[Severe orbital cellulitis: therapeutic results in 9 patients and review of the literature]

BACKGROUND

Orbital cellulitis can produce severe neuromeningeal infections. Modern antimicrobial agents such as imipenem can be a valid therapeutical choice.

METHODS

Patients with severe or complicated orbital cellulitis admitted to our hospital from 1986 through 1994 were retrospectively studied.

RESULTS

Nine patients with severe orbital cellulitis, seven of them older than 14 years, are reported. Cellulitis was secondary to different forms of sinusitis in five of them. The incriminated microorganisms were: Streptococcus viridans alone or combined to gram negative bacilli (3 cases), Prevotella melaninogenica and other anaerobes (2 cases), Enterococcus faecalis and Staphylococcus aureus (one case each). Three patients developed brain abscesses, one an acute bacterial meningitis and another a subdural empyema. Eight patients underwent a surgical drainage. Seven patients were treated with IV imipenem at doses of 2-3 g/day with complete cure of the orbital cellulitis and of the associated infectious complications and no secondary effects. Two patients died.

CONCLUSIONS

Imipenem is an effective antibiotic in the combined medical-surgical treatment of the severe or complicated orbital cellulitis.

[Infectious endocarditis of the native valve: its epidemiological profile and an analysis of its mortality between the years 1984 and 1993]

BACKGROUND

The description of the epidemiologic profile and analysis of the mortality of infectious endocarditis (IE) observed from 1984-1993.

METHODS

One hundred thirty episodes of IE in a native valve (30 in drug addicts [IVDA] and 20 cases of nosocomial acquisition) were analyzed with right/left/bilateral localization (42/84/4, respectively), infection of the mitral/aortic/tricuspid valve (52/47/34, respectively) and the etiology was determined as Staphylococcus aureus in 52 cases, 41 Streptococcus, 13 negative coagulase Staphylococcus, and 11 Enterococcus. High risk IE were identified by uni and multivariate analysis (MVA).

RESULTS

The incidence of IE ranged from 0.36 and 0.70 cases x 1.000 admitted adults/year (mean: 0.50). Transthoracic echocardiography detected bacterial vegetations in 67% of the cases with the validity to predict the development of embolisms being 55%. MVA showed the embolic episodes (present in 45% of the IE) to be associated with the IVDA patients and prolonged fever. The latter complication, being defined as > or = 10 days of fever under appropriate treatment, was observed in 32% of the cases and was due to mild (n = 15) and severe causes (n = 27). Postembolic septic complications were associated to fever with MVA. Twenty three patients died (18%), 2 IVDA and 5 nosocomial IE, mainly due to heart failure (n = 13). The independent risk factor predictors for death (p < 0.05) were: age > or = 60 years (mortality 34%), cerebral embolisms (55%), severe heart failure (37%), and the exclusion of the patient as a candidate for surgery (73%). To the contrary, right IE (mortality 0%) and cardiac surgery (5%) favoured survival.

CONCLUSIONS

To improve the prognosis of infectious endocarditis in high risk patients more opportune cardiac surgery accepting greater risks should be performed.

[Antiphospholipid antibodies in human immunodeficiency virus infection]

BACKGROUND

The frequency, clinical significance and prognosis of the lupic anticoagulant and the anticardiolipin antibodies were analyzed in patients with the human immunodeficiency virus infection.

METHODS

A group of 34 consecutive patients seropositive to HIV with lupic anticoagulant was studied in relation with 75 seropositive subjects without circulating anticoagulant and a control group of plasma of 23 seronegative individuals. The lengthening of thromboplastin time (relation > 1.3) was used as a screening test. The anticardiolipin antibodies IgG were studied by commercial enzymoimmunoassay.

RESULTS

Lupic anticoagulant was detected in 21% of the patients with AIDS and in 3% of the seropositive patients without AIDS. The anticoagulant was found in 13 of 53 cases with tuberculosis, in 8 of 57 with pneumonia by Pneumocystis carinii, in 4 of 32 with bacteremia and in 3 out of 8 with lymphoma. In another six patients other minor processes and/or HIV seropositivity were coexistent. Thrombosis was not seen in any case, and the rate of thrombocytopenia (18%) was that to be expected in this population. The patients with anticoagulant had a greater prevalence to developing AIDS, opportunistic infections and tuberculosis with respect to the seropositive group without anticoagulant, however, no differences were observed in the prevalence and levels of anticardiolipin antibodies and other nonspecific autoimmune phenomena. Periodic follow up of the patients with anticoagulant demonstrated persistence of the anticoagulant in 31% and reappearance of the same in 23% with new infections.

CONCLUSIONS

No correlation was found between the different antiphospholipid antibodies in the patient infected by the human immunodeficiency virus. Low titers of anticardiolipin antibodies are indicative of disease progression.

[Replication indexes of the human immunodeficiency virus: predictive value of viral culture and blood antigens]

BACKGROUND

To investigate the relation between markers of load and replication of the HIV [viral culture in plasma and in mononuclear cells of peripheral blood (MCPB) and antigen p24 (p24Ag) with the number of CD4+ cells and the prognosis of the patients.

METHODS

A retrospective study was performed in 188 patients who were analyzed and followed over a mean period of 431 days. The criteria of clinical progression (AIDS related complex, and new opportunistic infections), immunologic progression (CD4+ < 0.1 and < 0.05 + 10(9)/l) and death. Cocultures of HIV in free plasma and in MCPB were performed with the detection of complete AgHIV in the supernatant of the culture being used for analysis. Circulating p24Ag was determined by an ELISA technique without previous dissociation of the immunocomplexes.

RESULTS

HIV cultures in plasma, in MCPB and p24Ag were positive in 27, 48 and 33% of the patients, respectively. The sensitivity of the indexes increased in agreement with the clinical progression of the patients and was inversely proportional to the depletion of the CD4+ lymphocytes (79% of the patients with CD4+ lymphocytes < 0.05 x 10(9)/l presented positive HIV culture in plasma). Viremia in plasma and to a lesser measure p24Ag correlated with variables recognized as bad prognosis and were found to be predictive of unfavorable evolution. Multivariate analysis demonstrated that pertenence to a symptomatic group and the presentation of a number of CD4+ lymphocytes of less than 0.2 x 10(9)/l were independent factors associated to the positivity of the viral culture in plasma and p24Ag. The culture positive in MCPB was principally related with the volume of blood analyzed. The risk of death was 6.38 fold greater in the presence of a positive plasma culture and 2.02 fold greater in the presence of positive p24Ag. In contrast, the unquantified positive HIV culture in MCPB showed no statistical significance in relation with patient survival.

CONCLUSIONS

Positive HIV culture in plasma was the greatest prognostic index in patients with a number of CD4+ lymphocytes less than 0.2 x 10(9)/l. Unquantified cell culture had no predictive significance. To establish the prognosis of patients, the indexes of viral replication should not be used in isolation.

[Hospital infection caused by enterococci. The previous use of antibiotics as risk factors in a case-control study]

BACKGROUND

Nosocomial infection by enterococci is of growing importance and recognition. The risk factors, morbidity and prognosis of the same were investigated by a case and control study in a third level university hospital.

METHODS

One hundred patients with nosocomial infection by enterococci were compared with 100 randomly selected control patients with non enterococcic nosocomial infection. Cases and controls were taken from a series of 10,926 patients examined in search of nosocomial infection by successive cut offs of prevalence.

RESULTS

The prevalence of nosocomial infection by enterococci was found to be 9.9 per 1,000 admissions. Analysis among cases and controls by the odds ratio indicated a positive association for nosocomial infection by enterococci for the following risk factors: male sex (1.8), receipt of intensive care (3.6), predisposing diseases (3.1), urinary catheter (3), abdominal-genital surgery (2.4) or nephro-urologic surgery (4.6), other previous infections (1.9) and previous exposure to antibiotics (3.7), mainly aminoglucosides (4.2). Urinary infections and those of the surgical wound predominated, 15 patients had bacteremia, with mortality related with infection being 2%, preinfection hospital stay was 34.7 days and the mean stay was of 8.3 days but these data were not statistically different in the control group. The enterococcic infections were most frequently polymicrobian (odds ratio 5.5) received worse antibiotic coverage (5.1) and presented greater number of therapeutic failures or recurrences (2.5).

CONCLUSIONS

Nosocomial infection by enterococci is relatively frequent and virulent. The risk factors identified in this study are in agreement with those found in most series. The previous use of aminoglucosides was specially capable of selecting enterococci but only 13% demonstrated high level resistance to gentamicin.

[Epidemiologic study of Lyme disease in Asturias]

BACKGROUND

The aim of this study was to confirm the Sierra del Sueve (Asturias) as an endemic area for Lyme's disease and determine the seroprevalence of this disease in inhabitants of this and other zones of Asturias.

METHODS

A taxonomic study of 233 ticks in this county was carried out and the rate of infection by Borrelia burgdorferi was determined by culture in modified Kelly medium. Seroprevalence of Lyme's disease was studied by enzyme-immunoanalysis IgG-IgM in 150 inhabitants from several counties of Asturias.

RESULTS

The tick Ixodes ricinus is the most abundant species in the zone. All the cultures of Ixodes for Borrelia burgdorferi were negative. Among the farmers of the area of Sueve, seroprevalence of Lyme's disease was higher than in other population groups.

CONCLUSIONS

The Sierra del Sueve is an endemic area of Lyme's disease because of the appropriate vector I. ricinus and the super-population of Fallow deer. In this county the percentage of asymptomatic seropositives for this disease is much higher than that of other zones in Spain.

[Trends observed in the use of antimicrobial agents at a Spanish hospital from 1986 and 1991]

BACKGROUND

The recent introduction of new antimicrobials allows important changes in the controversial field of their prescription. Longitudinal analysis of the quality and tendencies of the use of antibiotics constitutes one of the basic tools for adapting antibiotic policy.

METHODS

This study was undertaken in a university hospital with antibiotic policy plans and institutional protocols of antibiotic prophylaxis. The use of antimicrobials with prophylactic and therapeutic aims has been analyzed by 12 prevalence studies over 6 years in a sample equivalent to 10.2% of the population admitted. A comparison between the first three counts (1986-1987) and the last three (1990-1991) was performed.

RESULTS

A mean of 26.6% of the patients admitted used antibiotics. Nonetheless, while its use as treatment grew with progressive deterioration in the quality of use, its use for prophylaxis decreased and improved. Parallel, the use of restricted antibiotics grew from 12 to 19%. The comparison of the habits of prescription between the onset and the end of the study showed the following important changes: decrease in the use of aminopenicillins and cotrimoxazole and increase in the use of first and third generation cephalosporins, antifungal drugs, tobramycin, vancomycin, the group of urinary antiseptics and quinolones and the miscellaneous group of antimicrobials of minor use.

CONCLUSIONS

Antibiotics for therapy have been used more and worse, despite the restrictive barriers. The control methods have been effective in prophylaxis with the exception of its excessive prolongation which remains the principal problem. Changes have been registered in the pattern of use of antibiotics in favor of new more effective drugs against multiresistant flora.

[The clinical significance of culturing Toxoplasma gondii on blood and other organic media]

BACKGROUND

The aim of this study was to determine the value of the Toxoplasma gondii culture in blood and in other organic fluids in HIV positive and negative patients.

METHODS

Retrospective analysis (October 1990-May 1992) was carried out including all patients with positive cultures for T. gondii admitted to the Hospital Central of Asturias. The parasite was identified by monoclonal antibodies against the tachyzoite membrane. All patients with positive cultures were treated with pyrimethamine and sulphadiazine.

RESULTS

Three hundred two samples from 256 patients, seropositive and seronegative for HIV, were analyzed. Of the seropositive group 8/45 (18%) had positive cultures for T. gondii versus 9/211 (4.3%) of the seronegative group (p = 0.002). Of the 19 positive samples, 15 were from blood, 3 from bronchoalveolar lavage and one from the vitreous fluid. Four out of 9 patients (44%) with AIDS and encephalic toxoplasmosis (ET) had blood cultures positive for T. gondii. Another 4 patients with AIDS presented toxoplasmenia without visceral involvement. Of the 9 HIV seronegative patients (3 immunodepressed patients), 4 had pulmonary toxoplasmosis, one ocular toxoplasmosis, and other clinical forms of toxoplasmosis were seen in the remaining 4. All the patients evolved to cure except 2 cases coinfected by cytomegalovirus who died.

CONCLUSIONS

The identification of Toxoplasma gondii may be performed by blood cultures in half of the patients with AIDS and encephalic toxoplasmosis and in an undetermined percentage of the other clinical forms both in immunocompetent and immunodepressed subjects. In addition, toxoplasmemia has been registered in AIDS patients preceding any other organic seating of the parasite. Early antitoxoplasma therapy may, therefore, be effective.

[Pulmonary toxoplasmosis. Study of 4 cases and review of the literature]

BACKGROUND

Description of four cases of pulmonary toxoplasmosis and review of the literature.

METHODS

A retrospective analysis (October 1990-December 1992) was carried out of the patients with samples of tracheal aspirate, bronchoalveolar lavage (BAL) and lung biopsy positive for T. gondii by immunofluorescence with anti-P30 monoclonal antibodies and cell cultures.

RESULTS

Four patients were diagnosed of pulmonary toxoplasmosis, three being immunosuppressed (one renal transplant, one with chronic lymphoid leukemia and one intravenous drug user HIV seronegative) and the remaining one healthy. All the patients developed progressive dyspnea and a radiologic pattern of interstitial pneumonitis (3) or alveolar condensation (1). Three of the patients were cured with pyrimethamine and sulphadiazine. One patient had coinfection by CMV and died. Another 52 cases of this rare condition have been reported in the literature.

CONCLUSIONS

In the authors experience, bronchoalveolar lavage material and lung biopsy for T. gondii culture should be performed in immunosuppressed patients with an unclear interstitial radiologic pattern to rule out pulmonary toxoplasmosis.

Diabetes mellitus and bacteraemia: a comparative study between diabetic and non-diabetic patients

OBJECTIVES

To compare the incidence, mortality, clinical characteristics and outcome between bacteraemias in diabetic and non-diabetic patients.

METHODS

A prospective study of all adult patients with bacteraemia admitted to a large Spanish teaching hospital during six consecutive years (1984-1990); 152 were diabetics and 1488 non-diabetics.

RESULTS

Rates per 1000 admissions when bacteraemic diabetic patients were compared with non-diabetics (p < 0.001) were respectively as follows: incidence 26.8/15.5, acquisition in the community 18.4/6.2, urinary tract source 8.7/2.2, and E. coli aetiology 8.9/3.4. Diabetes mellitus type II was found in 138 episodes. Glycosylated haemoglobin levels were 13 +/- 3%. Bacteraemia developed in association with hyperosmolar status in 14.5% of patients and with ketoacidosis in 5%. Patients in the diabetic group developed septic shock in 22% of the episodes, acute renal failure in 40%, superinfections in 22% and had an inappropriate empirical antibiotic treatment in 6%, vs 15.6%, 20%, 11% and 25% respectively of the non-diabetic bacteraemic patients (p < 0.05 for all comparisons). Overall mortality and bacteraemia-related mortality were similar in both groups. Multivariate analysis showed that the association with fatal diseases, shock and renal insufficiency negatively influenced the outcome of diabetic patients, while the nephro-urologic source and an appropriate therapy were accompanied by a better prognosis.

CONCLUSIONS

A higher incidence of bacteraemia, mainly of urinary source, community-acquired, and due to E. coli was found in the diabetic patients compared to non-diabetics. The common use of rapidly effective drugs for this predominant bacteraemia conditioned similar outcome and prognosis factors in both populations, in spite of the higher incidence of septic shock and acute renal failure in the diabetic population.

Synergistic effect of human lysozyme plus ampicillin or beta-lysin on the killing of Listeria monocytogenes

Although ampicillin is often only bacteriostatic for Listeria monocytogenes in vitro, serum from ampicillin-treated patients was bactericidal. The bactericidal effect of serum was partly removed by bentonite, Seitz-filtration, and addition of FeCl3, suggesting it is mediated by lysozyme and beta-lysin. Partly purified human beta-lysin plus purified human lysozyme or either protein plus ampicillin were bactericidal for L. monocytogenes. Hen egg white lysozyme was not active. Lysozyme and beta-lysin were not synergistic with tetracycline, trimethoprim/sulfamethoxazole, or chloramphenicol. Thus, lysozyme and beta-lysin may play a role in the natural resistance to L. monocytogenes, and these serum proteins could contribute to the effectiveness of ampicillin in vivo.

In vivo treatment with anti B-220 monoclonal antibody affects T and B cell differentiation

The B220 cell marker is expressed on B cells and on T cell precursors. In order to determine the involvement of the B220 antigen on murine lymphoid differentiation, we treated 5-10-week-old mice periodically with a specific anti-B220 antibody, RA3-6B2, a non-cytolytic IgG2b. After the third injection, a significant reduction (P less than 0.02) in the number of thymocytes and less dramatically in the number of splenocytes was observed. This reduction was predominantly due to a decrease of cells carrying the following markers: Thy-1.2+, Lyt-1+, Lyt-2.3+, L3T4+, and asGM1+. Mitogenic response to concanavalin A, phytohaemagglutinin and lipopolysaccharide, mixed lymphocyte reaction, cytotoxic T cell activity, and plaque-forming cell generation were significantly decreased after the treatment (P less than 0.01). These results show that the in vivo treatment with anti-B220 monoclonal antibody reduced the number of T and B cells and modified their functional activity. This suggests that the B220 antigen is involved in the maturation of both T and B cells.

Treatment of autoimmune MRL/lpr mice with anti-B220 monoclonal antibody reduces the level of anti-DNA antibodies and lymphadenopathies

The predominant accumulating cells in the lymphoid tissue of MRL/lpr mice have been shown to carry the B220 cell marker. This antigen is expressed on B cells and on T-cell precursors. In order to know the pathogenic involvement of cells carrying this marker, we treated MRL/lpr mice periodically with RA3-6B2, a specific anti-B220 monoclonal antibody, or rat IgG2b as a control. After 12 weeks of treatment, a significant reduction (P less than 0.01) in the size of the lymph nodes and spleen was observed only in the group treated with RA3-6B2 monoclonal antibody. This reduction was mainly due to a decrease in the Thy-1.2+ and B220+ subpopulations. Anti-DNA and anti-Sm antibody titres were also reduced significantly (P less than 0.01) after the therapy. Proliferative response to mitogens (Con A, PHA, LPS) and IL-2 production was not improved after the anti-B220 treatment. These results suggest a pathogenic role of lymphocytes carrying the B220 marker in the autoimmune disease of MRL/lpr mice.