A case of acute respiratory failure in pregnancy

Influenza is usually a benign, self-limiting illness. Occasionally influenza may be complicated by pneumonia. There is some impairment of cell-mediated immunity in pregnancy so that influenza pneumonia in pregnancy may rapidly progress to acute respiratory failure and other multisystem dysfunction. We present a case of influenza pneumonia in the third trimester of pregnancy in a normal host leading to acute respiratory failure which had a favorable outcome following standard supportive therapy.

Community-acquired pneumonia in a cohort of former injection drug users with and without human immunodeficiency virus infection: incidence, etiologies, and clinical aspects

Although the association among bacterial pneumonia, human immunodeficiency virus (HIV) infection, and injection-drug use seems to have been well established, accurate estimates of the risk of community-acquired pneumonia among HIV-positive and HIV-negative injection-drug users (IDUs) are still needed. To estimate the incidence of pneumonia in a community of former IDUs, we followed 4,236 persons between 1991 and 1994; 1,114 (26.3%) were HIV-positive and 3,122 (73.7%) were HIV-negative. All patients were evaluated for pneumonia by standard criteria, a serum sample was obtained from each participant at least once a year, and laboratory values were monitored. Overall, 149 episodes of pneumonia occurred among HIV-positive patients and 61 among HIV-negative patients; incidence rates were 90.5 and 14.2 (per 1,000 person-years), respectively. The most common etiologic agents were Streptococcus pneumoniae, Chlamydia pneumoniae, and Haemophilus influenzae. Among the HIV-positive former IDUs, there was a 1.37-fold increase in the relative risk of pneumonia for every decrease of 100/mm3 in the CD4 cell count (95% confidence interval, 1.16-1.61). The incidence of community-acquired pneumonia was markedly higher among HIV-positive participants than among HIV-negative ones, a finding similar to that concerning the general population.

Adult respiratory distress syndrome due to Chlamydia pneumoniae in a young adult

A case of life-threatening Chlamydia TWAR pneumonia complicated by encephalitis in a young, previously healthy adult is described. The patient presented with full blown adult respiratory distress syndrome and required prolonged ventilatory support and rigorous antibiotic and supportive care. He recovered fully without any neurologic sequelae. Chlamydia pneumoniae pneumonia should be included in the differential diagnosis of the severe community acquired pneumonia, because if properly sought and adequately treated, may have an excellent outcome.

Chlamydia pneumoniae infection in patients with cystic fibrosis

The prevalence of atypical community-acquired infections as acute pulmonary exacerbations in patients with cystic fibrosis was prospectively studied. Thirty-two patients admitted to the hospital because of acute pulmonary exacerbations and 24 clinically stable patients seen for their routine visits were examined. The prevalence of infection with Chlamydia pneumoniae was assessed by culture and serology, and the presence of IgE to C. pneumoniae was studied by immunoblotting. A subgroup of patients was also examined for the presence of Mycoplasma pneumoniae infection. C. pneumoniae was isolated from four patients presenting with acute pulmonary exacerbations (12.5%) and from none of the stable patients; all patients for whom cultures were positive also had IgE to C. pneumoniae. Polymerase chain reaction analysis for M. pneumoniae was not positive for any patient, and only one patient with an acute exacerbation had an antibody titer compatible with a recent infection. We conclude that infection with C. pneumoniae is associated with acute pulmonary exacerbations in some patients with cystic fibrosis and that it may trigger the production of IgE specific to C. pneumoniae, thus leading to bronchial reactivity in these patients.

Prevalence of associated infections in community-acquired spontaneous bacterial peritonitis

OBJECTIVES

The frequency with which other infections occur in association with spontaneous bacterial peritonitis is not known, but has implications for both pathogenesis and management. Spontaneous bacterial peritonitis that occurs in hospitalized patients is mainly a nosocomial infection, the study of which must take into account multiple confounding factors. We conducted a prospective study to compare the clinical features and the frequency of associated infections in patients with community-acquired spontaneous bacterial peritonitis to those of cirrhotic patients with ascites but without spontaneous bacterial peritonitis. Previous studies of spontaneous bacterial peritonitis have not found an infection consistently present at some other site, but those studies did not separate community-acquired from hospital-acquired spontaneous bacterial peritonitis.

METHODS

Over a 5-yr study period, 176 cirrhotic patients with ascites were enrolled and were followed. There were 68 patients who had 83 admissions with spontaneous bacterial peritonitis and 108 patients with 124 admissions without spontaneous bacterial peritonitis. Of the 68 patients with spontaneous bacterial peritonitis, 56 had single episodes of peritonitis and 12 had 27 episodes of recurrent bacterial peritonitis. All episodes of spontaneous bacterial peritonitis were diagnosed within 24 h of admission. All subjects had cultures of ascitic fluid, blood, and urine.

RESULTS

Patients with spontaneous bacterial peritonitis were more often symptomatic than the nonspontaneous bacterial peritonitis patients. Ascites cultures were positive in 63 (76%) episodes of spontaneous bacterial peritonitis. The frequency of bacteremia in the spontaneous bacterial peritonitis group was significantly higher than that of the nonspontaneous bacterial peritonitis (56.6% vs. 4.8%, p < 0.0001). Bacteriuria occurred in 51 episodes of spontaneous bacterial peritonitis compared with only nine in nonspontaneous bacterial peritonitis patients (61.4% vs. 7.3%, p < 0.0001). Bacteriuria was observed even more often in recurrent bacterial peritonitis patients than in single episode bacterial peritonitis patients (77.8% vs. 53.6%, p < 0.0001). Most patients with bacteriuria had no urinary tract symptoms. There was no significant difference between the frequency of pneumonia in spontaneous bacterial peritonitis patients compared with nonspontaneous bacterial peritonitis patients (8.4% vs. 10.5%, p = 0.17).

CONCLUSIONS

Asymptomatic bacteriuria occurs often in association with community-acquired spontaneous bacterial peritonitis.

Community acquired pneumonia in adults: a study comparing clinical features and outcome in Africa (Republic of Guinea) and Europe (France)

BACKGROUND

Community acquired pneumonia is the most common cause of death from infectious disease both in western and developing countries. A study was carried out in Conakry, Republic of Guinea and Tours, France in order to compare signs, symptoms, severity of illness, risk factors, and clinical outcome of community acquired pneumonia in adult patients admitted to hospital.

METHODS

The study was performed in the cities of Conakry and Tours over the same one year period. Patients with nosocomial pneumonia, tuberculosis, and those who were HIV positive were excluded. Data were recorded on the same forms in both centres. A severity score was calculated according to American Thoracic Society criteria. Follow up was evaluated at days 2, 7 and 15.

RESULTS

A total of 333 patients (218 from Conakry, 115 from Tours) were included in the study with a diagnosis of community acquired pneumonia, with or without lung abscess or pleural effusion. Mean age was higher and pre-existing illness rate, dehydration, agitation, and stupor were more frequent in patients in Tours. Respiration rates of > 30 breaths/min and the incidence of crackles were identical in the two centres. Fever above 39 degrees C, initial shock, chest pain, and herpes were significantly more frequent in Conakry. Initial chest radiographic abnormalities were similar in the two groups, ranging from unilateral pleuropulmonary involvement (89% and 83% in Conakry and Tours, respectively) to diffuse patchy parenchymal disease. Parapneumonic effusion was present in 17% and 16% of the patients of Conakry and Tours, respectively. Pneumonia was considered to be severe in 33% and 42% of the patients, respectively. In Conakry first line antibiotic therapy was penicillin alone (2 million units a day) for 197 patients (90%) and second line antibiotic therapy was prescribed for 25 patients (12%). In Tours first line therapy consisted of a single antibiotic (amoxicillin, third generation cephalosporins) for 65 patients (57%) and second line antibiotic therapy was prescribed for 55 patients (48%). The clinical outcome was similar in Conakry and Tours: 88% and 85% of patients, respectively, were afebrile or clinically cured at day 15. The mortality rate was similar (6% and 8%, respectively).

CONCLUSIONS

The problems encountered in the management of community acquired pneumonia are quite different in western and developing countries. This study shows that low doses of penicillin can cure 90% of African patients with pneumonia as effectively as more aggregative treatments in European patients who are both older and have greater comorbidity. Although pneumococci with reduced penicillin sensitivity occur in western countries, this does not seem to be the case in black Africa. For these reasons, low doses of penicillin or amoxicillin remain good first line treatment.

Consecutive salmonella outbreaks traced to the same bakery

Two consecutive community outbreaks of Salmonella enteritidis phage type 4 (PT4) traced to the same bakery occurred in Cardiff, Wales during August-September 1992. In the first outbreak, illness was associated with eating custard slices (odds ratio 23.8, 95% confidence interval 6.5-94.4, P < 0.0001), and in the second, with eating fresh cream cakes (odds ratio 15.8, 95% confidence interval 1.6-374, P = 0.004). Environmental investigations implicated cross-contamination during preparation of the cold-custard mix as the cause of the first outbreak, and inadequate cleaning and disinfection of nozzles used for piping cream in the second outbreak. S. enteritidis PT4 was isolated from fresh cream sponge cake retained by a case and from two fresh cream cakes and four environmental swabs obtained at the bakery. This incident illustrates the hazard of widespread environmental contamination with salmonella and the need for thorough environmental cleansing for any premises implicated in an outbreak of food poisoning.

Community-based respiratory viral infections in HIV positive patients with lower respiratory tract disease: a prospective bronchoscopic study

OBJECTIVES

To evaluate the contribution of community-based respiratory virus infections to lower respiratory tract disease in HIV-1 infected individuals.

DESIGN

Prospective clinical cohort study.

SETTING

Specialist in-patient unit for HIV and AIDS, University College London Hospitals, London.

SUBJECTS

44 consecutive HIV-1 antibody positive patients who underwent 47 diagnostic bronchoscopies for evaluation of the symptoms and signs of lower respiratory tract disease. TIME: Winter months of 1994/95.

MAIN OUTCOME MEASURES

Detection, in bronchoscopic alveolar lavage fluid, of infection with influenza A and B, respiratory syncytial virus (RSV), parainfluenza 1, 2 and 3 (by immunofluorescence and cell culture) and adenovirus and enteroviruses (by cell culture).

RESULTS

No evidence of influenza, RSV, parainfluenza, adenovirus, or enterovirus infection was detected.

CONCLUSIONS

Despite a marked increase in RSV and influenza B infection in the general population over the winter of 1994-95, respiratory virus infections were not detected in this cohort of HIV infected patients. As the organisms causing lower respiratory tract disease were related to immunosuppression, this study questions the value of routine identification of community-based respiratory viruses in this patient group.

Community-acquired pneumonia: an update

Despite the discovery of new pathogens and the evolving problem of antibiotic resistance, the basic trends in community-acquired pneumonia remain remarkably constant. This article reviews the common pathogens, new pathogens, their clinical presentations, the diagnostic workup, the decision to hospitalize, antibiotic resistance, and antibiotic choices.

Successful extracorporeal membrane oxygenation (ECMO) support for fulminant community-acquired pneumococcal pneumonia

A case is described of fulminant community-acquired pneumococcal pneumonia in a 16 year old girl with no previous history of respiratory disease or any predisposing factors. She required extracorporeal membrane oxygenation (ECMO) until the diagnosis could be made and appropriate antibiotic therapy established.

Parapneumonic effusions secondary to community-acquired bacterial pneumonia in human immunodeficiency virus-infected patients

The purpose of this study was to determine whether the clinical and microbiological characteristics of parapneumonic effusions in patients with community-acquired pneumonia (CAP) infected with the human immunodeficiency virus (HIV) were different from those observed in patients without HIV infection. One hundred and thirty seven patients with parapneumonic effusions were included and divided into two groups depending on whether they had HIV infection or not. The parapneumonic effusion rate was significantly higher in HIV-positive than in noninfected patients (21 vs 13%). Their clinical course was more severe, presenting a higher rate of bacteraemias (58 vs 18%). Pleural fluid in patients infected with HIV had significantly lower glucose levels than that of patients without HIV infection. Chest tube drainage was more frequent in parapneumonic effusions of patients infected with HIV than in those without HIV infection (71 vs 44%). Staphylococcus aureus was the most common microorganism found in the bacteriological samples of patients with CAP infected with HIV (53 vs 12%). We conclude that patients with community-acquired pneumonia and HIV infection have a higher rate of parapneumonic effusions and a more severe clinical course than non-HIV patients, and that Staphylococcus aureus predominates in their bacteriological samples.

A randomized trial of chloramphenicol vs. trimethoprim-sulfamethoxazole for the treatment of malnourished children with community-acquired pneumonia

Children in developing countries who present with malnutrition often have infections, particularly pneumonia, at the time of presentation. We evaluated the initial antibiotic management of 144 Gambian children who presented for the first time with malnutrition and who had clinical or radiologic evidence of pneumonia. They were enrolled in a double blind trial of trimethoprim-sulfamethoxazole vs. chloramphenicol. Most children in the study underwent detailed investigations of bacterial and viral etiology as part of another study. The study drug was administered for a week along with oral metronidazole, vitamins and standardized nutritional therapy. Treatment failure was defined as the need for change to parenteral antibiotics during treatment, failure to respond to a week of treatment with the study drug or relapse during the following 2 weeks. There were no differences between the treatment groups in the clinical indicators of severity, etiology or radiologic findings. Thirty-three children were excluded from the analysis because of tuberculosis, inappropriate enrollment or inadequate follow-up. Of the 111 children remaining, 32 (16 in each arm of the study) failed treatment. Clinical failure was not related to in vitro antimicrobial resistance in the 20 cases in which invasive bacterial isolates were obtained. Those who failed treatment were more likely to have had lower chest wall indrawing and positive bacterial cultures than those who were successfully treated. In an area with infrequent antimicrobial resistance of common respiratory pathogens, oral chloramphenicol and trimethoprim-sulfamethoxazole were equally effective in the initial management of malnourished children with community-acquired pneumonia.

Sepsis in children with human immunodeficiency virus infection. The Madrid HIV Pediatric Infection Collaborative Study Group

The aims of this retrospective study were to review the frequency and patterns of bacterial sepsis in children infected with human immunodeficiency virus. The charts of 233 human immunodeficiency virus-infected children cared for during a 10-year period in 4 tertiary hospitals in Madrid were reviewed. There were 43 episodes of sepsis in 31 (13%) children. Twenty of them had acquired immunodeficiency syndrome, 10 were class PA2 and 1 was class P1B. The most common organisms recovered were: nontyphoidal Salmonella, 10 cases (23%); Streptococcus pneumoniae, 9 cases (21%); Staphylococcus epidermidis, 6 cases (14%); Escherichia coli, 5 cases (12%); Enterococcus faecalis, 4 cases (9%); Campylobacter jejuni, 2 cases (5%). In 28 episodes of bacteremia there were other sites of associated infection: pneumonia, 6 cases; urinary tract infection (UTI), 5 cases; gastrointestinal disease, 4 cases; catheter-related bacteremia, 12 cases. Eight patients had more than 1 episode of bacteremia. The rate of complications was high: 6 children had septic shock; and 2 of them developed disseminated intravascular coagulation. There was 1 death directly related to sepsis.

Fungemia in children infected with the human immunodeficiency virus: new epidemiologic patterns, emerging pathogens, and improved outcome with antifungal therapy

We characterized 27 episodes of fungemia in 22 children infected with the human immunodeficiency virus (HIV). Fungemia in these patients presented as a community-acquired infection in the setting of outpatient total parenteral nutrition or intravenous antibiotic therapy through a chronically indwelling central venous catheter (CVC). Fungemia developed only in patients with CVCs (P < .001). Non-albicans Candida species, Torulopsis glabrata, Rhodotorula rubra, and Bipolaris spicifera constituted 52% of all causes. Fungemia was detected early, within a median of 2.4 days after the onset of new fever, which permitted prompt administration of amphotericin B (mean dosage, 0.7 mg/[kg.day]; median duration, 19 days). CVCs were removed in 23 (85%) of the episodes. We conclude that fungemia in HIV-infected children often presents as a community-acquired infection, is frequently due to newly emerging opportunistic fungi, and can be managed, with a high level of success (95% survival with no posttherapeutic sequelae), by early diagnosis, prompt initiation of amphotericin B therapy, and removal of the CVC.

Effects of aerosolized prostacyclin in severe pneumonia. Impact of fibrosis

The effects of aerosolized prostaglandin (PG) I2 on gas exchange and hemodynamics were investigated in patients ventilated mechanically because of severe community-acquired pneumonia. Group A were patients without preexisting lung disease (n = 6), and Group B were those with underlying chronic fibrotic interstitial lung disease (n = 6). Ventilation-perfusion distribution was assessed by the multiple inert gas elimination technique. In Group A, low doses of aerosolized PGI2 (mean, 6.6 +/- 3.0 ng/kg/min) sufficed to decrease the mean pulmonary artery pressure (Ppa) from 35.0 +/- 1.5 to 31.0 +/- 1.6 mm Hg (p < 0.05), to improve the ratio of arterial oxygen to the fraction of inspired oxygen (PaO2/FIO2 increase from 100 +/- 18 to 134 +/- 18; p < 0.05), and to decrease intrapulmonary shunt (36.9 +/- 4.7 to 27.5 +/- 4.5%; p < 0.05). Systemic arterial pressure (Psa) and cardiac output remained unchanged. In Group B, aerosolized PGI2 was ineffective in doses less than 10 ng/kg/min. A dosage of 33.6 +/- 12 ng/kg/min reduced Ppa (38.0 +/- 2.4 to 30.8 +/- 2.1 mm Hg; p < 0.05), but it also decreased Psa (80.3 +/- 3.6 to 71.3 +/- 4.7 mm Hg; NS) and PaO2/FIO2 (73.8 +/- 6.6 to 65.5 +/- 6.8 mm Hg; p < 0.05) values and increased intrapulmonary shunt (44.7 +/- 3.0 to 49.4 +/- 5.0%, NS). After withdrawal of the PGI2 aerosol, all gas exchange and hemodynamic changes returned to preaerosol baseline values within 60 min in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Community acquired pneumonia in adults in Addis Ababa: etiologic agents and the impact of HIV infection

SETTING

Black Lion Hospital, a tertiary care referral hospital in Addis Ababa, Ethiopia.

OBJECTIVE

To determine the prevalence of HIV infection in patients with Community Acquired Pneumonia (CAP) and compare the etiologic agents, clinical and radiographic presentation and outcome of the disease in HIV positive and negative patients.

DESIGN

A hospital based prospective study on 110 adult patients consecutively coming to Black Lion Hospital between August 1987 and July 1989.

RESULTS

8% of patients with pneumonia versus 2.4% for the general population (P < 0.05) were seropositive for HIV-I. Streptococcus pneumoniae was the most common offending pathogen. HIV positive patients were more likely to be male, young and of urban residence. They had fewer chills, increased bilateral and multilobar lung involvement, frequent association with pulmonary tuberculosis and recurrent chest infiltrate.

CONCLUSION

The incidence of Community Acquired Pneumonia in patients with HIV infection is likely to increase with the rapid rise in HIV infection. Future studies should therefore look further into (a) the pattern of etiologic agents, (b) unusual clinical patterns which may help set criteria for screening for HIV infection, and (c) the use of pneumococcal vaccine in selected groups of patients.

Serious Pseudomonas aeruginosa infection in AIDS

During a 7-year period, 32 patients with Pseudomonas aeruginosa infection were identified on an HIV treatment service at a university-affiliated teaching hospital. The number of cases increased from 2 in 1986 to 13 in 1992. Affected patients had evidence of advanced HIV infection. In those treated with antiretroviral therapy, 96% of infections occurred > 1 year after initial presentation with HIV disease. Eighteen cases of pneumonia and 14 nonpulmonary (central venous access device, soft tissue, middle ear-mastoid, corneal, and peritoneal) infections were seen. Comparison with matched controls identified use of a central venous access device and administration of aerosolized pentamidine, corticosteroids, or ganciclovir as risk factors for infection (odds ratios, 5.3, 6.5, 15.0, and 9.0, respectively; p = 0.004, 0.007, 0.02, and 0.02, respectively). Seventy-five percent of cases had community onset, but time since last hospital discharge was significantly shorter in study patients than in controls (mean difference, -85 days; 95% confidence interval, -24 to -146; p = 0.01). Among evaluable cases, outcome was fatal (survival < or = 30 days) in 2 of 16 (13%) patients in whom initial antibiotic therapy was appropriate and 8 of 14 (57%) patients in whom initial therapy was not appropriate (p = 0.016). Ten recurrent infections were seen in 8 of 21 patients who survived the initial infection. Median survival after onset of infection was only 80 days. Pseudomonas aeruginosa infection is an increasingly frequent, severe complication of advanced HIV disease. Several treatment and prevention strategies used in the management of advanced HIV disease are associated with an increased risk of infection.

Pneumonia and carcinoma of the lung

In a prospective study of 1269 patients with community-acquired pneumonia, 25 (1.97%) were found to have carcinoma of the lung. In 23 cases, the diagnosis was confirmed histologically. For nine of the 23 patients, this episode of pneumonia was the initial manifestation of carcinoma of the lung. The diagnosis of carcinoma was first suggested by the radiologist as the result of a chest radiograph in five of the nine cases. One patient with bronchoalveolar cell carcinoma presented with rapidly progressive diffuse airspace disease. The diagnosis in this case was made by means of open lung biopsy. Two of the 25 patients (8%) had pneumonia caused by Coxiella burnetii, a rate that was 2.4 times higher than that for the other patients with pneumonia. We conclude that pneumonia is uncommonly the presenting manifestation of carcinoma of the lung but is usually evident before the patient leaves hospital. The rate of pneumonia caused by C. burnetii among patients with carcinoma of the lung seems to be higher than that among patients who have pneumonia without carcinoma of the lung.

Severe community acquired pneumonia associated with a desquamating rash due to group A beta-haemolytic streptococcus

In recent years frequent and severe infections due to group A beta-haemolytic streptococci have been recognised with increasing frequency. Group A streptococcal pneumonia remains a rare disease occurring sporadically in contrast to epidemics in the past. The association between group A streptococcal pneumonia and a desquamating skin rash typical of scarlet fever has rarely been reported.

Listeriosis--a review of eighty-four cases

OBJECTIVE

To review the epidemiology, risk factors for acquisition, clinical features and outcomes of Listeria monocytogenes infection in Sydney.

DESIGN

A retrospective study over the period 1983-1992 at four university teaching hospitals in Sydney. Cases were identified from microbiology laboratory records of the isolation of L. monocytogenes from sterile sites.

RESULTS

Eighty-four cases were reviewed, with 72 patients (86%) having a predisposing underlying condition, including 13 perinatal patients (15%). Septicaemia (56%) and central nervous system disease (41%) were the major clinical presentations. Nineteen patients (23%) had hospital-associated infection. A mortality of 21% (18 patients) was directly attributable to L. monocytogenes infection, with another 10% (nine patients) dying of their underlying disease during admission. The 84 cases represented 80% of all L. monocytogenes cases occurring in Sydney during the study period.

CONCLUSIONS

Listeriosis is predominantly a disease of the elderly or of immunosuppressed individuals, pregnant women and neonates. The presentation and outcome in these groups are similar to those reported in other Western countries. A significant feature of this study was the number of cases occurring in already hospitalised patients, suggesting that L. monocytogenes may be an important hospital-associated pathogen in immunocompromised patients.

Community acquired pneumonia in adults in Addis Abeba: etiologic agents, clinical and radiographic presentation

We prospectively studied 110 adult patients coming to Black Lion Hospital between August 1987 and July 1989 with community acquired pneumonia (CAP) for various etiologic agents and clinical and radiographic presentation. Streptococcus pneumoniae was the most common offending pathogen in 72% and 67.5% from sputum and lung aspirate (LA) Gram stain respectively, and in 41% by pneumococcal serotyping of sputum. Blood and LA culture grew Streptococcus pneumoniae in 4 (6%), Staphylococcus aureus in 4 (6%), Enterobacteriaceae in (3%), Pseudomonas, Klebsiella and Streptococcus viridans in one case each. Non-bacterial pathogens included Mycoplasma pneumoniae in 3 (3%), Influenza A in 4 (4%), Influenza B in 3 (3%) and psittacosis/LGV in 4 (4%). Fever, cough, chest pain, tachypnea and coarse crepitations/bronchial breathing were the most common presenting signs and symptoms. Thirty per cent had associated diarrhoea and vomiting initially and 9% had altered state of consciousness at admission. Six patients came in a state of shock. Thirty-nine per cent had underlying illnesses. Ninety-three per cent had either segmental or lobar consolidation. Parapneumonic effusion occurred in 14%. The mortality was 11%. Tachypnea, the presence of underlying illness, altered state of consciousness, extreme leucocytosis and the presence of bilateral and multilobar lung involvement were found to be signs of poor prognosis. Our finding is similar to those from other African countries, except that we are reporting psittacosis/LGV for the first time in Africa.

[Rhabdomyolysis in community-acquired pneumonia]

Several cases of rhabdomyolysis associated with pneumococcal pneumonia have been recently reported. However their significance have been poorly investigated. In this retrospective study, we have compared the patients admitted in ICU for acute community-acquired pneumonia with or without rhabdomyolysis (group A: CPK > or = 1,000 Ul/l and group B: CPK < 1,000 Ul/l). Among the 41 patients of the study, 12 (29%) belonged to the group A (CPK = 1,852 +/- 535 Ul/l) and 29 (71%) to group B (CPK = 190 +/- 35 Ul/l). Neither the initial severity, nor renal impairment were different in the two groups. However the mortality was significantly higher in the group A (4/12) than in group B (2/29) (P < 0.05). In this study, pneumonia is frequently associated with rhabdomyolysis, without etiologic significance. In patients with pneumonia, rhabdomyolysis seems to be a bad prognostic indice unrelated with renal impairment.

Community acquired lobar pneumonia in patients with HIV infection and AIDS

BACKGROUND

Community acquired bacterial pneumonia is increasingly encountered in HIV infected individuals and some patients have a radiographic lobar pneumonia.

METHODS

A retrospective review of clinical features, microbiological diagnosis, and outcome of community acquired lobar pneumonia was carried out in HIV positive patients admitted to a specialist unit from 1987 to 1993.

RESULTS

Forty nine episodes occurred in 45 patients, all of whom were men. CD4 counts ranged widely. A bacteriological diagnosis was made in 25 episodes (51%), seven patients had more than one infective cause. The commonest pathogens were Streptococcus pneumoniae (11 episodes), Staphylococcus aureus (six), Pneumocystis carinii (three), Haemophilus influenzae (three), and Pseudomonas aeruginosa (two). Four patients died. Other complications included intrapulmonary cavitation or abscess formation (11 episodes), empyema (three), and pleural effusion (10 episodes).

CONCLUSIONS

Many different infections cause community acquired lobar pneumonia in HIV positive men. Some patients have co-infections and there is a high complication rate.

Severe pneumococcal pneumonia complicated by massive pulmonary gangrene

Massive pulmonary gangrene is a rare complication of pneumonia, particularly in the postantibiotic era. We report two cases of community-acquired Streptococcus pneumoniae pneumonia in young patients with a background of heavy alcohol abuse, but no other preexisting disease, which failed to respond to appropriate antibiotic therapy and intensive care. In both, there was extensive unilateral involvement, with initial dense consolidation followed by cavitation, but the previously reported classic later radiologic feature of coalescence into a large cavity with free-floating slough was not seen. Owing to ongoing sepsis with the development of multiple organ failure and the obvious failure of appropriate medical therapy, both patients underwent pneumonectomy with a successful outcome. These cases serve to emphasize the role of surgery in the management of massive pulmonary gangrene.

Septicaemia in patients with and without AIDS at Westminster Hospital, London

The types of organism causing septicaemia in patients with AIDS and without AIDS at Westminster Hospital were examined prospectively over a period of 2 years (1990-1991). Altogether 417 episodes of septicaemia were diagnosed, 148 (35%) of which were in patients with AIDS. Of septicaemias in patients with AIDS, 53 (36%) were caused by mycobacteria. Non-mycobacterial septicaemias were associated with IV access devices in 58 (61%) of patients with AIDS and in 50 (19%) of those without AIDS. Gram-negative organisms were responsible for septicaemia associated with IV access devices in 16 (28%) of 58 patients with AIDS and in 8 (16%) of 50 patients without AIDS. Non-typhoidal Salmonella species or Shigella species caused 13 (31%) of 42 episodes of septicaemia caused by Gram-negative organisms in patients with AIDS. These findings have influenced the strategy for empirical therapy of septicaemia in patients with AIDS at Westminster Hospital.

Endocarditis caused by Rochalimaea henselae

A case of community-acquired, culture-negative, infective endocarditis was diagnosed in a 57-year-old construction worker. Small, pleomorphic gram-negative rods were seen in Brown-Hopps tissue gram stains and Warthin-Starry silver stains. The organism was identified as Rochalimaea henselae by polymerase chain reaction amplification and sequencing of the 16S rDNA gene sequence. This is the first report of infective endocarditis caused by R henselae.