Pseudomonas aeruginosa orbital phlegmon in a patient treated for myelodysplastic syndrome with concomitant Sjögren's syndrome

Pseudomonas aeruginosa orbital infections have been described very rarely in patients with neutropenia after chemotherapy. We report the case of a woman with the unusual association of Sjögren's disease and myelodysplasia, who suffered from a Pseudomonas aeruginosa orbital phlegmon after chemotherapy for her myelodysplastic syndrome. Partial intestinal antibiotic decontamination with ciprofloxacine did not prevent the infection. She was treated successfully with intravenous ceftazidime, netilmicin and granulocyte-colony stimulating factor (G-CSF). The normalization of the granulocyte count seems to play a crucial role for recovery. We present the clinical and radiological findings, discuss the therapy and review the literature concerning ocular infections due to Pseudomonas. Other infections due to this germ in immunocompromised hosts are briefly reviewed.

Oral ciprofloxacin in the treatment of pseudomonas exacerbations of paediatric cystic fibrosis: clinical efficacy and safety evaluation using magnetic resonance image scanning

Ciprofloxacin is effective for treating pulmonary infection in adult cystic fibrosis patients, and demonstrates excellent efficacy against Pseudomonas aeruginosa, but its use in paediatric cystic fibrosis patients has been limited because quinolone-induced cartilage toxicity has been observed in juvenile animals and has been considered a potential risk for children. Children with cystic fibrosis (n = 26; aged 6-16 years), with proven P. aeruginosa colonization of their sputum, were enrolled into a 14-day, open, non-comparative study. Patients were assigned to twice-daily treatment with oral ciprofloxacin 250 mg, 500 mg or 750 mg, depending on their body weight. None of the patients exhibited any signs or symptoms of arthropathy, as assessed by magnetic resonance imaging of the right knee, during or immediately after treatment, or at the 3-month post-therapy assessment. Cough, sputum production and sputum purulence were improved in more than 70% of patients. Patients showed a mean weight increase of 0.4 kg (95% confidence interval 0.1 to 0.7 kg) over the study period. Only one patient required a repeat chest radiograph, which showed no resolution of the abnormal radiographic appearances. Three patients reported adverse events during the trial, none of which were considered to be related to the study treatment.

Primary pulmonary botryomycosis: case report and review

Botryomycosis is an uncommon bacterial disease characterized by the microscopic formation of eosinophilic granules that resemble those of infection by Actinomyces species. The diagnosis of botryomycosis can be made when microscopic inspection and culture of the granules reveal gram-positive cocci or gram-negative bacilli. Botryomycosis is caused by common bacterial pathogens including Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa, yet the host and microbial factors that contribute to the pathobiology remain unknown. Pulmonary botryomycosis can resemble actinomycosis, tuberculosis, or invasive carcinoma by causing a mass lesion with constitutional symptoms. Radiographically, it invades bone and disrupts tissue planes. Successful treatment often requires a combination of both surgical debridement and long-term antimicrobial therapy. We report a case of primary pulmonary botryomycosis and review the literature on this unusual infectious process.

The value of quantitative gallium-67 single-photon emission tomography in the clinical management of malignant external otitis

Malignant external otitis (MEO) is a severe infectious disorder usually caused by Pseudomonas aeruginosa, which most frequently affects diabetic patients. Due to its rarity, the diagnosis of MEO is often not made promptly. Extension into deeper structures or chronic osteomyelitis may occur without signs of infection on local clinical examination. Of the imaging techniques, magnetic resonance imaging provides a fairly adequate picture of the spread of the disease, but, as with computed tomography (CT) scanning and bone scintigraphy, the images remain unchanged for a long time after disease regression. The objective of this study was to establish whether quantitative gallium-67 single-photon emission tomography (SPET) represents an accurate method for the assessment of infection and, moreover, for the monitoring of therapeutic effect. Eight patients (five males, three females) with the clinical diagnosis of MEO were studied. In three patients antibiotic treatment was prolonged for several weeks because visual analysis of gallium scintigraphy still showed slightly increased uptake in the affected area on the first follow-up scan. In one patient, it was decided to stop antibiotic treatment despite a slight increase in uptake on the second follow-up scan. Lesion to non-lesion (L/NL) ratios obtained from 67Ga SPET images at initial diagnosis and during follow-up were assessed in correlation with clinical and biochemical data and with the results of CT scans. In addition to a raised erythrocyte sedimentation rate (ESR), all patients showed increased uptake on the affected side, with L/NL ratios ranging from 1.4 to 3.6 at the time of diagnosis. CT scans failed to demonstrate abnormalities in four patients. Including four scans demonstrating slightly increased uptake in the affected area, L/NL ratios after 6-8 weeks of antibiotic treatment were 1.0+/-0.1. Despite a persistently elevated ESR in the majority of patients, none of them demonstrated local recurrence or complications during follow-up. In all patients, leucocyte count was within the normal range throughout the course. No relation was found between the slightly increased uptake on the follow-up scans and surgical treatment. It is concluded that in addition to the visual analysis of 67Ga SPET imaging, L/NL ratios should be calculated for a more accurate assessment of disease activity in MEO. Despite visually slightly increased uptake, L/NL ratios of 1.0+/-0.1 during follow-up are highly indicative of complete recovery, regardless of ESR values or leucocytosis. CT scans are of little value for diagnosis or for monitoring of therapeutic effect.

Use of gallium-67 in the assessment of response to antibiotic therapy in malignant otitis externa--a case report

Malignant Otitis Externa (MOE) can cause considerable morbidity and mortality in affected individuals. The outlook is now much improved with the use of ciprofloxacin, but it is important to ascertain that the infection has been completely eradicated before stopping treatment, as undertreatment may lead to a recurrence which is usually more resistant than the initial infection. Gallium-67 Single Photon Emmision Computerised Tomography (SPECT) is a sensitive and cost effective tool in monitoring the disease activity of MOE, and should be used in the assessment of the response to antibiotic therapy.

A rare cause of late infective endocarditis after heart surgery

A case is reported of a male patient with rheumatic mitral valve disease and open mitral valve commissurotomy, performed 13 years before, who had fever and multiple septic embolic events. Serial blood cultures were positive for Pseudomonas aeruginosa. Transthoracic and transesophageal echocardiography demonstrated the presence of an irregular, round, very mobile mass inserted in the fossa ovalis region of the interatrial septum. After resolution of the infectious process, surgery was performed. The structure previously described corresponded to a elongated suture material covered by fibrin. It had been secondarily infected and it was the cause of the entire process.

Effects of airway infection by Pseudomonas aeruginosa: a computed tomographic study

BACKGROUND

Pseudomonas aeruginosa commonly infects the airways of patients with bronchiectasis. A study was undertaken to examine the relationship between infection of the airways with this pathogen, the morphological pattern of bronchiectasis on thin section computed tomographic (CT) scanning, symptom duration, smoking habits of the patients, and the presence of airflow obstruction.

METHODS

Thin section CT scans of 22 adult patients with bronchiectasis and concurrent sputum infected by P aeruginosa (Pa +ve) and those of 45 randomly selected patients not infected by P aeruginosa (Pa -ve) were analysed independently by two thoracic radiologists. Patients with cystic fibrosis were excluded. Each scan was scored at a lobar level for extent of bronchiectasis, severity of bronchial wall thickening and dilatation, predominant pattern of bronchiectasis, presence of mucus plugging, and degree of decreased attenuation of the lung parenchyma.

RESULTS

The Pa +ve group had more extensive bronchiectasis and a greater degree of bronchial wall thickening and dilatation on the CT scan than the Pa -ve group; more extensive decreased attenuation was seen in the Pa +ve group. These findings were robust on multivariate analysis; decreased attenuation was also independently related to the duration of sputum production.

CONCLUSION

Patients with bronchiectasis infected by P aeruginosa have more extensive and severe bronchiectasis on thin section CT scanning than those without P aeruginosa infection. The bronchi and small airways are both involved, reflecting the end result of complex interactions between host airways and the numerous virulence factors produced by P aeruginosa.

Pseudomonas aeruginosa bronchopulmonary infection in patients with advanced human immunodeficiency virus disease

Pseudomonas aeruginosa is increasingly reported as a respiratory pathogen in patients with advanced human immunodeficiency virus (HIV) disease. We retrospectively reviewed the chest radiographic appearances of 29 HIV-infected adults with bronchopulmonary infection in whom Pseudomonas aeruginosa was the sole respiratory pathogen isolated. The commonest radiographic abnormality was a diffuse reticular (11 patients) or reticulonodular (9 patients) infiltrate in the pulmonary interstitium. Alveolar opacification was seen in seven patients. Cavitation was rare (2 patients), as was ground-glass opacification (2 patients). Five patients had pleural effusions. No patient had mediastinal or hilar lymphadenopathy. Normal chest radiographs were seen in eight patients. Although the radiographic appearances of Pseudomonas bronchopulmonary infection in HIV-infected patients are non-specific, an interstitial infiltrate is a common finding. Pseudomonas aeruginosa should be considered along with the commoner pathogen Pneumocystis carinii in the differential diagnosis of an interstitial infiltrate in this group of patients.

Coalescent mastoiditis in a child with severe congenital neutropenia. Report of a case

This is a report of a case of coalescent mastoiditis seen in a 3-year-old child with severe congenital neutropenia. Pseudomonas aeroginosa was the main bacterial species recovered from the affected ear. Modified radical mastoidectomy was done and appropriate antibiotics administered. Operative wound infection with delayed wound healing was the hallmark of the postoperative follow-up period. Large spectrum oral antibiotics in addition to regular wound cleansing was an effective adjunct to therapy. On last follow-up operative wound was healed and mastoid cavity was clean. Occurrence, treatment, clinical and microbiological aspects of coalescent mastoiditis were described and discussed.

[Clinical experience with a new antimicrobially coated InterGard-IgK/AM vascular prosthesis in surgical treatment of deep wound infection with involvement of the synthetic bypass: report of 2 cases]

We report 2 cases of infected vascular prosthesis, where the infected alloplastic material was removed and the revascularisation of the lower extremity was done by implantation of the new antimicrobial surface-coated InterGard prosthesis in the area of the former infected graft. An extra-anatomical bypass was not promising in these cases. Clinical, bacteriological and granulocyte-scintigraphic examinations have provided no evidence for persisting infection 12 and 11 months after implantation of this prosthesis. We are aware that the postoperative observation periods are too short to allow definitive assessment. Nevertheless we still consider that this prosthesis means a new and promising option in the treatment of infected vascular graft.

Necrotizing (malignant) external otitis: prospective comparison of CT and MR imaging in diagnosis and follow-up

PURPOSE

To compare computed tomography (CT) and magnetic resonance (MR) imaging in the diagnosis and follow-up of necrotizing external otitis.

MATERIALS AND METHODS

CT and MR imaging were performed in seven patients at diagnosis and at 6 and 12 months after initiation of therapy. Imaging findings were compared and correlated with the clinical course of the disease.

RESULTS

Cortical bone erosion was best seen on CT scans (n = 5 vs n = 0 on MR images) and failed to normalize with cure. Subtemporal soft-tissue abnormalities (n = 7 with both modalities) were better appreciated with MR imaging and had low signal intensity on T1- and T2-weighted images. Soft-tissue changes improved but did not disappear completely with treatment.

CONCLUSION

CT is preferred at initial diagnosis, as small cortical erosions are better seen. Either modality can be used to follow up soft-tissue evolution. MR imaging may be better for evaluation and follow-up of meningeal enhancement and changes within the osseous medullary cavity.

Management of sinusitis in cystic fibrosis by endoscopic surgery and serial antimicrobial lavage. Reduction in recurrence requiring surgery

OBJECTIVE

An effective treatment program for refractory chronic sinusitis in patients with cystic fibrosis has not been achieved. We developed a long-term management approach by combining endoscopic surgery with serial antimicrobial lavage (ESSAL).

DESIGN

In a before and after trial, results of ESSAL in 32 patients were compared with those of conventional sinus surgery without serial antimicrobial lavage in 19 patients. At least 1 year follow-up was available in all but one patient.

SETTING AND PATIENTS

Patients attending the Stanford (Calif) Cystic Fibrosis Center were consecutively referred for otolaryngologic evaluation for symptoms and signs of refractory sinusitis. Those subjects who were evaluated before 1990 were treated conventionally and afterward by ESSAL.

INTERVENTION

Conventionally treated patients underwent one or more of the following procedures: polypectomy, ethmoidectomy, antrostomy, or Caldwell-Luc operation. The ESSAL approach incorporated preoperative rhinosinuscopy and computed tomography, endoscopic surgery, a postoperative course of antral antimicrobial lavage, and monthly maintenance antimicrobial lavage via brief antral catheterization.

MAIN OUTCOME MEASURE

Intensity and frequency of sinus surgery after initial presentation.

RESULTS

The two groups were similar demographically and in clinical presentation, including the presence of nasal polyposis in 34% and 42%, respectively. The ESSAL group had fewer operations per patient, Caldwell-Luc procedures, and a decrease in repeated surgery at 1-year (10% vs 47%) and 2-year (22% vs 72%) follow-ups.

CONCLUSION

The ESSAL is a successful approach to treatment of sinusitis in cystic fibrosis that reduces recurrence requiring further surgery for at least 2 years.

Bronchopulmonary infection with Pseudomonas aeruginosa in patients infected with human immunodeficiency virus

BACKGROUND

Pseudomonas aeruginosa infection is uncommon in HIV infected patients and is usually nosocomially acquired and associated with risk factors such as neutropenia or central lines. We have recently noted an increase in the number of respiratory isolates of Ps aeruginosa in hospitalised HIV positive patients and sought to describe the clinical correlates of this observation.

METHODS

A retrospective case notes review of HIV positive patients admitted to a specialist unit for respiratory investigations from January 1989 to December 1993 was undertaken in order to identify those with Ps aeruginosa respiratory infection and to describe associated risk factors, patterns of presentation and radiographic abnormalities.

RESULTS

Of 617 patients admitted 38 (6%) had Ps aeruginosa respiratory infection (notes were incomplete in 1 patient). All patients had advanced HIV disease; median CD4 = 0.02 x 10(9)/l. Two distinct presentations were seen; 9 patients had a fulminant course as part of a sepsis syndrome, 28 patients had an indolent presentation (18 had a single episode and 10 relapsed on one or more occasions, despite successful treatment of the initial episode). Infection was community acquired in 24 patients. Many patients had risk factors traditionally associated with Ps aeruginosa including neutropenia or indwelling central venous catheters, but 13 had no obvious risk factor. Most patients were receiving systemic pneumocystis prophylaxis and/or broad spectrum antibiotics; 20 had co-existent symptomatic sinus disease. A wide variety of chest radiographic abnormalities were seen including interstitial shadowing, mimicking pneumocystis pneumonia in 12 patients, lobar pneumonia in 2 and bronchial wall thickening in 13 patients.

CONCLUSIONS

Ps aeruginosa respiratory infection occurs with increased frequency in patients with advanced HIV disease; in a significant proportion infection is community acquired. Although recognised risk factors were present in two thirds of patients it appears that advanced HIV immunosuppression, use of systemic pneumocystis prophylaxis and/or broad spectrum antibiotics and sinus disease are important risk factors. The diagnosis should be considered in patients with advanced HIV disease who present with new respiratory symptoms.

Ventilator-associated Pseudomonas aeruginosa pneumonia: radiographic findings

PURPOSE

To characterize the radiographic features of ventilator-associated Pseudomonas aeruginosa pneumonia (PAP).

MATERIALS AND METHODS

In 56 patients (40 men and 16 women), PAP was documented with fiberoptic bronchoscopy. All patients underwent mechanical ventilation for at least 48 hours before diagnosis. The findings on chest radiographs were recorded. In eight patients in whom computed tomography (CT) was performed, results were compared with radiographic findings.

RESULTS

Twenty-six patients with adult respiratory distress syndrome (ARDS) had diffuse bilateral confluent opacities; 30 patients without ARDS had multifocal opacities. In 13 patients, cavities were detected at chest radiography, CT, or both. Seven of 29 patients with pleural abnormalities had empyema. CT provided important additional information (presence of cavities or effusions) in four cases.

CONCLUSION

Findings on chest radiographs are nonspecific for PAP. The frequencies of cavities and empyema are surprisingly low, perhaps owing to prompt diagnosis and therapy.

[Radiologic differential diagnosis of inflammatory round pulmonary infiltrates in immunocompromised patients. A prospective study using CT and MRT]

In a prospective study we examined the diagnostic ranking of CT and MR in 52 immunocompromised patients with nodular pulmonary lesions and clinical suspicion of invasive pulmonary aspergillosis (IPA). For early diagnosis of IPA (clinical symptoms having existed for less than 10 days) the CT halo sign proved highly sensitive and specific. MRT showed at this time a comparatively high sensitivity but only low specificity that could not be improved upon after Gd-DTPA. At a later stage of the aspergillosis infection (clinical symptoms manifested for more than 10 days) MR identified aspergillus-specific lesions with on-target characteristics (marked enhancement of margins after Gd-DTPA) or the so-called "reverse" target phenomenon (T2-weighted sequences). Such lesions were never seen in the early stage of the disease in patients with nodular pulmonary lesions of different aetiology (pseudomonal or staphylococcal pneumonia).