Aspergillus endophthalmitis in an intravenous drug user

A 27-year-old male drug user administered methamphetamine hydrochloride solution intravenously (IV) from a storage vial. Within two weeks he was admitted with a fungal endophthalmitis of the right eye. A diagnostic and therapeutic vitrectomy was performed. Aspergillus fumigatus was cultured from the drug storage vial and the vitreous biopsy specimen. The endophthalmitis was not controlled by IV and intravitreal amphotericin B. Pathological examination revealed fungal abscesses in the vitreous and subretinal space.

Coccidioidomycosis: early immunologic findings

T and B lymphocyte number and lymphocyte response to phytohemagglutinin, pokeweed mitogen, concanavalin A, coccidioidin and streptokinase-streptodornase (SKSD), plus monocyte ingestion of coccidioidin- and IgG-coated chicken erythrocytes were measured in 5 patients with coccidioidal meningitis, 11 with nonmeningeal extrapulmonary cocidioidomycosis and 5 with localized pulmonary infections. These cases were evaluated within six months of the onset of infection. Lymphocytic responses to phytohemagglutinin, pokeweed mitogen, concanavalin A, SKSD and coccidioidin and monocytic ingestion of coccidioidin- and IgG-coated chicken erythrocytes were severely decreased in patients with meningeal and nonmeningeal, extrapulmonary coccidioidomycosis but not in patients with localized pulmonary infections. T and B cell numbers, however, were normal in all groups. Thus, defects in cellular immunity are involved in the pathogenesis of extrapulmonary coccidioidomycosis and measurements of lymphocytic and monocytic function may identify patients prone to extrapulmonary infection.

Group B streptococcal lung infection in neonatal rabbits

The interaction of alveolar macrophages (AMs) and group B streptococci (GBS) was investigated in 1 and 2-day-old rabbits following infection in an exposure chamber containing 10(7) streptococci per cubic foot of air. The % of streptococci within AMs was similar at 0 and 4 h (36 and 65%) after infection for the two groups of rabbits. Twenty-four h after infection, the 2-day-old rabbits had a significantly higher % of ingested GBS (86 versus 68%). Sixty % of inspired GBS were inactivated by the older rabbits within 4 h after infection. This clearance persisted in the younger rabbits until 48 h (mean negative clearance of -17, -276, and -79% at 4, 24, and 48 h) before their numbers were reduced by inflammation. Sixty of 78 1-day-old rabbits had inflammatory responses between 24 and 72 h versus only 5 of 50 older rabbits. At 24 h after infection, AMs of 1-day-old rabbits contained significantly increased numbers of intracellular GBS microcolonies (17/20) than did AMs from 2-day-old rabbits (5/19). These observations suggest that the enhanced susceptibility to GBS infection in the immediate postnatal period is caused at least in part by ineffective intracellular killing by AMs.

Successful treatment of gram-negative bacillary meningitis with moxalactam

Meningitis caused by enteric gram-negative bacilli is relatively uncommon but is very difficult to treat despite susceptibility in vitro to many antimicrobics. A major problem appears to be poor entry of many drugs into the central nervous system. Moxalactam is an investigational cephalosporin that attains concentrations in the cerebrospinal fluid that are 15% to 30% of contemporaneous serum concentrations; moreover, it is quite active against many of the enteric gram-negative bacilli. We used moxalactam to treat meningitis caused by Enterobacter cloacae, Klebsiella pneumoniae, and Escherichia coli in four adults and one child, giving up to 100 mg/kg body weight per day by intravenous injection. The concentrations of moxalactam in serum, lumbar, and ventricular cerebrospinal fluid exceeded the minimal lethal concentrations of all causative bacteria. The patients were cured. In this small series, moxalactam, when administered intravenously as the sole agent of therapy, was effective in the treatment of meningitis caused by susceptible gram-negative bacilli.

Effect of ferrous sulfate aerosols and nitrogen dioxide on murine pulmonary defense

A murine infectivity model was used to test the effect of exposure to atmospheres containing 290 +/- 50 microgram/m3 of respirable sized ferrous sulfate (FeSO4) particles (0.4 micron mass median aerodynamic diameter) and 1.0 ppm nitrogen dioxide (NO2) prior to infection with aerosols of Staphylococcus aureus or group C streptococci. Exposure to these combined pollutants for 24 or 48 hr did not impair pulmonary inactivation of S. aureus. Exposure to FeSO4 or NO2 for 48 hr, or to both pollutants for 24 or 48 hr, resulted in significant decreases in inactivation of inhaled group C streptococci. Mortality studies following pollutant exposure demonstrated earlier, but not an increased number of deaths. These studies demonstrate the importance of the test organism in assessing air quality standards with the infectivity model and enhanced toxicity and prolongation of exposure to relatively low levels of submicron-size particles of FeSO4 and NO2.

Effect of ozone on concentrations of lysozyme in phagocytizing alveolar macrophages

Demonstration of lysozyme by the immunoperoxidase method was used to determine whether ozone-induced defects in phagocytic killing of inhaled Staphylococcus aureus by rat alveolar macrophages were associated with absence of this important bactericidal enzyme. Rats were infected with aerosols of S. aureus and then exposed for 5 hr to 2.5 ppm of ozone. Left lungs were cultured for staphylococci; right lungs were stained for lysozyme and bacteria. Compared with control animals, rats exposed to ozone showed diminished rates of bacterial killing; a larger percentage of extracellular, uningested bacteria; an increased number of intracellular staphylococcal clumps; and absence of lysozyme in macrophages permitting staphylococcal proliferation. These results, in which absence of enzyme activity occurred in macrophages subjected to the dual insults of ozone exposure and ingested bacteria, provide an explanation for the inability of phagocytes to kill ingested bacteria after exposure to ozone.

Use of radiologic modalities in coccidioidal meningitis

The diagnostic utility of pentetate indium trisodium in 111 CSF studies, technetium Tc 99m brain scans, and computerized tomographic (CT) scans was evaluated in eight patients in whom coccidioidal meningitis developed following a dust storm in the Central Valley of California. The 111In flow studies and the CT scans demonstrated hydrocephalus in five patients with clinical findings suggesting this complication. Ventriculitis has not previously been diagnosed before death in patients with coccidioidal meningitis; however, it was demonstrated in two patients by the technetium Tc 99m brain scan. Basal meningitis, which is indicative of fungal infection, is also detectable on contrast-enhanced CT scan. The finding that communicating hydrocephalus occurs early in meningitis and interferes with CSF flow into infected basilar regions has important therapeutic implications in that antifungal agents injected into the lumbar subarachnoid space may not reach these regions.

Pulsatile lavage in the management of postoperative wound infections

High-pressure pulsatile lavage is more effective than conventional irrigation in cleansing recently contaminated wounds. This method of irrigation was applied to postoperative infections in an attempt to lower wound bacterial counts to 10(5) or fewer organisms per gram of tissue, a level predictive of safe primary reclosure. Sequential wound biopsies for quantitative bacterial analysis demonstrated that high-pressure lavage is more effective than conventional irrigation in lowering bacterial counts in postoperative staphylococcal wound infections in guinea pigs. However, reductions were transient and did not lower counts sufficiently to permit safe reclosure. In contrast to results in newly contaminated wounds, pulsatile lavage of postoperative infections did not have therapeutic benefit. Reclosure of wounds with greater than 10(5) organisms per gram of tissue is unsafe even after five days of therapy.

Treatment of coccidioidomycosis with miconazole

Miconazole was injected intravenously in six patients with coccidioidomycosis. Two patients received 101 and 185 g, respectively, without clinical response and with persistence of positive cultures for Coccidioides immitis. In one patient, symptoms were suppressed when amphotericin B was given with miconazole, but new lesions developed with miconazole alone (total dose, 963 g). Three patients received smaller doses: 30.6 g before death from an unrelated complication; 17 and 22.3 g before development of severe allergic reactions. Because of the high rate of initial failures and relapses, miconazole is not recommended as primary therapy for coccidioidomycosis.

Diagnostic value of gallium and bone scans in evaluation of extrapulmonary coccidioidal lesions

The value of 67Ga and methylene diphosphonate labeled with 99mTc in detecting extrapulmonary lesions was evaluated in 12 patients win whom disseminated nonmeningeal coccidioidomycosis developed after a single epidemic exposure in December 1977. Studies were performed with each radionuclide from 4 to 9 months after infection. Comparison of scintigraphy with radiography showed that eight of 14 osteolytic lesions identified by radiography were present on the bone and gallium scans; four were present only on the gallium scan, and two were undetected. Of 15 additional lesions present in both scanning procedures, eight were not present in matching roentgenograms and seven were in unstudied areas. Gallium scans detected seven of 14 soft tissue lesions. Few diagnostically confusing noninfectious lesions were observed. Because nuclear scanning detected almost all lesions present in radiographs and demonstrated otherwise unrecognized lesions, scans should be performed in all patients in whom coccidioidal dissemination is suspected.

[Lipocorticotropic peptides in Cushing's disease: in vitro studies]

The immunologic patterns of 3 human pituitary adenomas of Cushing's disease have been studied after gel exclusion chromatography (Sephadex G-50). The immunologic characteristics were examined with three radioimmunoassays specific for human corticotropin (ACTH), lipotropin (LPH) and beta-endorphin (beta-End). In cell tumor extracts, chromatographic peaks corresponding to beta-LPH, gamma-LPH, beta-End and ACTH were identified. The ACTH/beta-LP-beta-End ratio was 1 in the 3 cases. Additionally, in the 3 cases, a chromatographic peak, partially cross-reacting in the beta-End assay, was eluted after beta-End, thus suggesting the presence of a fragment of the molecule. In 1 case, a peak of large molecular weight material with N- and C-terminal beta-LPH and ACTH immunoreactivity was observed, which corresponded to the precursor material. The release and the effects of various stimuli were studied on dispersed tumor cells in primary culture. The tumor cells had a biphasic basal secretion rate with a rapid increase of ACTH/beta-LPH-beta-End in the culture medium during the first 2 h. Then the release, studied during 2 days, was slower. Chromatographic studies showed that the beta-LPH/beta-End ratio was 0.8 in the cells and 0.3 in the medium, due essentially to the release of beta-End and beta-End-like materials. The cells released ACTH and beta-LPH-beta-End in equimolar ratio after stimulation with arginine vasopressin (AVP). The maximum effect was obtained with 10(-6) M AVP (D50 = 1 10(-9) M). Dibutyryl cyclic AMP (2. 10(-3) M) induced maximal release of ACTH/beta-LPH-beta-End. This stimulation was suppressed by a 48-hour preincubation with dexamethasone (10(-8)-10(-6) M). There was no effect of TRH and LH-RH on cell release. Dopamine (10(-6) M) specifically blocked the release of ACTH/beta-LPH-beta-End in 1 case. These data showed (a) heterogeneity of chromatographic profiles from case to case; (b) the presence of material in the tumor, cell extracts and culture medium corresponding to fragment(s) of beta-End; (c) culture studies demonstrated that tumor cells remain responsive to AVP stimulation and dexamethasone suppression, and (d) the dopamine inhibition of ACTH and beta-End release needs further investigation.

Effect of near ambient exposures to sulfur dioxide and ferrous sulfate particles on murine pulmonary defense mechanisms

An infectivity model was used to test the safety margins for presently established air quality standards for sulfur dioxide and sulfate particles. Mice and rats were exposed to atmospheres of sulfur dioxide and mono-disperse ferrous sulfate particles from 3 to 6 times the standard for 17 hr prior to, or 4 hr after infection with aerosols of Staphylococcus aureus or Group C Streptococci. Exposure to these concentrations of pollutants did not impair the rodents' ability to ingest and inactivate the minimally virulent Straphylococcus or enhance the virulence of the Group C Streptococci. Insofar as these results can be extrapolated to man, the present air quality standards for sulfur dioxide and sulfate particles are protective in regard to respiratory bacterial infection.

Effect of protein A on the antistaphylococcal defence mechanisms of the murine lung

The importance of IgG attached to protein A in the initial reaction of inspired Staphylococcus aureus and alveolar macrophages was studied by infecting unimmunized mice with aerosols of S. aureus strains 566 and Wood 46 with high and low protein A content. At 2, 4, and 8 hr after infection, the presence of IgG attached to S. aureus and rates of staphylococcal ingestion and killing by macrophages were determined. IgG was detected by staining of sections of the right lung with fluorescein-labeled goat antibody to mouse IgG. For S. aureus strain 566, 25%--40% of the total number of bacteria, as determined in equivalently sized subjacent sections stained by the Brown and Brenn tissue gram stain, contained attached IgG. A few S. aureus strain Wood 46 were surrounded by dimly fluorescing complexes. Since rates of bacterial ingestion and killing were similar for both strains in this in vivo model of infection, IgG binding to protein A does not affect the bactericidal capacity of alveolar macrophages.

Lung response to congenitally athymic (nude), heterozygous, and Swiss Webster mice to aerogenic and intranasal infection by Nocardia asteroides

Congenitally athymic (nude, Nu/Nu), heterozygous (Nu/+), and Swiss Webster mice were exposed to virulent Nocardia asteroides GUH-2 inhaled from aerosols or administered intranasally. Clearance of the bacteria from the lungs was determined at 6 h and 1, 2, 3 and 7 days after infection. N. asteroides aspirated into the lungs from intranasal administration were killed less rapidly and induced more severe pulmonary infections than did comparable numbers of organisms inhaled from aerosols. Bacterial clearance and histological data indicated that nude mice were significantly more susceptible to nocardial infection than were heterozygous littermates or Swiss Webster mice. From these data we conclude that: (i) pulmonary defenses cope less well with intranasally administered N. asteroides than with aerosolized organisms, (ii) alveolar macrophages alone appear not to be an efficient barrier to nocardial infections, and (iii) T cells are important to pulmonary clearance and prevention of dissemination of N. asteroides from the lung.

Effect of ozone on lysosomal enzymes of alveolar macrophages engaged in phagocytosis and killing of inhaled Staphylococcus aureus

The role of lysosomal enzymes in the inactivation of inhaled bacteria by alveolar macrophages was studied in rats infected with aerosols of Staphylococcus aureus and then exposed for 5 hr to 2.5 ppm of ozone to determine whether pollutant-induced defects in phagocytic killing were associated with reduction in enzyme activity. Rates of bacterial ingestion and the activities of cellular acid phosphatase and beta-glucuronidase were measured simultaneously in in situ perfused right lungs by sequential staining of frozen sections for enzyme and bacteria. Quantitative measurements of enzyme activity within macrophages without ingested bacteria were made with a computer-controlled cytospectrophotometry system. Exposure to ozone resulted in diminished rates of bacterial clearance and ingestion, large increases in numbers of intra- and extracellular staphylococcal microcolonies, and an absence of enzyme activity for macrophages containing bacterial microcolonies. Enzyme activity was unimpaired in macrophages without ingested bacteria. These results, in which absence of enzyme activity occurred only in macrophages subjected to the dual insults of ozone exposure and ingested bacteria, prove a relationship between impairment in bactericidal capacity and cellular activities of lysosomal enzymes.

Rapid treatment of percodan addiction: a case report

This is a case study of narcotic addiction in which the patient was completely withdrawn from 12 to 20 Percodan tablets daily within 7 days. Signs and symptoms of the Abstinence Syndrome were minor and required minimal medication for their control. In addition, no electroshock treatment was necessary, nor were any other narcotic or other drug substituted for the Percodan.

Considerations in diagnosing brain abscess with computerized axial tomography

Four studies with computerized axial tomography (CT scan) were performed in a 20-year-old man in whom multiple brain abscesses developed while hospitalized for complications of regional enteritis. A large frontal lobe abscess appeared as a nonspecific region of decreased density on the initial CT scans. When iodine was used to enhance the diagnostic sensitivity of the CT scan, this areas was identifiable as an abscess. However, a 1-cm lesion in the right parietal area that extended into the choroid plexus was not delineated. Radionuclide scans detected both lesions, but did not allow pathological identification. We conclude that CT scans should be performed with iodine enhancement whenever brain abscesses are suspected, and that some abscesses that are undetected by CT scans even with iodine enhancment may be delineated but not identified by sodium pertechnetate Tc 99m imaging.

Treatment of adolescent phencyclidine (PCP) abusers

Little data exists relative to ongoing treatment of adolescent phencyclidine (PCP) abusers. This paper presents data gathered on a cohort of 87 residents in an adolescent social rehabilitation program. Approximately 50% of this cohort were either chronic or occasional PCP users. Both groups were found to be regular users of other drugs. Demographic characteristics are described, as are behaviors and symptoms reflective of various emotional and behavioral problems. When length of stay on non-PCP users and occasional and chronic users were compared, it was found that chronic users remain in treatment longest. No PCP-induced psychosis was found. Symptoms of depression, anxiety, aggitation, and other reported psychological effects of PCP were seen. Considerations for treatment are briefly discussed.