[A patient with tetanus without an obvious point of entry]. / Een patiënt met tetanus zonder aantoonbare porte d'entrée.

A 59-years-old man with oesophageal cancer (T3NXMo) presented with trismus, dysarthria and diaphoresis. Later, he developed opisthotonus and generalized spasms. Despite negative blood cultures and sufficiently high anti-tetanus-titres, tetanus was suspected, on clinical grounds. He was intubated and treated with tetanus toxoid, human antitetanus immunoglobulin, benzylpenicillin, propofol, benzodiazepines, vecuronium, and sufentanil, and recovered gradually. Tetanus is caused by Clostridium tetani, a Gram-positive rod capable of remaining present latently in the body for years. Absence of a visible external wound suggests that the oesophageal mucosal cancer lesion could have served as portal of entry or that endogenous reactivation of latent tetanus bacteria had taken place.

Efficacy of itraconazole in the prevention of fungal infections among neutropenic patients with hematologic malignancies and intensive chemotherapy. A double blind, placebo controlled study.

We studied the efficacy and safety of itraconazole for the prevention of fungal infection in neutropenic patients given cytotoxic chemotherapy for hematologic malignancies. Patients were randomly allocated to receive either itraconazole (200 mg bd) or placebo in addition to oral amphotericin B until the patient either developed fungal infection or had completed antileukemic treatment. Forty six patients (83 neutropenic episodes) treated with itraconazole and 46 placebo treated patients (84 neutropenic episodes) were evaluable. No specific toxicity was noted. Nine fungal infections developed in the itraconazole group, of which four were histologically or microbiologically proven and 15 in the patients given placebo (eight proven) (p < 0.12). All these patients received IV amphotericin B. The incidence of Candida albicans infections tended to be lower in the itraconazole group, but overall, there was no measurable improvement in the prevention of fungal infections and mortality by itraconazole.

Itraconazole and multidrug resistance: possible effects on remission rate and disease-free survival in acute leukemia.

Itraconazole, a triazole antifungal agent, has been reported to reverse drug resistance against daunorubicin in acute leukemia. In a subanalysis from a double-blind, placebo-controlled trial examining the effects of itraconazole on the prevention of fungal infections in neutropenic patients, we studied the effects of itraconazole on remission rate and disease-free survival in patients with acute lymphoblastic (ALL) and acute myelogenous leukemia (AML) receiving remission induction treatment schedules containing daunorubicin (DNR). Eleven ALL and 17 AML patients received itraconazole and 12 ALL and 25 AML patients were given placebo. Among AML patients the remission rate was slightly higher in the itraconazole group, whereas the disease-free survival was higher among ALL patients given itraconazole. In AML patients DFS was comparable in both groups but the number of high-risk patients in the itraconazole group was higher. These preliminary results may suggest a role for itraconazole in reversing multidrug resistance. Larger trials, however, are required to substantiate these findings and to correlate them with its in vitro effects on multidrug resistance.

Rapid diagnosis of acute meningococcal infections by needle aspiration or biopsy of skin lesions.

OBJECTIVES: To evaluate the usefulness of Gram staining and culture of skin lesions in patients with acute meningococcal infections. DESIGN: Retrospective study. SETTING: Community hospital and intensive care unit of a teaching hospital. SUBJECTS: 51 patients admitted from 1989 to 1993 with proved meningococcal infections and microbiological examination of specimens from skin lesions. INTERVENTIONS: Needle aspiration of a skin lesion before start of antibiotic treatment in 26 patients in the community hospital; punch biopsy of skin lesion after start of antibiotic treatment in 25 patients in the teaching hospital. MAIN OUTCOME MEASURES: Detection of meningococci by Gram staining of specimens from skin lesions according to category of infection (meningococcaemia, meningitis, meningitis with shock, or septic shock without meningitis). RESULTS: Bacteria were detected in the specimen from haemorrhagic skin lesions by culture or Gram staining, or both in 32 (63%) patients. The sensitivity of the Gram stain was 51% and did not differ significantly from its sensitivity in detecting bacteria in cerebrospinal fluid. In meningococcal sepsis, however, a Gram stained skin lesion was significantly more sensitive (72%) than Gram stained cerebrospinal fluid (22%). In patients with meningitis skin lesions gave positive results on staining more often if shock was present. The results for punch biopsy specimens were not affected by antibiotics as Gram staining gave positive results up to 45 hours after the start of treatment and culture gave positive results up to 13 hours. CONCLUSION: Microbiological examination of skin lesions is informative, especially in patients with sepsis and inconclusive results from cerebrospinal fluid, and may provide a diagnosis in such patients within 45 minutes. It differentiates well between meningitis with and without haemodynamic complications, and the result is not affected by previous antibiotic treatment.

Prosthesis-related infection. Etiology, prophylaxis and diagnosis (a review).

The recent literature concerning prosthesis-related infection is reviewed with respect to etiology, prophylaxis and diagnosis. Most prosthesis-related infections are initiated during operation by contamination with bacteria-carrying particles from the air as a result of dispersion of skin scales from individuals in the operating room. A small number of infections are caused by hematogenous seeding of bacteria. Glycocalyx, a slime layer produced by bacteria, plays an important role in the pathogenesis of infections, especially in the presence of biomaterial. Clean-air systems in combination with perioperative systemic antibiotics reduce prosthesis-related infections from 3 or 4 per cent to a few per thousand. The use of antibiotic-loaded bone cement is advised in high risk patients although further evaluation is needed. Physical examination of the patient, laboratory tests such as the E.S.R. and C-reactive protein, serial radiograms, isotope scanning techniques and joint aspiration can all help diagnose prosthesis-related infection. However definitive diagnosis is possible only by culturing several samples of material obtained from the interface during revision operation. A perioperative frozen section of interface tissue showing acute (more than 5 leucocytes per field) or severe chronic (more than 50 lymphocytes) inflammation is highly suggestive of sepsis.

Kearns syndrome or Kearns disease. Further evidence of a genuine entity in a case with uncommon features.

A 20-year-old man with the characteristic findings of infantile onset Kearns syndrome is described. Morphological and biochemical investigations proved a mitochondrial disease which we believe to be the cause of the symptoms in various organs. We assume an autosomal-dominant inheritance, the marker sign of which is blepharoptosis in several family members. Characteristic clinical, morphological and biochemical findings, combined with an autosomal-dominant inheritance with very variable expression, mark the Kearns syndrome as an individual disease, not as a symptom complex (syndrome). Kearns disease can be divided into three forms--an infantile form ("Kearns-Sayre syndrome') with early onset, rapid progression, multisystemic involvement and a severe course; and a juvenile and an adult form with onset in the second, respectively third (or later) decades with a generally slower and more benign course and less widespread expression in various organ systems. Furthermore, the occurrence of a curious orthoptic abnormality is described, indicating one of the possible ways to avoid diplopia in chronic progressive external ophthalmoplegia: the coexistence of normal and gliding abnormal retinal correspondence.