Acquisition of coccidioidomycosis at necropsy by inhalation of coccidioidal endospores

Coccidioidomycosis is accepted as being noncontagious because the infectious arthroconidial form of Coccidioides immitis is not produced in humans and other mammalian hosts. However, disseminated coccidioidomycosis developed in a veterinarian who autopsied a horse with disseminated disease but without draining lesions or productive cough. We postulate transmission occurred by inhalation of tissue-phase endospores aerosolized in the course of dissection.

Clinical use of amphotericin B and derivatives: lore, mystique, and fact

Since 1955, when amphotericin B was introduced into clinical therapy, a lore has grown up surrounding its use that often lacks evidential basis. Matters such as rate of intravenous injection, periodicity of administration, dosage, and the monitoring of therapy should not be shrouded in a mystique that is passed on from one generation of house officers to another. Factual rationalization of the use of amphotericin B should be pursued and is attempted in this article.

Antibodies that neutralize human beta interferon biologic activity recognize a linear epitope: analysis by synthetic peptide mapping

The location of biologically relevant epitopes on recombinant human beta interferon in which Ser-17 replaces Cys-17 (rh[Ser17]IFN-beta) was evaluated by testing the immunoreactivity of antibodies against 159 sequential, overlapping octamer peptides. Three monoclonal antibodies (mAbs) that neutralize rh[Ser17]IFN-beta biologic activity, designated A1, A5, and A7, bound to peptides spanning only residues 39-48, whereas nonneutralizing mAb bound less specifically at multiple sites near the amino terminus. The immunoreactivity of peptides spanning residues 40-47 that contained a series of single amino acid substitutions suggested that residues 41-43 (Pro-Glu-Glu) and 46 (Gln) are important for the binding of neutralizing mAbs. The reactivity of mAbs to larger synthetic peptides containing rh[Ser17]IFN-beta sequences from residue 32 through residue 56 was evaluated. All mAbs except A7 reacted with synthetic peptides representing rh[Ser17]IFN-beta residues 32-47, 40-56, and 32-56, but only mAbs A1 and A5 bound to the core peptide composed of residues 40-47. Peptide 32-56 effectively blocked the binding of mAbs A1 and A5 to rh[Ser17]IFN-beta and markedly inhibited their neutralizing activity. Biologic activity of the peptides was undetectable. Rabbit antisera raised against peptides 32-47 and 40-56 recognized rh[Ser17]IFN-beta but did not neutralize its antiviral activity. Thus, structure-function analysis by peptide mapping has permitted the identification of a linear epitope recognized by neutralizing antibody on a biologically active cytokine. We conclude that the region spanning residues 32-56 is of major importance in the expression of the biologic activity of human IFN-beta.

Itraconazole treatment of phaeohyphomycosis

Nineteen patients with phaeohyphomycosis were treated with itraconazole. Of these, 17 were assessable for clinical outcome. Of these, two had received no prior therapy, five had failed amphotericin B therapy, four had failed ketoconazole or miconazole therapy, and five had failed both amphotericin B and azole therapy. One patient had received only prior surgical intervention. Fungi of seven different genera caused disease of the skin in nine patients, soft tissue in nine, sinuses in eight, bone in five, joints in two, and lungs in two. Itraconazole was given in dosages ranging from 50 to 600 mg/day for 1 to 48 months. Clinical improvement or remission occurred in nine patients. Two patients have had stabilization of disease. Six patients failed treatment, one had a relapse after initially successful treatment. Itraconazole appears to be highly effective in some patients with phaeohyphomycosis, including patients refractory to other antifungal agents.

Identification of immunodominant regions of transforming growth factor alpha. Implications of structure and function

Human transforming growth factor alpha (TGF alpha) is a 50-residue mitogenic peptide with a compact structure restrained by three disulfide bonds. Sequential and overlapping synthetic peptides were made to identify epitopes of TGF alpha using a panel of murine monoclonal antibodies and rabbit polyclonal antibodies. Antibodies were raised against human TGF alpha from different preparations obtained from either chemical synthesis or recombinant DNA techniques. Two related methodologies were used in these experiments. In the first method, probes were synthesized as peptides immobilized on polyethylene pins by the method of Geysen et al. (Geysen, H. M., Meloen, R. H., and Barteling, S. J. (1984) Proc. Natl. Acad. Sci. U.S.A. 81, 3998-4002). Three sets of sequentially overlapping tetrapeptides, hexapeptides, and octapeptides covering the entire length of the human TGF alpha sequence were synthesized. In the second method, a set of overlapping 8-residue synthetic peptides, freely soluble in solution, were used as probes. By both methods, the nonneutralizing monoclonal antibodies, i.e. those that did not inhibit TGF alpha in mitogenic assays, recognized two immunodominant regions represented by the NH2-terminal segment (residues 1-9) and the most prominent beta-sheet of the molecule (residues 22-31). The NH2 terminus and the beta-sheet-(22-31) are in the same face of the molecule as determined by the solution structure. These two immunodominant regions were also recognized by the polyclonal antibodies as well as regions in the COOH terminus as minor epitopes. However, none of the neutralizing monoclonal antibodies recognized any synthetic peptides. Thus, our results suggest that the receptor-binding surface of TGF alpha does not involve the face represented by the NH2-terminal fragment and the major beta-sheet of residues 22-31, but rather, that the opposite face represented by two loops formed by residues 12-20 and 34-43 may be involved in TGF alpha binding to its receptor.

Successful treatment of progressive disseminated histoplasmosis with amphotericin B methyl ester

Amphotericin B methyl ester (AME) has been used to treat fungal infections, most often those caused by Coccidioides immitis. We describe the only patient with disseminated histoplasmosis who has been treated with AME. After having had alarming reactions to amphotericin B, the patient was treated and cured with AME without adverse drug effect or later relapse.

Treatment of fungal infections with semisynthetic derivatives of amphotericin B alpha

AME appeared to be as effective as AmB in the treatment of mycoses in humans. AME was much less nephrotoxic than AmB, and was better tolerated in terms of rapid onset and reversible adverse reactions. AME may be more ototoxic than AmB. AME, even as AmB and OAME, may cause neurotoxicity and leukoencephalopathy, particularly when high doses are given for long periods.

Effect of recombinant human interleukin 2 in experimental murine coccidioidomycosis

The therapeutic effect of recombinant human interleukin 2 (rH IL-2) was assessed in experimental murine coccidioidomycosis by daily IV injection for 30 days of doses ranging decimally from 2.5 X 10(1) to 2.5 X 10(5) units. The treatment with rH IL-2 had neither adverse nor salutary effects.

Multifocal systemic sporotrichosis with lobar pulmonary involvement

Multifocal systemic sporotrichosis (disseminated sporotrichosis) with lobar pulmonary involvement is uncommon. We describe successful treatment with amphotericin B in such a patient and review data from 1 other similar case previously reported and 7 with nonlobar pulmonary involvement.

Entry of five antifungal agents into the ovine lung

The passage of antifungal agents into pulmonary parenchyma was studied in normal sheep prepared by cannulation of the right external jugular vein and the efferent duct of the right caudal mediastinal lymph node. Five sheep were given single, sequential, intravenous injections of flucytosine, ketoconazole, BAY n 7133, amphotericin B methyl ester, and amphotericin B. Venous blood plasma and pulmonary lymph were collected before infusion and from 5 min to 24 h postinfusion; the concentrations of the drugs were assayed by a well-agar diffusion method. All drugs appeared promptly in the pulmonary lymph and disappeared at approximately exponential rates from both liquids. The lymph/plasma ratios of the drug concentrations did not differ between flucytosine and the two azoles but were lower for both polyenes. Binding by plasma proteins did not appear to be a determinant of pulmonary entry.

Effect of buffers on testing of Candida species susceptibility to flucytosine

Synthetic amino acid medium for fungi (SAAMF) is a totally defined, nutritionally adequate, macromolecule-free culture medium for fungi that is buffered with an organic weak acid-weak base pair: 2-(N-morpholino)-propanesulfonic acid (MOPS) and 2-amino-2-(hydroxymethyl)-1,3-propanediol (Tris). In 1984, it was reported that MOPS-Tris in SAAMF antagonized the activity of flucytosine against Candida albicans (D. L. Calhoun and J. N. Galgiani, Antimicrob. Agents Chemother. 26:364-367, 1984). Accordingly, we evaluated the buffering capacity of seven synthetic organic buffers and monobasic potassium phosphate, both singly and in pairs, over the pH range 7.4 to 6.0. Of these buffers, MOPS, BES [N,N-bis(2-hydroxyethyl)-2-aminomethanesulfonic acid], a BES-MOPS combination, and KH2PO4 provided the best buffering. Growth of C. albicans, in unbuffered SAAMF was equivalent overall to that in SAAMF containing buffers, singly or in pairs. Twelve strains of C. albicans and five strains of Candida lusitaniae were tested for susceptibility to flucytosine in SAAMF, with and without buffers. In the presence of Tris, the geometric mean MICs were 6.5- and 3.6-fold higher, respectively, for C. albicans and C. lusitaniae. We recommend replacing Tris with the nonantagonistic MOPS.

Comparative efficacy of forphenicinol, cyclosporine, and amphotericin B in experimental murine coccidioidomycosis

Cohorts of ten mice, uninfected and infected (intratracheal injection of coccidioidal arthroconidia), were treated for 23 days by intravenous injections of either 5% glucose solution, an immunostimulant (forphenicinol), an immunodepressant (cyclosporine), or amphotericin B. All mice were autopsied (survivors at 26 days postinoculation) and suspensions of lungs, livers, and spleens were cultured. All uninfected animals survived and gained weight, whereas, only 20% of the infected controls survived, and all lost weight. Treatment with forphenicinol had no effect on survival or weight. Cyclosporine secured 90% survival at the lowest dose and 60% at the higher doses, with no net loss of weight; however, all cultures of organs yielded heavy growth of Coccidioides immitis. With amphotericin B, all mice survived and gained weight; four mice from each of the two treatment groups yielded modest growth of C. immitis from the lungs, and one mouse of each group yielded sparse growth from liver and spleen. The paradox of no effect from an immunostimulant and therapeutic effect from an immunodepressant correlated with susceptibility testing of C. immitis in vitro.

Ovine pulmonary transit of tetracycline and minocycline

Following cannulation of the right external jugular vein and the efferent duct of the right caudal mediastinal lymph node (the caudal end of this node was ligated to cut off the inflow of systemic lymph, i.e., 90%-95% of the efferent lymph was of pulmonary origin), sheep were given either tetracycline or minocycline as single doses of 5 mg/kg body weight infused intravenously over 30 min. Venous blood plasma and pulmonary lymph collected contemporaneously before infusion and from 5 min to 24 hr postinfusion were assayed by a well-agar diffusion method using Bacillus cereus. Peak concentrations of both drugs were observed in both plasma and lymph at 5 min postinfusion. Tetracycline penetrated into the lymph better than minocycline (percent penetration 67.3% of cf. 38.2%). The concentration of tetracycline was significantly higher in lymph during and 5 min postinfusion (p less than 0.01), a factor that may be of importance when selecting a tetracycline for the treatment of a pulmonary infection.

Pericarditis caused by beta-lactamase-producing Haemophilus influenzae: report of two cases in adults and review of the literature

Two adult patients with pericarditis caused by beta-lactamase producing Haemophilus influenzae are reported and their management reviewed. Both had pharyngitis, epiglottitis, pneumonia, empyema, or septicemia and were cured with antimicrobics and pericardial drainage (one by catheter and one by surgery). Eleven previously reported cases of pericarditis caused by Haemophilus influenzae are also reviewed. In reviewing this rare cause of bacteria pericarditis, it is important to recognize the antibiotic resistance profile, the incidence of pericardial tamponade, and the use of surgical drainage. Antibiotic selection for this organism is also discussed, as well as the importance of biotyping.

The HTLV-III envelope protein contains a hexapeptide homologous to a region of interleukin-2 that binds to the interleukin-2 receptor

A region of human interleukin-2 (IL-2) which was predicted to be a contact point with its receptor was used to locate a homologous region in the envelope protein of human T-lymphotropic retrovirus (HTLV-III). This homologous six amino acid peptide from the carboxy (C)-terminus of the HTLV-III envelope protein was found to inhibit the biological activity of human IL-2 in a murine spleen cell proliferation assay. When conjugated to a carrier protein, this peptide inhibited the binding of radiolabelled IL-2 to its receptor. The biological activity of the peptide was antagonized by a six amino acid peptide fragment of the IL-2 receptor which was predicted to be the contact point on the receptor that corresponded to the binding region of IL-2. The HTLV-III peptide also inhibited the binding of radiolabelled IL-2 to polyclonal anti-IL-2 antiserum. These data support the previous assignment of contact points between IL-2 and its receptor. They also suggest two possible mechanisms of immunosuppression during acquired immunodeficiency syndrome (AIDS). One involves direct competition of the envelope protein or its fragments with IL-2 for binding to the IL-2 receptor. The other involves antibodies to the envelope protein which crossreact with and neutralize IL-2.

Influence of culture medium on susceptibility testing with BAY n 7133 and ketoconazole

The effect of four culture media (two complex and undefined [Sabouraud glucose and Kimmig] and two synthetic and defined [synthetic amino acid medium, fungal, and modified yeast nitrogen base]) on the activity in vitro of two newer azole compounds (BAY n 7133 and ketoconazole) was assessed with five strains each of Candida albicans, Candida parapsilosis, and Cryptococcus neoformans. Also, the nutritional adequacy of the four media was evaluated with the same 15 strains of yeastlike fungi. While the MICs of BAY n 7133 were higher in the complex media, the activity of ketoconazole was little affected. The Candida spp. grew least well and the C. neoformans grew best in yeast nitrogen base.

Helical conformation at the carboxy-terminal portion of human C3a is required for full activity

Human C3a, a 77-residue fragment released during complement activation, is a potent spasmogen that contracts smooth muscle, enhances vascular permeability, and suppresses humoral immune responses. Studies with synthetic peptides have shown that the active site of this anaphylatoxin resides in the COOH-terminal portion of C3a; the minimal peptide structure capable of expressing activity contains residues 73-77, Leu-Gly-Leu-Ala-Arg (C3a-73-77). Longer synthetic C3a analogue peptides, e.g., C3a-57-77 containing the 21 COOH-terminal amino acids, exhibit activity nearly equivalent to that of intact C3a. Circular dichroism spectra of peptide C3a-57-77 in aqueous buffer containing 25% (v/v) trifluoroethanol indicated helical structure (41% helix), and analysis of the sequence suggested an amphipathic surface. We have synthesized several 21-residue peptide analogues of the natural C3a sequence containing residues 57-77 that were designed to enhance helix and to accentuate amphipathy. Syntheses were designed to include strategic placement of the helix-promoting residues 2-aminobutyric acid (beta-methylalanine) and 2-aminoisobutyric acid (alpha-methylalanine). Two 21-residue C3a analogue peptides that were designed to enhance helical content were shown to exhibit greater biological activity than either the native factor C3a or C3a-57-77. Moreover, activity was abrogated by the appropriate placement of helix-breaking residues, e.g., proline, suggesting that a conformational requirement for activity is genuine. These observations suggest that a helical conformation is requisite for optimal C3a activity and that in intact C3a the NH2-terminal portion (residues 1-21) and the disulfide-linked core (residues 22-57) function primarily to stabilize ordered conformation at the COOH-terminal region of the molecule.

Activity of BAY n 7133 and BAY 1 9139 in vitro and in experimental murine coccidioidomycosis

The activity of two new antifungal azoles, BAY n 7133 and BAY 1 9139, against Coccidioides immitis was compared with that of ketoconazole in vitro and in experimental murine coccidioidomycosis. Daily intravenous injections were given for 30 days. All mice were autopsied and suspensions of lung, liver and spleen cultured. BAY n 7133 was as active as ketoconazole while Bay 1 9139 was les active. All three drugs were coccidioidostatic only both in vitro and in vivo.

Evidence for a role of the amino-terminal region in the biological activity of the classical anaphylatoxin, porcine C5a des-Arg-74

The presence of methionyl residues at positions 1 and 17 in porcine classical anaphylatoxin (e.g. C5a des-Arg-74) permits chemical cleavage of the factor with cyanogen bromide to generate two defined fragments. Peptides corresponding to the amino-terminal fragment, CN-I, and the carboxyl-terminal peptide, CN-II, were purified from the CNBr digest of C5a des-Arg-74 by reverse-phase high performance liquid chromatography. The isolated derivatives were assessed for their abilities to cause contraction of isolated guinea pig ileal smooth muscle, guinea pig lung parenchymal strips, and degranulation of guinea pig polymorphonuclear neutrophils. In each assay, CN-I was devoid of biological activity at concentrations greater than 10(-6) M. In contrast, the carboxyl-terminal 56-residue fragment, CN-II, possessed weak (10(-6) versus 10(-9) M for classical anaphylatoxin) agonist activity in each of the assay systems. Our data suggest that structural information contained in the amino-terminal 17 residues of the C5a des-Arg-74 molecule contributes to the biological potency of the intact factor, but is not an essential component of the active site. Whether the structural information in residues 1-17 relates to receptor binding directly or serves to stabilize the conformation of the 18-73-fragment containing the active center of the molecule is yet to be determined.

A synthetic nonapeptide corresponding to the NH2-terminal sequence of C3d-K causes leukocytosis in rabbits

Numerous biologically active fragments have been described that are derived from the C3 molecule. Recently, a polypeptide (Mr 41,000) generated from the alpha chain of human iC3b by limited proteolysis with plasma kallikrein was shown to exhibit several biological functions. This C3-derived cleavage product, C3d-K, suppresses mitogen- and antigen-induced proliferation of human T-lymphocytes and induces leukocytosis in rabbits. We have identified and synthesized a portion of C3d-K that is associated with the leukocytosis phenomenon. A nonapeptide corresponding to the amino-terminal nine residues of C3d-K was synthesized using conventional Merrifield solid-phase peptide chemistry; the structure of this peptide is Thr-Leu-Asp-Pro-Glu-Arg-Leu-Gly-Arg (TLDPERLGR). At a final concentration of 4 X 10(-6) M, both the nonapeptide and the des-Arg octapeptide (TLDPERLG) were capable of inducing leukocytosis in rabbits. Additionally, both peptides enhance vascular permeability when injected in guinea pig skin. These activities are similar to those previously attributed to a C3 fragment identified as C3e by Ghebrehiwet and Müller-Eberhard (Ghebrehiwet, B., and Müller-Eberhard, H.J. (1979) J. Immunol. 123, 616-621). We conclude that the nonapeptide TLDPERLGR represents the active center of the C3-derived leukocytosis factors C3e and C3d-K. This active synthetic analogue of C3d-K should prove valuable in elucidating the mechanism of action for complement-dependent leukocyte mobilization in vivo.

Bioactive complement fragments in immunoregulation

Several fragments derived from complement components have been identified as potent effector substances in in vitro assays that measure cell proliferation and antibody synthesis. The anaphylatoxin C3a suppresses the immune response but fails to influence T- or B-cell proliferation. The factor C5a augments both antibody production and antigen-induced, but not mitogen-induced, T-cell proliferation. C3a-mediated suppression occurs through the activation of a suppressor T-cell cascade with macrophage collaboration. C5a-mediated enhancement, depending upon the in vitro system studied, acts at the level of the helper T cell and/or macrophage. A fragment generated from treating iC3b with kallikrein (c3d-K) has aided in defining a structural region of the C3b molecule that can influence the level of circulating leukocytes. The factor C3d-K is also capable of suppressing both specific and non-specific T-cell proliferative responses and mitogen-induced B cell growth. The mechanism of C3d-K action is defined as a direct effect on "activated" T cells, even though IL-2 synthesis of treated cells is diminished. The effect of C3d-K is long lasting, non-reversible and requires only a short exposure to the target cell.

Toxicity of amphotericins on chronic administration to mongrel dogs

Conditioned mongrel dogs were given 30 i.v. injections of either AMB (amphotericin B, 0.75 mg/kg body weight), AME (amphotericin B methyl ester, 10 mg/kg body weight), or 5% glucose solution without antimicrobic. Severe loss of body weight and nephrotoxicity occurred with AMB; hepatic dysfunction resulted with AME; astrogliosis and pallor of the myelin were found in dogs given AME and 5% glucose solution.

In vitro activities of two new antifungal azoles

The antifungal activities of equimolar quantities of three azole compounds, Bay n 7133 [1-(4-chlorophenoxy)-3,3-dimethyl-2-(1,2,4-triazole-1-yl)methylbutan-2-O1], Bay 1 19139 [1-(4-chlorophenoxy)-1-(1-imidazolyl)-3,3-dimethyl-2-butanol hydrochloride], and ketoconazole, were compared by testing the susceptibility in vitro of 10 clinical isolates each of Candida albicans, Candida parapsilosis, Torulopsis glabrata, Cryptococcus neoformans, Aspergillus fumigatus, Aspergillus niger, Aspergillus flavus, Rhizopus spp., Mucor spp., and Coccidioides immitis. Molecule for molecule, ketoconazole was consistently the most active drug. All three azoles were primarily fungistatic, although they were fungicidal at clinically relevant concentrations against some strains of A. niger.

Entry of four cephalosporins into the ovine lung

Following cannulation of the right external jugular vein and the efferent duct of the right caudal mediastinal lymph node (the caudal end of this node having been ligated to cut off the inflow of systemic lymph), sheep were each given one of four "cephalosporins" (cefazolin, moxalactam, cefoperazone, or ceftriaxone) as single doses injected iv over 30 min. All of the drugs appeared in the pulmonary lymph during iv infusion. Peak concentrations in the lymph were attained at 5 min postinfusion with cefazolin, cefoperazone, and ceftriaxone; the peak for moxalactam was attained at 30 min postinfusion. Cefazolin and cefoperazone penetrated better than did ceftriaxone, which penetrated better than did moxalactam. The concentrations of moxalactam, as compared with the other drugs, declined more gradually in both venous blood and pulmonary lymph. In view of the prompt entry and transit through the lungs and the high concentrations attained in the pulmonary lymph, these drugs should be effective in the treatment of pneumonias caused by susceptible bacteria.

Analysis of bacterial isolates from cerebrospinal fluid

We set out to determine the frequency of occurrence of contamination of cerebrospinal fluid with bacteria, seeking also to identify aids to differentiating contaminants from etiologically significant isolates. From 2,091 specimens, 182 bacterial isolates were obtained from 129 patients. Meningitis was the source of 81 isolates (32 patients); contamination yielded 101 isolates (97 patients). The cell counts and protein and glucose concentrations in the cerebrospinal fluid were significantly more often abnormal in specimens from patients with meningitis. Haemophilus influenzae and enteric gram-negative bacilli were usually cause for meningitis, whereas Staphylococcus epidermidis was the most common contaminant. In view of the reported high rate of procedural error in carrying out lumbar puncture, a program aimed at teaching proper technique is recommended to decrease the frequency of false-positive cultures of cerebrospinal fluid.

Activity of two polyene and two imidazole antimicrobics on Candida albicans in human fibrin clots

The vegetations of infective fungal endocarditis were simulated by preparing human fibrin clots containing 10(5) CFU of Candida albicans per clot. Clots were incubated in human serum without drugs (controls) or with equimolar concentrations (2.5 to 20 nmol/ml) of four antifungal antimicrobics: AMB and miconazole (both colloidal suspensions) and DAB and KET (both molecularly dispersed). Over a period of 4 days of incubation, clots were resuspended in freshly prepared serum-antimicrobic every 12 hr. Cohorts of control and drug-exposed clots were cultured quantitatively at 24 hr intervals. Neither imidazole at any concentration tested prevented growth of C. albicans to an extent that was significantly different from growth in the control clots. Both polyenes reduced the CFU/clot, with AMB significantly more active than DAB.

Dimeric half-molecules of human fibrinogen are joined through disulfide bonds in an antiparallel orientation

Human fibrinogen is a dimer composed of two identical halves. Each dimeric half contains three peptide chains (alpha, beta, and gamma) linked by disulfide bonds. The two half-molecules are joined by three disulfide bonds, one between the two alpha-chains (residue alpha-28) and two between the two gamma-chains (residues gamma-8 and gamma-9). In the absence of any difinitive experimental evidence, it has been presumed that the joined halves were aligned in a parallel orientation similar to the situation found in immunoglobulins. We have now determined that the two gamma-chains--hence, the dimeric halves--are connected in an antiparallel manner. A tryptic peptide containing gamma-chain residues 6-14 was isolated as a disulfide-linked dimer from CNBr-treated fragment E. Synthetic peptides corresponding to this sequence were prepared, from which parallel and antiparallel dimers were constructed. During the syntheses, cysteine thiol groups were protected as p-methoxybenzyl and acetamidomethyl sulfides; the peptides were dimerized by selective deprotection and disulfide bond formation. First, the p-methoxybenzyl groups were removed by liquid hydrogen fluoride and the newly exposed thiols oxidized in the presence of potassium ferricyanide. Then the monocystine compound was converted to the double-cystine product by iodolytic cleavage of the acetamidomethyl group with concomitant disulfide bond formation. This selectivity was used to prepare peptide dimers which modeled both parallel and antiparallel arrangements. The antiparallel-oriented synthetic peptide was indistinguishable from the native tryptic peptide as judged by elution from reverse-phase high-performance liquid chromatography and circular dichroism spectroscopy. The parallel-oriented synthetic peptide differed from the native material by both criteria.

Treatment of open fractures: a prospective study

A double-blind prospective study was done to assess the benefit of delaying closure of the wounds associated with open fractures. An additional double-blind study compared the effectiveness of clindamycin versus cefazolin for prophylactic antibiotic coverage. Quantitative cultures of the wounds were accomplished at the time of debridement and again at the time of closure if the wound was not closed initially. Almost half of the wounds were contaminated (46%) at the time of debridement, although the incidence of wound infection was low (6.5%). Gram-negative organisms resistant to the prophylactic antibiotic were recovered initially only eight times, but four of these (50%) became infected. The contaminating organisms in each case were present in high concentration (greater than 10(5) CFU/gm of tissue) at initial culture. The time of wound closure, cefazolin versus clindamycin, and internal fixation of the fracture were not followed by significant differences in the development of clinical infection in this series.

Long-term venous access in rhesus monkeys

Long-term, intermittent, intravenous infusion of substances, such as amphotericin B, with a high potential for causing peripheral vein thrombophlebitis was feasible by means of a subcutaneously implanted silastic reservoir catheter device, which gave access to the central venous compartment. The implanted reservoirs withstood at least 100 percutaneous entries with a 27-gauge needle; injections were carried out by using an infusion pump. With precautions taken to prevent infection, clotting, or the formation of precipitates in the catheter, the device permitted easy intravenous injection and was well tolerated.

Successful treatment of gram-negative bacillary meningitis with moxalactam

Meningitis caused by enteric gram-negative bacilli is relatively uncommon but is very difficult to treat despite susceptibility in vitro to many antimicrobics. A major problem appears to be poor entry of many drugs into the central nervous system. Moxalactam is an investigational cephalosporin that attains concentrations in the cerebrospinal fluid that are 15% to 30% of contemporaneous serum concentrations; moreover, it is quite active against many of the enteric gram-negative bacilli. We used moxalactam to treat meningitis caused by Enterobacter cloacae, Klebsiella pneumoniae, and Escherichia coli in four adults and one child, giving up to 100 mg/kg body weight per day by intravenous injection. The concentrations of moxalactam in serum, lumbar, and ventricular cerebrospinal fluid exceeded the minimal lethal concentrations of all causative bacteria. The patients were cured. In this small series, moxalactam, when administered intravenously as the sole agent of therapy, was effective in the treatment of meningitis caused by susceptible gram-negative bacilli.

Use of radiologic modalities in coccidioidal meningitis

The diagnostic utility of pentetate indium trisodium in 111 CSF studies, technetium Tc 99m brain scans, and computerized tomographic (CT) scans was evaluated in eight patients in whom coccidioidal meningitis developed following a dust storm in the Central Valley of California. The 111In flow studies and the CT scans demonstrated hydrocephalus in five patients with clinical findings suggesting this complication. Ventriculitis has not previously been diagnosed before death in patients with coccidioidal meningitis; however, it was demonstrated in two patients by the technetium Tc 99m brain scan. Basal meningitis, which is indicative of fungal infection, is also detectable on contrast-enhanced CT scan. The finding that communicating hydrocephalus occurs early in meningitis and interferes with CSF flow into infected basilar regions has important therapeutic implications in that antifungal agents injected into the lumbar subarachnoid space may not reach these regions.

Treatment of coccidioidomycosis with miconazole

Miconazole was injected intravenously in six patients with coccidioidomycosis. Two patients received 101 and 185 g, respectively, without clinical response and with persistence of positive cultures for Coccidioides immitis. In one patient, symptoms were suppressed when amphotericin B was given with miconazole, but new lesions developed with miconazole alone (total dose, 963 g). Three patients received smaller doses: 30.6 g before death from an unrelated complication; 17 and 22.3 g before development of severe allergic reactions. Because of the high rate of initial failures and relapses, miconazole is not recommended as primary therapy for coccidioidomycosis.

Current principles of antimicrobic therapy

The bases for successful antimicrobial therapy are reviewed. The impact of antimicrobics on the resident microbiota of the body and the development of resistance are considered. The phenomenon of tolerance to antimicrobics is described and a pharmacotherapeutic response is outlined. The distribution and penetration of antimicrobics is related to therapeutic needs. Finally, the choice of antimicrobics for use in obstetric and gynecologic infections is discussed.

Diagnostic value of gallium and bone scans in evaluation of extrapulmonary coccidioidal lesions

The value of 67Ga and methylene diphosphonate labeled with 99mTc in detecting extrapulmonary lesions was evaluated in 12 patients win whom disseminated nonmeningeal coccidioidomycosis developed after a single epidemic exposure in December 1977. Studies were performed with each radionuclide from 4 to 9 months after infection. Comparison of scintigraphy with radiography showed that eight of 14 osteolytic lesions identified by radiography were present on the bone and gallium scans; four were present only on the gallium scan, and two were undetected. Of 15 additional lesions present in both scanning procedures, eight were not present in matching roentgenograms and seven were in unstudied areas. Gallium scans detected seven of 14 soft tissue lesions. Few diagnostically confusing noninfectious lesions were observed. Because nuclear scanning detected almost all lesions present in radiographs and demonstrated otherwise unrecognized lesions, scans should be performed in all patients in whom coccidioidal dissemination is suspected.

Occurrence of protein A in Staphylococcus aureus and closely related Staphylococcus species

All but 1 of 143 strains of Staphylococcus aureus were positive for protein A, whereas all 34 strains of Staphylococcus hyicus and 123 of 127 strains of Staphylococcus intermedius were devoid of this cell wall component.

In vitro susceptibilities of Naegleria fowleri strain HB-1 to selected antimicrobial agents, singly and in combination

The overall prognosis of primary amoebic meningoencephalitis remains poor. The results of this study support previous finding that amphotericin B is the most efficacious drug against the Naegleria species in in vitro testing. In addition, the methyl ester of amphotericin B, a new derivative, also appears to be an effective agent. Of the drug combinations studied, amphotericin B plus minocycline and amphotericin B plus tetracycline showed synergy. The clinical significance of these findings remains to be determined.