Renal aspergilloma: an unusual cause of infection in a patient with the acquired immunodeficiency syndrome.

The case of a 36-year-old man with the acquired immunodeficiency syndrome (AIDS) and a renal aspergilloma is reported. Aspergillus infections are uncommon in patients with AIDS. Isolated renal aspergillomas have rarely been reported in the non-AIDS population (14 cases) and have never been reported in a patient with AIDS. The patient we describe was clinically symptomatic and initially treated medically, but he did not respond to intravenous amphotericin and oral itraconazole. He eventually required nephrectomy; however, there was local recurrence of the aspergilloma postoperatively. We comment on some issues in the spectrum of Aspergillus infections in AIDS and review the literature on the manifestations and treatment of renal aspergillomas.

Mucormycosis in a transplant recipient.

Mucormycosis classically occurs in patients who have uncontrolled diabetes who develop rhinocerebral disease. A fatal case of rhinocerebral infection caused by Rhizopus arrhizus in a 53-year-old man who had received a renal homograft three years previously is reported. Only five similar cases have been documented, all since 1970. Although direct smears of the purulent nasal exudate revealed the presence of numerous Gram-negative bacilli, later identified as Haemophilus influenzae, the diagnosis of mucormycosis was made by demonstrating the typical broad, nonseptate branched hyphae in the necrotic tissue obtained by surgical debridement of the paranasal sinuses. Culture of this material revealed growth of mold-like fungus which, upon direct microscopic examination, showed sporangiophores bearing spherical sporangia arising directly from a cluster of root-like structures of rhizoids. Despite the immediate institution of therapy with amphotericin B postoperatively, the patient died 48 hours later. Subsequently, the Rhizopus isolated was shown to be resistant to both amphotericin B and 5-fluorocytosine. The present case and two others stress the importance of an aggressive diagnostic approach to patients suspected of having mucormycosis, because the usual microbiologic technics are frequently, inexplicably, unsuccessful, and possibly even misleading in this disease.

Extended-interval dosing of aminoglycosides.

Aminoglycosides are efficacious agents. Their use has declined partly because of the development of newer, presumably less toxic agents. Research shows that aminoglycosides can be dosed differently than in the past, maintaining efficacy while reducing aminoglycoside toxicities. Aminoglycosides administered with newer agents may help overcome antibiotic bacterial resistance and thus yield safe and more effective therapy. This study focused on the efficacy and safety of the aminoglycosides extended-interval dosing regimen and was conducted by a search of the literature. Data from The Mount Sinai Hospital regarding bacterial resistance patterns were collected. A nomogram describing the administration of the extended-interval dosing regimen is provided. Extended-interval dosing of aminoglycosides is as efficacious as administering these agents every 8 hours and may result in lower rates of toxicities. Extended-interval dosing also may cost less and be easier to administer. Aminoglycosides are less susceptible to bacterial resistance than many of the newer, currently favored antibiotics. Increasing the usage of aminoglycosides is likely to be safe and beneficial in the treatment of certain bacterial infections.

Pasteurella multocida empyema: case report and review of the literature.

A case report and review of 13 cases of Pasteurella multocida empyema in the English literature demonstrate the apparent increased pathogenicity of this organism in patients with chronic lung disease. The infections were marked by their indolence, minimal febrility, blood-tinged pleural fluid, and predilection for the elderly. The was no characteristic roentgenographic pattern. Animal exposure commonly preceded the illnesses. It is postulated that the disease occurs in patients with impaired pulmonary defenses who acquire the organism via the inhalation of infectious droplets aerosolized from the oropharynx of animals where P multocida is part of the normal flora. Although most isolates were penicillin sensitive, there was significant mortality.

Toward the development of consumer-based criteria for the evaluation of assistive devices.

The most important basis for evaluating an assistive device is whether it satisfies the needs of the disabled consumer. However, the factors that consumers consider in determining whether a device meets their needs are not well understood. This preliminary study applied a small focus group process to identify and prioritize factors used by long-term users of assistive technology in assessing their devices. A modified version of the Delphi Method was applied to two groups of long-term users--a Panel of Consumer Experts with Mobility Impairments and a Panel of Consumer Experts with Sensory Impairments. In total, the panels identified and prioritized 17 general factors for 11 types of assistive technologies. This study constitutes an initial step toward the development of design, engineering, and selection criteria based on the specific concerns of consumers.

The AAMI contract approach to standards development.

In summary, the AAMI approach enables the FDA to utilize all available resources needed to identify critical characteristics that should be subjected to standards; to develop rationale for those parameters that should not be subjected to standards; and to develop standards in those areas where standards should be developed. During the process, appropriate checks and balances are available because of AAMI's multidisciplinary approach, which is not available using other approaches. The AAMI approach is extremely participatory and, consequently, will result in the production of a standard that will be acceptable to the largest number of people without compromising critical safety and efficacy considerations.

Continuing changing patterns of disease in pyogenic liver abscess: a study of 38 patients.

Changes in the etiology, clinical features, methods of diagnosis, and treatment of pyogenic liver abscess have occurred slowly but continuously over the past century. The earlier changes are well documented in the literature, and continuing variations in the classic patterns of disease are now evident. These include 1) a recent increase in incidence reflecting more accurate diagnostic techniques; 2) changes in bacteriology with a high incidence of Klebsiella infection; 3) a reduction in mortality, reflecting earlier diagnosis and more refined therapeutic methods; and 4) changes in the population at risk namely a large population of terminal cancer patients. Thirty-eight patients treated at the Mount Sinai Hospital over the past 16 years, 1967-1982, have been divided into two groups, each of 8 years duration, reflecting an earlier era before routine use of scanning procedures, and a later period when technetium, gallium, sonographic, and more recently CT imaging procedures were regularly done. During the latter period there was a significant increase in both the total number of liver abscesses diagnosed and in the number estimated as a proportion of all hospital admissions. Mortality has continued to fall to more acceptable levels with a 25% reduction overall. In the early era, extrahepatic intra-abdominal infection caused all four deaths. In the past 8 years obstructing or metastatic cancer has caused four of the five deaths. Bacteremia occurred in six of the nine deaths, five of these being of biliary origin. The decrease in mortality may reflect earlier diagnosis, an increase in the number of solitary abscesses, and better therapy.

Severe acquired immunodeficiency in male homosexuals, manifested by chronic perianal ulcerative herpes simplex lesions.

Four homosexual men presented with gradually enlarging perianal ulcers, from which herpes simplex virus was cultured. Each patient had a prolonged course characterized by eight loss, fever, and evidence of infection by other opportunistic microorganisms including cytomegalovirus, Pneumocystis carinii, and Candida albicans. Three patients died; Kaposi's sarcoma developed in the fourth. All were found to have depressed cell-mediated immunity, as evidenced by skin anergy, lymphopenia, and poor or absent responses to plant lectins and antigens in vitro. Natural-killer-cell activity directed against target cells infected with herpes simplex virus was depressed in all patients. The absence of a history of recurrent infections or of histologic evidence of lymphoproliferative or other neoplastic diseases suggests that the immune defects were acquired.