Expanding the horizons of histoplasmosis: disseminated histoplasmosis in a renal transplant patient after a trip to Bangladesh.

Histoplasmosis is recognized to occur in the Ohio and Mississippi River Valleys of the United States, but less widely appreciated is its worldwide distribution. We report a case of disseminated histoplasmosis with disease involving skin, lungs, and epiglottis in a renal transplant patient 6 months after a trip to Bangladesh, to highlight the potential risk of acquisition of this infection in the Indian subcontinent.

Errors in isolation of patients with infectious tuberculosis at a public teaching hospital in New York.

BACKGROUND: Studies report variability in the rates and causes of isolation errors among in-patients with active tuberculosis (TB). We reviewed our experience with delays or premature discontinuation of airborne infection isolation (AII). METHODS: Medical records of patients admitted to the Bellevue Hospital Center, New York City Health & Hospitals, New York, NY, USA, between January 2006 and July 2012 with a positive respiratory culture for Mycobacterium tuberculosis were reviewed. Patients who were out of AII despite being infectious were identified, as the episodes had prompted a contact investigation. RESULTS: Of 246 admissions with positive respiratory cultures, 35 AII errors were identified among 27 patients. Most patients had signs or symptoms of TB on admission. Only four patients had positive sputum smears. In 16 (46%) episodes, the patients had never been isolated, 11 (31%) had delayed isolation, and 8 (23%) were prematurely taken off AII. The most common reasons for patients being off AII while infectious were an incorrect alternative diagnosis (15/35, 43%) or a dual diagnosis (9/35, 26%). CONCLUSIONS: Particularly in smear-negative cases, AII errors due to TB may occur when providers conclude that another diagnosis explains their findings. In many cases, that diagnosis is correct, but TB is also present. This error rate might be a useful quality indicator.

Fibrous myopathy in association with pentazocine.

Cutaneous complications of chronic parenteral narcotic use have been described. A 61-year-old man had severe joint restriction secondary to fibrous replacement of proximal muscles. Parenteral pentazocine lactate use was implicated in the cause of his condition.

Low-dose intermittent trimethoprim-sulfamethoxazole for prevention of Pneumocystis carinii pneumonia in patients with human immunodeficiency virus infection.

The important role of chemoprophylaxis for the prevention of Pneumocystis carinii pneumonia (PCP) in human immunodeficiency virus type 1 (HIV)-infected patients is undisputed. The most cost-effective regimen, however, is unknown. We reviewed our experience at two hospitals in the New York City area in which low-dose, intermittent therapy with the combination of trimethoprim and sulfamethoxazole was used to prevent PCP in HIV-infected patients. During a total of 202 months of primary prophylaxis in 32 patients and 319 months of secondary prophylaxis in 35 patients, PCP was diagnosed only once. More than 80% of patients were receiving zidovudine concomitantly. Adverse reactions to trimethoprim-sulfamethoxazole occurred in 31% and 52% of those receiving primary or secondary prophylaxis, respectively. When those patients who were considered ineligible to receive trimethoprim-sulfamethoxazole prophylaxis (principally based on a prior adverse drug reaction) are also factored in, then approximately 50% of HIV-infected patients are candidates for long-term trimethoprim-sulfamethoxazole prophylaxis. The projected cost savings of this prophylaxis regimen, compared with those currently recommended by the US Public Health Service, are enormous.

Utility of dapsone for prophylaxis of Pneumocystis carinii pneumonia in trimethoprim-sulfamethoxazole-intolerant, HIV-infected individuals.

OBJECTIVE: To determine the safety and efficacy of 100 mg dapsone three times weekly for Pneumocystis carinii pneumonia (PCP) prophylaxis in HIV-infected, trimethoprim-sulfamethoxazole (TMP-SMX)-intolerant patients. DESIGN: Retrospective chart review of patients followed-up to 22 May 1992. SETTING: Infectious diseases outpatient clinic of a tertiary care center in suburban New York City. PATIENTS: Twenty-three HIV-infected patients requiring PCP prophylaxis with documented intolerance to TMP-SMX. MAIN OUTCOME MEASURES: Patients were followed clinically and with laboratory testing at approximately monthly intervals. RESULTS: Dapsone was discontinued in nine (39%) patients because of adverse reactions. All reactions occurred within the first 2 months of treatment. Two (14%) of the remaining 14 patients developed histologically proven PCP over 126 patient-months of follow-up. CONCLUSION: Approximately 40% of TMP-SMX-intolerant HIV-infected individuals are also intolerant of dapsone. Prophylaxis failures may be expected on a dose regimen of 100 mg dapsone three times weekly. More experience with other dose regimens and alternative agents is needed.

Laboratory methods of diagnosis of syphilis for the beginning of the third millennium.

Despite that the whole genome of T. pallidum, the causative agent of syphilis, has been sequenced, syphilis is, and will remain for some time, diagnosed by direct clinical observation and by laboratory methods. This review presents comprehensively most of the practical techniques used for direct detection of T. pallidum and lists all practical methods for phospholipid and treponemal antibodies detection. It describes most novel tests for syphilis, discusses problems with sero-creossreactivity in Lyme disease, immune responses in HIV-syphilis coinfected patients, and reviews serologic responses to antibiotic treatment.

Nocardiosis in patients with human immunodeficiency virus infection. Report of 2 cases and review of the literature.

Nocardia infection is a rarely reported opportunistic infection in HIV-infected patients. Nocardiosis typically occurs in HIV-infected patients with advanced immunodeficiency (89% of cases), often as the initial serious opportunistic infection (42% of cases). In most HIV-infected patients, nocardia infection is disseminated at the time of diagnosis and is characterized by an indolent course that may be difficult to differentiate from other systemic infections. Invasive procedures to obtain tissue of fluid for culture are frequently necessary to make the diagnosis, although a Gram or modified acid-fast stain of sputum or other infected material may suggest the etiologic agent. Although trimethoprim-sulfamethoxazole is the most commonly used initial therapy, it was discontinued in 50% of cases because of adverse reactions. Even though the optimal treatment has not been defined, nocardiosis in HIV-infected patients can be treated successfully with or without sulfa-containing antimicrobial regimens, along with surgical drainage when necessary. Recurrence is noted after short duration of treatment, and consideration should be given to lifelong maintenance therapy.

Brachial plexopathy associated with human granulocytic ehrlichiosis.

Human granulocytic ehrlichiosis is a tick-borne disease of humans. Involvement of the peripheral nervous system is well known with Lyme disease and some rickettsioses but has yet to be described with this disease. We describe a man with bilateral brachial plexopathies associated with an acute febrile illness and clinical, laboratory, and serologic evidence diagnostic of human granulocytic ehrlichiosis. The clinical presentation suggests that the peripheral neuropathy was postinfectious. Human granulocytic ehrlichiosis should be considered in the differential diagnosis in patients with peripheral nervous system involvement, including brachial plexopathy, of individuals who live or recreate in areas known to harbor ticks.

Concomitant human immunodeficiency virus protease inhibitor therapy markedly reduces tacrolimus metabolism and increases blood levels.

We present the case of a patient with hepatitis C-induced cirrhosis and concomitant human immunodeficiency virus infection who underwent orthotopic liver transplantation. The patient developed severe, prolonged tacrolimus toxicity in the presence of human immunodeficiency virus protease inhibitors. At various times, the patient received saquinavir, ritonavir, and nelfinavir in conjunction with tacrolimus. In each instance, the tacrolimus concentration rose to toxic levels. We hypothesize that the protease inhibitors' competition for binding to cytochrome P450 isoenzyme system CYP3A induced extreme prolongation of tacrolimus metabolism. After stabilization of the patient, reinstitution of treatment with nelfinavir resulted in a >95% reduction in tacrolimus dosing from 4 mg twice per day to 0.5 mg once every 3-5 days.

Costs and savings associated with infection control measures that reduced transmission of vancomycin-resistant enterococci in an endemic setting.

OBJECTIVE: To determine the costs and savings of a 15-component infection control program that reduced transmission of vancomycin-resistant enterococci (VRE) in an endemic setting. DESIGN: Evaluation of costs and savings, using historical control data. SETTING: Adult oncology unit of a 650-bed hospital. PARTICIPANTS: Patients with leukemia, lymphoma, and solid tumors, excluding bone marrow transplant recipients. METHODS: Costs and savings with estimated ranges were calculated. Excess length of stay (LOS) associated with VRE bloodstream infection (BSI) was determined by matching VRE BSI patients with VRE-negative patients by oncology diagnosis. Differences in LOS between the matched groups were evaluated using a mixed-effect analysis of variance linear-regression model. RESULTS: The cost of enhanced infection control strategies for 1 year was $116,515. VRE BSI was associated with an increased LOS of 13.7 days. The savings associated with fewer VRE BSI ($123,081), fewer patients with VRE colonization ($2,755), and reductions in antimicrobial use ($179,997) totaled $305,833. Estimated ranges of costs and savings for enhanced infection control strategies were $97,939 to $148,883 for costs and $271,531 to $421,461 for savings. CONCLUSION: The net savings due to enhanced infection control strategies for 1 year was $189,318. Estimates suggest that these strategies would be cost-beneficial for hospital units where the number of patients with VRE BSI is at least six to nine patients per year or if the savings from fewer VRE BSI patients in combination with decreased antimicrobial use equalled $100,000 to $150,000 per year.

Positive Lyme disease serology in patients with clinical and laboratory evidence of human granulocytic ehrlichiosis.

In 10 consecutive patients with an acute febrile illness, human granulocytic ehrlichiosis was confirmed with specific polymerase chain reaction studies, serologic conversion, or both. Although no patients had the clinical features most suggestive of early Lyme disease (eg, erythema migrans or cranial nerve palsy), tests for antibody to Borrelia burgdorferi produced a reaction in most patients. In 6 of 7 patients (86%) with evaluable results, enzyme-linked immunosorbent assay yielded positive or equivocal findings, and an immunoblot technique yielded positive findings in 60% to 90% of patients, depending on the criteria used for interpretation. Inasmuch as approximately 25% of nymphal Ixodes scapularis ticks in Westchester County, New York, are infected with B burgdorferi, the probability that at least 9 of these patients were coinfected with B burgdorferi and human granulocytic ehrlichiosis by the same tick bite is estimated to be .00003. These observations suggest that serodiagnosis is insufficient to establish the presence of coinfection with B burgdorferi.

Tuberculin skin test conversion in hospital employees vaccinated with bacille Calmette-Guérin: recent Mycobacterium tuberculosis infection or booster effect?

OBJECTIVE: A rise in the incidence of purified protein derivative (PPD) skin test conversions among employees at our medical center between 1991 and 1993 prompted an examination of factors associated with PPD skin test conversion. We focused on the effect of bacille Calmette-Guérin (BCG) vaccination on PPD skin test conversion because of changes in employee health service policies in 1990 regarding testing of persons who had received BCG vaccination. METHODS: The study took place in a university teaching hospital employee health service. Charts of employees who had PPD skin test conversion (> 10 mm increase in induration of the PPD response within 2 years if younger than 35 years of age or > 15 mm if older than 35 years of age) between 1988 and 1993 were reviewed for factors that could have influenced PPD skin test conversion and compared with data from 271 randomly selected charts of employees who underwent annual employee assessments in 1993 but did not have PPD skin test conversion. RESULTS: PPD skin test conversions rose from 0.06% (1/1604) to 1.3% (22/1760; p = 0.000001) in employees tested between 1988 and 1993. Of 41 persons with PPD skin test conversion between 1991 and 1993, 29 (71%) had received BCG vaccination. Only 21% of control subjects (56/271) had received BCG vaccination (p < 0.000001 for comparison of BCG vaccination among those with PPD skin test conversion with that among control subjects). When BCG recipients were not included as having PPD skin test conversion, there was no significant increase in PPD skin test conversions. Twenty-three BCG recipients had PPD skin test conversion on their second PPD skin tests. CONCLUSION: A large proportion of PPD skin test conversions at hospitals that employ large numbers of health care workers who have received BCG vaccination may not represent recently acquired tuberculosis. Rather, these conversions may be effects of previous BCG vaccination. Two-step initial PPD skin testing may help to eliminate nearly 80% of such false-positive conversions.

Stepdown single agent antibiotic therapy for the management of the high risk neutropenic adult with hematologic malignancies.

The standard of therapy for the high risk adult neutropenic host being treated with broad spectrum antibiotics for fever has been to continue intravenous antibiotics until neutropenia resolves. We performed a small, limited pilot study to determine if it is safe to switch these patients to oral monotherapy with ciprofloxacin. Ten patients with hematologic malignancies who had < or = 108 granulocytes/mm3 after cytoreductive therapy and were afebrile for at least five days had intravenous antibiotics discontinued and were placed on oral ciprofloxacin. Eight patients were able to be discharged from the hospital and seven were treated without the need for reinstitution of intravenous therapy. Of the three failures, one developed fever with a new bloodstream infection and two developed fever with relapse of leukemia. Patients remained on ciprofloxacin an average of 14.5 days (range 4 to 35 days). Aggregate cost savings for the 10 patients from this approach were estimated to be $11,400 for antibiotics and $88,800 for hospitalization. If corroborated in larger, randomized studies, the use of "stepdown monotherapy" may be a cost effective approach to the management of the stable neutropenic patient.

Central catheter-related infections: comparison of pulmonary artery catheters and triple lumen catheters for the delivery of hyperalimentation in a critical care setting.

We prospectively studied the risk of catheter-related sepsis (CRS) in 75 critically ill patients who received total parenteral nutrition (TPN) through 158 pulmonary artery catheters (PACs) and 214 triple-lumen catheters (TLCs). We relied on semiquantitative cultures of the catheter tips, peripheral blood cultures in febrile patients and clinical response to catheter removal to diagnose catheter-related sepsis. The infection rate was 2.5% (4/158) of PACs and 6.5% (14/214) of TLCs (p = 0.124). Colonization rates were 29.1% for PACs and 32% for TLCs. PACs were left in place a significantly shorter length of time than TLCs, 3.1 vs 5.1 days (p less than 0.005). Guidewire exchanges and subclavian vein insertions were associated with a decreased rate of CRS when compared to new insertions and internal jugular vein insertions, respectively. We conclude that pulmonary artery catheters can be used safely for the delivery of hyperalimentation in critically ill patients with no increased risk for catheter-related sepsis compared to triple-lumen catheters. The use of the PAC in this manner allows for the use of a single central venous catheter for the delivery of hyperalimentation and hemodynamic monitoring.

Risk of hepatitis E infection to travelers.

Hepatitis E virus (HEV), previously referred to as enterically transmitted non-A, non-B hepatitis, is a major cause of epidemic hepatitis and acute, sporadic hepatitis in endemic areas of the world. The existence of HEV was suspected based upon epidemiological grounds for many years. However, it was only in the early 1990s that confirmation occurred when two prototype strains of HEV from Burma and Mexico were sequenced.1-3 Outbreaks of HEV infection as well as sporadic transmission commonly occur in Asia, Africa, Central and South America, the Middle East, and the Republics of the former USSR. Southeast Asia seems to be a particularly high HEV endemic region. HEV is transmitted via the fecal-oral route, and contaminated drinking water is a common source of infection.4 Many of the large outbreaks have occurred after heavy rains and flooding.4 During interepidemic periods sporadic infections occur frequently. This suggests a constant environmental reservoir, allowing for transmission between epidemics. The existence of a zoonotic reservoir for the virus is likely. HEV has been detected in a number of species, including swine, rats, and chicken.

Human immunodeficiency virus infection, Part I.

Initially recognized in 1982, acquired immunodeficiency syndrome (AIDS) has been the leading cause of death among young adults in the United States for much of this decade, and it has had a devastating impact on people in the developing world. It is estimated that 42 million people worldwide have been infected with human immunodeficiency virus (HIV), the virus that causes AIDS, and that almost 12 million people have died from AIDS-related diseases through 1997. Among these 12 million are 3 million children. Two thirds of the more than 30 million people with HIV or AIDS reside in sub-Saharan Africa. In the United States, 641,086 patients have been diagnosed with AIDS through 1997, and at least 385,000 have died. However, for the first time, new highly active antiretroviral therapies that include multiple drugs that attack the virus at several sites have slowed the progression from HIV to AIDS and from AIDS to death for those infected with HIV. The cumulative effect of these changes has been a reduction in both AIDS incident cases and AIDS deaths. Recent epidemiologic trends indicate that the proportion of AIDS incident cases and new HIV infections are increasing among women, African-Americans, and Hispanics, and the infections are more likely to be acquired through heterosexual transmission. The clinical management of HIV infection and AIDS has become increasingly complex in recent years. In addition to complete medical and social histories and physical examinations, hematologic, biochemical, serologic, and immunologic laboratory tests are required to predict the likelihood that patients will develop opportunistic infections and other complications related to HIV infection. Among the most important laboratory tests are measurements of HIV in plasma (viral load) in conjunction with peripheral blood CD4+ helper T lymphocyte counts. These tests are potent predictors of disease progression and their results have become markers for clinical response to therapy. The development of highly active antiretroviral therapy has had a profound impact on the epidemiology of AIDS and on the lives of individual patients. Through combinations of antiretroviral drugs, especially protease inhibitors, viral suppression can be achieved. However, adherence to these complex medical regimens and drug interactions have been problems for many patients. In addition, numerous questions remain unanswered, most importantly those regarding the timing of the initiation of treatment, the durability of viral suppression and clinical response, and the optimal "salvage" regimens for patients failing therapy either clinically or virologically.

Human immunodeficiency virus infection, Part II.

The acceptance of highly active antiretroviral therapy (HAART) among patients and health care providers has had a dramatic impact on the epidemiology and clinical characteristics of many opportunistic infections associated with human immunodeficiency virus (HIV). Previously intractable opportunistic infections and syndromes are now far less common. In addition, effective antibiotic prophylactic therapies have had a profound impact on the risk of patients developing particular infections and on the incidence of these infections overall. Most notable among these are Pneumocystis carinii, disseminated Mycobacterium avium complex, tuberculosis, and toxoplasmosis. Nevertheless, infections continue to cause significant morbidity and mortality among patients who are infected with HIV. The role of HAART in many clinical situations is unquestioned. Compelling data from clinical trials support the use of these therapies during pregnancy to prevent perinatal transmission of HIV. HAART is also recommended for health care workers who have had a "significant" exposure to the blood of an HIV-infected patient. Both of these situations are discussed in detail in this article. In addition, although more controversial, increasing evidence supports the use of HAART during the acute HIV seroconversion syndrome. An "immune reconstitution syndrome" has been newly described for patients in the early phases of treatment with HAART who develop tuberculosis, M avium complex, and cytomegalovirus disease. Accumulating data support the use of hydroxyurea, an agent with a long history in the field of myeloproliferative disorders, for the treatment of HIV. Newer agents, particularly abacavir and adefovir dipivoxil, are available through expanded access protocols, and their roles are being defined and clarified.

Clinical and laboratory evolution of a culture-confirmed case of human granulocytic ehrlichiosis.

A 74-year-old man from suburban New York City, who was hospitalized because of chest pain and fever, was diagnosed as having human granulocytic ehrlichiosis on the eighth hospital day. Although leukocyte and platelet counts were normal on admission, they fell to abnormally low values then normalized prior to specific therapy against the human granulocytic ehrlichiosis agent. Intracytoplasmic inclusions suggestive of Ehrlichia were observed in up to six percent of granulocytes, and the human granulocytic ehrlichiosis bacterium was cultured in an HL 60 human promyelocytic cell line. The patient improved dramatically within 24 hours of doxycycline treatment, after failing to improve on various beta lactam antimicrobial agents. He was discharged from the hospital 14 days after admission. Because human granulocytic ehrlichiosis was not diagnosed until his eight hospital day, clinical and laboratory parameters prior to specific treatment were available. This case illustrates the clinical and laboratory evolution of the infection with human granulocytic ehrlichiosis agent in humans.