Transient bacteremia associated with barium enema.

A group of 175 patients had barium enema. Pour-plate blood cultures were obtained immediately before and after the procedure and 5, 10, 15, and 30 minutes later. Bacteremia was demonstrable in 20 (11.4%) patients. In some, blood cultures were positive for as long as 15 minutes after barium enema; all were negative at 30 minutes. Among the bacteria associated with the 20 episodes of bacteremia were Escherichia coli, Klebsiella, enterococci, Proteus morganii, Bacteroides, and Veillonella. The incidence of bacteremia among patients with ulcerative colitis, regional enteritis, rectal polyps, colonic or rectal carcinoma, nonspecific diarrhea, or other lower intestinal tract disorders was not much different from patients free of rectosigmoid disease. The results of this study suggest that a history of recent barium enema may be important in patients who have endocarditis.

Varicella hepatitis: a fatal case in a previously healthy, immunocompetent adult. Report of a case, autopsy, and review of the literature.

Varicella, usually a benign infection of childhood, is known to be associated with more serious complications, especially in adults and immunocompromised patients. Of these, varicella pneumonitis is the most common. Primary varicella hepatitis has been described, though rarely, in immunocompromised patients. We present a case of a previously healthy human immunodeficiency virus-negative 26-year-old immigrant from El Salvador in whom primary varicella developed that rapidly progressed to fulminant hepatic failure, disseminated intravascular coagulation, and death. Autopsy revealed evidence of varicella in the liver, adrenal glands, and myometrium. To our knowledge, this is the first report of a fatal case of varicella hepatitis in a previously healthy, immunocompetent patient.

The significance and mechanism of an increased serum phenylalanine-tyrosine ratio during infection.

Infections or inflammatory states often cause significant increases in serum phenylalanine and the phenylalanine-tyrosine ratio. More than 95% of samples obtained during inflammatory diseases in man showed phenylalanine-tyrosine ratio increases greater than the maximum normal values. An increase in this ratio also occurred in monkeys with induced Rocky Mountain spotted fever, viral encephalitis, yellow fever, or pneumococcal and Salmonella infections, as well as in rats with pneumococcal and Salmonella infections, as well as in rats with pneumococcal, Salmonella or tularemia infections. A similar ratio increase occurred in rats inoculated with unpurified mediator substances (released by activated leukocytes) that appear to initiate many of the secondary metabolic phenomena associated with infection and/or inflammation. To identify responsible mechanisms, rats were given lethal doses of Streptococcus pneumoniae; serum phenylalanine and phenylalanine-tyrosine ratios increased significantly. Hepatic phenylalanine hydroxylase activities were slightly decreased when compared to noninfected controls. Infected and noninfected rats showed comparable oxidation rates for 14C-phenylalanine given with an oral phenylalanine load, as a pulse-oral dose, or as an intraperitoneal injection. After 8 hr, both infected and control rats had similar amounts of radioactivity in total body protein, but tissue distributions were markedly altered during pneumococcal sepsis. Serum proteins of infected rats contained almost twice as much total radioactivity as that found in controls, while the amount of labeled phenylalanine in skeletal muscle protein was significantly reduced in the infected group. Isolated muscles from infected rats released more phenylalanine and less tyrosine than control muscles. Infection-related increases in serum phenlalanine could not be explained by decreased hydroxylation or oxidation. Rather, the data were consistent with an increased flux of phenylalanine into serum, most likely as the result of increased skeletal muscle catabolism. Elevations in the serum phenylalanine-tyrosine ratio have potential value for estimating the presence of an inflammatory fisease and the catabolic state of a patient.

Extracorporeal photopheresis in the treatment of AIDS-related complex: extended trial.

The objective of this study was to further evaluate the relative safety of extracorporeal photopheresis in the treatment of patients with AIDS-related complex. Twenty patients with AIDS-related complex, three from the initial report and 17 additional patients, were enrolled. The patient population had various risk factors. There were nine homosexuals, five heterosexual consorts of human immunodeficiency virus (HIV)-positive patients, four reformed i.v. drug abusers, and two hemophilia patients. The patients received monthly treatment with extracorporeal photopheresis. In 16 of the 19 patients, this study provides evidence of clinical stability over a longer period. The relative stability of beta 2-microglobulin and neopterin levels demonstrates that photopheresis therapy does not have an untoward effect on the degree of activation of the immune system with respect to induction of HIV replication. Antibody titers to the major viral antigens, envelope glycoproteins (gp) 120 and 41, reverse transcriptase enzyme gp 66/31 and 55, and the core protein p24 remained stable throughout the course of therapy. A subjective improvement was noted in the majority of patients. The evaluation of T-cell subsets revealed that the photopheresis treatment did not have a detrimental effect on CD3 and CD8 cells. Some decreases were noted in the CD4 cell counts but the decline may be less than is normally seen at corresponding stages of HIV infection. Skin test responsivity improved in 11 patients, remained unchanged in seven patients, and declined in two. The preliminary results suggest that in HIV disease, extracorporeal photopheresis is safe and warrants a prospective controlled trial.

Surface alterations due to endotracheal intubation.

The varied complication of prolonged endotracheal intubation, including tracheal stenosis, stricture and tracheomalacia, are thought to be directly related to lateral tracheal wall pressure. To investigate the initiation, relevance and duration of these changes, studies were undertaken to assess the effects of intubation on the surface anatomy of the trachea by scanning electron microscopy. Tracheal mucosal morphology was studies in (1) anesthetized "normal" dogs; (2) d-ogs sacrificed 2 hours after intubation with cuff deflated or inflated to the "just seal" point using a cuff system producing the lowest tracheal wall pressure; and (3) dogs intubated for 2 hours and then examined at 2 and 7 days after extubation. Intubation without cuff inflation resulted in distinct linear areas of nearly complete ciliary denudation along the tract of tubal insertion within 2 hours. Inflated cuffs produced similar but more widespread changes especially over tracheal rings, indicating that pressure in areas of least resiliency significantly contributes to these alterations. Regeneration of cilia could be seen 2 days after extubation, but many anatomic features remained distorted; at 7 days, regeneration was nearly complete, but isolated areas of denudation could still be identified. Scanning electron micrographs of human tracheas taken at autopsy from patients who had had prolonged intubation with the same cuff system correlated well with those obtained from dogs.

Clindamycin.

Clindamycin is an excellent, well tolerated, effective antimicrobial agent that can be used clinically in the treatment of specific anaerobic infections as well as clinical situations when both S. aureus and anaerobes occur together.

Cytolytic response to HIV in patients with HIV disease treated with extracorporeal photochemotherapy: preliminary study.

Extracorporeal photochemotherapy (photopheresis), an immunomodulatory therapy that targets circulating T helper lymphocytes, has been applied to the management of human immunodeficiency virus (HIV) disease. Any therapy that exerts its actions on CD4+ T cells has the potential of exacerbating HIV infection. Therefore, it was necessary to observe immune function during treatment. Because cytotoxic T lymphocytes (CTL) and natural-killer cells are thought to play an important role in the response against HIV infection, we examined the effect of photopheresis on HIV cytolytic activity. The study group consisted of seven patients with late-stage HIV disease who had not received any previous treatment for HIV infection. Patients were treated exclusively with photopheresis on two consecutive days each month for 14-32 months (average, 25 months). Peripheral lymphocytes, collected at various points during treatment, were used as effectors in a 51Cr release assay. Epstein-Barr virus (EBV)-transformed autologous B cell lines transfected with recombinant vaccinia vectors that expressed the HIV env (gp120, gp41) and gag (p24) proteins were used as target cells. All seven patients demonstrated relatively constant levels of cytolysis (>10% above controls) during treatment in the context of stable CD4+ T cell counts and a stable clinical status. These results suggest that extracorporeal photochemotherapy did not impair the cytolytic response to HIV infection and may have enhanced it in some patients.

Aspiration pneumonia: a ten-year review.

Aspiration pneumonitis is an important cause of many anesthetic and non-surgical deaths and complication. One hundred and eight cases from 1964 to 1974 were reviewed to study the factors associated with aspiration pneumonia. Forty surgical and 68 non-surgical patients were evaluated and compared. Predisposing factors included impaired consciousness, esophageal and neurological disorders, cardiac resuscitation, debilitation, presence of a nasogastric tube or tracheostomy. The most common findings in both groups were dyspnea, cough, cyanosis, fever, tachycardia, rhonchi, rales and wheezes. Sputa of 64 patients failed to reveal the precise etiologic agent. High mortality (30%) and morbidity were found in both groups even with optimum treatment. The causes of morbidity in both groups of patients were pneumonia, lung abscess, myocardial infarction, gastrointestinal hemorrhage, and pulmonary embolus. Prevention, with particular attention to high-risk patients and to factors influencing aspiration in groups of surgical and non-surgical patients, is the solution to the problem.

Case report: post-transfusion purpura.

Post-transfusion purpura (PTP) is a rare disorder characterized by the abrupt onset of severe thrombocytopenia following a blood transfusion. We describe a case of PTP in a patient treated with plasmapheresis, noting that this is an uncommon but treatable disease entity.