Unusual infections due to Listeria monocytogenes in the Southern California Desert.

BACKGROUND: During the past 22 years, 14 patients have been hospitalized with infection due to Listeria monocytogenes at the Eisenhower Medical Center, a regional 300-bed hospital in the desert southwest of Southern California. A large number of patients are retired, elderly, and have underlying and often systemic disease. METHODS: Blood agar and routine media were inoculated with liquid from a sterile site such as blood, cerebrospinal fluid, or joint fluid and observed daily for growth. Appropriate biochemical studies were used to speciate the organism. RESULTS: While bacteremia and meningitis constitute 75% of infections in most studies, they made up only 36% of patients in the current study. Listeriosis occurred mostly in patients with infected aortic aneurysms and brain abscesses, and in prosthetic joint infections. While mortality is generally stated to be around 45% in patients with listeriosis, it was 35% in this study. However, there were no deaths in five patients with bacteremia or meningitis inferring that organ involvement poses a greater hazard for survival. CONCLUSIONS: Listeriosis usually presents as a bacteremia or meningitis due to a food-borne invasive infection. In the desert of Southern California most cases are seen in older patients with underlying disease and present with infected aortic aneurysms, prosthetic joints, and brain abscesses. They represent a greater threat to survival due to organ involvement.

Infective endocarditis associated with spondylodiscitis and frequent secondary epidural abscess.

BACKGROUND: Although many patients with IE complain of joint, muscle, and back pain, infections at these sights are rare. Indeed, in patients with back pain and endocarditis, less than 4% actually demonstrate spondylodiscitis. CASE DESCRIPTION: We recently encountered 4 patients with this complication, one each caused by Staphylococcus aureus, Streptococcus bovis, Streptococcus mitis, and Enterococcus faecalis, and wondered whether the nature of the infecting organism determined the development of spondylodiscitis and epidural abscess. In a literature review, 36 patients with endocarditis and spondylodiscitis were identified. Only 9 (25%) were caused by Streptococcus viridans and the remainder by staphylococci, enterococci, and other streptococci. Usually more than 50% of all cases of IE were caused by Streptococcus viridans, although more recent studies would indicate an incidence of about 40%. CONCLUSION: We conclude that spondylodiscitis with epidural abscess is more likely to occur in those patients with endocarditis who are infected by organisms with pyogenic potential.

PET positive generalized lymphadenopathy and splenomegaly following interferon-alfa-2b adjuvant therapy for melanoma.

Interferon-alfa (IFN-alpha) is used in patients with various inflammatory and neoplastic disorders. We recently encountered fluorodeoxyglucose (FDG) uptake in generalized lymphadenopathy, splenomegaly, and the marrow in a patient receiving high dose interferon-alpha-2b (IFN-alpha) as adjuvant therapy for the treatment of malignant melanoma. Biopsy of an enlarged hypermetabolic axillary lymph node revealed only a reactive node. Discontinuation of IFN-alpha caused regression of splenomegaly and lymphadenopathy within 3 months.A marrow "hyperstimulation" pattern that can include the spleen is a well-recognized phenomenon on (fluorodeoxyglucose) FDG positron emission tomography/computed tomography (PET/CT) scans in patients receiving chemotherapeutic agents like interferon, though classically due to colony stimulating factors, but does not generally include lymphadenopathy. This case, which likely reflects an interferon-induced pseudolymphoma, highlights the importance of a drug history and clinical correlation for the proper interpretation of FDG PET/CT scans.

Brain abscess due to Streptococcus acidominimus: first case report.

BACKGROUND: Streptococcus acidominimus resembles Streptococcus viridans, but they can now be differentiated by phenotypic studies. Only a single previous case of pneumonia, pericarditis, and meningitis has been reported. CASE DESCRIPTION: We recently encountered a patient with brain abscess from which S acidominimus was isolated after initially being recorded as S viridans. Because 49% of all S viridans isolated from abscesses are resistant to beta-lactam antimicrobials, speciation is important as well as in vitro sensitivity testing. Streptococcus acidominimus is ordinarily sensitive to beta-lactams, and the use of ceftriaxone for 6 weeks successfully resulted in cure of the brain abscess. CONCLUSION: The use of speciation in treatment of S viridans should improve clinical outcomes.

An early favorable outcome of streptococcal toxic shock syndrome may require a combination of antimicrobial and intravenous gamma globulin therapy together with activated protein C.

Streptococcal toxic shock syndrome (STSS) associated with a group A beta hemolytic streptococcal infection was described 18 y ago. Since then, although the pathophysiology of the syndrome has been clarified, mortality can be as high as 80%. A middle-aged female developed STSS associated with a group A streptococcal pneumonia. Laboratory studies confirmed respiratory and renal failure as well as disseminated intravascular coagulation with a striking reduction in endogenous procoagulants. The patient, probably due to her HLA DRB1*14 haplotype was unable to generate anti-streptococcal antibodies. She was treated with appropriate antimicrobial therapy together with intravenous gamma globulin and drotrecogin or activated protein C. Her response to this combined therapy was accompanied by a rapid resolution of the multiorgan failure and correction of the accompanying disseminated intravascular coagulation. This rapid response to treatment supports the hypohesis that several host factors including the immune response and loss of procoagulants determine the development and severity of the toxic shock syndromes. Further studies with this combined approach appear warranted.

Staphylococcal septic synovitis of the sternoclavicular joint with retrosternal extension.

Bacterial arthritis of the sternoclavicular joint is an uncommon disorder caused by a variety of microorganisms. Both Gram-positive and Gram-negative bacteria have been identified as etiologies of an acute suppurative arthritis, whereas a few other bacteria such as mycobacteria and treponemes have been incriminated in chronic disease of the sternoclavicular joint. We recently treated a patient with staphylococcal synovitis of the sternoclavicular joint, which is the 24th recorded in the literature. His illness was complicated by a retrosternal abscess, soft tissue abscess of the chest, septic bursitis, and lumbosacral discitis. He recovered after 6 weeks of nafcillin therapy without any residual infection. Six previous patients with extension into the substernal space and mediastinum have been described. Staphylococcal infection of the sternoclavicular joint, although usually confined to the joint, can be associated with sepsis and metastatic abscess formation as well as substernal extension even in immunocompetent individuals.

The serologic prevalence of Q fever (Coxiella burnetii) complement-fixing antibodies in the Peninsular bighorn sheep of Southern California.

Q fever is a rare illness in the Southern California desert. During the past 34 years only 6 patients have been diagnosed with the disease at the Eisenhower Medical Center, a referral center for much of the desert and surrounding mountains. In all but 2 instances, Q fever was identified in patients who have been in contact with imported domestic sheep who are brought to the desert to graze and lamb in the fall and winter. The sheep are sent back to Idaho, Wyoming, and Montana in the spring. With frequent infection by Coxiella burnetii established in domestic sheep, we elected to study the prevalence of complement fixing antibodies to Coxiella burnetii in native bighorn sheep who reside in the lower levels of the mountains surrounding the desert. From 1992 to 1999, of 268 serum samples drawn from male and female lambs and adult sheep, 27 tested positive (10%), which is strikingly low when compared with Dall sheep in Alaska (12 of 15), kangaroos, wild rabbits, and brown rats. Because changes have been made in Peninsular bighorn sheep habitat since the animals were listed as endangered in 1998, further follow-up in Q fever serology testing will be of interest.

Q fever in the Southern California desert: epidemiology, clinical presentation and treatment.

Despite the absence of a natural reservoir for Q fever in the desert of Southern California, six cases have been identified during the past 32 years. During that period of time, two areas have been used by northern sheep ranchers from Idaho and Wyoming to import sheep to an area in the Coachella Valley through 1985. Thereafter, because of housing development, the sheep area was moved to Blythe along the Colorado River. All but two of these patients probably acquired infection by Coxiella burnetii by living or working in close proximity to these grazing areas but not directly involved with the sheep. The shift of infected patients from the Coachella Valley to Blythe (100 miles distant) seems to support that supposition. All patients with acute Q fever developed antibodies primarily to phase II antigen, whereas the only person with chronic Q fever developed phase I antibodies. All patients presented with granulomatous hepatitis. One also had a pulmonary infiltrate, and the single individual with chronic Q fever also had a mitral valve prosthesis, although echocardiography could not define endocarditis. All patients with acute infections responded to 3-5 weeks of therapy with doxycycline, whereas the patient with chronic disease failed 3 years of therapy with combination regimens. Further studies at the Eisenhower Medical Center on the prevalence of infection in Blythe, CA, and elsewhere are anticipated.

Molecular interactions of leptin and prostate cancer.

BACKGROUND: Epidemiological studies have found obesity to be a risk factor for prostate cancer. Our prior independent studies in women have reported a strong relationship between variants of OB (leptin) gene, body mass index, and age at menarche and sporadic breast cancer. The current study investigates an association between genetic variants of the human obesity gene, serum leptin levels, and body mass index in subjects with prostate carcinoma and in age- and gender-matched normal subjects. METHODS: Blood samples from 69 patients with prostate cancer and 137 age-matched control subjects were collected. Serum leptin level was investigated by radioimmunoassay, and body mass index was calculated. Allele sizes were determined via standard polymerase chain reaction. Statistical analysis was performed using SPSS10.0 computer software. RESULTS: There was a strong association with significantly elevated serum leptin levels, high body mass index, and higher frequency of LEPR longer alleles in patients with prostate cancer than in control subjects. By contrast, a modest but not significant increase in the frequency of LEP short alleles was found in patients with prostate cancer as compared with control subjects. Analysis within groups 1 (low leptin level and low body mass index) and 2 (other) showed a significant association only in group 2, with high frequency of OB gene variants (LEPR long alleles and LEP short alleles) in patients with prostate cancer but not in control subjects. CONCLUSIONS: These results represent the first report of a significant association between specific leptin gene alleles, serum leptin levels, and body mass index in subjects with prostate cancer. Consistent with prior reports, we also report a significantly elevated serum leptin level in patients with prostate cancer, suggesting a strong link with obesity as an increased risk factor.

Leptomeningeal carcinomatosis in a patient with metastatic prostate cancer: case report and literature review.

BACKGROUND: Leptomeningeal metastasis is discovered at autopsy in approximately 5% of patients with systemic cancer. Until recently with the introduction of magnetic resonance imaging (MRI), premorbid diagnosis was extremely difficult. In particular, initial spinal fluid cytology is diagnostic in less than 50% of autopsy-verified patients, although repeated spinal fluid examinations may increase the yield significantly. Leptomeningeal metastasis in metastatic prostate cancer has been reported in only 14 patients previously. CASE DESCRIPTION: We recently studied such a patient and were able to establish a correct diagnosis based solely on the MRI and the presence of an elevated cerebrospinal fluid (CSF) prostate-specific antigen (PSA). Only 3 previous patients with leptomeningeal prostate metastasis have undergone CSF PSA evaluations. CONCLUSION: We believe that, in such patients, the combination of MRI and CSF studies can overcome the lack of sensitivity of CSF cytology.

Staphylococcus capitis endocarditis due to a transvenous endocardial pacemaker infection: case report and review of Staphylococcus capitis endocarditis.

OBJECTIVES: Newer microbiologic methods to determine the species of coagulase-negative staphylococci (CoNS) have evolved which have shown that most endocarditis due to CoNS is caused by Staphylococcus epidermidis, and far fewer by Staphylococcus warneri and Staphylococcus lugdunensis. METHODS: The recent opportunity to successfully treat a patient with methicillin-resistant Staphylococcus capitis endocarditis secondary to an infected transvenous pacemaker led to a review of the literature relating to S. capitis endocarditis. RESULTS: Thirteen previously recorded patients were identified. Twelve (86%) patients were male. Ten had endocarditis associated with a native valve, two with prosthetic valves and one with a transvenous pacemaker. Mortality was low in all 14 cases (including this case report) with only two deaths; one in a patient with a native valve and the other with a prosthetic valve. Four of the isolates were methicillin resistant but sensitive to vancomycin, which was used in the treatment of eight patients. Those patients with prosthetic cardiac devices appear to do better when the devices are surgically removed. CONCLUSIONS: CoNS as a cause of endocarditis appears to be increasing and the current ability to determine the species of these organisms should elicit the epidemiology, clinical characteristics and biomolecular mechanisms involved in the induction of valvular disease.

Fatal Bacillus cereus endocarditis masquerading as an anthrax-like infection in a patient with acute lymphoblastic leukemia: case report.

A 38-year-old male farm worker with relapsing acute lymphoblastic leukemia spontaneously developed an ulcerating ulcer on his anterior thigh which was surrounded by a non-tender area of erythema. Bacillus cereus was isolated from the ulcer and blood, and the patient received intravenous penicillin and vancomycin for one week. When sensitivity studies were returned he was treated with gatifloxacin orally. After two weeks of combined antimicrobial therapy and negative blood cultures, the patient received combination chemotherapy with vincristine, prednisone, doxorubicin and cyclophosphamide. He was hospitalized a day after completing chemotherapy with neutropenic sepsis due to B. cereus. He received similar antimicrobial therapy as previously, but died three days later. At autopsy, the patient was found to have acute mitral valve endocarditis and bilateral brain abscesses. This was the first case of B. cereus endocarditis reported in a patient with acute lymphoblastic leukemia.

RANTES: a genetic risk marker for multiple sclerosis.

UNLABELLED: Regulated upon activation, normal T-cell expressed and secreted (RANTES) is a beta-chemokine and has been detected in brain lesions of multiple sclerosis (MS) patients. Considering its potential role in MS, we screened two functional polymorphisms in the proximal promoter region of the RANTES in MS patients versus controls. METHODS: We examined 140 postmortem brain samples from subjects with a primary diagnosis of MS, and peripheral blood samples from 216 control subjects. The RANTES-28C/G and -403G/A promoter polymorphisms were examined. All subjects were non-Hispanic Caucasians. RESULTS: MS cases differed from controls showing a significant association with the 403G/A polymorphism (odds ratio, 2.359, [1.465-3.799]; P=0.0001), but not the -28C/G (P=NS) polymorphism. There was a significant association of the -28G allele with both early onset (P=0.031) and longer survival (P=0.006). CONCLUSION: There is a significant but complex association of the RANTES gene with MS.

Association of CCR5 delta32 deletion with early death in multiple sclerosis.

PURPOSE: The interaction between chemokines and their receptors is extremely important in controlling T cell migration into sites of CNS inflammation. Because trafficking of inflammatory T cells into the central nervous system (CNS) is a key player in the pathogenesis of multiple sclerosis (MS), we investigated the possible association of CCR5 delta32 deletion in this disorder. METHODS: DNA isolated from postmortem brain tissue samples of 132 patients with MS and from blood tissue samples of 163 gender and ethnicity-matched healthy controls was used to screen for the CCR5 delta32 deletion allele. RESULTS: An increased frequency of 32-bp deletion allele was found to be associated with early death (P = 0.00005) and with a progressive reduction in the years of survival (onset to death). The death hazard ratio of CCR5 with deletion versus no deletion was 2.12, suggesting that MS patients with the 32-bp deletion have twice the mortality rate of patients with the normal genotype. This effect was more significant in females (hazard ratio 3.58). CONCLUSION: A strong association of the CCR5delta32 deletion with early death could serve as a prognostic marker for MS.

Diagnosis and treatment of Candida vertebral osteomyelitis: clinical experience with a short course therapy of amphotericin B lipid complex.

BACKGROUND: Musculoskeletal candidiasis occurs in some patients with candidemia resulting from organ infection, IV drug use, or indwelling central venous catheters. Diagnosis is often difficult because of vague symptomatology and a frequent afebrile course. CASE DESCRIPTION: Three patients with Candida vertebral osteomyelitis are presented. All followed the use of indwelling central venous access catheters and antimicrobial therapy between 6 months and 3 years earlier. In 2, fungemia with the same Candida spp. preceded the spondylodiskitis. These 3 patients bring to nearly 75 the number of reported individuals with what was once quite rare. Although IV amphotericin B doxycholate and fluconazole have usually been effective therapy over prolonged periods of time, we used liposomal amphotericin B to treat 2 of our 3 patients. Both received 5 mg/kg daily for 18-42 days that resulted in total disappearance of signs and symptoms. CONCLUSION: This relatively brief duration of therapy reduces treatment time and is cost-effective.

Purpura fulminans due to Streptococcus pneumoniae sepsis following gastric bypass.

An older female underwent bariatric surgery which was followed by a significant weight loss and diarrhea, from which C. difficile was isolated just before her hospitalization. Less than 48 hours after admission, she became febrile, developed deep venous thrombosis of the leg and a pulmonary embolus. Blood cultures grew out Streptococcus pneumoniae and the patient developed purpura fulminans. There was convincing laboratory evidence for disseminated intravascular coagulation and a marked depletion of proteins C and S as well as antithrombin. Treatment with ceftriaxone and drotrecogin alfa together with parenteral nutrition led to disappearance of the pathogen and ultimate normalization of the anticoagulant factors. We believe that malabsorption of vitamin K dependent proteins C, S and antithrombin due to bariatric surgery predisposed the patient to purpura fulminans and disseminated intravascular coagulation.

Clinical experience with drotrecogin alfa in treating gram-positive and -negative pathogens in patients with severe sepsis.

BACKGROUND: Newer concepts in the management of severe sepsis and, in particular, in the understanding of the relationship between proinflammatory and procoagulant activities during severe infection have led to the introduction of activated protein C (drotrecogin) into the therapeutic program. The combination of effective antimicrobial therapy, aggressive supportive care, and efforts to antagonize procoagulants and inhibitors of fibrinolysis was used in this study. METHODS: We treated 12 patients with severe sepsis using this combination of antimicrobial agents and drotrecogin. All patients presented with hypotension and organ failure and some with multiple organ failure. Infected patients were separated into those with gram-positive and those with gram-negative infections. RESULTS: In contrast to an expected mortality rate of nearly 40% in this group of patients, only 2 (9%) expired. Both deaths were due to infection by gram-negative organisms in patients with complicated abdominal infections and concurrent cancer. All patients with gram-positive organisms survived. CONCLUSION: Those patients with infections caused by gram-positive organisms seemed to have a better prognosis than those with gram-negative infections, perhaps because their illnesses are less complicated by local disease. Although our study is small, it suggests that activated protein C will have a significant beneficial effect on the future treatment of severe sepsis and can reduce the mortality rate significantly. Further improvement in survival rates will require more effective treatment of local disease and associated noninfectious ailments.