Fulminant community-acquired infectious diseases: diagnostic problems

The processes presented here do not represent an all-inclusive list of fulminant infectious diseases. Some of the more common acute, overwhelming infections of the central nervous system and lungs are covered elsewhere in this issue. We have selected less common, potentially catastrophic syndromes that might be recognized earlier if certain historical clues, physical findings, or laboratory abnormalities are appreciated. Specific and effective therapy is available for most of the diseases we have chosen. Meningitis due to Naegleria fowleri, a free-living ameba that may invade the central nervous system through the cribriform plate in persons swimming in brackish water, and hemorrhagic mediastinitis due to inhalation of Bacillus anthracis, which is acquired in occupational exposure to goat's hair, wool, or an animal with anthrax, are other examples but are lacking in proven effective therapy. Although most physicians quickly consider exotic and overwhelming infections in the severely compromised patient, fewer recognize this risk in the diabetic, cirrhotic, or healthy person with a unique occupational or travel history. During the present epidemic of AIDS, previous exposure to the HTLV-3 virus must be considered in all severely ill patients. The proper use of new diagnostic tests may permit the physician to intercede effectively if these life-threatening diseases are suspected.

Comparative longitudinal study of 2 methods of scheduling maintenance visits; 2-year data

This report compares the clinical and microbiological status of 2 groups of subjects with treated periodontis on different maintenance schedules. 43 control (C) subjects were given prophylaxes every 3 months. 40 test (T) subjects were given this service on a flexible schedule according to the proportions of spirochetes and/or motile rods in fresh smears of subgingival scrapings. Both groups were examined every 6 months clinically and microbiologically. This report presents base line, 1- and 2-year data. Generally, mean values for both groups did not differ significantly from one another. Both groups exhibited comparable increases in GI and PLI scores during the first 2 years of this study. No change in probing depth was noted between base line and the 2-year examination. However, a slight increase in attachment level, as determined by probing, was noted in both groups. Both groups also exhibited similar proportions of bacterial morphotypes at base line and subsequent examinations. Disease recurrence, defined as an increase in probing depth of 3 mm or more from base line on any tooth surface during the 2-year period, tended to be more prevalent in the C than in the T group (15/43 C and 9/40 T subjects). However, the proportional difference between the groups was not statistically significant. Subjects with disease recurrence in the T group had greater proportions of spirochetes at base line than subjects in the same group without disease recurrence (20.2% versus 9.8%, p less than 0.01). This difference in proportions persisted if both groups were examined jointly, but was only of borderline significance (16.0% versus 10.5%, p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Glycated plasma proteins in normal and diabetic mothers and their offsprings

Glycated plasma proteins (GPP) and glycated hemoglobin (G Hb) has been evaluated in 134 non-diabetics (ND), 299 women with potential abnormality of glucose tolerance (pot.AGT), 75 with impaired glucose tolerance (IGT) and 34 insulin dependent diabetics (IDDM) during pregnancy or postpartum including 94 cord blood determinations. Mean HbA1c levels were significantly elevated in IDDM (6.6 +/- 1.3% M +/- SD) compared to ND (5.1 +/- 0.7%; P less than 0.01), but were similar for the other groups studied. Mean GPP were increased for the IDDM (0.58 +/- 0.29 nmol 5- HMF/mg protein; M +/- SD) and the IGT-group (0.53 +/- 0.22) over ND (0.3 +/- 0.13; P less than 0.01) and the Pot.AGT group (0.37 +/- 0.14; P less than 0.01). 6% of the ND, 15% of the Pot AGT-, 52% of the IGT- and 62% of the IDDM group were found to have GPP values exceeding the 97% confidential limit of the ND. However, the large overlap of individual values from patients with different degrees of glucose intolerance with the normal range of pregnancy precludes the use of GPP as a screening parameter for IGT during pregnancy. A 30-35% reduction of fetal hemoglobin- and plasma protein glycosylation relative to maternal values was observed.

In vitro activity of ketoconazole against herpes simplex virus

The effects of ketoconazole alone and in combination with acyclovir and adenine arabinoside upon the replication of herpes simplex virus types 1 and 2 (HSV-1 and -2) were investigated by using a yield reduction assay. Ketoconazole demonstrated antiviral activity against HSV-1 and -2 and synergistic antiviral activity when it was combined with acyclovir. Combinations of ketoconazole with adenine arabinoside resulted in either interference or indifference. The effects of ketoconazole upon the protein synthesis of HSV-2-infected cells were also determined in an effort to define the mechanism of action for the antiviral activity of ketoconazole. There was no reduction of HSV proteins when compared with acyclovir. These findings suggest that further investigations of the use of ketoconazole for the treatment of HSV infections are warranted.

Limited dermal ossification: clinical features and natural history

For 9 years we have observed a girl who has ossification in the dermis with a strikingly limited distribution. Recently a second girl with similar dermal ossification restricted to a single extremity was identified. The ectopic bone is histologically identical to normal membranous bone. These two patients have no obvious underlying cause for soft tissue bone formation, and no disorder of calcium or phosphate metabolism. Ossification first involved the dermal and subcutaneous connective tissue, and with time advanced locally in the affected areas to bridge joints and limit mobility. The ossification has now extended to involve muscle fascia but has not involved the muscle itself. This disease appears to represent a heretofore unrecognized disorder of mesenchymal differentiation.

Future trends in aminoglycoside therapy

The aminoglycosidic aminocyclitols have been utilized extensively for three decades. Nonetheless, the future use of this class of agents has been questioned of late. Recognized inadequacies of the aminoglycosides and the development of new antibiotics with significant activity against gram-negative bacilli are commonly cited reasons for the theorized decline of these compounds. However, resistance to newly developed antibiotics already has become evident. This insures a continuing role for the aminoglycosides in the treatment of nosocomial infections. Aminoglycosides will have continued use as empiric, potentially synergistic therapies for hospital-acquired infections in neutropenic patients with bacteremia, in enterococcal endovascular infections, and in patients with serious infections associated with Pseudomonas aeruginosa. Those factors that will influence the future role of aminoglycosides in these settings will include economic, administrative, and space pressures to restrict the number of antibiotics available in hospitals, the discovery of novel antibiotics, the utility of combination therapies employing an aminoglycoside and newly available drugs, the comparative toxicities of new antimicrobial regimens, and considerations of cost containment.

Caffeine effect on respiratory muscle endurance and sense of effort during loaded breathing

The present study examined respiratory muscle endurance and the magnitude of the sense of effort during inspiratory threshold loading following a dose of caffeine (600 mg) previously observed to increase diaphragm strength. Experiments were performed on 12 normal subjects. Respiratory muscle endurance at a given level of load was assessed from the time of exhaustion and from the time course of the change in the power spectrum (centroid frequency) of the diaphragm electromyogram (EMG). The intensity of the sense of effort during loaded breathing was evaluated using a category (Borg) scale. Increasingly severe loads were associated with more rapid onset of fatigue. At a given load, caffeine prolonged the time to exhaustion and decreased the rate of fall of the centroid frequency of the diaphragm EMG. Caffeine also decreased the sense of effort during loaded breathing in 9 of 11 subjects. Changes in respiratory muscle endurance after caffeine administration were not explained by changes in the pressure-time index of the respiratory muscles or the pattern of thoracoabdominal movement. We conclude that caffeine enhances inspiratory muscle endurance, while concomitantly reducing the sense of effort associated with fatiguing inspiratory muscle contractions.

Effects of suramin on in vitro HBsAg production by PLC/PRF/5 cells and hepatitis B virus DNA polymerase activity

The effects of suramin, an antiparasitic agent, upon in vitro hepatitis B surface antigen production by the human hepatoma cell line PLC/PRF/5 and hepatitis B virus associated DNA polymerase activity in the serum of a chronically infected patient were examined. Treatment with suramin resulted in decreases in hepatitis B surface antigen production and hepatitis B-virus associated DNA polymerase activity. The decrease in hepatitis B surface antigen production was paralleled by a general decrease in hepatoma cell viability and cellular protein synthesis. Although the inhibitory effects of suramin for hepatitis B virus appear to be nonspecific as demonstrated in these two in vitro systems, the recently announced trial of suramin for the treatment of the acquired immunodeficiency syndrome should afford an unusual opportunity to evaluate the effectiveness of suramin in the treatment of chronic hepatitis B virus infection.

Haemophilus influenzae meningitis in the presence of a cerebrospinal fluid shunt

Haemophilus influenzae meningitis in the presence of a cerebrospinal fluid shunt has been reported uncommonly. Staphylococcus aureus and Staphylococcus epidermidis, the most common etiological agents, are usually acquired by contiguous spread from an intraoperative or perioperative source. These infections usually occur within 2 months of shunt insertion and are rarely associated with bacteremia. Review of the literature shows that infection with H. influenzae typically occurs later than with the more common pathogens, is commonly associated with bacteremia, and frequently can be treated with antibiotics alone.

Endogenous opioid modulation of pancreatic hormone secretion: studies in dogs

The role of endogenous opioid peptides in the modulation of secretion of hormones from the endocrine pancreas was studied in dogs. In response to insulin-induced hypoglycemia, plasma glucagon secretion significantly increased, followed by an increase in plasma somatostatin immunoreactivity. Pretreatment with the opiate antagonist, naloxone, prevented the somatostatin response but had no effect on the augmented glucagon secretion. Neither the degree of hypoglycemia nor recovery from the induced glucose nadir were affected by naloxone. Arginine Hcl administration resulted in prompt increases in immunoreactive glucagon and insulin secretion, as well as a rise in serum glucose. Pretreatment with naloxone failed to affect any of these responses. Our results suggest that endogenous opioid peptides mediate the somatostatin response following hypoglycemia-induced glucagon secretion.

Selected overview of nongynecologic surgical intra-abdominal infections. Prophylaxis and therapy

True prophylaxis of intra-abdominal nongynecologic infections is limited to elective, nonemergency surgery and is best shown in three clean-contaminated surgical procedures. All of these have an infection rate of approximately 10 to 20 percent and include all colon resection surgery, most gastric surgery, and about one third of the cholecystectomies for chronic calculous cholecystitis. Each of these three surgical procedures has a somewhat different pattern of bacterial pathogens. The most useful comparative studies of early preoperative therapy have been performed in cases of suspected appendicitis (50 percent of which usually show perforation or gangrene at the time of surgery) and penetrating abdominal wounds (80 percent of which usually enter some part of the bowel and theoretically soil the peritoneum). These procedures are usually classified as contaminated, with a 20 to 30 percent infection rate, or dirty, with a more than 30 percent infection rate, depending upon several factors. Comparative investigations of intraoperative and postoperative antibiotic therapy of established intra-abdominal infections are more difficult to obtain because of the heterogeneity of the sites, organisms, and medical and surgical therapy. The initial pathogens causing secondary peritonitis and hepatic, perirectal, diverticular, and most other types of intraperitoneal abscesses are mixed coliforms and anaerobes, with emphasis on the anaerobes. Retroperitoneal abscesses, pancreatic abscesses, and biliary tract infections are predominantly caused by coliforms. The organisms responsible for these early infections are usually community-acquired rather than more antibiotic-resistant hospital-acquired bacteria. Considering the availability of a large number of effective broad-spectrum antibacterial agents and therapeutic combinations, it has become increasingly difficult to assess the rightful place of any new prospective antimicrobial regimen unless it has quite unique characteristics. Most empiric therapy in established intra-abdominal infection studies have compared gentamicin and clindamycin, the most popular regimen in the United States over the past 15 years, with a cephalosporin, broad-spectrum penicillin, or aminoglycoside, either alone or together with clindamycin or metronidazole. Results have usually been considered similar in most studies, although in some studies, agents with limited Bacteroides fragilis activity, such as cefamandole or cefaperazone, have been considered inferior. Most new prophylactic regimens have been compared with the first-generation cephalosporins and, again, similar results have been obtained between the groups with two exceptions. Cepha

Results of a screening method used in a 12-month stool survey for Escherichia coli O157:H7

Escherichia coli serotype O157:H7 has been epidemiologically linked to outbreaks of hemorrhagic colitis associated with fast-food restaurants and nursing homes. Sporadic cases now exceed those associated with outbreaks. The incidence of the organism in patients with common diarrhea syndromes and in asymptomatic persons is unknown. Routine serotyping of E. coli isolates is impractical for most clinical microbiology laboratories. We developed a screening plate by utilizing sorbitol fermentation as a biochemical marker to identify organisms for serotyping. A total of 2,552 stool samples were screened. In 106 (4.1%), sorbitol-negative E. coli were identified. Of these, two were serotype O157:H7, and both produced a Vero cell toxin. One patient had hemorrhagic colitis and the other a mild, febrile, self-limited diarrhea with no other bacterial pathogen identified. This plate provides an easy, effective method of screening for sorbitol-negative E. coli, a process facilitating the selection of organisms for serotyping and one that may help clarify this organism's role in human disease.

Interferon system in acute transient synovitis

The interferon system of 20 children aged 2 to 11 years (mean 5 years), diagnosed as having transient synovitis of the hip by clinical criteria, was studied. The mean blood interferon concentration was significantly higher than that of normal children, and the incidence of an antiviral state of cells (in 78% of patients) was also significantly higher than in the control group. These findings are compatible with the hypothesis that the aetiology of transient synovitis is an acute, possibly unusual, viral infection.

Ca2+ channel blockers stimulate ileal and colonic water absorption

The effects of calcium channel blockers on water transport in the rat ileum and distal colon were studied in vivo using the single-pass perfusion technique. Parenteral but not intraluminal verapamil, and parenteral nifedipine increased ileal water absorption, with effects lasting at least 60 min. In contrast, i.p. verapamil had no effect on rat distal colonic water absorption, whereas intraluminal verapamil significantly stimulated colonic water absorption. Similarly, perfusing the rat descending colon with low-Ca2+ Ringer's-HCO3 stimulated colonic water absorption. Verapamil was not antisecretory because the theophylline-induced decrease in ileal water transport was similar in control animals and in animals pretreated with i.p. verapamil. In addition, nifedipine stimulated active Na and Cl absorption in rabbit ileum. These studies demonstrate that the Ca2+ channel blockers verapamil and nifedipine stimulate basal absorption of water in rat ileum and distal colon in vivo, and stimulate active Na and Cl absorption in rabbit ileum in vitro. The verapamil stimulation of colonic water absorption from the luminal surface was duplicated by perfusion with a low-Ca2+ bathing solution. This suggests the presence of apical membrane Ca2+ channels in rat colon, which appear to be involved in regulation of basal water transport, and that these Ca2+ channels are in a partially open state under basal conditions. Because verapamil stimulates absorption systemically (ileum) as well as intraluminally (colon), Ca2+ channel blockers have properties that might be useful in treatment of diarrheal diseases.

Changes in thyroidal function and liver UDPglucuronosyltransferase activity in rats following administration of a novel imidazole (SC-37211)

SC-37211, an imidazole with antianaerobic activity, was administered po to male rats for 2 weeks at dosages of 20, 60, and 200 mg/kg/day. Histological changes in the thyroid included irregularly shaped follicles and slightly enlarged follicular cells. Serum triiodothyronine (T3) and/or thyroxine (T4) were significantly decreased in treated animals at all dosages; these decreases were not observed following a 2-week recovery period. The half-life of serum [125I]thyroxine was also significantly decreased in rats treated with SC-37211. Morphological changes in the thyroid are likely the result of thyroid-stimulating hormone (TSH) stimulation, a response to decreased serum T3 and T4 concentrations. The decreases in T3 and T4 were not due to decreases in iodide uptake or organification. There were dose-dependent increases in liver weights, liver-to-body weight ratios, and UDPglucuronosyltransferase activity toward p-nitrophenol and T4. Therefore, the decreases in serum T3 and T4 were probably due to an increase in hepatic metabolism rather than to a direct effect of SC-37211 on the thyroid.

A urine preservative system to maintain bacterial counts. A laboratory and clinical evaluation

The urinary tract is a common site of infection in the hospitalized, institutionalized, or ambulatory patient population. Ideally, urine should be cultured immediately or refrigerated up to 24 hours for quantitative examination for microorganisms. In the evaluation of patients at their homes or in long-term care facilities, rapid plating or refrigeration may not be practical. This is also true when evaluating small children in whom external collection devices are required to obtain a specimen. Because of these limitations, we evaluated a urine preservative and transport system, the Sage Products Urine Culture Tube, in a study of 1469 clinical specimens. This tube utilizes boric acid (1.1% final concentration) as a preservative. The Urine Culture Tube was easy to use and was as effective as refrigeration in maintaining bacterial counts. This system may be particularly useful where rapid transport or refrigeration is limited.

Antibodies to hepatitis B surface antigen as the sole hepatitis B marker in hospital personnel

The epidemiologic and serologic differences between hospital employees with antibodies to hepatitis B surface antigen (anti-HBs) alone or in combination with antibodies to hepatitis B core antigen (anti-HBc) were evaluated. Of 105 employees with anti-HBs, 38 (36%) did not have anti-HBc. Sera from employees with anti-HBs alone had significantly lower mean sample ratio units of anti-HBs than sera with both antibodies (15.9 +/- 43.2 as compared to 110.3 +/- 73.9, p less than 0.0005) and more commonly had less than 10 sample ratio units of anti-HBs (32 [84%] of 38 as compared to 9 [13%] of 67, p = 0.0001). The anti-HBs in sera with anti-HBs alone was predominantly IgM as shown by inactivation with 2-mercaptoethanol and the presence of anti-HBs activity in serum IgM fractions. Failure of protection from hepatitis B virus infection in persons with anti-HBs alone and the presence of nonprotective IgM anti-HBs in chimpanzees has been reported. Our data suggest the use of anti-HBs as a single serologic screening test for hepatitis B virus immunization programs may not be reliable in identifying employees with protective antibodies.

Intraoral benign mesenchymoma

Benign mesenchymoma is a tumor composed of two or more benign mesenchymal elements in addition to fibrous connective tissue. A case of benign mesenchymoma of the lip in a 38-year-old man is presented, and the literature is reviewed.

Interferon deficiency syndrome

Activation of the interferon (IFN) system is an early defence mechanism against viral infections. The virus stimulates production of IFN by nucleated cells including the peripheral blood mononuclear cells (PBMC), and this IFN in turn activates several IFN-dependent immune mechanisms including the induction of an anti-viral state in cells, which prevents or retards further intracellular viral replication. In an ongoing study of 1,500 individuals of all ages and with various illnesses, we found 15 cases (representing 5% of patients with acute viral disease) in whom the IFN system response during an acute viral illness was absent or grossly deficient. There was no detectable IFN in the blood, PBMC did not produce IFN-alpha and IFN-gamma or produced minimal amounts of one of them in vitro following appropriate stimulation, and the patients' PBMC were not in an anti-viral state. These patients had severe progressive or fulminant viral disease, often ending fatally. IFN therapy appears to be beneficial in these cases, as it rapidly induced a cellular antiviral state in most cases, stimulated in vitro IFN-alpha and IFN-gamma production by PBMC, and led to rapid recovery in seven of the nine patients who received treatment for at least 3 days. In our opinion IFN replacement therapy should be commenced as early as possible in such cases, and before irreversible cell and organ damage occur.