Randomized, controlled study of the safety and efficacy of intravenous cidofovir for the treatment of relapsing cytomegalovirus retinitis in patients with AIDS

To assess the effect of intravenous cidofovir on delaying progression of previously treated, relapsing cytomegalovirus (CMV) retinitis, we conducted a randomized, controlled comparison of two maintenance dose levels of cidofovir. One hundred and fifty patients with AIDS and CMV retinitis that had progressed or was persistently active despite treatment with ganciclovir, foscarnet, or both were randomized to receive induction cidofovir, 5 mg/kg once weekly for 2 weeks, then maintenance therapy with either 5 mg/kg or 3 mg/kg once every other week. Concomitant probenecid and intravenous hydration were administered with each cidofovir dose. Retinitis progression was assessed in the first 100 patients by bilateral, full-field retinal photographs read at a central reading center by an ophthalmologist masked to treatment assignment. Incidence of side effects, changes in visual acuity, and mortality were also assessed. Median time to retinitis progression as assessed by retinal photography was not reached (95% confidence interval [CI], 115 days-upper limit not reached) in the 5-mg/kg group, and was 49 days (95% CI, 35-52 days) in the 3-mg/kg group (p = .0006). Dose-dependent asymptomatic proteinuria (39%) and serum creatinine elevation (24%) were the most common adverse events thought to be related to cidofovir. Reversible probenecid reactions including constitutional symptoms and nausea occurred in 65 of 150 (43%) patients. Cidofovir therapy is effective in delaying progression of CMV retinitis that had previously progressed using other anti-CMV therapies.

Mycobacterium kansasii bacteremia in patients infected with human immunodeficiency virus

In a retrospective review of microbiology records at the George Washington University Hospital from 1980 through 1990, Mycobacterium kansasii bacteremia was identified in 10 patients; this finding represented 4.5% of nontuberculous mycobacterial blood cultures. M. kansasii was isolated from respiratory specimens from all 10 patients, and pulmonary parenchymal changes were noted in five patients. The median survival time was 14 weeks; however, only five patients received therapy with two or more drugs active against M. kansasii.

Wasting syndrome in AIDS: pathophysiologic mechanisms and therapeutic approaches

Wasting syndrome is a common complication of HIV infection and is marked by progressive weight loss and weakness, often associated with fever and diarrhea. The pathophysiologic mechanisms responsible for this syndrome are not well defined, but it is clear that this is a multifactorial process in which the relative contribution of individual etiologic factors vary among patients. Considerations include inadequate diet, malabsorptive phenomena, metabolic derangements, and cytokine activity. The onset of opportunistic infections is often accompanied by a hypermetabolic state characterized by progressive weight loss. Potential cytokines that may promote weight loss in AIDS patients include tumor necrosis factor, interleukin-1, interleukin-6, and alpha-interferon. At present there is no effective treatment. Multiple therapeutic methods, including enteral and parenteral alimentation, appetite stimulants, recombinant growth hormone, and cytokine modulators, are currently being explored.

Fascioliasis: case reports and review

Fasciola hepatica, a zoonotic liver fluke, can cause disease in humans. Fascioliasis, while common in some tropical and developing countries, is uncommon in the United States. We report two cases of fascioliasis that illustrate both the hepatic and biliary stages of the disease. Clinical features and diagnostic aspects including serologic, radiographic, and histopathologic studies are emphasized. Praziquantel was ineffective in treatment of both patients. Bithionol appears to be an effective treatment for fascioliasis.

Ganciclovir treatment of cytomegalovirus ventriculitis in a patient infected with human immunodeficiency virus

Histopathologic evidence of central nervous system involvement with cytomegalovirus (CMV) has been well recognized in patients infected with human immunodeficiency virus (HIV). However, clinically symptomatic disease has been decidedly less common. In this report, we describe a patient infected with HIV who developed an acute change in neurological status. Gadolinium-enhanced magnetic resonance imaging and analysis of cerebrospinal fluid revealed CMV ventriculitis and meningoencephalitis. Treatment with ganciclovir resulted in radiological improvement of the ventriculitis and negative CMV cultures but little clinical neurological improvement.

Listeria monocytogenes infections in patients with AIDS: report of five cases and review

Five patients with AIDS and Listeria monocytogenes infection (three cases of bacteremia and two of meningitis) are reviewed. Four patients had prior or concurrent gastrointestinal illness. Two patients received corticosteroids. A 7- to 21-day course of ampicillin was administered with or without a 7- to 14-day course of gentamicin. This regimen was effective, with no evidence of relapse 7-8 months after therapy was discontinued. The relative infrequency of infection with L. monocytogenes in AIDS patients is unexpected. Tumor necrosis factor (TNF) appears to be essential in the inhibition of Listeria in vivo. Elevated levels of TNF in AIDS patients may be protective against listeriosis and thus help explain the low prevalence of listerial infection in this population. Nonetheless, although L. monocytogenes is an uncommon cause of illness in patients infected with the human immunodeficiency virus, it cannot be dismissed as a cause of undefined meningitis or sepsis.

Association of circulating receptor Fc gamma RIII-positive monocytes in AIDS patients with elevated levels of transforming growth factor-beta

Monocytes in the circulation of normal individuals express two receptors for the constant region of immunoglobulin, Fc gamma RI and Fc gamma RII. In contrast, we have observed that AIDS monocytes express significant levels of a third Fc gamma R, Fc gamma RIII (CD16), which is normally associated with activation or maturation of the monocyte population. By dual-fluorescence analysis using a monoclonal antibody specific for Fc gamma RIII (MAb 3G8), 38.5 +/- 3.2% of the LeuM3 (CD14)-positive monocytes in AIDS patients were CD16 positive as compared to 10.4 +/- 1.0% for healthy individuals (n = 29; P less than 0.005). Furthermore, AIDS monocytes expressed Fc gamma RIII-specific mRNA which is expressed minimally or not at all in control monocytes. As a recently identified inducer of Fc gamma RIII expression on blood monocytes, transforming growth factor-beta (TGF-beta) was found to be elevated in the serum and/or plasma of AIDS patients. Moreover, incubation of normal monocytes with AIDS serum or plasma induced CD16 expression which correlated with serum TGF-beta levels (r = 0.74, P less than 0.001) and was inhibited with a neutralizing antibody to TGF-beta. Thus, the increased CD16 expression on peripheral blood monocytes in AIDS patients may be the consequence of elevated circulating levels of the polypeptide hormone TGF-beta.

Flavimonas oryzihabitans (Pseudomonas oryzihabitans; CDC group Ve-2) bacteremia in the immunocompromised host

Flavimonas oryzihabitans, known previously as Pseudomonas oryzihabitans, and a member of the Centers for Disease Control group Ve-2, is a gram-negative organism that has rarely been implicated as a human pathogen. Flavimonas oryzihabitans appears to be a soil and saprophytic organism that survives in moist environments and is indigenous to rice paddles. To our knowledge, only seven cases of human infection caused by this organism have been reported; they involved four patients with bacteremia and three patients with peritonitis who were receiving continuous ambulatory peritoneal dialysis. In this report, we describe three immunocompromised patients with catheter-associated bacteremia: a patient with cancer, a patient with acquired immunodeficiency syndrome, and a patient with sickle cell disease. There is emerging clinical evidence that F oryzihabitans should be recognized as an organism that is capable of causing human disease, particularly in immunocompromised patients and with the increased usage of permanent catheters.

Peripheral blood mononuclear cell interleukin-2 and interferon-gamma production, cytotoxicity, and antigen-stimulated blastogenesis during experimental rhinovirus infection

To determine whether rhinovirus infection induced a systemic cellular immune response in humans, specific antigen-stimulated blastogenesis, natural killer cell activity, and mitogen-stimulated production of interleukin-2 and interferon-gamma by peripheral blood mononuclear cells (PBMC) were quantified during experimental rhinovirus infection of normal volunteers. Phytohemagglutinin-stimulated interleukin-2 production by PBMC collected on day 5 after rhinovirus inoculation was increased fourfold compared with production by PBMC collected before rhinovirus challenge (P less than .05); phytohemagglutinin-stimulated interferon-gamma production was doubled (P less than .05). An inverse relationship was observed between the increase in interleukin-2 production and both nasal mucus production (P less than .02) and the number of days virus was cultured from nasal washings (P less than .02). Natural killer cell-mediated cytotoxicity of PBMC collected on day 5 after rhinovirus challenge was also increased (P less than .01) compared with preinfection levels, as was specific antigen-stimulated blastogenesis on day 21 (P less than .05). The extent of blastogenic response correlated directly with both mucus production (P less than .05) and the number of days virus was cultured from nasal washings (P less than .05). These observations are consistent with the hypothesis that rhinovirus infection results in activation of a systemic cellular immune response.

Prevalence of cardiac abnormalities in human immunodeficiency virus infection

The prevalence of cardiac abnormalities in the spectrum of human immunodeficiency virus (HIV) infection is unknown. Sixty consecutive HIV-infected patients were studied using echocardiograms, electrocardiograms (50 patients) and ambulatory electrocardiographic monitoring (43 patients). Group A (25 patients) were seropositive but pre-AIDS, whereas group B (35 patients) had AIDS and included 24 with an active opportunistic infection (group B1) and 11 without it (group B2). Abnormalities were identified in 32 of 60 patients (53%) and were more frequent in group B (23 of 35, 66%) than in group A (9 of 25, 36%, p less than 0.05) but independent of active opportunistic infection (15 of 24, 62%, in group B1 vs 8 of 11, 73%, in group B2). Echocardiographic abnormalities were identified in 21 of 60 patients (35%), including 7 of 25 (28%) in group A vs 14 of 35 (40%) in group B (difference not significant), and 7 of 24 (29%) in group B1 vs 7 of 11 (64%) in group B2 (difference not significant). Those patients with an absolute CD4 lymphocyte count less than or equal to 100/mm3 had a higher prevalence of echocardiographic abnormalities (12 of 22) than those with CD4 counts greater than 100/mm3 (1 of 14, p less than 0.01). Left ventricular dilation or hypokinesis was identified in 14 of 60 patients (23%), including 4 of 25 (16%) in group A and 10 of 35 (29%) in group B. Electrocardiographic abnormalities were seen in 22 of 50 patients (44%) including 5 of 18 (28%) in group A and 17 of 32 (53%) in group B (difference not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Corneal ulcers in house staff: are risk factors identifiable?

Thirty-six incoming house officers and 20 incoming third-year medical students had conjunctival cultures taken before and after hospital exposure. The groups were divided evenly between contact-lens and noncontact-lens wearers. A decrease in incidence of positive conjunctival cultures was observed after hospital exposure. Within this group, a lower incidence of positive cultures was observed in contact-lens wearers compared with noncontact-lens wearers. The clinical records of corneal ulcer patients during a three-year period from October 1982 through October 1985 were also reviewed. Significant associated risk factors were identified, the largest of which was contact-lens wear.

Candida vertebral osteomyelitis: report of three cases and a review of the literature

We have recently treated three patients with Candida vertebral osteomyelitis. In each patient there was at least one characteristic prodromal condition, including trauma, multiple antibiotics following bowel surgery, and acute nonlymphocytic leukemia. All patients were treated successfully with amphotericin B. Based on our findings and a review of the literature, we would recommend a 1.0-1.2 gm total dosage of amphotericin B. Alternative therapeutic choices such as 5FC and/or ketoconazole, under specific clinical conditions, have been successfully employed. However, cure can best be confirmed by post-treatment biopsy.

In vitro effects of thymosin and lithium on lymphoproliferative responses of normal donors and HIV seropositive male homosexuals with AIDS-related complex

The in vitro effects of thymosin fraction 5 (TF5) and lithium chloride (LiCl) on the ability of peripheral blood mononuclear cells (PBMC) obtained from 37 normal male donors and 33 male patients with AIDS-related complex (ARC) to respond to alloantigenic stimulation (mixed leukocyte reaction, MLR) and to produce interleukin 2 (IL-2) in response to mitogens were studied. TF5 significantly increased MLR responses in normal donors (P less than 0.01) and in a group of 33 ARC patients with depressed cellular immunity (P less than 0.05). Similar effects were observed when LiCl was added to the MLR assays in both the normal and the ARC patient groups. Furthermore, TF5 and LiCl exhibited additive immunoenhancing properties. In 10 normal donors TF5 enhanced phytohemaggutinin (PHA)-induced IL-2 production as well as IL-2 production in response to pokeweed mitogen (PWM) (P less than 0.02). TF5-mediated enhancement of IL-2 production by PBMC obtained from ARC patients was observed in response to both mitogens, i.e., PHA and PWM. Additionally, LiCl increased PHA-induced IL-2 production in both normal subjects and ARC patients. LiCl and TF5 together had an additive effect in the enhancement of IL-2 production in both groups of subjects. Our data extend previous observations regarding the immunoregulatory activities of TF5 and LiCl and provide evidence that PBMC obtained from ARC patients have the potential to respond in vitro to these agents. The significance of these findings is discussed.

Clinical, immunological, and virological effects of ampligen, a mismatched double-stranded RNA, in patients with AIDS or AIDS-related complex

10 patients with the acquired immunodeficiency syndrome (AIDS), AIDS-related complex (ARC), or lymphadenopathy syndrome (LAS) were given 200-250 mg ampligen, a mismatched double-stranded (ds) RNA with in-vitro antiviral activity against human immunodeficiency virus (HIV), twice a week for up to 18 weeks, without side-effects or toxicity. In all 9 patients who were positive for HIV RNA in peripheral blood mononuclear cells before therapy, levels became undetectable between days 10 and 40 of the start of therapy. 6 of the 7 patients with ARC or LAS also showed a progressive reduction in HIV load as measured by co-culture assays. All 10 patients had augmentation of delayed-type hypersensitivity skin reactions. Other changes noted during ampligen therapy included an increase in or maintenance of numbers of helper-inducer T lymphocytes, improvements in HIV-related symptoms, rises in titre of neutralising antibodies against HIV, and restoration of proper functioning of the natural lymphocyte antiviral dsRNA-dependent (2'-5'-oligoadenylate/RNA-ase L) pathway. Thus, in the short term, ampligen seems to have the dual ability to restore immunological function and to control HIV replication.

Intracranial tuberculosis due to Mycobacterium bovis

A case of intracranial tuberculosis due to Mycobacterium bovis is presented. Computed tomography (CT) identified multiple enhancing lesions which by biopsy proved to be intracranial tuberculomas. The CT appearance, epidemiology and bacteriology as well as pharmacotherapy of this uncommon entity are discussed.

Phase I/II trial of thymosin fraction 5 and thymosin alpha one in HTLV-III seropositive subjects

Forty-two male homosexuals and/or hemophiliacs with depressed helper/suppressor T-cell ratios were treated with one of three different doses of thymosin fraction 5 (TF5, 30, 60, and 120 mg), or a single dose of thymosin Alpha One (TA1, 600 micrograms), by daily subcutaneous (SQ) administration for 10 weeks, followed twice weekly for 4 weeks. No major toxicity was noted for any of the preparations tested, although three subjects treated with TF5 had to discontinue therapy because of severe local skin reactions. Of the doses and preparations tested, only 60 mg TF5 was capable of significantly improving (p less than 0.02) mean T-cell lymphoproliferative responses to alloantigens (MLR) for six HTLV-III seropositive subjects who were abnormal prior to therapy. Peripheral blood lymphocytes from subjects treated with 60 mg TF5 also exhibited a transient restoration of mean mitogen-induced interleukin-2 (IL-2) production to normal. No effects were observed with any of the four treatment regimens on absolute helper T-cell numbers, NK activity, antibody titers to HTLV-III, or in the expression of a variety of surrogate markers for acquired immunodeficiency syndrome (AIDS). Four of the six seropositive subjects treated with 60 mg TF5 exhibited a return to depressed baseline MLR, after switching to twice weekly injections. With a median follow-up time of 20 months, six cases of AIDS developed. However, none of the five subjects whose MLR improved following treatment progressed to AIDS. We recommend daily subcutaneous (SQ) administration of 60 mg (40 mg/m2) TF5 for use in combined modality trials, along with drugs capable of suppressing replication of HTLV-III.

Subacute pulmonary mucormycosis

This report describes two patients with subacute pulmonary mucormycosis who died of pulmonary hemorrhage. Both patients had diabetes mellitus, but neither patient had the typical fulminant illness associated with this infection. The subacute progressive illness seen in these patients is unusual and suggests the need for aggressive diagnostic and therapeutic measures in patients who are at risk for this infection.

Treatment of HTLV-III/LAV-infected patients with D-penicillamine

13 asymptomatic, HTLV-III/LAV-infected male homosexuals with generalized lymphadenopathy were treated with oral D-penicillamine. All patients had depressed T4/T8 ratios and 12 had impaired T-cell function. An escalating dose schedule was employed over 2-6 weeks with doses from 0.5 to 2 g/day. Generalized skin rashes developed in 4 patients which required discontinuation of therapy in one patient. Two patients developed mild transient elevations of hepatocellular enzymes. Reversible decreases in lymph node size, absolute lymphocyte counts, and T-cell lymphoproliferative responses were observed in the majority of patients without change in baseline T4/T8 ratios. All 10 patients treated for at least 2 weeks exhibited evidence for suppression of HTLV-III/LAV replication; complete inhibition of virus expression was seen in 60% of patients treated for 6 weeks. Three of the patients treated for 6 weeks remained culture negative for at least 6 weeks after stopping the drug. D-Penicillamine appears to be an effective drug for suppressing HTLV-III/LAV expression in vivo. Its potential role in the treatment of patients with the acquired immune deficiency syndrome (AIDS) and AIDS-related complex (ARC) will require further evaluation.

The human intestinal microflora

The major host defense mechanisms against bacterial overgrowth in the small bowel are the normal propulsive activity of the bowel itself and gastric acid secretion. Microbial interactions are a major factor in regulating the indigenous bacterial flora. Studies of the bacterial enzymes of the gut suggest that changes in diet may lead to marked changes in the colonic flora. Antibiotics affect the composition of the colonic microflora. The microflora also influence the degradation of mucin, the conversion of urobilin to urobilinogen, of cholesterol to coprostanol, and the production of short chain fatty acids. Current interests are focused on the bacterial flora of tropical sprue, the role of bacteria in colorectal cancer, and the involvement of intestinal microflora in the enterohepatic circulation of sex steroid hormones.

Treatment of silastic catheter-induced central vein septic thrombophlebitis

Two patients with surgically implanted right atrial silastic catheters for home hyperalimentation developed central vein septic thrombophlebitis. Initial treatment including removal of the catheter and antibiotic therapy was unsuccessful and both patients had persistent fever and bacteremia. A clinical and microbiologic response occurred when anticoagulation therapy with heparin was added to the treatment regimen. Although a surgical approach has been emphasized in patients with peripheral vein suppurative thrombophlebitis, anticoagulation therapy may be a useful alternative in the treatment of patients with central vein infection.

Hemophilus influenzae septic arthritis in adults. A report of four cases and a review of the literature

The clinical and diagnostic features of 29 adult patients with H. influenzae septic arthritis are reviewed. Twelve men and 17 women ranging in age from 22 to 82 years developed the infection. H. influenzae septic arthritis is an acute, febrile disease with a mean duration of symptoms before diagnosis of 4 days. Fifteen patients had monoarticular arthritis, 6 with an infected knee. Polyarticular involvement, with a range of 2 to 9 joints, was diagnosed in 14 patients. Nineteen patients had concurrent extraarticular sites of infection, including meningitis, pneumonia, pharyngitis, sinusitis, conjunctivitis, and cellulitis. Twenty-two of 29 patients had predisposing factors for infection, including ethanolism, trauma, rheumatoid arthritis, systemic lupus erythematosus, diabetes mellitus, splenectomy, multiple myeloma, lymphoma, gout, and acquired common variable hypogammaglobulinemia. Characteristic synovial fluid findings included purulent, greenish fluid, elevated WBC count, and gram-negative pleomorphic microorganisms. Treatment for these patients included antibiotic therapy, most often ampicillin and chloramphenicol, and joint drainage by repeated arthrocentesis or arthrotomy. A favorable outcome was reported in 25 of 29 patients. Hemophilus influenzae septic arthritis should be suspected in adults who are immunocompromised and have a concurrent extraarticular source of infection.

Peptococcaceae bacteremia

Bacteremia with Peptococcaceae is an uncommon clinical manifestation of infection with this family of microorganisms. A 20-month review of 12 patients with bacteremic infections due to anaerobic gram-positive cocci revealed that obstetrical patients during the peripartum period constitute the group at greatest risk for the development of such infections. Eight of the 12 patients were young women hospitalized on the obstetrical service. Seven patients had postpartum endometritis and one patient had chorioamnionitis. The remaining four patients include a single patient each with pylephlebitis and microabscesses of the liver, ascending cholangitis, thoracic empyema, and necrotizing soft-tissue infection. Bacteriologic identification of the microorganisms revealed the following: Peptostreptococcus micros (5 patients), Peptostreptococcus asaccharolyticus (5 patients), Peptostreptococcus magnus (1 patient), and Peptococcus species (1 patient). Eleven of the 12 patients received appropriate antibiotic therapy. All patients did well and there were no major sequelae.

Experimental Bacteroides fragilis bacteremia in a primate model: evidence that Bacteroides fragilis does not promote the septic shock syndrome

Experimental Bacteroides fragilis bacteremia was studied in subhuman primates. Following intravenous infusion of viable B. fragilis there was an exponential clearance of organisms from the bloodstream. The major clearance organ was the liver, which accumulated 68.2% of the total inoculum. The most efficient clearance was exhibited by the spleen, with uptake of 1.16% gm tissue. Hemodynamic studies revealed no significant changes in heart rate, mean arterial pressure, or cardiac output following B. fragilis infusion. Complement activity as measured by CH50, alternative pathway hemolytic activity, granulocyte aggregometry, C4, C3, properdin, and Factor B levels were similarly unaffected by infusion of B. fragilis. In contrast, profound hemodynamic changes and a consistent decrease in complement activity was noted after challenge with S. minnesota. The results of this study suggest that B. fragilis bacteremia has a minor role in producing the acute hemodynamic changes associated with the septic shock syndrome.

Utility of gallium67 scintigraphy and bronchial washings in the diagnosis and treatment of Pneumocystis carinii pneumonia in patients with the acquired immune deficiency syndrome

Twenty patients with the acquired immune deficiency syndrome (AIDS) and suspected Pneumocystis carinii pneumonia were evaluated by gallium67 (Ga67 scintigraphy and fiberoptic bronchoscopy for initial diagnosis and response to therapy. Lung uptake of Ga67 was demonstrated in 100% of AIDS patients with P. carinii pneumonia, including those with subclinical infection. Fiberoptic bronchoscopy identified P. carinii in the bronchial washings of 100% of cases (19 patients), whereas only 13 of 16 (81%) patients had P. carinii in lung tissue obtained by transbronchial biopsy. Repeat fiberoptic bronchoscopy was performed in 16 of 20 patients. After 2 to 4 wk of therapy, P. carinii was identified in bronchial washings in 8 of 16 (50%) patients and in transbronchial biopsy in 1 of 10 (10%) patients examined. Bronchial washing has a higher yield than transbronchial biopsy in demonstrating P. carinii in patients with AIDS and may evolve as the procedure of choice in such patients. Based on the clinical course and results of Ga67 scintigraphy and fiberoptic bronchoscopy in AIDS patients with P. carinii pneumonia, optimal therapy may require at least 3 wk of treatment.

Ultrastructural markers in circulating lymphocytes of subjects at risk for AIDS

One hundred random lymphocytes in each of 168 buffy coat preparations from 59 subjects at risk for AIDS (50 homosexuals, 7 hemophiliacs, and 2 combined, all with T4:T8 ratios of less than or equal to 1.2) were screened for the presence of ultrastructural markers, "tubuloreticular structures" (TRS), and "test tube and ring-shaped forms" (TRF). Twenty-six (44%) of the subjects were TRS positive (71 specimens) and 12 (20%) were TRS/TRF positive (34 specimens). TRF were only observed in TRS-positive specimens. There was an inverse relationship between the incidence and abundance of markers and the T4:T8 ratios, i.e., mean T4:T8 +/- SE for TRS-negative, TRS-positive, and TRS/TRF-positive subjects were 0.59 +/- 0.05, 0.42 +/- 0.05, and 0.19 +/- 0.06, respectively. Markers were present for as long as 16 months before AIDS was diagnosed in four subjects and before the appearance of features suggestive of AIDS in two others. The assessment of TEM markers in peripheral blood lymphocytes is a simple method for screening at-risk subjects in whom AIDS is likely to develop.

Paranasal sinus mucormycosis in an immunologically competent host

A case of paranasal sinus mucormycosis in an immunocompetent patient is reported. After an extensive evaluation, no evidence of either diabetes mellitus or underlying immunologic abnormality was found. The combination of excisional surgery and amphotericin B therapy resulted in an excellent response. High-resolution axial and coronal computed tomography was useful in both planning treatment and monitoring the response to therapy.

Septic phlebitis caused by Candida albicans and diagnosed by needle aspiration

We have described a patient who had Candida albicans suppurative thrombophlebitis at the site of an indwelling intravenous catheter. The microbial etiology was established by needle aspiration of the venipuncture site, affording rapid and accurate identification of the infecting organism and providing prompt institution of therapy. Phlebectomy and a brief course of amphotericin B prevented further dissemination of the infection.

Diagnosis of intra-abdominal abscesses. A review

Intra-abdominal abscess, resulting either from primary intraperitoneal disease or as a complication of surgery, remains a serious problem with high patient mortality if not treated early and adequately. The initial attempt at diagnosis rests on strong clinical evidence supported by nonspecific laboratory findings. The most helpful advance over conventional x-ray studies has been the advent of noninvasive imaging techniques such as ultrasonography or computed tomography. Radioisotopic scanning with gallium or indium makes possible a generalized survey of the peritoneal cavity, but only after a delay from the time of injection. Ultrasonography is somewhat limited in utility, particularly in the left subphrenic space, and CT scanning remains the technique with highest resolution. These noninvasive imaging techniques also have the potential for directed percutaneous catheter drainage.

Listeria monocytogenes sepsis and small cell carcinoma of the rectum: an unusual presentation of the acquired immunodeficiency syndrome

A 26-year-old male homosexual initially presented with Listeria monocytogenes sepsis and a small cell carcinoma of the rectum. His subsequent course included esophageal candidiasis, Pneumocystis carinii pneumonia, and severe T-lymphocyte abnormalities on immunologic testing, consistent with the acquired immunodeficiency syndrome (AIDS). This represents the first case of AIDS associated with this unusual tumor and Listeria infection.

Disseminated talc granulomatosis. An unusual finding in a patient with acquired immunodeficiency syndrome and fatal cytomegalovirus infection

The association of disseminated magnesium silicate talc granulomatosis and acquired immunodeficiency syndrome is reported in a male homosexual who used intravenous drugs and who died of overwhelming cytomegalovirus (CMV) infection. Autopsy findings included widespread deposition of talc crystals in the lungs, liver, lymph nodes, bone marrow, and spleen. Typical CMV inclusions were seen in the lungs, kidneys, adrenal glands, gastrointestinal tract, and right eye. There was no evidence of malignancy. Analysis of peripheral blood neutrophil function revealed impaired chemotaxis and chemokinesis, but opsonophagocytosis had remained normal. The CMV infection in the small bowel was extensive and resulted in severe destruction of the muscularis propria and neural plexi, leading to marked dilatation and persistent diarrhea. The terminal course was marked by intractable hypotension, pneumonitis, and malnutrition, which could be attributed respectively to CMV involvement of the adrenal glands, lungs, and small bowel. The etiology and possible role of systemic talc granulomatosis in the development of immunosuppressive illness is reported herein.

Adverse reactions to trimethoprim-sulfamethoxazole in patients with the acquired immunodeficiency syndrome

We reviewed the charts of 38 patients with the acquired immunodeficiency syndrome who were treated for Pneumocystis carinii pneumonia. Only 5 of 37 patients started on trimethoprim-sulfamethoxazole were able to complete treatment; in 29 patients drug toxicity occurred and in 19 treatment was changed due to adverse reactions that included rash, fever, neutropenia, thrombocytopenia, and transaminase elevation. Pentamidine was given to 30 patients (1 as initial treatment); toxicity occurred in 13 but only 4 required a change in drug. Adverse reactions from pentamidine included fever, rash, neutropenia, transaminase elevation, azotemia, and hypoglycemia. Patients received trimethoprim-sulfamethoxazole a median of 9.5 days, and pentamidine, a median of 12.5 days. Toxicity from trimethoprim-sulfamethoxazole appeared earlier than toxicity associated with pentamidine (7.5 versus 9.5 days of treatment). In patients with the acquired immunodeficiency syndrome, trimethoprim-sulfamethoxazole has a higher incidence of adverse reactions than pentamidine (p less than 0.005).

Penetration of clindamycin into experimental Staphylococcus aureus infections

Inactivation of clindamycin at the site of experimental infection with Staphylococcus aureus was studied using rabbits with plastic capsules implanted in the peritoneal cavity. The mean percentage penetration of bioactive clindamycin (concentration in capsule divided by simultaneous concentration in serum times 100) into infected and noninfected capsules was 30.4 per cent and 13.0 per cent, respectively. In contrast, the mean penetration of radiolabeled clindamycin into infected capsules was 38.4 per cent. These findings indicate that the observed loss of bioactivity in infected capsules is due to intracapsular inactivation of clindamycin and not to an alteration in capsular permeability. Biologic inactivation of clindamycin was not evident after in vitro incubation of the drug with Staphylococcus aureus. These results suggest that the observed loss of bioactivity may be due to chemical modification by enzymes in the inflammatory exudate or to binding of the antibiotic to tissue components.

Candida albicans meningitis in a parenteral drug abuser

We have described a patient with meningitis due to Candida albicans, in whom the only identifiable risk factor was a history of intravenous amphetamine abuse. Despite intravenous therapy with 2 gm of amphotericin B and concurrent 5-fluorocytosine, symptoms, CSF pleocytosis, and hypoglycorrhachia persisted. After a brief course of intrathecal amphotericin B therapy, the patient improved clinically and the CSF returned to normal.

A comparative study of surgical skin preparation methods

Analysis of a randomized study of preoperative skin preparation techniques in thoracic and general surgical patients revealed that the use of a one minute alcohol cleansing and application of an antimicrobial film provides equivalent bactericidal activity to a five minute iodophor scrub and paint. Initial bacterial kill is greater with a one minute alcohol cleansing than a five minute iodophor scrub. There were fewer patients with high bacterial counts at the time of closure in the groups treated with the antimicrobial film than in the traditional iodophor scrub group. Saving in preoperative operating room time can be achieved using a one minute alcohol cleansing plus application of an antimicrobial film with equal antibacterial efficacy to that of conventional methods.

Paratyphoid orchitis

A case of pyogenic orchitis due to infection with Salmonella enteritidis ser. Paratyphi B is discussed. Unlike previously reported cases of Salmonella orchitis, this patient developed infection by bacteremic spread and not by direct extension from the epididymis. Therapy with chloramphenicol resulted in an excellent clinical response.

Synovial fluid inhibits killing of Staphylococcus aureus by neutrophils

Serum in the extracellular environment promotes neutrophil bactericidal activity apart from its opsonizing properties. We examined the effect of non-inflammatory osteoarthritic synovial fluid on serum-mediated neutrophil killing of Staphylococcus aureus. This was done to evaluate the effect of synovial fluid on neutrophil bactericidal activity independent of opsonin concentration. With an initial inoculum of 5 X 10(6) CFU/ml, 1.47 +/- 0.14% bacteria survived after 120 min of incubation with 10% serum and neutrophils. In contrast, 4.07 +/- 0.33% bacteria survived after incubation in serum plus synovial fluid (P less than 0.001). This inhibitory effect was directly related to the concentration of synovial fluid in the incubation mixture. Increasing the concentration of synovial fluid resulted in an increased percent survival. Studies utilizing preopsonized bacteria and radiolabeled organisms demonstrated that synovial fluid did not interfere with opsonization or phagocytosis. Intracellular bactericidal activity was assayed separately from phagocytosis by utilizing a brief ingestion period followed by the removal of extracellular bacteria by either differential centrifugation or lysostaphin treatment. The reincubation of cells and associated bacteria with serum or serum plus synovial fluid revealed that synovial fluid significantly inhibited the promoting effect of serum on neutrophil bactericidal activity. After 60 min of incubation with 10% serum, 13.0 +/- 1.2% bacteria survived, whereas 21.5 +/- 2.3% survived after incubation in serum plus synovial fluid (P less than 0.005). Superoxide production was not affected by the presence of synovial fluid. These findings suggest that the inhibitory effect of synovial fluid is due to an interaction between synovial fluid and the serum factors that promote intracellular killing.