Acute respiratory failure due to sweet syndrome

A 67-year-old patient with newly diagnosed acute myeloid leukemia developed acute respiratory failure with high-grade fever and bilateral pulmonary infiltrates. Blood cultures were sterile and no bacterial or fungal pathogen was identified in the endotracheal aspirate. The patient did not respond to antibiotic and antifungal therapy. One week after intensive care unit (ICU) admission, erythematous skin lesions appeared at the vascular catheter puncture sites. Sweet syndrome with pulmonary involvement was suspected and a treatment with corticosteroids was started. Sweet syndrome was confirmed by skin biopsy. After corticosteroid therapy respiratory symptoms rapidly improved, the patient became afebrile and the cutaneous lesions rapidly disappeared. Only three cases of Sweet syndrome presenting with pulmonary involvement before the appearance of skin lesions are reported in the literature. Even if typical skin lesions are initially absent, early recognition of Sweet syndrome with pulmonary involvement is important because of the possibility of severe respiratory impairment, which can be avoided through prompt administration of corticosteroids.

Therapie und Prävention der Lyme-Borreliose

Die verschiedenen Stadien der Lyme-Borreliose können wirksam antibiotisch behandelt werden. In der Regel müssen nur Lyme-Borreliosen mit einer ZNS-Beteiligung oder Lyme-Karditis und AV-Block III. Grades parenteral behandelt werden, während alle anderen Formen der Lyme-Borreliose per os behandelt werden können. In den letzten Jahren kann eine Tendenz zur Verlängerung der Therapien festgestellt werden. Allerdings existieren keine Studien, welche einen Vorteil von längeren Therapien zeigen. Das Risiko einer Lyme-Borreliose nach einem Zeckenstich in der Schweiz ist gering. Eine Antibiotika-Prophylaxe nach Zeckenstich wird nicht empfohlen.

Staphylococcus aureus in patients with rheumatoid arthritis under conventional and anti-tumor necrosis factor-alpha treatment

OBJECTIVE

To compare the prevalence of nasal and oral Staphylococcus aureus in patients with rheumatoid arthritis (RA) with the prevalence in controls with other rheumatic diseases, and to determine predictors of S. aureus carriage and the influence of treatment with anti-tumor necrosis factor-a (anti-TNF-alpha) agents.

METHODS

Eighty-one patients with RA and 83 other control patients of 2 outpatient rheumatology clinics were cultured for nasal and oral carriage of S. aureus. Quantitative nasal cultures for S. aureus were performed from swabs of the anterior nares, the posterior pharynx, and the soft palate. Information on medications, medical conditions, and risk factors for S. aureus carriage was collected from all participants by a questionnaire and confirmed by chart review.

RESULTS

The S. aureus carriage rate (nasal and/or oral colonization) was 34.6% among RA patients and 32.5% among controls (p = 0.87). Being treated with an anti-TNF-alpha agent plus methotrexate (MTX) was the only independent predictor of S. aureus carriage (OR 3.24, 95% CI 1.16-9.05, p = 0.025). The S. aureus carriage rate among RA patients treated with an anti-TNF-alpha agent plus MTX was 60% (9/15) versus 23.1% (3/13) in RA patients treated with an anti-TNF-alpha agent only (p = 0.049). All S. aureus isolates were susceptible to oxacillin.

CONCLUSION

The S. aureus carriage rate among patients with RA was not higher than among controls. Treatment with anti-TNF-alpha agents was not associated with an increased S. aureus carriage rate. However, treatment with an anti-TNF-alpha agent plus MTX may predispose patients to S. aureus carriage.

Tropenr�ckkehrerin mit papulovesikul�rem Exanthem und grippe�hnlichen Beschwerden

African tick bite fever (ATBF) is an infectious disease commonly observed in travelers to sub-Saharan Africa. Because the presentation of the disease is often not specific, ATBF is frequently not diagnosed or confused with Mediterranean spotted fever. We present the case of a 63-year-old woman with typical history and symptoms. The diagnosis of ATBF was serologically confirmed by immunofluoroscence. ATBF is an important differential diagnosis of fever in patients returning from sub-Saharan Africa.

Rickettsiosen der Zeckenbissfieber-Gruppe

Rickettsioses are among the most frequent causes of febrile diseases in travelers, as shown in several studies in the last years. Furthermore, since 1991, with the introduction of new testing methods, 8 new Rickettsia species (or new diseases) have been described. Typical symptoms of rickettsial infections are high fever, headaches and myalgias, frequently associated with a rash and/or an inoculation eschar ("tache noire") at the site of tick bite. The rapid recognition of a rickettsiosis and the immediate start of appropriate antibiotic therapy are important because some rickettsioses (e. g. the Rocky Mountain spotted fever) are associated with relevant morbidity and mortality. This paper reviews the spotted fever group rickettsioses.

Staphylococcus aureus Infections in Injection Drug Users: Risk Factors and Prevention Strategies

Infections, in particular soft tissue infections (cellulitis, skin abscesses), are the leading cause for emergency department visits and hospital admissions of drug injection users (IDUs). Staphylococcus aureus is the most relevant bacterial pathogen in this population. It is the main cause of soft tissue infections and of severe infections such as endocarditis and bacteremia. Moreover, epidemic spread of methicillin-resistant S. aureus (MRSA) among IDUs has occurred in Europe and North America. Nasal carriage of S. aureus is associated with an increased risk of subsequent S. aureus infections, and it has been shown that active IDUs have a higher rate of colonization with S. aureus than the general population. However, it is still unknown why an individual carries S. aureus. In particular, repeated injections do not appear to be the main predisposing factor for S. aureus carriage. Infections associated with injection drug use are frequently the consequence of the illegal status of street drugs. Harm reduction programs, including needle exchange programs, safer injecting facilities and injection opiate substitution programs can reduce the incidence of infections among severely addicted IDUs.

["Antibiotic stewardship": catchword or necessity?]

Als «antibiotic stewardship» bezeichnet man Strategien oder Massnahmen zur Optimierung des Antibiotika-Einsatzes. «Antibiotic stewardship» Programme sind ein wichtiger Bestandteil der Prävention von Antibiotika-Resistenzen. Von «antibiotic stewardship»-Programmen ist nicht nur ein Nutzen auf gesellschsaftlicher Ebene zu erwarten (weniger Antibiotika-Resistenzen), sondern auch auf individueller Ebene: jeder einzelne Patient profitiert von der korrekten Anwendung der Antibiotika (Einsatz der Substanz mit der besten Wirkung gegen den jeweiligen Krankheitserreger, korrekte Dauer der Therapie usw.). Zusätzlich können «antibiotic stewardship»-Programme einen Beitrag zur Kontrolle der Medikamenten-Ausgaben leisten.

Endocarditis caused by Finegoldia magna (formerly Peptostreptococcus magnus): diagnosis depends on the blood culture system used

We present a patient with prosthetic valve endocarditis caused by Finegoldia magna (formerly Peptostreptococcus magnus). Blood cultures in the BacT/ALERT and BACTEC 9240 system were negative. We therefore tested different blood culture systems: F. magna grew in the SEPTI-CHEK BHI-S and in the ISOLATOR, but not in the BacT/ALERT system.

Clinical implications of Mycobacterium kansasii species heterogeneity: Swiss National Survey

Several subtypes of Mycobacterium kansasii have been described, but their respective pathogenic roles are not clear. This study investigated the distribution of subtypes and the pathogenicity of M. kansasii strains (n = 191) isolated in Switzerland between 1991 and 1997. Demographic, clinical, and microbiological information was recorded from clinical files. Patients were classified as having an infection according to the criteria of the American Thoracic Society. Subtypes were defined by PCR-restriction enzyme analysis of the hsp65 gene. Subtype 1 comprised 67% of the isolates (n = 128), while subtypes 2 and 3 comprised 21% (n = 40) and 8% (n = 15), respectively. Other subtypes (subtypes 4 and 6 and a new subtype, 7) were recovered from only 4% of patients (n = 8). M. kansasii subtype 1 was considered pathogenic in 81% of patients, while M. kansasii subtype 2 was considered pathogenic in 67% of patients and other subtypes were considered pathogenic in 6% of patients. The majority of patients with M. kansasii subtype 2 were immunocompromised due to the use of corticosteroids (21% of patients) or coinfection with HIV (62.5% of patients). Subtyping M. kansasii may improve clinical management by distinguishing pathogenic from nonpathogenic subtypes.

Legionella resources on the world wide web

Internet resources that focus on Legionella and legionnaires disease are presented. Web sites were selected on the basis of their content and adherence to suggested standards of medical Internet publishing. Free, accessible, English-language Web sites were categorized according to users' needs as follows: (1) those with comprehensive information on Legionella infection (including pathophysiologic characteristics, symptoms, and treatment of legionnaires disease), (2) those with information on outbreaks and epidemiology (including information for travelers), (3) those with information for researchers, (4) those about prevention, and (5) those with information for laypersons.

Infections requiring hospitalization of injection drug users who participated in an injection opiate maintenance program

A retrospective analysis of hospitalizations due to infection in 175 injection drug users was performed for the 3 years before and the period during their participation in an injection opiate maintenance program (mean duration during program, 2.6 years). Skin infections were the main reason for hospitalization. The injection opiate maintenance program did not reduce the incidence of infection leading to hospitalization among the injection drug users studied.

Nasal carriage of Staphylococcus aureus among patients receiving allergen-injection immunotherapy: associated factors and quantitative nasal cultures

OBJECTIVE

To compare the prevalence of nasal Staphylococcus aureus carriage among outpatients receiving allergen-injection immunotherapy with the prevalence among healthy controls and to determine predictors of nasal S. aureus carriage.

DESIGN

Survey.

SETTING

Allergy clinic of a university hospital.

PARTICIPANTS

A volunteer sample consisting of 45 outpatients undergoing desensitization therapy and 84 first- and second-year medical students.

RESULTS

The nasal S. aureus carriage rate was significantly higher among patients (46.7%) than among students (26.2%; P=.019). In a multivariate model adjusted for age and gender, the presence of atopic dermatitis or eczema was the only independent predictor of nasal S. aureus carriage (odds ratio [OR], 4.4; 95% confidence interval [CI95], 1.2-16.0; P=.02). The only other participant characteristic associated with nasal S. aureus carriage was immunotherapy with allergen injections (OR, 1.98; CI95, 0.7-6.0), but this association did not reach statistical significance (P=.23). The probability of nasal S. aureus carriage was 88.9% for patients receiving allergen injections and having atopic dermatitis or eczema, and 36.1% for patients receiving allergen injections without atopic dermatitis or eczema.

CONCLUSIONS

Patients undergoing desensitization have a higher nasal carriage rate of S. aureus. However, factors other than the regular use of needles, and in particular abnormalities related to the atopic constitution of these patients, may predispose this population for S. aureus carriage.

Prolonged antimicrobial activity of a catheter containing chlorhexidine-silver sulfadiazine extends protection against catheter infections in vivo

The present study evaluated in vitro and in vivo a new chlorhexidine (C)-silver sulfadiazine (S) vascular catheter (the CS2 catheter) characterized by a higher C content and by the extended release of the surface-bound antimicrobials. The CS2 catheter was compared with a first-generation, commercially available CS catheter (the CS1 catheter). The CS2 catheter produced slightly smaller zones of inhibition (mean difference, 0.9 mm [P < 0.001]) at 24 h against Staphylococcus aureus and five other microorganisms by several different methodologies. However, in a rabbit model, both CS catheters were similarly efficacious in preventing a catheter infection when the rabbits were inoculated with 10(4) to 10(7) CFU of S. aureus at the time of catheter insertion. The CS2 catheter retained its antimicrobial activity significantly longer in vitro and in vivo (half-lives exceeded 34 and 7 days, respectively) and was also significantly more efficacious in preventing a catheter infection when 10(6) CFU of S. aureus was inoculated 2 days after catheter implantation (P < 0.001). These results suggest that prolonged anti-infective activity on the external catheter surface provides improved efficacy in the prevention of infection.

"Cloud" health-care workers

Certain bacteria dispersed by health-care workers can cause hospital infections. Asymptomatic health-care workers colonized rectally, vaginally, or on the skin with group A streptococci have caused outbreaks of surgical site infection by airborne dispersal. Outbreaks have been associated with skin colonization or viral upper respiratory tract infection in a phenomenon of airborne dispersal of Staphylococcus aureus called the "cloud" phenomenon. This review summarizes the data supporting the existence of cloud health-care workers.

In vitro zones of inhibition of coated vascular catheters predict efficacy in preventing catheter infection with Staphylococcus aureus in vivo

This report summarizes data from 35 rabbit model experiments investigating the relationship between in vitro anti-infective catheter coating zones of inhibition and in vivo efficacy. The rabbit model studies involving 15 anti-infective coatings demonstrate an inverse correlation between the sizes of zones of inhibition of Staphylococcus aureus and both the quantity of Staphylococcus aureus removed from the catheter and the risk of a purulent infection. The review of seven previously published clinical trials reveals that the use of anti-infective coated catheters, efficacious in the rabbit model, was associated with a higher success rate than the use of uncoated catheters in preventing both Staphylococcus aureus catheter colonization (odds ratio: 1.28; 95% confidence interval: 0.84-1.93) and Staphylococcus aureus catheter-related bloodstream infection (odds ratio: 3.07; 95% confidence interval: 0.98-9.60) in humans. These findings strongly suggest a correlation between zones of inhibition and in vivo efficacy. In vitro zones of inhibition may serve as a useful screening test for evaluating new anti-infective coatings.

Effects of early antiretroviral treatment on HIV-1 RNA in blood and lymphoid tissue: a randomized trial of double versus triple therapy. Swiss HIV Cohort Study

To assess the effects of early initiation of antiretroviral therapy on cell-free and cell-associated viral load in blood and lymphoid tissue, we performed a randomized, open-label, multicenter trial comparing a double (zidovudine + lamivudine) and triple (zidovudine + lamivudine + ritonavir) drug combination in treatment-naive, asymptomatic patients with CD4 counts >400 cells/microl. HIV-1 RNA was measured in plasma, peripheral blood mononuclear cells, and sequential tonsil or lymph node biopsies (27 patients); the study follow-up was 2 years. Among 42 randomized patients, the proportion with plasma HIV-1 RNA <50 copies/ml was 16% and 74% at week 24 (p<.001) in those randomized to double and triple therapy, respectively, necessitating frequent treatment intensification in the double arm. After a rapid decline within 4 weeks in both arms, cell-associated HIV-1 RNA decreased further only in those patients with sustained suppression of plasma viral load, but remained almost always detectable at low levels, indicating persisting transcription of viral RNA. CD4 counts increased by 200 to 250 cells/microl at week 96 in both arms without significant differences (intent-to-treat analyses). Thus, even if treatment is initiated early in asymptomatic patients with preserved CD4 counts, three drugs are necessary to achieve sustained decreases of HIV load in blood and lymphoid tissue.

Nutritional supplements combined with dietary counselling diminish whole body protein catabolism in HIV-infected patients

BACKGROUND

Weight loss and protein malnutrition are frequent complications in HIV-infected patients. The effect of an oral nutritional supplement combined with nutritional counselling on whole body protein metabolism was assessed.

MATERIALS AND METHODS

HIV-infected individuals with a body mass index < 21 kg m-2 or CD4-T cells < 500 micro L-1 in stable clinical condition were randomly allocated to [1] receive either oral nutritional supplements (containing 2510 kJ, complete macro- and micronutrients) and dietary counselling (n = 8), or [2] identical monitoring but no supplements or specific nutritional advice (controls, n = 7). Whole body leucine kinetics and leucine oxidation rate were determined by [1-13C]-leucine infusions and lean and fat mass were measured before and 12 weeks after intervention.

RESULTS

Leucine oxidation (protein catabolism) decreased in the group receiving nutritional intervention from 0.33 +/- 0.02 to 0.26 +/- 0.02 micromol kg-1 min-1 after 12 weeks (P < 0.05; P < 0.05 vs. control group) but remained unchanged in the control group. Whole body leucine flux showed a tendency to decrease in the intervention group from 1.92 +/- 0.19 to 1.73 +/- 0.14 micromol kg-1 min-1 (P = 0.07) and remained unchanged in the control group (2.21 +/- 0.16 and 2.27 +/- 0.14 micromol kg-1 min-1, respectively). Lean body mass determined by bioelectrical impedance analysis increased in the nutritional intervention group from 84 +/- 2 to 86 +/- 2 per cent (P < 0.05) and fat mass decreased from 17 +/- 2 to 14 +/- 2 per cent (P < 0.05) of total body weight whereas neither mass changed in the control group. Nutritional intervention had no significant effect on lymphocyte CD4 counts, on plasma TNFR 55, TNFR 75 and ILR 2 concentrations and on quality of life.

CONCLUSIONS

The data demonstrate an anticatabolic effect of nutritional supplements combined with dietary counselling in HIV-infected subjects. They suggest that diminished whole body protein catabolism resulted in a change of body composition (increased lean mass, decreased fat mass).