Effects of celecoxib, medroxyprogesterone, and dietary intervention on systemic syndromes in patients with advanced lung adenocarcinoma: a pilot study

Systemic syndromes characterized by a persistent activity of circulating mediators (cytokines) are frequently present with advanced cancer. We grouped under the general heading of "Systemic Immune-Metabolic Syndrome (SIMS)" a particular variety of distressing systemic syndrome characterized by dysregulation of the psycho-neuro-immune-endocrine homeostasis, with overlapping clinical manifestations. SIMS may include cachexia, anorexia, nausea, early satiety, fatigue, tumor fever, cognitive changes and superinfection. The aim of this study was to ameliorate some of the SIMS symptoms in a homogeneous group of lung adenocarcinoma patients using a multitargeted therapy. Fifteen patients with evidence of SIMS were studied. SIMS was defined as the presence of weight loss, anorexia, fatigue performance status>/=2 and acute-phase protein response. Patients received medroxyprogesterone (MPA) (500 mg twice daily), celecoxib (200 mg twice daily), plus oral food supplementation for 6 weeks. After treatment, 13 patients either had stable weight (+/- 1%) or had gained weight. There were significant differences in improvement of body-weight-change rate, nausea, early satiety, fatigue, appetite and performance status. Patients who had any kind of lung infection showed higher levels of IL-10 compared to non-infected patients (P=0.039). Our results suggest that patients with advanced lung adenocarcinoma, treated with MPA, celecoxib and dietary intervention, might have considerable improvement in certain SIMS outcomes. This multitargeted symptomatic approach deserves further study.

Fatal hemorrhagic pneumonia caused by infection due to Kytococcus sedentarius--a pathogen or passenger?

A 55-year old man developed a hemorrhagic pneumonia, likely due to infection with Kytococcus sedentarius during neutropenia following induction chemotherapy for acute myeloid leukemia. Severe mucosal barrier injury and the selective pressure of broad-spectrum antibiotics probably made it possible for this normally harmless commensal to penetrate the gut, spread through the blood stream, and invade the lungs.

[A case of strongyloidiasis hyperinfection during oral corticosteroid therapy associated with a nephrotic patient infected with HTLV-1]

There have been some reports of disseminated Strongyloidiasis associated with immunosuppressive therapy around the endemic area. We encountered an elderly patient with Strongyloidiasis hyperinfection during corticosteroid therapy. The case was a 75-year-old man, living in Tokunoshima, Kagoshima Prefecture, who had no remarkable past history. He visited a clinic because of exertional dyspnea and edema of the lower limbs. Laboratory examination showed renal dysfunction, microscopic hematuria and proteinuria. On December 2000, he was admitted to our hospital on a suspected diagnosis of rapidly progressive glomerulonephritis. Further examinations showed normal serum creatinine, severe microscopic hematuria and proteinuria of more than 3 g per day. Although we wanted to determine a treatment based on a pathologic diagnosis, considered his age and severe kyphosis, he had 30 mg of prednisolone as an empiric treatment. Strongyloides stercoralis were identified from his sputa and stool by microscopic investigation 21 days after initiation of corticosteroid therapy. Subsequently, 6 mg of Ivermectin was given twice every two weeks. S. stercoralis were eradicated and his proteinuria improved. This case suggests that S. stercoralis could be the cause of urine abnormality.

Influenza A virus-infected hosts boost an invasive type of Streptococcus pyogenes infection in mice

The apparent worldwide resurgence of invasive Streptococcus pyogenes infection in the last two decades remains unexplained. At present, animal models in which toxic shock-like syndrome or necrotizing fasciitis is induced after S. pyogenes infection are not well developed. We demonstrate here that infection with a nonlethal dose of influenza A virus 2 days before intranasal infection with a nonlethal dose of S. pyogenes strains led to a death rate of more than 90% in mice, 10% of which showed necrotizing fasciitis. Infection of lung alveolar epithelial cells by the influenza A virus resulted in viral hemagglutinin expression on the cell surface and promoted internalization of S. pyogenes. However, treatment with monoclonal antibodies to hemagglutinin markedly decreased this internalization. Our results indicate that prior infection with influenza A virus induces a lethal synergism, resulting in the induction of invasive S. pyogenes infection in mice.

Viral respiratory infections in association with asthma and sinusitis: a review

OBJECTIVE

Viral respiratory infections (VRIs) commonly precede asthma exacerbations in both children and adults. Likewise, VRIs may affect the paranasal sinuses, predisposing infected individuals to the development of subsequent acute bacterial sinusitis. This article discusses the role that viruses play in both the development of asthma and in acute asthma exacerbations. Mechanisms by which viral infections provoke asthma exacerbations are reviewed, and treatment of such episodes is discussed. The pathogenesis of sinusitis and association with VRIs is reviewed along with treatment recommendations.

DATA SOURCES

Relevant articles in the medical literature were reviewed with sources including randomized, controlled clinical trials, review articles, epidemiologic studies, and standard textbooks in allergy and immunology.

CONCLUSIONS

This review highlights the prominent role that viral pathogens (especially rhinovirus) play in exacerbation of asthma and in the development of sinus disease. The specific mechanisms whereby viral infection leads to an acute asthma exacerbation or to subsequent bacterial sinusitis are described. Treatment options are outlined including the potential future application of antiviral compounds.

[Efficacy of monotherapy by meropenem in ventilator-associated pneumonia]

We performed a prospective, open label, randomized study in intensive care unit patients with ventilator-associated pneumonia (VAP) to determine the efficacy and safety of empiric intravenous (i.v.) meropenem monotherapy compared with the combination of ceftazidime plus amikacin. A total of 140 patients receiving mechanical ventilation and diagnosed with pneumonia were included in the study. Patients were randomized to receive either 1 g meropenem i.v. every 8 hours or 2 g ceftazidime i.v. every 8 hours plus 15 mg/kg amikacin daily, administered to patients with normal renal function as two daily doses. Satisfactory clinical responses (cure or improvement) were achieved at the end of treatment in 68.1% of meropenem-treated patients and 54.9% in the ceftazidime/amikacin treated group (relative risk 1.25; 95% confidence interval > 1.00, 1.55). When non-evaluable patients were excluded from the analysis, the satisfactory clinical response was 82.5% and 66.1% for the meropenem and ceftazidime/amikacin patients, respectively (p = 0.044). Logistic regression demonstrated that treatment with meropenem and both the basic traumatic and medical pathologies were significantly associated with a satisfactory response. Adverse events judged to be possible or probably related to treatment were reported by seven (10.1%) patients in the meropenem group and by eight patients (11.3%) in the ceftazidime/amikacin group. The results of this study confirm that monotherapy with meropenem is well tolerated and provides superior efficacy to the conventional combination of ceftazidime and amikacin in combating VAP.

Role of the respiratory burst in co-operative reduction in neutrophil survival by influenza A virus and Escherichia coli

Influenza A virus (IAV)-induced impairment of neutrophil function or survival may be a cause of bacterial superinfection of IAV-infected subjects. This study was performed to determine the mechanism through which the combination of IAV and Escherichia coli co-operatively reduces neutrophil survival. Neutrophil binding of annexin-V and caspase-3 activation was significantly increased by either IAV or E. coli, supporting the concept that the micro-organisms accelerate neutrophil apoptosis. The anti-apoptotic agent granulocyte-macrophage colony stimulating factor (GM-CSF) did not improve, but further reduced, survival of neutrophils treated with IAV and E. coli. As addition of E. coli resulted in greater neutrophil uptake of IAV and greater neutrophil respiratory burst responses to IAV, this study tested whether respiratory burst activation by IAV and E. coli contributes to reducing neutrophil survival. The cell-permeant NADPH oxidase inhibitor, diphenylene iodonium, significantly increased survival of neutrophils treated with either E. coli alone or the combination of IAV and E. coli. In contrast, catalase, which is not cell permeant, did not alter survival of E. coli- and IAV-treated neutrophils. Azide enhanced neutrophil hydrogen peroxide responses to IAV and E. coli, and reduced survival of these cells. These results indicate that co-operative induction of intracellular respiratory burst responses by IAV and E.coli mediates the reduced neutrophil survival caused by these pathogens in vitro.

Latest discoveries on the infection and coinfection with hepatitis D virus

HDV is an incomplete virus that has HBV infection as a prerequisite. Superinfection by HDV leads to acute hepatitis and causes progression to liver cirrhosis in a significant proportion of HBsAg carriers. The traditional methods for the diagnosis of HDV infection, such as detection of serum anti-HD antibodies, are sufficient for the clinical diagnosis of delta infection. However, such techniques lack the sensitivity and specificity required to more accurately characterize the nature of HDV infection and to assess the efficacy of therapies. Recent improvements in molecular techniques, such as HDV RNA hybridization and RT-PCR, have provided increased diagnostic precision and a more thorough understanding of the natural course of HDV infection. These advances have enhanced the clinician's ability to accurately evaluate the stage of HDV infection, response to therapy, and occurrence of reinfection after orthotopic liver transplant.

Why we need to know whether prophylactic antibiotics can reduce measles-related morbidity

In some parts of the world, measles vaccination has resulted in very substantial reductions in measles-related morbidity and mortality. Even so, it has been estimated that 30 million people still contract the disease every year, that nearly 1 million of these die, and that measles-related deaths account for about 10% of all deaths in children under the age of 5 in developing countries. Existing evidence from controlled trials suggests that antibiotic prophylaxis in measles can result in important reductions in measles-related morbidity, and, at a World Health Organization meeting convened in 1993 to decide on research priorities for the treatment of measles, highest priority was accorded to additional controlled trials of prophylactic antibiotics. As controlled trials of vitamin A in measles have made clear, such trials are feasible. Continued acquiescence in uncertainties about the effects of prophylactic antibiotics in a disease that continues to afflict so many children worldwide is unacceptable.

[Acute hepatitis C in the presence of chronic HBV infection]

Acute HCV superinfection was studied in 23 patients with chronic hepatitis B virus infection. HBsAg, anti-HCV (C-100, core, NS3, NS5) were detected in patients' sera at first investigation. Predominant replication of HBV DNA was detected in the sera of 68% patients and HCV RNA in only 24% patients. The clinical course of acute hepatitis C in patients with chronic HBV infection in general corresponded to HCV monoinfection except for more pronounced biochemical shifts and shorter intoxication. The role of HBV and HCV in infectious process is discussed.

Acute exacerbations of chronic hepatitis B are rarely associated with superinfection of hepatitis B virus

There are 7 genotypes of hepatitis B virus (HBV). Whether superinfection of HBV carriers with different HBV genotypes occurs remains unknown. We therefore determined the HBV genotype and association between superinfection and acute exacerbation of disease in a cohort of 244 patients with chronic HBV infection who had elevated serum aminotransferase levels for at least 1 year. Within this group, 103 patients experienced acute exacerbation with an annual incidence of 13%, and 20 of the 103 patients had IgM antibody to hepatitis B core antigen (IgM anti-HBc). These 20 patients had a higher prevalence of genotype C infection (65%) than the remaining 83 anti-core IgM-negative patients (40%) who also had acute exacerbations (P <.05). Detailed analysis of HBV genotypes and sequences of the variable pre-S gene were determined in serial samples from 20 patients with IgM anti-HBc-positive acute exacerbations (group A), 20 patients with IgM anti-HBc-negative acute exacerbations (group B), and 20 patients without exacerbations (group C). Two (10%) of the group A patients had virologic evidence of HBV superinfection during acute exacerbation, one superinfected with heterotypic virus and the other with homotypic virus. The newly introduced virus disappeared after the exacerbation and the original virus resumed thereafter. The calculated prevalence of HBV superinfection in the hepatitis B carriers and those with acute exacerbations was 0.8% (2 of 244) and 1.9% (2 of 103), respectively. In conclusion, superinfection of HBV on hepatitis B carriers indeed occurs and may cause acute exacerbations, albeit at a low frequency even in hyperendemic areas of HBV infection.

[Beginning rheumatoid arthritis revealed during bronchiectasis surinfections. Value of cyclic antibiotherapy?]

Incidence of symptomatic bronchiectasis (BR) occurs in around 2% in patients with late rheumatoid arthritis (RA). Its seems that the association BR-RA could be a worsening factor for outcome of RA patients. A 58-year-old woman without dry syndrome, suffering from bronchial purulence over one year was admitted to the Department of Pneumology for hemoptysis and arthritis (knees, ankles, and wrists). Three prior episodes of inflammatory articular pain had occurred after transient bronchial purulence or pneumonitis. CT-scan showed bilateral bronchiectasis. Diagnosis of early RA was proved after the third episode of bronchial purulence related to a strain of Haemophilus influenzae. A strain of Coxiella burnetii was probably responsible for one of the three bronchial surinfections. Latex and Waaler Rose tests were transiently positive during the first episode, and became positive after the third one. At that time, RA was relevant in view of ARA criteria. Cyclic prophylactic antibiotic regimens could be proposed to patients suffering from RA-BR association, in contrast to the cases of patients with isolated BR. This approach could prevent destabilization of RA and reinforce of anti-rheumatic therapy. Activation and release of cytokines (NFk-B, TNF-alpha), and/or bacterial epitopes seems to be directly responsible for the articular destabilization.

[Stay away from surgery: ecthyma contagiosum]

15 patients with Orf's disease were evaluated. Seven out of 15 patients (Group 1) were treated surgically because of different diagnoses. Seven patients who were misdiagnosed and treated surgically (Group 1), and eight patients (Group 2) were followed conservatively. The aim of this study is to compare the treatment period of the misdiagnosed surgically treated (Group 1) group and conservatively treated group (Group 2). Lesions were aggravated and delayed healing was observed in Group 1. Diagnosis of Orf disease may sometimes be difficult because of concominant bacterial superinfections and surgical trauma. Careful history and clinical findings point to the correct diagnosis. Contrary to other infections of the hand, surgery can cause further complications in this disease. Conservative treatment is the gold standard, even in complicated cases.

Superinfection of Posttraumatic Retroperitoneal Hematoma Secondary to Ascending Urinary Tract Infection

Retroperitoneal hematoma is a common feature after blunt abdominal trauma, but secondary infection of these hematomas is a rare complication and its mechanisms have not been fully elucidated. We report a case of infected retroperitoneal hematoma secondary to renal trauma related to ascending urinary tract infection.

Effects of empiric antibiotic administration for suspected pneumonia on subsequent opportunistic pulmonary infections

Optimal guidelines for empiric antibiotic (EAB) therapy in cases of suspected post-traumatic ventilator-associated pneumonia (VAP) are not well defined. EAB administration is thought to increase the incidence of opportunistic organisms; however, culture-directed (as opposed to empiric) treatment may delay antibiotic administration with possible adverse consequences. Our goal was to examine the impact of EAB administration on the incidence of subsequent VAP and opportunistic organisms in a series of critically injured patients with sepsis syndrome. This is a retrospective review of all patients admitted to a Level I trauma center who underwent multiple fiberoptic bronchoscopies (FOBs) for diagnosis of suspected VAP as the cause of postinjury sepsis syndrome. The relationships between EAB administration, positive cultures (>10(5) colony-forming units) at repeat FOB, and prevalence of opportunistic organisms (methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, Stenotrophomonas species, Acinetobacter species, and/or yeast) were evaluated. Over a 13-month period ending on January 1, 1999, 36 intubated trauma patients underwent more than one FOB during their intensive care unit stay. Twenty-nine patients received EAB immediately after the initial FOB. There was no difference in the rate of EAB administration in patients who developed subsequent VAP after initial FOB (19 of 24, 79%) versus those who did not develop VAP (10 of 12, 83%; P = 0.65). There were 30 VAPs diagnosed in 58 subsequent FOBs (i.e., after the initial FOB) of which 23 were due to an opportunistic organism compared with two VAPs due to an opportunistic organism diagnosed at initial FOB (P < 0.001). Twenty-one of the 23 opportunistic VAPs at subsequent FOBs had received EAB before the first FOB compared with four of seven nonopportunistic organisms (P = 0.06). Administration of EAB does not impact the incidence of subsequent VAP. However, EAB may be related to the development of subsequent opportunistic pulmonary infections.

Fungal colonization and invasive fungal infections following allogeneic BMT using metronidazole, ciprofloxacin and fluconazole or ciprofloxacin and fluconazole as intestinal decontamination

Invasive fungal infections (IFI) are increasingly diagnosed in patients undergoing allogeneic BMT. We have previously shown that the addition of metronidazole to ciprofloxacin for gastrointestinal bacterial decontamination significantly reduces the incidence of grades II-IV aGVHD by reduction of the anaerobic intestinal bacterial flora. Here, we found that the combined use of ciprofloxacin, metronidazole and fluconazole as antifungal prophylaxis increased intestinal yeast colonization when compared to ciprofloxacin and fluconazole alone (P < 0.01). Based on the EORTC criteria, a total of 18 out of 134 study patients developed IFI: seven of 68 (10%) patients who received metronidazole compared to 11 of the 66 (17%) patients decontaminated without metronidazole developed IFI (log-rank P = 0.36). Lethal IFI occurred in two of seven patients receiving metronidazole and in four of 11 patients without anaerobic decontamination. In conclusion, bacterial intestinal decontamination using metronidazole as an antibiotic with activity against most anaerobic intestinal bacteria significantly increases the intestinal yeast burden without influencing the incidence of IFI in patients undergoing allogeneic BMT.

Childhood visceral leishmaniasis complicated by bacterial infections

Bacterial superinfection is one of the major complications leading to death in patients with visceral leishmaniasis. We studied the frequency and type of bacterial infection in 54 patients admitted to hospital with visceral leishmaniasis. The patients were children who ranged in age from 3 1/2 months to 7 years. Bacterial infections were found in 22 (41%) of the patients. Bacteria were isolated in patients with pneumonia, septicaemia, otitis media, urinary tract infections and skin infections. Enterobacteriaceae were the most common bacterial agents isolated. In infants with visceral leishmaniasis, fatal bacterial infections can be accompanied by nonspecific signs and symptoms. Thus, it is important to initiate antibiotic treatment early.

[The BMW (biosurgical mechanical wound treatment) in diabetic foot]

The BMW-concept (Biosurgical-Mechanical-Wound treatment) is a effective supplement of already existing options of wound treatment. Based on the established principles of septic surgery vacuum sealing, instillation vacuum sealing and the application of sterile maggots optimize the treatment of diabetic foot ulcers, reduce time of treatment and offers a high comfort to the patient.

[Diabetic foot: is preventive surgery possible?]

The diabetic foot and its complications are in many cases leading to minor- or major amputations. If macro-vascular diseases are excluded, most of the patients are in a conservative follow-up. Surgeons are only involved if infections occur. In this series of 34 patients and surgery on 39 feet 2/3 consisted in incision/debridement and/or partial ray resections. Nevertheless 1/3 of the surgery could be considered as prophylactic. This means performing surgery at a state of "hyperceratosis" of the foot, a sign of high pressure areas. Of these patients all wounds healed per primam and no additional footwear was necessary. We believe that teamwork, especially with the surgeon, should lead to an early diagnosis of diabetic foot disorders. If necessary surgery should be performed in order to avoid the mal perforans and by this avoiding infection or amputation.

[The diabetic foot from the viewpoint of infection surgery]

Pressure ulceration and bacterial superinfection are main risk factors for the diabetic foot. Surgical interventions for prophylaxis and treatment of infection are demanded. The aim of emergency surgery to treat infection is conservation of as much foot as possible. Therapeutic strategies and an algorithm are established for definite treatment of the infected diabetic foot: primary treatment of infection--arterial revascularization--amputation--orthopedic shoesupply.