Pyogenic liver abscesses due to Klebsiella pneumoniae in a diabetic patient.

Pyogenic liver abscess due to Klebsiella pneumoniae is a rare clinical entity. It has emerged as an important infection complication in diabetics and its incidence in diabetics without intraabdominal or biliary tract infections is increasing. We present herein a case of multiple pyogenic liver abscesses due to K. pneumoniae in a diabetic patient and discuss clinical course, treatment and possible reasons for association between K. pneumoniae liver abscess and diabetes.

Utilization of parenteral nutrition in patients receiving peripheral blood stem cell transplantation.

A paucity of information is available on the use of parenteral nutrition (PN) in patients undergoing peripheral blood stem cell transplantation (PBSCT). To characterize the utilization of PN in patients undergoing PBSCT, we conducted a retrospective chart review study on adult patients receiving autologous and allogeneic PBSCT. Data collection included nutritional parameters such as indications for PN, days of PN administration, and PN-associated complications (i.e., metabolic, infectious, and mechanical). Outcome parameters assessed included length of hospitalization, days to engraftment, graft versus host disease (GVHD), and veno-occlusive disease (VOD). A total of twenty-one consecutive patients were evaluated with 12 receiving allogeneic PBSCT and 9 receiving autologous PBSCT. The allogeneic group received PN for a mean of 25 days compared to 21 days for the autologous group. The rate of metabolic abnormalities was significantly higher in the allogeneic group compared to the autologous group (1.02 abnormalities/PN days vs 0.61 abnormalities/PN day, p < 0.05), but mechanical and infectious complications were similar between the two groups. Length of hospitalization, days to engraftment, incidence of GVHD and VOD did not differ significantly between the two groups. However, mortality prior to discharge was significantly higher in the allogeneic vs autologous group (58% vs 0%, p < 0.05). We conclude that allogeneic PBSCT patients appear to be at a greater risk for metabolic complications while receiving PN as compared to autologous PBSCT patients. As nausea and vomiting are two primary reasons for initiation of PN in this patient population, further studies of aggressive antiemetic therapy may prove to decrease the need for PN in PBSCT patients.

Massive upper gastrointestinal hemorrhage due to cytomegalovirus infection in two patients with acquired immunodeficiency syndrome.

Massive upper gastrointestinal (GI) hemorrhage is a rare manifestation of GI cytomegalovirus (CMV) infection. A review of the English language literature yielded 21 well-documented cases of gastric ulcers due to CMV, and 7 of these 21 cases were complicated by significant GI bleeding. This report describes two cases of massive upper GI hemorrhage due to CMV infection in patients with acquired immunodeficiency syndrome (AIDS).

Hepatotoxicity from isoniazid and rifampin in inner-city AIDS patients.

OBJECTIVE: To determine the incidence of hepatotoxicity due to isoniazid and rifampin in inner-city patients with active tuberculosis. DESIGN: A hospital-based review of 70 consecutive in-patients in a 770-bed, inner-city hospital. The patient population is primarily African-American and Hispanic. METHODS: Fifty-eight men and 12 women were followed from 2-12 wk (median 4 wk). Patients had to be treated for at least 2 wk to be eligible for the study. Patients were excluded if they had been on any anti-tuberculous or any other hepatotoxic drug during the 2-month period before their hospitalization. Aminotransferases, alkaline phosphatase, bilirubin, and albumin were obtained at least every 2 wk. RESULTS: Hepatocellular toxicity, defined as AST and/or ALT greater than 200 IU/L, occurred in eight out of 70 (11.4%) patients. The mean age of these patients was 38.9 yr (22-58 yr). Patients with AIDS were significantly more likely to develop hepatotoxicity than those with any other risk factor (p < 0.01). CONCLUSIONS: Baseline aminotransferases followed by monitoring may be necessary in AIDS patients.

Distribution of adenomatous polyps in African-Americans.

OBJECTIVES: Previous research has suggested that polyps and colon cancer occur more commonly in the right colon in African-Americans compared with the general population. The purpose of this study is to determine the pattern of distribution of colonic polyps in African-Americans. METHODS: We retrospectively evaluated 141 colonoscopies in which 179 polypectomies were done. The polyps were described on the basis of anatomical distribution, gross description, size, and histology. Sixty-nine males and 72 females had colonoscopic polypectomies. The mean age was 67 yr (range, 43-91 yr). RESULTS: Seventy-seven (43%) were classified as left sided, and 102 (57%) were right sided. Left-sided polyps were more likely to be pedunculated than right-sided polyps (p < 0.01). Larger polyps were more common on the left side than the right side (p < 0.01), but villous histology was almost as high on the right side as on the left side. Polyps that had the highest malignant potential were found almost as commonly on the right side as on the left side. CONCLUSIONS: This study supports previous work that suggests that there is a significant shift to the right in the anatomical distribution of polyps in African-Americans. It also shows that the malignant potential is as high for right-sided polyps as it is for those on the left. Current screening recommendations may not be effective enough for preventing colon cancer in this population.

Pathogenesis, diagnosis, and treatment of diverticular disease of the colon.

Diverticular disease of the colon is a disease of twentieth century Western society. A diverticulum is an outpouching of mucosa through the colonic wall. Etiology and pathogenesis are related to altered colonic structure and physiology in an aging population. Epidemiological evidence suggests that a decrease in dietary fiber, as well as increasing age, lead to formation of diverticula. Diverticular disease includes pain without inflammation, diverticulitis, and bleeding. Severe diverticulitis is often complicated by abscess or fistula formation or peritonitis. Young obese men and immunocompromised patients have a more virulent course. Diverticular bleeding occurs as a result of a diverticulum eroding through a nutrient artery. Treatment of diverticular disease depends on severity and clinical presentation. A higher-fiber diet is recommended if there is no acute inflammation. Broad-spectrum antibiotics, diagnostic and therapeutic computed tomography scans, and early surgical intervention have improved the treatment of hospitalized patients with diverticular disease. The one-stage operation has increased in popularity for patients with localized disease because it reduces reoperative rates and hospitalization costs. Mortality remains high in patients with purulent and fecal peritonitis, and early recognition and treatment may benefit this subset of patients.

Cluster of fulminant hepatitis B in crack users.

Fulminant hepatitis occurs in only 1% of acute hepatitis B patients, requiring hospitalization, but coinfection with delta virus increases the incidence. Hepatitis B and D infection are commonly associated with intravenous drug abuse, but there have been no previous reports of an association with nonparenteral cocaine. Crack use, via sexual promiscuity, is associated with an increased risk for human immunodeficiency virus infection, but has never been associated with viral hepatitis. We report four fatal cases of fulminant hepatitis B including, one with delta virus coinfection and one with human immunodeficiency virus (HIV) infection, in young, sexually active, heterosexual crack users. These patients denied a history of intravenous drug abuse. Our patients probably contracted hepatitis B infection via heterosexual contact. Chronic cocaine exposure may or may not have contributed to the fulminant outcome. Crack users may be at increased risk of developing hepatitis B and D infection. Epidemiological studies are needed to evaluate their risk of viral hepatitis and the effect of cocaine on its outcome.