Successful treatment of a patient with seropositive human immunodeficiency virus with high risk Burkitt's leukemia.

A 24-year-old male patient seropositive for the human immunodeficiency virus with Burkitt's Leukemia was treated successfully with aggressive systemic chemotherapy and central nervous system prophylaxis. He presented with a leukocyte count of 68,900/microliter with 33% L3 lymphoblasts, massive hepatosplenomegaly, generalized lymphadenopathy, a lactic dehydrogenase level of 9105 IU/l, creatinine level of 5.8 mg/dl, and a uric acid level of 43.5 mg/dl. Hemodialysis, intrathecal methotrexate, hydrocortisone and cytosine arabinoside, and fractionated doses of cyclophosphamide followed by vincristine and doxorubicin were promptly instituted. He received eight subsequent courses of chemotherapy consisting of either methotrexate with leucovorin rescue and high dose, continuous infusion cytosine arabinoside or cyclophosphamide, vincristine, and methotrexate with leucovorin. There was marked hematologic toxicity resulting from this treatment. However, the patient was alive and in complete remission more than 6 years from diagnosis. This paper demonstrated that it is possible to successfully treat a patient who is HIV-1 antibody positive with poor prognosis Burkitt's Leukemia. Further studies need to be undertaken to define the least toxic, most effective therapy for this disease.

Acute and subacute deep infection after uncemented total hip replacement using antibacterial prophylaxis.

Nine hundred thirty-two uncemented total hip replacement arthroplasties were studied. Seven hundred nineteen of these were primary operations with or without bone autograft. Two hundred thirteen were revisions with bone autograft and/or allograft. All were done by a single surgeon in a single operating theater. Prophylaxis included perioperative and postoperative antibiotics using either cefazolin or vancomycin, the use of a laminar flow room, and the use of total body exhaust systems. Aspiration of the hip with culture of the derived joint fluid was carried out preparatory to revision surgery. In each instance, the culture was negative. One acute infection and three subacute infections occurred three months and five months respectively after the index operation. One infection occurred seven months following complex revision surgery with bone allografting and autografting. The overall incidence of deep sepsis (four of 932 total cases) was 0.43%. The incidence of deep sepsis in the primary cases alone (three of 719) was 0.42%. In the revision series, the incidence of deep sepsis (one of 213) was 0.47%. No attempt was made to quantify the incidence of late sepsis. The incidence of acute and subacute postoperative deep sepsis after uncemented hip replacement, including revision surgery with major bone grafting, was comparable to other previously reported results on cemented hips.

Clinical evaluation of piperacillin with observations on penetrability into cerebrospinal fluid.

Piperacillin, a new semisynthetic penicillin, was evaluated for efficacy and safety in 26 patients, most of whom had pneumonia. Included were four patients with gram-negative meningitis in whom the penetration of piperacillin into cerebrospinal fluid was determined. Cure was achieved in 11 of 17 patients with pneumonia; another 4 were improved. One relapse and one failure occurred among nine patients with gram-negative pneumonia. Cure or improvement occurred in seven of nine patients with gram-negative infection in various extrapulmonary sites. Piperacillin given by continuous infusion in a dosage ranging from 324 to 436 mg/kg of body weight per day to four patients with meningitis resulted in a mean cerebrospinal fluid level of 23 micrograms/ml at 24 h; the mean penetration of piperacillin into the cerebrospinal fluid was 32% at this interval. Levels of piperacillin in cerebrospinal fluid collected later during the course of therapy were also adequate. Adverse effects were noted in six patients, but only one episode of granulocytopenia was serious. Emergence of resistance to piperacillin did not occur, and only one superinfection was noted. Piperacillin appeared to be efficacious in the treatment of pneumonia. It penetrated well into the cerebrospinal fluid of patients with meningitis and may be useful for treatment of selected gram-negative infections in extrapulmonary sites.