Prosthetic valve endocarditis due to coagulase-negative staphylococci: findings from the International Collaboration on Endocarditis Merged Database

Infective endocarditis due to coagulase-negative staphylococci is increasingly recognized as a difficult-to-treat disease associated with poor outcome. The aim of this report is to describe the characteristics and outcome of patients with prosthetic valve endocarditis (PVE) due to coagulase-negative staphylococci versus those of patients with PVE due to Staphylococcus aureus and viridans streptococci. Patients were identified through the International Collaboration on Endocarditis Merged Database. A total of 54 cases of coagulase-negative staphylococci PVE, 58 cases of S. aureus PVE, and 63 cases of viridans-streptococci-related PVE were available for analysis. There was no difference between the three groups with respect to the type of valve involved or the rate of embolization. However, heart failure was encountered more frequently with coagulase-negative staphylococci (54%) than with either S. aureus (33%; p=0.03) or viridans streptococci (32%; p=0.02). In addition, valvular abscesses complicated 39% of infections due to coagulase-negative staphylococci compared with 22% of those due to S. aureus (p=0.06) and 6% of those due to viridans streptococci (p<0.001). Mortality was highest in patients with S. aureus and coagulase-negative staphylococcal endocarditis (47 and 36%, respectively; p=0.22) and was considerably lower in patients with viridans streptococcal endocarditis (p=0.002 compared to patients with coagulase-negative staphylococcal endocarditis). The results of this analysis demonstrate the aggressive nature of coagulase-negative staphylococcal PVE and the substantially greater morbidity and mortality associated with this infection compared to PVE caused by other pathogens.

Diagnostic strategy in cancer patients with acute respiratory failure

OBJECTIVE

Nearly 15% of cancer patients experience acute respiratory failure (ARF) requiring admission to the intensive care unit, where their mortality is about 50%. This review focuses on ARF in cancer patients. The most recent literature is reviewed, and emphasis is placed on current controversies, most notably the risk/benefit ratio of fiberoptic bronchoscopy and BAL in patients with severe hypoxemia.

BACKGROUND

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is the cornerstone of the causal diagnosis. However, the low diagnostic yield of about 50%, related to the widespread use of broad-spectrum antimicrobial therapy in cancer patients, has generated interest in high-resolution computed tomography (HRCT) and primary surgical lung biopsy. In patients with hypoxemia, bronchoscopy and BAL may trigger a need for invasive mechanical ventilation, thus considerably decreasing the chances of survival.

DISCUSSION

The place for recently developed, effective, noninvasive diagnostic tools (tests on sputum, blood, urine, and nasopharyngeal aspirates) needs to be determined. The prognosis is not markedly influenced by cancer characteristics; it is determined chiefly by the cause of ARF, need for mechanical ventilation, and presence of other organ failures. Although noninvasive ventilation reduces the need for endotracheal intubation and diminishes mortality rate, its prolonged use in patients with severe disease may preclude optimal diagnostic and therapeutic management. The appropriateness of switching to endotracheal mechanical ventilation in patients who fail noninvasive ventilation warrants evaluation.

CONCLUSION

This review discusses risks and benefits from invasive and non invasive diagnostic and therapeutic strategies in critically ill cancer patients with acute respiratory failure. Avenues for research are also suggested in order to improve survival in these very high risk patients.

Successful treatment of Candida parapsilosis mural endocarditis with combined caspofungin and voriconazole

Background

Fungal mural endocarditis is a rare entity in which the antemortem diagnosis is seldom made. Seven cases of mural endocarditis caused by Candida spp. have been collected from literature and six of these patients died after treatment with amphotericin B.

Case presentation

We report a case of mural endocarditis diagnosed by transesophageal echocardiogram and positive blood cultures to Candida parapsilosis. Because blood cultures continued to yield C. parapsilosis despite caspofungin monotherapy, treatment with voriconazole was added.

Conclusion

This is the first description of successful treatment of C. parapsilosis mural endocarditis with caspofungin and voriconazole.

Improved survival for HIV infected patients with severe Pneumocystis jirovecii pneumonia is independent of highly active antiretroviral therapy

BACKGROUND

Despite a decline in incidence of Pneumocystis jirovecii pneumonia (PCP), severe PCP continues to be a common cause of admission to the intensive care unit (ICU) where mortality remains high. A study was undertaken to examine the outcome from intensive care for patients with PCP and to identify prognostic factors.

METHODS

A retrospective cohort study was conducted of HIV infected adults admitted to a university affiliated hospital ICU between November 1990 and October 2005. Case note review collected information on demographic variables, use of prophylaxis and highly active antiretroviral therapy (HAART), and hospital course. The main outcome was 1 month mortality, either on the ICU or in hospital.

RESULTS

Fifty nine patients were admitted to the ICU on 60 occasions. Thirty four patients (57%) required mechanical ventilation. Overall mortality was 53%. No patient received HAART before or during ICU admission. Multivariate analysis showed that the factors associated with mortality were the year of diagnosis (before mid 1996 (mortality 71%) compared with later (mortality 34%; p = 0.008)), age (p = 0.016), and the need for mechanical ventilation and/or development of pneumothorax (p = 0.031). Mortality was not associated with sex, ethnicity, prior receipt of sulpha prophylaxis, haemoglobin, serum albumin, CD4 count, PaO2, A-aO2 gradient, co-pathology in bronchoscopic lavage fluid, medical co-morbidity, APACHE II score, or duration of mechanical ventilation.

CONCLUSIONS

Observed improved outcomes from severe PCP for patients admitted to the ICU occurred in the absence of intervention with HAART and probably reflect general improvements in ICU management of respiratory failure and ARDS rather than improvements in the management of PCP.

Endocarditis and pericarditis complicating pneumococcal bacteraemia, with special reference to the adhesive abilities of pneumococci: results from a prospective study

The incidence of pneumococcal cardiac infections is unknown and the pathogenicity of such complications is poorly understood. In a prospective, international, observational study, eight of 844 patients hospitalised with Streptococcus pneumoniae bacteraemia developed endocarditis (n = 5) or pericarditis (n = 3). The clinical and microbiological characteristics of these patients were compared with those of control patients. The corresponding incidence of pneumococcal endocarditis was c. 1-3/1 million inhabitants/year. There was no common pattern in the medical history of patients with an infectious cardiac complication. The severity of illness upon admission was comparable with that for patients without infectious cardiac complications, as was the 14-day mortality rate (25% and 17%, respectively). For encapsulated S. pneumoniae, no significant differences were found between patients with infectious cardiac complications and controls in adherence assays. However, non-encapsulated S. pneumoniae showed higher hydrophobicity and increased adherence to human epithelial cells.

Austrian syndrome: Report of two new cases and literature review

In April 2004, Rammeloo et al. reported a child-aortic-valve endocarditis following pneumococcal meningitis. Classically, the association of pneumococcal pneumonia along with meningitis and infectious endocarditis (IE) is known as Austrian syndrome. We assessed the incidence, clinical manifestations and follow-up of patients diagnosed with Austrian syndrome in Lugo (Northwest Spain) between 1987 and 2002. A computerized MEDLINE search was also performed for literature review. During the study period 165 Lugo patients met criteria for definite IE. Two of the 3 patients with definite streptococcus pneumoniae IE also met definitions for Austrian syndrome. The incidence of this syndrome in Lugo patients with definite IE was 1.2%. In the literature review 48 cases, including our two patients, were found. Complete clinical information was only available on 16 patients. Alcoholism constituted the most common predisposing factor. Aortic valve involvement and high grade of valve regurgitation leading to cardiac failure and the need of cardiac surgery during the admission were common in these patients. This review confirms that Austrian syndrome is a rare but severe disease. Early recognition of these patients is required to avoid ominous complications.

Adverse reactions to first-line antituberculosis drugs

INTRODUCTION

Tuberculosis continues to be a major cause of morbidity and mortality worldwide. Currently available drugs are effective for treatment of the disease or latent infection, but may cause serious adverse effects.

METHODS

The authors reviewed the literature for side effects of five first-line antituberculous medications (isoniazid, rifampin, pyrazinamide, ethambutol and streptomycin). Incidence of the major side effects were compiled with particular attention to the incidence of isoniazid hepatotoxicity.

RESULTS

Hepatotoxicity to isoniazid is a serious problem. Although overall incidence may be decreasing, incidence averaged 9.2 per 1000 patients who were compliant, in multiple studies, with a case fatality rate of 4.7%. The incidence is higher with increasing age. Other serious adverse effects include dermatological, gastrointestinal, hypersensitivity, neurological, haematological and renal reactions. They can lead to drug discontinuation (in up to 10% of patients) or even more serious morbidity or mortality.

CONCLUSIONS

Side effects to antituberculosis drugs are common, and include hepatitis, cutaneous reactions, gastrointestinal intolerance, haematological reactions and renal failure. These adverse effects must be recognised early, to reduce associated morbidity and mortality.

Culture-positive and culture-negative endocarditis in patients with cancer: a retrospective observational study, 1994-2004

Endocarditis is uncommon in patients with cancer. The characteristics of culture-positive (CPE) and culture-negative endocarditis (CNE) in high-risk cancer patients are not known; therefore we sought to evaluate the disease characteristics in patients with endocarditis at a comprehensive cancer center. We retrospectively reviewed the transthoracic (TTE) and transesophageal (TEE) echocardiograms obtained from 654 consecutive cancer patients in whom endocarditis was suspected between 1994 and 2004. Endocarditis was confirmed in 45 (7%) of 654 patients using modified Duke University criteria based on information obtained from hospital records and computerized data systems. In 21 (95%) of 22 cases, TEE examinations were diagnostic, and 16 (42%) of 38 patients with initially nondiagnostic TTE studies had the diagnosis confirmed by TEE study; this difference between diagnostic TEE and initial nondiagnostic TTE was significant (p < 0.0001). Among the 26 (58%) patients with CPE, Staphylococcus aureus (35%) was the most common organism isolated, followed by coagulase-negative Staphylococcus species (23%). Eighteen (78%) of 23 patients with a central venous catheter had CPE, whereas only 8 (36%) of 22 patients without a central venous catheter had CPE (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.69-23.53; p < 0.006). Vegetations were larger in patients with CPE than in patients with CNE (median +/- standard deviation, 10 +/- 8.8 vs. 8.7 +/- 3.9 mm). Fifteen patients (58%) with CPE and 10 (53%) with CNE had embolic complications. We note that cutaneous and septic pulmonary emboli were more common in patients with CPE than in patients with CNE (31% vs. 11% and 15% vs. 0%, respectively), whereas embolic cerebrovascular and fatal embolic coronary events were more common in patients with CNE than in those with CPE (37% vs. 12% and 21% vs. 0%, respectively; p = 0.026). The 4-week endocarditis-attributable death rate did not differ significantly between the groups (CPE, 15% vs. CNE, 32%; p = 0.28). On stepwise multivariate regression analysis, patients with neutropenia (OR, 22.52; 95% CI, 2.25-225.48; p < 0.008) and those with embolic cerebrovascular events (OR, 17.07; 95% CI, 1.63-178.45; p < 0.01) had an increased probability of death due to endocarditis. The clinical spectrums of CPE and CNE differed in these patients with cancer. In patients with CNE, embolic cerebrovascular and fatal myocardial infarction were relatively common.

Acute lung infections in normal and immunocompromised hosts

Pulmonary infections are among the most common causes of morbidity and mortality worldwide, and contribute substantially to annual medical expenditures in the United States. Despite the availability of antimicrobial agents, pneumonia constitutes the sixth most common cause of death and the number one cause of death from infection. Pneumonia can be particularly life-threatening in the elderly, in individuals who have pre-existing heart and lung conditions, in patients who have suppressed or weakened immunity, and in pregnant women. This article discusses some of the important causes of acute lung infections in normal and immunocompromised hosts. Because there often is considerable overlap, infections are categorized by the host immune status that is most likely to be associated with a particular pathogen.

Reduced skeletal muscle inhibitor of kappaB beta content is associated with insulin resistance in subjects with type 2 diabetes: reversal by exercise training

Skeletal muscle insulin resistance plays a key role in the pathogenesis of type 2 diabetes. It recently has been hypothesized that excessive activity of the inhibitor of kappaB (IkappaB)/nuclear factor kappaB (NFkappaB) inflammatory pathway is a mechanism underlying skeletal muscle insulin resistance. However, it is not known whether IkappaB/NFkappaB signaling in muscle from subjects with type 2 diabetes is abnormal. We studied IkappaB/NFkappaB signaling in vastus lateralis muscle from six subjects with type 2 diabetes and eight matched control subjects. Muscle from type 2 diabetic subjects was characterized by a 60% decrease in IkappaB beta protein abundance, an indicator of increased activation of the IkappaB/NFkappaB pathway. IkappaB beta abundance directly correlated with insulin-mediated glucose disposal (Rd) during a hyperinsulinemic (40 mU x m(-2) x min(-1))-euglycemic clamp (r = 0.63, P = 0.01), indicating that increased IkappaB/NFkappaB pathway activity is associated with muscle insulin resistance. We also investigated whether reversal of this abnormality could be a mechanism by which training improves insulin sensitivity. In control subjects, 8 weeks of aerobic exercise training caused a 50% increase in both IkappaB alpha and IkappaB beta protein. In subjects with type 2 diabetes, training increased IkappaB alpha and IkappaB beta protein to levels comparable with that of control subjects, and these increments were accompanied by a 40% decrease in tumor necrosis factor alpha muscle content and a 37% increase in insulin-stimulated glucose disposal. In summary, subjects with type 2 diabetes have reduced IkappaB protein abundance in muscle, suggesting excessive activity of the IkappaB/NFkappaB pathway. Moreover, this abnormality is reversed by exercise training.

Microbiologic features and outcome of pneumonia in transplanted patients

We prospectively evaluated lower respiratory tract infections in solid organ transplantation (SOT) patients to determine the microbiologic diagnosis and clinical outcomes. We diagnosed 83 cases of pneumonia, 38 of which were community acquired and 45 were nosocomial. Those with bilateral infiltrates or absence of improvement after 3 days of treatment underwent fiberoptic bronchoscopy. Bacterial pneumonia was the most frequent diagnosis and mixed infection predominated in the nosocomial group (11/45 nosocomial versus 1/38 community). Fiberoptic bronchoscopy with bronchoalveolar lavage had higher diagnostic yield in nosocomial pneumonia (77% versus 47%). Mortality differences between the 2 groups were 58% nosocomial versus 8% community-acquired infections (P < 0.001). SOT patients with nosocomial pneumonia, or those who needed mechanical ventilation, had a high mortality rate and benefits from the fiberoptic diagnostic techniques.

Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America

BACKGROUND

Despite advances in medical, surgical, and critical care interventions, infective endocarditis remains a disease that is associated with considerable morbidity and mortality. The continuing evolution of antimicrobial resistance among common pathogens that cause infective endocarditis creates additional therapeutic issues for physicians to manage in this potentially life-threatening illness.

METHODS AND RESULTS

This work represents the third iteration of an infective endocarditis "treatment" document developed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease of the Young. It updates recommendations for diagnosis, treatment, and management of complications of infective endocarditis. A multidisciplinary committee of experts drafted this document to assist physicians in the evolving care of patients with infective endocarditis in the new millennium. This extensive document is accompanied by an executive summary that covers the key points of the diagnosis, antimicrobial therapy, and management of infective endocarditis. For the first time, an evidence-based scoring system that is used by the American College of Cardiology and the American Heart Association was applied to treatment recommendations. Tables also have been included that provide input on the use of echocardiography during diagnosis and treatment of infective endocarditis, evaluation and treatment of culture-negative endocarditis, and short-term and long-term management of patients during and after completion of antimicrobial treatment. To assist physicians who care for children, pediatric dosing was added to each treatment regimen.

CONCLUSIONS

The recommendations outlined in this update should assist physicians in all aspects of patient care in the diagnosis, medical and surgical treatment, and follow-up of infective endocarditis, as well as management of associated complications. Clinical variability and complexity in infective endocarditis, however, dictate that these guidelines be used to support and not supplant physician-directed decisions in individual patient management.

[Incidence and impact of HIV infection among patients with bacterial pleurisy in Lomé (Togo)]

A prospective study was made in the Tokoin university hospital in Lomé (Togo) to determine the incidence and the impact of HIV among patients with bacterial pleurisy. Two hundred cases of bacterial pleurisy were consecutively included over 17 months. The HIV diagnostic was performed using ELISA (Vironostika HIV Uni-Form II plus O and HIV1 and 2 Bispot Immunocomb II). The 200 cases of pleurisy included 152 (76%) tuberculous pleural effusion and 48 (24%) pleural empyema. Staphylococcus aureus (32%), Streptococcus pneumoniae (14.9%), and Pseudomonas (14.9%) were the main causes of pleural empyema. The HIV incidence was 61% (122/200). The mortality rate ranged from 26.2% in the HIV positive group to 5.1% in HIV negative group (P = 0.0001). The bacterial aspect of pleural empyema was heterogeneous in both groups but Salmonella Enteritidis and Salmonella Typhimurium were identified only among patients with HIV.

Current issues in critical care of the human immunodeficiency virus-infected patient

OBJECTIVE

To provide current information on the epidemiology of human immunodeficiency virus (HIV)-infected patients admitted to the intensive care unit during the era of combination antiretroviral therapy and to review issues related to the administration of antiretroviral therapy that are relevant to the intensivist.

DESIGN

Review of literature related to intensive care of HIV-infected patients.

RESULTS

Overall mortality of HIV-infected patients in the intensive care unit has decreased in the era of combination antiretroviral therapy, and patients are more commonly admitted with non-HIV-related illnesses. Use of antiretroviral therapy in the intensive care unit is difficult but may be associated with improved outcomes.

CONCLUSIONS

HIV-infected patients are less likely to be admitted to the intensive care unit with opportunistic infections but more likely to be admitted with problems unrelated to HIV infection or with conditions related to antiretroviral therapy. With current management strategies, more patients survive intensive care unit admission. Intensivists need to be familiar with antiretroviral therapy to recognize life-threatening toxicities unique to these drugs; to avoid drug interactions, which are extremely common and potentially life-threatening; and to avoid enhancing HIV drug resistance, an occurrence that could have devastating consequences for the patient following intensive care unit discharge.

Fever, Human Herpesvirus-6 (HHV-6) Seroconversion, and Acute Rejection Episodes as a Function of the Initial Seroprevalence for HHV-6 in Renal Transplant Recipients

Human herpesvirus-6 (HHV-6) is an opportunistic viral pathogen of emerging clinical significance in immunocompromised patients. We performed a seroepidemiological survey to test the relation between seroprevalence among donors and recipients for HHV-6 at three endpoints. Before transplantation sera obtained from cadaveric donors and from potential recipients were tested for IgG antibodies against HHV-6 using an enzyme-linked immunoassay. The group of recipient sera, including samples obtained before as well as 2, 4, 12, and 48 weeks after transplantation, were tested for anti-HHV-6 IgM antibodies using an indirect immunofluorescence assay. The statistical analysis was performed with the Cox proportional hazards models. The HHV-6 seronegative group (n = 11) compared with the HHV-6 seropositive group (n = 109) showed twice the risk of HHV-6 IgM seroconversion (RR = 2.24; P < .04), with a greater risk of fever, namely 3.8, which was on the verge of statistical significance. The opposite trend toward an association with acute rejection episodes was observed among HHV-6 seronegative patients (RR = 1.81). The presence of IgG antibody in the sera of donors to IgG seropositive recipients had no association with the occurrence of IgM seroconversion. In contrast, IgM antibodies to HHV-6 appeared in four of five seronegative patients who received allografts from IgG seropositive donors. These preliminary data suggest that the effects seem to be the consequence of HHV-6 transmission through a renal allograft.

Tuberculosis in children: an update

TB is a common and serious global infection that is spread exclusively from person to person. The initial infection in most healthy people leads to LTBI 95% of the time, but untreated individuals have a 5% to 10% lifetime risk for reactivating their infection to develop highly infectious cavitary pulmonary TB or extrapulmonary disease. Following primary infection progressive disease is more likely to develop in children younger than 5 years old or those who are immunocompromised, particularly those with HIV infection. The diagnosis of TB in most of the world depends on the presence of a clinical illness typical for TB in concert with radiographic changes, the presence of AFB in sputum, or a positive TST. Newer methods of in vitro stimulation of T lymphocytes from TB-infected people to produce interferon may be more accurate than a TST but have yet to be well studied in children. Treatment of children with LTBI is generally 9 months of daily isoniazid unless the child has been in contact with an adult with known isoniazid-resistant TB. For active TB, children generally are treated for 6 months with an initial 2 months of isoniazid, rifampin, and pyrazinamide. Where exposure to an isoniazid-resistant strain is likely, ethambutol is added. After 2 months, pyrazinamide is discontinued unless the patient has been confirmed to have been infected with a resistant strain of M. tuberculosis. BCG, rarely used in the United States, is still considered important to prevent meningitis and miliary disease in very young children in areas of the world with a high prevalence of TB.

Adenylate cyclase toxin (ACT) from Bordetella hinzii: characterization and differences from ACT of Bordetella pertussis

Bordetella hinzii is a commensal respiratory microorganism in poultry but is increasingly being recognized as an opportunistic pathogen in immunocompromised humans. Although associated with a variety of disease states, practically nothing is known about the mechanisms employed by this bacterium. In this study, we show by DNA sequencing and reverse transcription-PCR that both commensal and clinical strains of B. hinzii possess and transcriptionally express cyaA, the gene encoding adenylate cyclase toxin (ACT) in other pathogenic Bordetella species. By Western blotting, we also found that B. hinzii produces full-length ACT protein in quantities that are comparable to those made by B. pertussis. In contrast to B. pertussis ACT, however, ACT from B. hinzii is less extractable from whole bacteria, nonhemolytic, has a 50-fold reduction in adenylate cyclase activity, and is unable to elevate cyclic AMP levels in host macrophages (nontoxic). The decrease in enzymatic activity is attributable, at least in part, to a decreased binding affinity of B. hinzii ACT for calmodulin, the eukaryotic activator of B. pertussis ACT. In addition, we demonstrate that the lack of intoxication by B. hinzii ACT may be due to the absence of expression of cyaC, the gene encoding the accessory protein required for the acylation of B. pertussis ACT. These results demonstrate the expression of ACT by B. hinzii and represent the first characterization of a potential virulence factor of this organism.

Candida glabrata prosthetic valve endocarditis treated successfully with fluconazole plus caspofungin without surgery: a case report and literature review

Reported here is the case of a 72-year-old man who was diagnosed with Candida glabrata prosthetic mitral valve endocarditis and treated successfully with fluconazole plus caspofungin after he refused and was determined unfit for surgery. Initial treatment with intravenous amphotericin B resulted in acute renal impairment. Despite 8 days of intravenous fluconazole therapy, he remained fungemic. Caspofungin was added to the treatment regimen with subsequent sterilisation of blood culture. The patient was treated for 34 days with caspofungin and 41 days with fluconazole. He continued oral fluconazole after hospital discharge and remained well at follow-up 11 months later. The role of fluconazole and caspofungin in the treatment of Candida endocarditis is discussed.

Subcutaneous alternariosis

A case of subcutaneous alternariosis caused by Alternaria alternata is reported in a 52-year-old male who underwent kidney transplantation 1 year earlier. The infection manifested as a vegetating mass about 7 cm in diameter on the right forearm. Histological examination with Grocott staining and periodic acid-Schiff diastase revealed fungal spores and hyphae with chronic granulomatous inflammation. Biopsy fragments inoculated on Sabouraud-glucose agar with chloramphenicol produced colonies which were identified as Alternaria alternata on the basis of macroscopic and microscopic characters.

Resection of a Pulmonary Lesion After Liver Transplantation: Report of a Case

A 44-year-old Chinese-Indonesian man who underwent living-donor liver transplantation with a right liver graft presented 4 months later with a cough and fever. Chest X-ray showed a nodular shadow in the apex of the left lung, which was diagnosed as pulmonary tuberculosis. After 1 week of antituberculous chemotherapy, we performed a left upper lobectomy. Postoperative antituberculous chemotherapy, consisting of isoniazid (300 mg/day) and rifampin (450 mg/day), was continued for 4 months, and there has been no sign of recurrence for 1 year since the thoracotomy. This case supports the feasibility of surgery for localized pulmonary tuberculosis soon after transplantation.

[Infectious pulmonary complications in HIV-infected patients in the high by active antiretroviral therapy era in Spain]

Pulmonary complications in HIV-infected patients are at present a first-rate problem. They are the main cause of hospital admission of these patients in our country. Most HIV-patients have a pulmonary complication during the evolution of the infection. The main etiologic diagnosis is bacterial pneumonia, especially pneumococcal pneumonia; the second most frequent cause is Pneumocystis jiroveci (previously named P. carinii) pneumonia and the third cause is mycobacteriosis, particularly Mycobacterium tuberculosis. From early studies, important changes in the epidemiology of HIV-related pulmonary complications have occurred. General prescription of P. jiroveci primary prophylaxis is probably one of the main causes, and, more recently, the use of highly active antiretroviral therapy may also be an underlying explanation. In this review, epidemiology, diagnosis and outcome of HIV-related pulmonary complications in our country are update.

High-resolution computed tomography (HRCT) of lung infections in non-AIDS immunocompromised patients

Non-AIDS immunocompromised patients are susceptible to infections by a wide range of organisms. In the past several decades, advances in the treatment of cancer, organ transplantation, and immunosuppressive therapy have resulted in large numbers of patients who develop abnormalities in their immune system. Moreover, mildly impaired host immunity as it occurs in chronic debilitating illness, diabetes mellitus, malnutrition, alcoholism, advanced age, prolonged corticosteroid administration, and chronic obstructive lung disease have also been regarded as predisposing factors of pulmonary infections. Imaging plays a crucial role in the detection and management of patients with pulmonary infectious diseases. When pulmonary infection is suspected, knowledge of the varied radiographic manifestations will narrow the differential diagnosis, helping to direct additional diagnostic measures and serving as an ideal tool for follow-up examinations. Combination of pattern recognition with knowledge of the clinical setting is the best approach to pulmonary infection occurring in the immunocompromised patients.

The changing face of infective endocarditis

Infective endocarditis (IE) is an evolving disease with a persistently high mortality and morbidity, even in the modern era of advanced diagnostic imaging, improved antimicrobial chemotherapy, and potentially curative surgery. Despite these improvements in health care, the incidence of the disease has remained unchanged over the past two decades and may even be increasing. Chronic rheumatic heart disease is now an uncommon antecedent, whereas degenerative valve disease of the elderly, mitral valve prolapse, intravenous drug misuse, preceding valve replacement, and vascular instrumentation have become increasingly common, coinciding with an increase in staphylococcal infections and those caused by fastidious organisms. The current understanding of this difficult condition is reviewed and recent developments in medical and surgical management are updated.

Efficacy of beta-lactams against experimental pneumococcal endocarditis caused by strains with different susceptibilities to penicillin

OBJECTIVES

To compare the in vitro and in vivo activity of penicillin, cefotaxime and ceftriaxone, using three strains of Streptococcus pneumoniae with different susceptibilities to penicillin (MICs of 0.015, 0.25 and 2 mg/L, respectively).

METHODS

Time-kill curves and an experimental model of endocarditis in rabbits.

RESULTS

Penicillin was efficacious in clearing bacteria from vegetations and blood irrespective of whether infections were caused by penicillin-susceptible or penicillin-resistant strains (P < 0.01 with respect to control groups). The same efficacy was shown with cefotaxime and ceftriaxone. Comparing the results of the in vivo model with those obtained in time-kill curves, penicillin showed the best results.

CONCLUSIONS

These results confirm that penicillin is efficacious in the treatment of pneumococcal infections, including those produced by strains with MICs < or = 2 mg/L (with the exception of pneumococcal meningitis). These results also suggest that the breakpoints to define susceptibility and resistance of S. pneumoniae to penicillin must be reviewed, as has been done with amoxicillin and third-generation cephalosporins.

Detection of severe human metapneumovirus infection by real-time polymerase chain reaction and histopathological assessment

BackgroundInfections with common respiratory tract viruses can cause high mortality, especially in immunocompromised hosts, but the impact of human metapneumovirus (hMPV) in this setting was previously unknown

MethodsWe evaluated consecutive bronchoalveolar lavage and bronchial wash fluid samples from 688 patients—72% were immunocompromised and were predominantly lung transplant recipients—for hMPV by use of quantitative real-time polymerase chain reaction (PCR), and positive results were correlated with clinical outcome and results of viral cultures, in situ hybridization, and lung histopathological assessment

ResultsSix cases of hMPV infection were identified, and they had a similar frequency and occurred in a similar age range as other paramyxoviral infections. Four of 6 infections occurred in immunocompromised patients. Infection was confirmed by in situ hybridization for the viral nucleocapsid gene. Histopathological assessment of lung tissue samples showed acute and organizing injury, and smudge cell formation was distinct from findings in infections with other paramyxoviruses. Each patient with high titers of hMPV exhibited a complicated clinical course requiring prolonged hospitalization

ConclusionsOur results provide in situ evidence of hMPV infection in humans and suggest that hMPV is a cause of clinically severe lower respiratory tract infection that can be detected during bronchoscopy by use of real-time PCR and routine histopathological assessment

Cytarabine-induced lung injury: case report

We report the case of a 65-year-old male patient with acute myelogenous leukemia who developed severe respiratory failure after receiving cytarabine treatment. Chest radiograph showed bilateral alveolar infiltrates. He was intubated and underwent flexible bronchoscopy. An extensive diagnostic work-up revealed no evidence of infection. Steroids were added to empiric antibiotic treatment and the patient was successfully extubated in 5 days. Cytarabine-induced lung injury should be considered in the differential diagnosis of alveolar infiltrates in immunocompromised patients. If bronchoscopy fails to confirm an infectious cause, a short course of steroids must be tried, which probably leads to a favorable outcome.

Staphylococcus aureus native valve infective endocarditis: report of 566 episodes from the International Collaboration on Endocarditis Merged Database

BACKGROUND

Staphylococcus aureus native valve infective endocarditis (SA-NVIE) is not completely understood. The objective of this investigation was to describe the characteristics of a large, international cohort of patients with SA-NVIE.

METHODS

The International Collaboration on Endocarditis Merged Database (ICE-MD) is a combination of 7 existing electronic databases from 5 countries that contains data on 2212 cases of definite infective endocarditis (IE).

RESULTS

Of patients with native valve IE, 566 patients [corrected] had IE due to S. aureus, and 1074 patients had IE due to pathogens other than S. aureus (non-SA-NVIE). Patients with S. aureus IE were more likely to die (20% vs. 12%; P < .001), to experience an embolic event (61% [corrected] vs. 31%; P < .001), or to have a central nervous system event (21% [corrected] vs. 13%; P < .001) and were less likely to undergo surgery (26% vs. 39%; P < .001) than were patients with non-SA-NVIE. Multivariate analysis of prognostic factors of mortality identified age (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.7), periannular abscess (OR, 2.4; 95% CI, 1.0 [corrected] -5.6), heart failure (OR, 3.9; 95% CI, 2.3-6.7), and absence of surgical therapy (OR, 2.3; 95% CI, 1.3-4.2) as variables that were independently associated with mortality in patients with SA-NVIE. After adjusting for patient-, pathogen-, and treatment-specific characteristics by multivariate analysis, geographical region was also found to be associated with mortality in patients with SA-NVIE (P < .001).

CONCLUSIONS

S. aureus is an important and common cause of IE. The outcome of SA-NVIE is worse than that of non-SA-NVIE. Several clinical parameters are independently associated with mortality for patients with SA-NVIE. The clinical characteristics and outcome of SA-NVIE vary significantly by geographic region, although the reasons for such regional variations in outcomes of SA-NVIE are unknown and are probably multifactorial. A large, prospective, multinational cohort study of patients with IE is now under way to further investigate these observations.

Pneumonia associated with HIV infection

PURPOSE OF REVIEW

Pneumonia occurs commonly in HIV-infected patients and this review highlights some of the recent findings in the epidemiology, pathogenesis, clinical features, treatment and prevention of this condition.

RECENT FINDINGS

Pneumonia remains an important cause of morbidity and mortality in HIV-infected patients. A number of factors have been identified that increase the risk of pneumonia. Cigarette smoking increases the risk of lung colonization, as well acute pneumonia due to Pneumocystis jiroveci, and has been documented to produce significant depression of the phagocytic function of alveolar macrophages in HIV-infected patients, which may underlie this risk. Legionella pneumophila infections appear to be uncommon in HIV-infected patients, while pneumonia with Streptococcus pneumoniae continues to occur with regularity, including infections with antibiotic-resistant isolates. Pneumocystis pneumonia occurs with a low incidence in patients receiving HAART, once the CD4 count increases to over 200 microl. Studies of invasive pneumococcal infections (predominantly pneumonia) indicate that in critically ill cases, including HIV-seropositive patients, combination antibiotic therapy is associated with a lower mortality than monotherapy. The 23-polyvalent pneumococcal vaccine has been shown to reduce the risk of pneumococcal infection in HIV-infected adults receiving HAART, and a 9-valent conjugate pneumococcal vaccine has been shown to reduce the incidence of radiologically confirmed pneumonia in HIV-seropositive and HIV-seronegative children.

SUMMARY

Pneumonia remains an important condition in HIV-infected patients, but recent studies demonstrate that antibiotic prophylaxis, the introduction of HAART, recognition of specific risk factors, new antibiotic treatment strategies and effective vaccines should serve to decrease its impact.

Diffuse pulmonary infiltrates after bone marrow transplantation: the role of open lung biopsy

BACKGROUND

Diffuse pulmonary infiltrates is the major complication and cause of mortality after bone marrow transplantation. We analyzed the etiologies and prognostic factors in bone marrow recipients with diffuse pulmonary infiltrates and assessed the role of open lung biopsy in managing this complication.

METHODS

Medical records of patients with diffuse pulmonary infiltrates after bone marrow transplantation were reviewed. Possible prognostic factors were analyzed by multivariate logistic regression.

RESULTS

Sixty-eight (20%) of 341 bone marrow recipients had diffuse pulmonary infiltrates and 34 died. Thirty-five underwent open lung biopsy, resulting in therapeutic changes in 22 (63%) and clinical improvement in 16 (46%). The leading diagnoses were idiopathic interstitial pneumonitis (40%) and cytomegalovirus pneumonitis (20%). Cytomegalovirus pneumonitis caused radiographically observable interstitial infiltrates exclusively and was frequently associated with hepatitis. Idiopathic interstitial pneumonitis resulted in either diffuse ground-glass opacity or interstitial infiltrates. Three (9%) patients had miliary tuberculosis. Respiratory failure (p < 0.001) and acute graft-versus-host disease (p = 0.016) were the poor prognostic factors.

CONCLUSIONS

Among bone marrow recipients, we found diffuse pulmonary infiltrates in 20% and a mortality rate of 50%. Idiopathic interstitial pneumonitis and cytomegalovirus pneumonitis were the most common causes and should be suspected in patients with diffuse interstitial infiltrates. In endemic areas, miliary tuberculosis should be suspected in bone marrow recipients with diffuse reticulonodular lesions. Respiratory failure and acute graft-versus-host disease were poor prognostic factors. By establishing a correct diagnosis, open lung biopsy led to treatment changes in about two-thirds of these patients.

Viral infection in the renal transplant recipient

Viruses are among the most common causes of opportunistic infection after transplantation and the most important. The risk for viral infection is a function of the specific virus encountered, the intensity of immune suppression used to prevent graft rejection, and other host factors governing susceptibility. Viral infection, both symptomatic and asymptomatic, causes the "direct effects" of invasive disease and "indirect effects," including immune suppression predisposing to other opportunistic infections and oncogenesis. Rapid and sensitive microbiologic assays for many of the common viruses after transplantation have replaced, for the most part, serologic testing and in vitro cultures for the diagnosis of infection. Furthermore, quantitative molecular tests allow the individualization of antiviral therapies for prevention and treatment of infection. This advance is most prominent in the management of cytomegalovirus, Epstein-Barr, hepatitis B, and hepatitis C viruses. Diagnostic advances have not been accompanied by the development of specific and nontoxic anti-viral agents or effective antiviral vaccines. Vaccines, where available, should be given to patients as early as possible and well in advance of transplantation to optimize the immune response. Studies of viral latency, reactivation, and the cellular effects of viral infection will provide clues for future strategies in prevention and treatment of viral infections.

Bronchoalveolar lavage in immunocompromised patients with haematological malignancy--value of new microbiological methods

PURPOSE

To assess the usefulness of new culture-independent microbiological methods to analyse bronchoalveolar lavage (BAL) fluid from haematological patients with clinical pneumonia.

PATIENTS AND METHODS

Results of 135 BALs from 122 disease episodes in 99 patients treated between 1996 and 2002 were retrospectively analysed. Forty-three patients had undergone haematopoietic stem cell transplantation and 56 patients had been treated with conventional chemotherapy for haematological malignancy. In addition to conventional microbiological methods, polymerase chain reaction (PCR) tests for Pneumocystis carinii, cytomegalovirus (CMV), Legionella sp., mycobacterium, Mycoplasma pneumoniae, and Chlamydia pneumoniae and the Aspergillus antigen test were performed.

RESULTS

Three (2.2%) quantitative and four (3.0%) special bacterial cultures gave an aetiological diagnosis. A respiratory virus was isolated in 10 episodes (8.2%). The diagnostic yield increased to 35.6% (48 of 135) by other methods. The P. carinii PCR test was positive in 21 of 24 patients with P. carinii pneumonia, being the only microbiological indication of P. carinii in four cases. The CMV PCR test was positive in 18 patients, but in 14 patients the clinical significance of the finding remained unproven. The Aspergillus antigen test was positive in seven of nine patients with aspergillosis, being the only microbiological indication of Aspergillus in three cases. The result of BAL indicated commencement of specific antimicrobial treatment in 27 episodes (22.1%).

CONCLUSION

The contribution of new culture-independent methods to the total diagnostic yield was of note. Among these methods, the P. carinii PCR and Aspergillus antigen tests proved the most valuable, while the CMV PCR test was not clinically useful.

Mycobacterium tuberculosis Infection in Recipients of Solid Organ Transplants

Tuberculosis is a serious opportunistic infection that may affect transplant recipients. The incidence of tuberculosis among such persons is 20-74 times higher than that for the general population, with a mortality rate of up to 30%. The most common form of acquisition of tuberculosis after transplantation is the reactivation of latent tuberculosis in patients with previous exposure. Clinical presentation is frequently atypical and diverse, with unsuspected and elusive sites of affection. Manifestations include fever of unknown origin and allograft dysfunction. Coinfection with other pathogens is not uncommon. New techniques, such as PCR and quantification of interferon- gamma , have been developed to achieve more-rapid and -accurate diagnoses. Treatment requires control of interactions between antituberculous drugs and immunosuppressive therapy. Prophylaxis against latent tuberculosis is the main approach to treatment, but many issues remain unsolved, because of the difficulty in identifying patients at risk (such as those with nonreactive purified protein derivative test results) and the toxicity of therapy.

Culture results of heart valves resected because of streptococcal endocarditis: insights into duration of treatment to achieve valve sterilization

OBJECTIVES

To analyse the culture results of heart valves removed following streptococcal endocarditis in order to gain insight into the duration of treatment required for valve sterilization.

PATIENTS AND METHODS

Retrospective review of 131 episodes of streptococcal endocarditis: 94 due to alpha-haemolytic streptococci; 15 due to beta-haemolytic streptococci; 10 due to nutritionally deficient streptococci; eight due to the Streptococcus anginosus group and four due to Streptococcus pneumoniae. Patients had their valves removed during antimicrobial treatment. Culture results were analysed with respect to duration of treatment before surgery.

RESULTS

For alpha-haemolytic streptococci, 17 (18%) valves were culture-positive and 77 (82%) culture-negative after a median (range) of 4 (1-20) and 16 (4-58) days of treatment, respectively, P < 0.001. For beta-haemolytic streptococci, two valves (13%) were culture-positive; both patients had received < or = 4 days of treatment. Four patients (40%) with nutritionally deficient streptococci were culture-positive, and had received < or = 8 days of treatment. For the S. anginosus group, two valves (25%) were culture-positive; both patients had received < or = 4 days of treatment before operation. Overall, only one of 131 (0.8%) valves was culture-positive after 14 days of treatment. All valves infected with beta-haemolytic streptococci, nutritionally deficient streptococci and the S. anginosus group, who were treated for more than 8 days before surgery, were culture-negative.

CONCLUSIONS

Our findings support current treatment guidelines for endocarditis caused by alpha-haemolytic streptococci. We suggest that the recommended duration of treatment for endocarditis resulting from other streptococci may be excessive and treatment trials evaluating 2 and 4 week regimens are justified.

Staphylococcus lugdunensis infective endocarditis: description of 10 cases and analysis of native valve, prosthetic valve, and pacemaker lead endocarditis clinical profiles

OBJECTIVE

To evaluate the incidence and the clinical and echocardiographic features of infective endocarditis (IE) caused by Staphylococcus lugdunensis and to identify the prognostic factors of surgery and mortality in this disease.

DESIGN

Prospective cohort study.

SETTING

Study at two centres (a tertiary care centre and a community hospital).

PATIENTS

10 patients with IE caused by S lugdunensis in 912 consecutive patients with IE between 1990 and 2003.

METHODS

Prospective study of consecutive patients carried out by the multidisciplinary team for diagnosis and treatment of IE from the study institutions. English, French, and Spanish literature was searched by computer under the terms "endocarditis" and "Staphylococcus lugdunensis" published between 1989 and December 2003.

MAIN OUTCOME MEASURES

Patient characteristics, echocardiographic findings, required surgery, and prognostic factors of mortality in left sided cases of IE.

RESULTS

10 cases of IE caused by S lugdunensis were identified at our institutions, representing 0.8% (four of 467), 1.5% (two of 135), and 7.8% (four of 51) of cases of native valve, prosthetic valve, and pacemaker lead endocarditis in the non-drug misusers. Native valve IE was present in four patients (two aortic, one mitral, and one pulmonary), prosthetic valve aortic IE in two patients, and pacemaker lead IE in the other four patients. All patients with left sided IE had serious complications (heart failure, periannular abscess formation, or shock) requiring surgery in 60% (three of five patients) of cases with an overall mortality rate of 80% (four of five patients). All patients with pacemaker IE underwent combined medical treatment and surgery, and mortality was 25% (one patient). In total 59 cases of IE caused by S lugdunensis were identified in a review of the literature. The combined analysis of these 69 cases showed that native valve IE (53 patients, 77%) is characterised by mitral valve involvement and frequent complications such as heart failure, abscess formation, and embolism. Surgery was needed in 51% of cases and mortality was 42%. Prosthetic valve endocarditis (nine of 60, 13%) predominated in the aortic position and was associated with abscess formation, required surgery, and high mortality (78%). Pacemaker lead IE (seven of 69, 10%) is associated with a better prognosis when antibiotic treatment is combined with surgery.

CONCLUSIONS

S lugdunensis IE is an uncommon cause of IE, involving mainly native left sided valves, and it is characterised by an aggressive clinical course. Mortality in left sided native valve IE is high but the prognosis has improved in recent years. Surgery has improved survival in left sided IE and, therefore, early surgery should always be considered. Prosthetic valve S lugdunensis IE carries an ominous prognosis.

Coronary artery bypass grafting in a patient with HIV

We report a successful case of a conventional coronary artery bypass operation performed in a patient with HIV infection and severe three-vessel coronary artery disease. The signal change in outcome of HIV disease, in addition to the reported evidence for accelerated atherosclerosis caused by the disease itself and by its treatment with protease inhibitors, is likely to produce a larger population of HIV-infected patients developing premature coronary artery disease for whom cardiac surgery will be required. Surgical risk, outcome and operative team risk are discussed.

Inflammatory response associated with pulmonary complications in non-HIV immunocompromised patients

BACKGROUND

A study was undertaken to evaluate the local and systemic inflammatory response associated with pulmonary complications in immunocompromised patients and potential implications regarding severity and prognosis.

METHODS

Levels of different inflammatory mediators were measured in the bronchoalveolar lavage (BAL) fluid and serum on days 1 and 4 after the identification of the pulmonary complication in 127 patients with different immunosuppressive conditions.

RESULTS

Pulmonary complications were characterised by a high percentage of neutrophils and increased levels of tumour necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8 and IL-10 in the BAL fluid and high serum levels of TNF-alpha, IL-6, and plasma C-reactive protein (CRP). The inflammatory response was similar in the different groups of immunocompromised patients evaluated. The levels of proinflammatory cytokines were higher in patients with pulmonary infections, particularly those of bacterial aetiology. Patients with a more severe pulmonary infection had a more intense local and systemic inflammatory response. A BAL fluid IL-6 level of >40 pg/ml was an independent predictor of mortality (OR 4.65, 95% CI 1.3 to 16.1), together with a need for mechanical ventilation (OR 13.5, 95% CI 3.2 to 57.3). Patients who died had persistently high levels of CRP on day 4.

CONCLUSIONS

The evaluation of the inflammatory response, particularly the determination of IL-6 levels in the BAL fluid and CRP in the serum, may be useful for deciding the appropriate management of pulmonary complications in immunocompromised patients.

Kutane Alternariose

Localized skin infections caused by the pigmented fungi of the genus Alternaria are being increasingly observed. In the past, primarily patients receiving long-term glucocorticoid therapy were likely to have this mycosis, which is commonly traumatic, but now it is frequently encountered in organ transplantation patients. Possible therapeutic options and differential diagnosis are discussed by means of two case reports--a female renal transplant patient infected by A. alternata and a patient with iatrogenic Cushing syndrome infected by A. infectoria. Histopathological differentiation from other fungal infections may be difficult but is of therapeutic and prognostic significance. Finding short hyphae in tissue sections is an important clue. Since A. infectoria shows little conidial growth in culture, rDNA ITS sequencing offers another diagnostic possibility. Therapy has not yet been standardized. Along with surgical intervention, systemic itraconazole is the usual choice.

The prognosis of acute respiratory failure in critically ill cancer patients

Acute respiratory failure (ARF) in patients with cancer is frequently a fatal event. To identify factors associated with survival of cancer patients admitted to an intensive care unit (ICU) for ARF, we conducted a prospective 5-year observational study in a medical ICU in a teaching hospital in Paris, France. The patients were 203 cancer patients with ARF mainly due to infectious pneumonia (58%), but also noninfectious pneumonia (9%), congestive heart failure (12%), and no identifiable cause (21%). We measured clinical characteristics and ICU and hospital mortality rates.ICU mortality was 44.8% and hospital mortality was 47.8%. Noninvasive mechanical ventilation was used in 79 (39%) patients and conventional mechanical ventilation in 114 (56%), the mortality rates being 48.1% and 75.4%, respectively. Among the 14 patients with late noninvasive mechanical ventilation failure (>48 hours), only 1 survived. The mortality rate was 100% in the 19 noncardiac patients in whom conventional mechanical ventilation was started after 72 hours. By multivariable analysis, factors associated with increased mortality were documented invasive aspergillosis (odds ratio [OR], 2.13; 95% confidence intervals [CI], 1.05-14.74), no definite diagnosis (OR, 3.85; 95% CI, 1.26-11.70), vasopressors (OR, 3.19; 95% CI, 1.28-7.95), first-line conventional mechanical ventilation (OR, 8.75; 95% CI, 2.35-35.24), conventional mechanical ventilation after noninvasive mechanical ventilation failure (OR, 17.46; 95% CI, 5.04-60.52), and late noninvasive mechanical ventilation failure (OR, 10.64; 95% CI, 1.05-107.83). Hospital mortality was lower in patients with cardiac pulmonary edema (OR, 0.16; 95% CI, 0.03-0.72). Survival gains achieved in critically ill cancer patients in recent years extend to patients requiring ventilatory assistance. The impact of conventional mechanical ventilation on survival depends on the time from ICU admission to conventional mechanical ventilation and on the patient's response to noninvasive mechanical ventilation.