differential diagnosis of the postpartum patient presenting with severe vulvar pain and erythema. Our patient exemplifies the obscure presentation with seemingly minimal skin changes. Any delay in diagnosis and treatment, which must include expeditious aggressive surgical debridement, will likely result in severe morbidity or mortality.

Transient aplastic anemia caused by parvovirus B19 infection in a heart transplant recipient.

Parvovirus B19 infection in the transplant patient is rarely reported, although cases have occurred in patients with bone marrow, liver, and renal transplants and in children undergoing heart transplantation. We present the first reported case of an orthotopic heart transplant recipient with aplastic crisis caused by parvovirus B19. The infection was diagnosed by bone marrow biopsy, confirmed by serologic studies and polymerase chain reaction, and successfully treated with intravenous immunoglobulin.

Influenza. More than mom and chicken soup.

Influenza is an epidemic respiratory illness caused by one of three viral subtypes: A, B, or C. Influenza A causes higher mortality than influenza B and C and is often responsible for pandemics and yearly epidemics of this common, infectious disease. Clinically, patients with influenza present with an abrupt onset of fever, malaise, headache, and a dry, hoarse cough. These symptoms usually last three to five days. Amantadine and rimantadine may be used to prevent and to treat influenza A infection, but not B or C. Ribavirin, however, may be effective treatment for severe influenza pneumonia caused by either A or B subtype, although it is not FDA approved for this application. Annual influenza vaccination should be administered between mid-October and mid-November to any person at increased risk for complications. Health-care workers, those in close contact with high-risk individuals, and personnel vital to community function should also be immunized.

Management of the transplant recipient with pulmonary infection.

Pneumonia is a common and potentially fatal complication of transplantation. The clinical approach to this problem requires a multipronged attack. Thorough evaluation of the donor and recipient reduces the risk of infection while pointing to likely infectious complications to be anticipated posttransplant. Careful attention to infection control measures with emphasis on handwashing, high efficiency particulate air filtration, and aggressive outbreak investigation minimizes nosocomial pneumonias. Appropriate use of vaccines and prophylactic antimicrobial therapies decreases posttransplant morbidity and mortality. Once pneumonia occurs, a rapid, thorough diagnostic evaluation increases the likelihood of survival for the individual patient and focuses attention on environmental risks that may pose a hazard to the other transplant recipients in the clinician's institution.

Seabather's eruption.

Seabather's eruption is an unusual rash that develops in individuals who have been swimming in the ocean. We report the case of a 25-year-old woman who had the rash in a typical bathing suit distribution. Several species of cnidarian larvae have been implicated in causing the disease. Symptomatic treatment is the mainstay of therapy for this self-limited rash. Preventive measures allow patients to avoid the disease altogether.

Barriers to immunization--an examination of factors that influence the application of pneumococcal vaccine by house staff.

Pneumococcal infection is a leading cause of adult morbidity and mortality in the United States. Immunization against this infection is a valuable strategy in preventive medicine. An effective pneumococcal vaccine has been available in this country for over a decade, but it remains poorly utilized. The purpose of the present investigation was to analyse the factors that affect the use and administration of the pneumococcal vaccine and to identify barriers to use. Upper-level internal medicine residents (n = 33) from two medical clinics associated with an academic medical centre completed an explanatory survey. This explored the levels of house-staff knowledge, perception and attitudes regarding the vaccine and the existence of practical barriers against its utilization. chi 2 analyses and z tests were carried out to determine significance, where appropriate. The majority of the house staff (22, 66.7%) answered correctly regarding vaccine target groups, and all residents indicated that they generally obtain a vaccination history in adult patient evaluation. However, a sizeable number (14, 42.4%) did not indicate a time of the year when they routinely administered vaccines to patients. They were not confident about their knowledge regarding vaccine guidelines (23, 69.7%) and had an exaggerated fear of hypersensitivity reactions from immunization (20, 60.6%). Neither the expense of the vaccine nor adverse publicity were impediments to immunization (24, 72.7% and 28, 84.8%, respectively). Although most physicians knew of the usefulness of the vaccine (31, 93.9%), many failed to translate this knowledge into clinical practice (22, 66.7%). 'Pressing' clinical issues were viewed as barriers to vaccination (18, 54.5%) and placed the practice of preventive medicine in a subordinate position.(ABSTRACT TRUNCATED AT 250 WORDS)

Probing for answers. Use of DNA probes in infectious diseases.

Diagnostic molecular biology is at the forefront in the diagnosis of infectious diseases. Through the use of deoxyribonucleic acid (DNA) probes in conjunction with other molecular techniques such as polymerase chain reaction (PCR), physicians will be able to more rapidly and accurately diagnose causative agents in a variety of infectious diseases. This article will focus on the molecular basis of these techniques, how they may aid the physician in patient diagnosis, and the shortcomings of this new and exciting technology.

Kaposi's sarcoma mimicking cellulitis.

Although Kaposi's sarcoma is not the most common cause of death in AIDS patients, it is often one of the initial opportunistic illnesses associated with human immunodeficiency virus infection. Extensive plaque formation and edema in the lower extremities may take on the appearance of cellulitis, and in dark-skinned persons, the lesions of the neoplasm may not be noticeable. Treatment is palliative; therapy for local effect is appropriate unless lesions are extensive or systemic involvement is present.

Hantavirus: an old bug learns new tricks.

Hantaviruses are a diverse group of RNA arboviruses in the Bunyaviridae family. Although their role as the causative agents of HFRS has been well established, the recent outbreak of a new disease in the Southwest clearly demonstrates the protein clinical manifestations that this pathogen can produce. Furthermore, whereas hantaviruses have been characterized largely as focal agents in the production of geographically delimited diseases, recent trends indicate that endemic areas for the virus are expanding. Outbreaks often occur in clusters as a result of the epizoology of rodent hosts, but isolated cases of hantavirus-related disease also may be observed. Although hantaviruses have proven their pathogenic capability in other areas of the world, it was perceived widely that they were of little consequence to public health in the United States. However, as more is learned about the nature of this truly global infectious agent, its potential danger to mankind becomes increasingly apparent. It is hoped that continued research will elucidate all the facets of hantavirus-induced disease.

Lithium-induced nephrogenic diabetes insipidus treated with indomethacin.

NDI occurs in 5% to 20% of patients receiving long-term lithium therapy. The associated polyuria usually resolves within 3 weeks of lithium discontinuance but can persist beyond a year. For such patients, hydrochlorothiazide and amiloride therapy has been hampered by the delayed effect and intrinsic side effects of these agents. We have described the case of a 66-year-old man with a history of bipolar disorder treated with lithium who was transferred to the intensive care unit with coma. Indomethacin therapy, at a dose of 50 mg every 8 hours, was begun and improvement of the NDI state was observed within 3 hours of lithium administration. There was complete normalization of mental status and laboratory studies after 36 hours. A complete 3-week course of indomethacin was required to keep the patient free of symptoms of NDI. We have also discussed the role of indomethacin in reversing lithium-induced NDI and reviewed pertinent prior reports in the literature.