[Adult celiac disease and hepatopathy]

A retrospective study was performed in order to evaluate the prevalence of significant hepatic disease in patients with coeliac disease and its outcome after a gluten-free diet. Out of 46 patients with coeliac disease, 28 (60.87%) presented abnormal liver function test. These tests were normal after a gluten-free diet in 20 patients; one patient presented an acute B-virus hepatitis and in the remaining 7 patients a chronic liver disease was diagnosed (2 chronic persistent hepatitis, 1 chronic active hepatitis, 1 steatosis, 2 cirrhosis and 1 primary biliary cirrhosis). In conclusion, the high prevalence of significant hepatic disease in our patients with coeliac disease (15%) suggests an association between both disorders. Gluten-free diet does not modify the course of hepatic disease.

Listeriosis in patients infected with human immunodeficiency virus

Although resistance to Listeria monocytogenes infection requires intact T cell-mediated immunity, only 20 patients with human immunodeficiency virus (HIV) infection and listeriosis (including one patient described herein) have been reported to date. Listeriosis developed before AIDS in five cases. Syndromes included meningitis in nine cases, bacteremia in nine, brain abscess in one, and endocarditis in one. Eighteen patients were treated with ampicillin, penicillin, or amoxicillin with or without aminoglycosides. Clinical and microbiologic responses were obtained in one patient with bacteremia treated with vancomycin and in one patient with meningitis treated with trimethoprim-sulfamethoxazole. Three of the nine patients with meningitis died, as did the patient with brain abscess. All nine patients with bacteremia and the patient with endocarditis survived. No case of relapse was documented. L. monocytogenes, although uncommon, should be considered in the differential diagnosis of febrile illness, meningitis, and brain abscess in patients with HIV infection.

[Multicenter study of fluconazole in the treatment of oropharyngeal candidiasis in immunodepressed patients]

We have evaluated the efficacy of fluconazole, 50 mg/day for 2 weeks, to treat oropharyngeal candidiasis in immunologically compromised patients. There were overall 27 patients, 25 of which were HIV+ and 2 had neutropenia. The rate of clinical response at the end of therapy, and one week and one month afterwards were 96%, 76% and 64%, respectively. The microbiological eradication was achieved in 36% of patients. The tolerance of the drug was satisfactory, although in 3 cases features of hepatic toxicity were detected. The convenience, good tolerance and clinical efficacy of fluconazole make it the therapy of choice for oropharyngeal candidiasis in immunologically compromised patients.

Beta-lactam-fosfomycin antagonism involving modification of penicillin-binding protein 3 in Pseudomonas aeruginosa

Antagonism between fosfomycin and antipseudomonal penicillins, cefotaxime, and ceftriaxone was observed in Pseudomonas aeruginosa RYC212. Fosfomycin, a non-beta-lactam antibiotic that acts on bacterial cell wall synthesis, decreased the expression of penicillin-binding protein 3 and induced beta-lactamase. The antagonistic effect was reduced in the presence of high concentrations of the beta-lactamase inhibitor tazobactam or in fosfomycin-resistant mutants. We suggest that products resulting from fosfomycin cell wall damage could interact with a system that regulates penicillin-binding protein and beta-lactamase production.

[Infectious complications in neutropenic patients with malignant hemopathies. A prospective study of 279 cases of neutropenia]

We prospectively evaluated the infective complications in 279 neutropenic episodes which developed during the treatment of 79 patients with malignant hemopathies over a 35 month period. In 150 episodes (53.73%) infections were detected: one infection in 121 episodes and two in 29 episodes. Overall 179 infections were detected. 75 of them (41.89%) were considered as possible, 57 (31.84%) were microbiologically documented with bacteremia/fungemia 24 (13.40%) were clinically documented, and 23 (12.84%) were microbiologically documented without bacteremia/fungemia. The portal of entry could not be identified in 121 infections (67.59%), 26 (14.76%) originated in the skin and soft tissues, 14 (7.82%) in the lung, 7 (3.91%) in the oropharynx, 5 (2.79%) in a catheter, and 6 (3.33%) were of miscellaneous origin. Of 80 microbiologically documented infections, 39 (48.75%) were due to gram-negative bacteria, 23 (28.75%) to gram-positive bacteria, 12 (15%) to fungi, and 6 (7.5%) to polymicrobial flora. The overall mortality rate was 4.3%. It was 8% for episodes complicated by infection and 0 in episodes of neutropenia without infection.

Central nervous system toxoplasmosis in AIDS patients: efficacy of an intermittent maintenance therapy

Fifty-five episodes of central nervous system (CNS) toxoplasmosis developing in 43 of the 329 AIDS cases seen at our institution were diagnosed during a 34-month period and were prospectively studied. Acute episodes were treated with a pyrimethamine/sulfadiazine (P/S) combination for a mean of 21 days. Because of a previously known major allergy to sulfonamides, three episodes were treated with clindamycin instead of sulphadiazine. In those patients who accepted maintenance therapy, a combination of P/S or pyrimethamine and clindamycin (P/C) was administered 2 days per week. Thirty-six patients (83.7%) survived the first episode. Four of these 36 were lost to further study. Six of the 12 (50%) who decided not to undergo maintenance therapy relapsed (mean follow-up: 12 months). Fourteen patients were given P/S and none relapsed while they were on maintenance therapy (mean follow-up: 10.3 months). Six patients received an intermittent maintenance treatment with P/C and one relapsed 2 months after starting the maintenance therapy (mean follow-up: 13.7 months). We conclude that an intermittent (2 days per week) maintenance treatment for CNS toxoplasmosis with P/S was effective in preventing relapses, although prospective randomized studies remain to be done.

[Mucormycosis. The disease spectrum in 13 patients]

Mucormycosis is an uncommon infection caused by fungi of the order Mucorales. During an 8-year period, mucormycosis was diagnosed in 13 patients from three Madrid hospitals. There were 8 males and 5 females, with ages ranging from 21 to 75 years (mean 45 years). There were several underlying diseases, and 4 patients had more than one. Five had diabetes mellitus, 4 chronic renal failure, 2 acute myeloblastic leukemia, 2 were narcotic abusers and were infected by the human immunodeficiency virus (HIV), 1 had non-Hodgkin's lymphoma, 1 was a carrier of a renal allograft and 1 had systemic necrotizing vasculitis. There were different clinical presentations: rhino-orbital in 3, paranasal in 2, cutaneous in 2, pulmonary in 2, primary cerebral in 2, rhinocerebral in 1, and peritoneal in 1. The diagnosis was made during the first week in 6 patients, in the second week in 4, and it was delayed for more than one month in 2. Fresh examination of clinical samples was carried out in 3 patients and hyphae were visualized in all 3. Cultures were taken in 10 patients and they were positive in 7. All isolates were identified as Rhizopus sp. One patient died within 24 hours without being treated, 12 were treated with amphotericin B and 9 received surgical therapy. Six patients (46%) died. The involvement of central nervous system and the absence of surgical therapy were associated with a poor outcome. These results indicate that mucormycosis can develop in several clinical contexts and has a varying clinical presentation. It is a potentially curable infections when early diagnosed and appropriately treated.

[Thoracic pain possibly of esophageal origin. Results of a prospective study]

We have studied the prevalence of esophageal pathology, by means of esophagogram, esophagogastroscopy, manometry, 24-hours ambulatory pH measurement and acid perfusion of the esophagus, in 44 patients with thoracic pain suggestive of angina. Esophageal pathology was demonstrated in 30 (68.3%) cases; 25 patients were diagnosed of reflux and 5 of primary motor alteration. All the patients received specific treatment; the response to treatment was good in 22 of them (17 with reflux and 5 with motor alterations). In conclusion, esophageal pathology is a common cause of thoracic pain, and reflux is the most frequent finding.

[Early complications of pneumatic dilatation in the treatment of primary motility disorders of the esophagus]

We analyze the incidence and evolution of the early complications of 96 consecutive patients with primary esophagus motor disorders, treated with pneumatic dilatation under endoscopic control (1.4 sessions per patient). In 4 (0.042/patient, 0.029/dilatation) patients the esophagus was perforated; the diagnosis was made in the first 24 hours; pneumomediastinum was a constant finding in the radiological exploration. In three cases the complication was suspected because of the apparition of sustained thoracic pain after the dilatation maneuver and in one case the presentation symptom was bleeding of cardial mucosa, larger than usual, at the end of the dilatation. The four patients evolved favorably with conservative treatment (avoidance of oral food intake, gastroesophageal aspiration, antibiotic therapy and parenteral nutrition).

Penicillin-binding protein 3 of Listeria monocytogenes as the primary lethal target for beta-lactams

Penicillin-binding proteins (PBPs) of Listeria monocytogenes were detected by their ability to bind to [2,3-3H]benzylpenicillin. Five proteins with Mrs of 95,000, 84,000, 80,000, 76,000, and 49,000 were detected. PBPs 1 to 4 had a high affinity for [2,3-3H]benzylpenicillin and were relatively scarce (80 to 150 molecules per cell). In contrast, PBP 5 was more abundant (600 molecules per cell) but had a low affinity for [2,3-3H]benzylpenicillin. L. monocytogenes has a relatively high natural resistance to cephalosporins. Competition experiments showed that cephalosporins bound very poorly to PBP 3 but were good inhibitors of PBPs 1, 2, and 4, which were completely blocked at concentrations well below the MIC. Analysis of a spontaneous imipenem-resistant mutant revealed that resistance was likely due to an altered PBP 3 with a reduced affinity for [2,3-3H]benzylpenicillin. These results suggest that PBP 3 is a primary lethal target for beta-lactams in L. monocytogenes.

Impact of the BACTEC NR system in detecting Candida fungemia

As a result of the growing importance of candidemia, various techniques for the detection of Candida spp. in blood have been designed with a view to speeding up the laboratory procedure. We have performed a retrospective comparison of the efficiencies of the conventional VACUTAINER system (Becton Dickinson Vacutainer Systems) and the BACTEC NR system (Johnston Laboratories, Inc.). During a 4-year period, 88,300 blood cultures were processed, with growth of Candida species in 552. The mean times required for the detection of growth were 7.55 days with the VACUTAINER system and 4.1 days with the BACTEC NR system (P less than 0.05). During the first week of incubation, the VACUTAINER system detected 56.1% of the candidemias and the BACTEC NR detected 93.6% (P less than 0.05). Use of the BACTEC NR therefore permits reduction of the incubation period from the previously established 4 weeks to a more convenient 7 to 14 days.

[Wilson's disease: difficulties in diagnosis and therapeutic management in our country]

The clinical analytical and therapeutic results of a retrospective study of 11 cases of Wilson's disease carried out in "La Fe" Hospital in Valencia are presented. The disease had a neurological onset in 5 cases, an hepatic onset in 4 cases (3 acute hepatitis and 1 chronic hypertransaminemia), 2 cases started as an acute hemolytic anemia; one of the outbreaks occurred during a period of treatment interruption. Diagnosis showed some difficulty in one case since the disease was associated with positive hepatitis B markers, positive anti HIV antibodies and initially normal ceruloplasminemia values. The diagnostic difficulties derived from the interpretation of ceruloplasminemia, and blood and urine copper levels are pointed out as well as the difficulties encountered in our environment to determine intrahepatic copper levels and to perform a kinetic study with radioactive copper both of which are of vital importance to confirm doubtful cases. Two patients became pregnant in the course of the disease having normal pregnancies and deliveries, without any apparent abnormalities in the newborns. Treatment with D-Penicillamine was started in 9 cases, observing a low to moderate intolerance in 7 cases; there was one case of severe intolerance for which treatment had to be interrupted. The new therapeutical approaches based on the use of trientine (not available in our country) are discussed, together with the expectations of liver transplant in this disease.

Central nervous system infection caused by Pseudallescheria boydii: case report and review

Pseudallescheria boydii is an uncommon cause of central nervous system (CNS) infections. Of a total of 21 cases of CNS infections caused by P. boydii (one described for the first time and 20 reported previously in the English-language literature), eight occurred in immunosuppressed patients and four in patients who nearly drowned; three were trauma related and two were iatrogenic (epidural anesthesia and ventriculoperitoneal shunt, respectively); one occurred in a patient with insulin-dependent diabetes mellitus, and three, in patients without underlying disease or predisposing conditions. The clinical manifestations included brain abscesses (13 cases), spinal pachymeningitis (two cases), chronic meningitis (two cases), intraventricular device-related ventriculitis (two cases), cranial epidural abscess (one case), and acute meningitis (one case). Seven patients showed clinical evidence of extraneural involvement by P. boydii. The outcome is known for 20 patients. Of these, the diagnosis was established while the patient was alive in 18 cases, in spite of which, 15 patients died. All five survivors were managed surgically, and two received intravenous miconazole. P. boydii should be included in the differential diagnosis of CNS infections that occur in the face of immunosuppression, near drowning, and trauma. Occasionally P. boydii can cause CNS infection in the absence of underlying disease or predisposing conditions.

Visceral leishmaniasis in patients infected with human immunodeficiency virus (HIV)

In an 8-month period nine patients with human immunodeficiency virus (HIV) infection were diagnosed as having visceral leishmaniasis; all diagnoses were based on cultures (eight from bone marrow and one from the skin). Visceral leishmaniasis developed before full-blown acquired immunodeficiency syndrome (AIDS) in seven patients and at the same time as or after AIDS in the other two patients. Three patients had a history of leishmaniasis. Clinical manifestations and laboratory findings were atypical. Leishmania species were cultured from samples taken from all patients; however, six patients had an insignificant antileishmanial antibody titer and Leishmania amastigotes were not seen in their bone marrow smears. Four isolates were identified by isoenzyme analysis as Leishmania donovani infantum. Five patients died, including two patients who had completed at least one 3-week course of therapy with N-methylglucamine antimoniate. Screening should be done for visceral leishmaniasis in patients with HIV infection who live or travel in areas where the disease is endemic. The diagnosis of visceral leishmaniasis may frequently be missed if cultures are not done.

[Bacteremia caused by Bacteroides. An analysis of 50 episodes]

During the 32 months between October 1984 and May 1987 there were 72,800 admissions in our center; 31,523 blood cultures were undertaken and in 3,831 of them (11.5%) at least one significant organism was recovered; 6.7% of blood cultures yielded anaerobic bacteria, and 3.1% Bacteroides spp. In the 1,478 instances of bacteremia recorded during that period, the relative frequencies of bacteremia by anaerobic bacteria and by Bacteroides were 8.6% and 3.9%, respectively. In overall 50 Bacteroides bacteremias (47 due to Bacteroides fragilis and 3 to Bacteroides spp), 32 (64%) were hospital acquired and 14 (28%) postsurgical. Their most common source was the abdominal cavity (25, 50%), followed by the skin and soft tissues (7, 14%), feminine pelvis (4, 8%), miscellaneous (8, 16%), and unknown (7, 14%). Fifteen bacteremias (30%) were polymicrobial, 20 (40%) were associated with septic shock, and 15 (30%) with renal failure. Overall mortality rate was 52%, and that directly attributable to bacteremia was 32%. Poor prognostic predictors included the source from a perforated viscus, septic shock, renal failure or gastrointestinal hemorrhage, and the absence of adequate antimicrobial therapy.

[Combined therapy with chenodeoxycholic acid and ursodeoxycholic acid of radiolucent biliary lithiasis]

27 patients with radiolucent biliary stones in normofunctioning gall bladder were treated with a combination of CDCA and UDCA (CDCA doses = 7.7 mg/kg/day; UDCA--6.5 mg/kg/day); only 23 continued in the study for at least one year. The reasons for leaving were in one case the necessity of a cholecystectomy and treatment interruption in 3 cases. The rate of complete dissolution was of 39%, being of 17% the partial dissolution rate. The only biochemical alteration was the increase of HDL cholesterol at 9 and 12 months of treatment (p less than 0.05 and p less than 0.01 respectively). Transient diarrhea was seen in 17% of the patients and it did not require treatment. The incidence of liver colic during the year before treatment was 26% and it decreased during the 1st year of treatment to 4%. The non-specific dyspepsia observed during the year before treatment was of 48%, and decreased to 17% during the first year of treatment. Only one patient developed calcification of the gallstone, 12 months after treatment.

Prospective assessment of donor blood screening for antibody to hepatitis B core antigen as a means of preventing posttransfusion non-A, non-B, hepatitis

The relationship between donor status for antibody to hepatitis B core antigen and the occurrence of non-A, non-B posttransfusion hepatitis in the recipient was prospectively studied in 112 patients undergoing open-heart surgery who were followed for 6.5 months after surgery. Non-A, non-B posttransfusion hepatitis occurred in five (7.93%) of 63 patients who had received at least one anti-HBc-positive blood unit compared to seven (14.28%) of 49 patients who received anti-HBc-negative blood only. Statistical analysis revealed that the incidence of non-A, non-B posttransfusion hepatitis was independent of the use of blood positive for anti-HBc. Based upon these results and the high prevalence (17.3%) of anti-HBc among our blood donor population, the exclusion of anti-HBc-positive blood does not seem appropriate to achieve a reduction in the incidence of non-A, non-B posttransfusion hepatitis.

Endoscopic biliary manometry in patients with suspected sphincter of Oddi dysfunction and in patients with cystic dilatation of the bile ducts

We studied the motility of the sphincter of Oddi in 12 patients with suspected sphincter of Oddi dysfunction, in four patients with cystic dilatation of the bile ducts (two Caroli's cases and two fusiform choledochal cyst cases), and in 33 patients with retained common duct stones. In these last 33 patients, the motor activity of the sphincter of Oddi was similar to that recorded in nine control subjects without pancreatic or biliary diseases. In the suspected Oddi dysfunction cases, both the basal sphincteric pressure and the frequency of the phasic contractions were significantly elevated (P less than 0.001). Patients with biliary cystic dilatation showed an increased basal pressure, but the frequency of the contractions was elevated in only those with choledochal cysts and the amplitude in only one of the two patients with Caroli's disease. Motor disorders of the sphincter of Oddi provide a basis for an alternative etiopathogenesis of cystic disease of the biliary system and a possible explanation for pain and dilatation of the bile duct in patients with suspected sphincter of Oddi dysfunction.

Motor pattern of the sphincter of Oddi in patients with bilioenteric shunt: a manometric study

An endoscopic biliary manometry was performed on 11 patients with a surgical bilioenteric shunt--choledochoduodenostomy--and no pressure gradient between common bile duct and duodenum. Basal pressure and frequency of the phasic waves of the sphincter of Oddi were significantly higher in these patients than in controls or in patients with retained common bile duct stones. These results suggest a functional adaptation of the sphincter of Oddi in an attempt to recover the normal pressure in the biliary tract.

Diagnosis of malignant ascites. Comparison of ascitic fibronectin, cholesterol, and serum-ascites albumin difference

The ascitic fluid concentrations of cholesterol and fibronectin and the serum-ascites albumin difference were compared with two conventional tests of ascitic fluid, total protein and LDH, in their diagnostic ability for detection of malignancy in ascitic samples from 69 patients with ascites: 54 with ascites due to liver disease and 15 whose ascites was caused by peritoneal metastases. Sixteen cirrhotic patients with superimposed hepatocellular carcinoma in whom ascites was of uncertain etiology were considered separately. The mean ascitic fluid total protein, LDH, cholesterol, and fibronectin values in the peritoneal metastases group were 3.70 +/- 1.20 g/dl, 247.26 +/- 148.14 units/liter, 109.06 +/- 29.85 mg/dl, and 91.57 +/- 41.52 micrograms/ml, respectively, and all were significantly higher than the corresponding values in the liver disease group (P less than 0.001), which were 1.37 +/- 0.59 g/dl, 75.40 +/- 110.70 units/liter, 23.75 +/- 11.22 mg/dl, and 31.86 +/- 10.51 micrograms/ml, respectively. Mean serum-ascites albumin difference in the peritoneal metastases group was 0.62 +/- 0.38 g/dl, which was significantly different from the corresponding value in the liver disease group (1.92 +/- 0.41 g/dl, P less than 0.001). Both ascitic cholesterol above 46 mg/dl and an ascitic fibronectin concentration greater than 50 micrograms/ml had high diagnostic accuracy (97%) for malignancy, being higher than that achieved using a serum-ascites albumin difference under 1.1 g/dl and an ascitic total protein above 2.5 g/dl, which had accuracies of 94% and 93%, respectively. Ascitic fluid LDH was the least reliable test. No differences in the ascitic fluid analysis were found between cirrhotic patients with and without hepatocellular carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)