[Progressive multifocal leukoencephalopathy associated with leukopenia of unknown (iatrogenic?) origin]

Progressive multifocal leukoencephalopathy is a virtually always opportunistic infection of central nervous system caused by papova viruses, which clinically presents with symptoms and signs of involvement of different encephalic levels. We report a case with a double interest: on the one hand, both clinical features and lesions were limited to the brainstem and cerebellum; on the other hand, the disease developed in a previously healthy female in whom laboratory evidence of immunodeficiency of unknown origin was demonstrated. A reason for immunodeficiency was also not found at autopsy, being speculated that it could have been iatrogenically associated with antidepressant drugs.

Neutropenia complicating parenteral antibiotic treatment of infected nonunion of the tibia

Fifty patients with posttraumatic tibial nonunion complicated by chronic refractory osteomyelitis were treated with intravenous antibiotics. Fifteen patients (30%) experienced 18 episodes of leukopenia; seven of these patients became neutropenic and three became severely neutropenic. No patient became neutropenic prior to the 20th day of antibiotic therapy. The classic findings of fever, pruritus, maculopapular rash, and eosinophilia did not correlate with either the onset or the severity of the neutropenia. Neutropenia can develop precipitously. Prevention of neutropenia is difficult in a patient population receiving long-term antibiotic therapy. Regular monitoring of the white blood cell count and differential cell count minimizes the risk of developing prolonged, severe neutropenia with potential complications. No patient in this series had any serious or infectious complication secondary to neutropenia.

Complications from long-term indwelling central venous catheters in hematologic patients with special reference to infection

Forty-three evaluable patients with hematologic malignancies, mainly acute leukemia, were prospectively randomized to receive a double lumen central venous catheter or a totally implantable venous access system. The mean catheter stay was 166 days (median, 104 days) for the 23 double lumen catheters and 164 days (median, 65 days) for implanted systems. Exit site infections were not encountered in double lumen catheters, but there were two proven infections around the injection port of implanted devices. Tunnel infections did not occur. Seven double lumen catheters and four implanted systems were removed because of infection. Staphylococcus epidermidis was the predominant microorganism cultured from these catheters. Five of nine patients with double lumen catheters and catheter-related S. epidermidis infection and the two patients with implanted systems in whom S. epidermidis was cultured were on selective gut decontamination. The pattern of infection did not seem to be influenced by this regimen. Totally implantable systems proved to be as safe as double lumen central venous lines.

Impact of the dosage schedule on the efficacy of ceftazidime, gentamicin and ciprofloxacin in Klebsiella pneumoniae pneumonia and septicemia in leukopenic rats

The impact of the dosage schedule on the therapeutic efficacy of antibiotics was investigated in experimental Klebsiella pneumoniae pneumonia and septicemia in leukopenic rats. The daily doses (mg/kg) that protected 50% of the animals from death, when calculated for administration at 6 h intervals or by continuous infusion, were as follows: ceftazidime 24.4 and 1.5 (p less than 0.001), gentamicin 2.8 and 3.8 (p greater than 0.05), and ciprofloxacin 3.3 and 6.5 (p less than 0.05), respectively. This correlates with the observation that ceftazidime killed Klebsiella pneumoniae slowly but constantly, and relatively independently of concentration, whereas killing by gentamicin or ciprofloxacin was rapid, and markedly dependent on antibiotic concentration. Exposure of bacteria for 1 h to concentrations of fivefold the MBC did not give rise to a postantibiotic effect for any of the drugs. In our model ceftazidime was far more effective when given continuously than when administered at 6 h intervals. On the other hand, the activity of gentamicin was not influenced by the mode of administration, whereas ciprofloxacin was slightly more effective when given intermittently. However, to avoid misleading conclusions regarding the use of antibiotics in humans, the pharmacokinetic differences between rats and man must be considered when interpreting these results.

Combination effect of recombinant human interleukin-1 alpha with antimicrobial agents

Combination effects of recombinant human interleukin-1 alpha with ceftazidime, moxalactam, gentamicin, enoxacin, amphotericin B, miconazole, or an immunoglobulin preparation were evaluated in systemic infections with Pseudomonas aeruginosa, Klebsiella pneumoniae, and Candida albicans in normal mice and systemic infection with P. aeruginosa in mice with leukopenia induced by preadministration of cyclophosphamide. Synergistic effects were generally observed at interleukin-1 alpha doses as low as 1 to 30 ng per mouse with most combinations. The results show the possibility that recombinant human interleukin-1 alpha could be of help for treating obstinate infections not successfully treated with antimicrobial agents alone.

Leukopenia in acute thermal injury: evidence against topical silver sulfadiazine as the causative agent

White blood cell data from time of admission to 4 days after burn injury was retrospectively reviewed to determine differences in the incidence of leukopenia in patients with burn injuries treated topically with either silver sulfadiazine or silver nitrate. WBC counts decreased in both groups of patients during the first 3 days after burn injury. An incidence of leukopenia (WBC count less than or equal to 5000/mm3) was observed in of 40 (47.5%) patients treated with silver sulfadiazine and in 13 of 30 (43.3%) patients treated with silver nitrate. There was no statistical difference in the incidence of leukopenia between the two treatment groups. These data suggest that silver sulfadiazine may not be the cause of the leukopenia observed early after burn injury.

Disseminated Trichosporon beigelii infection after orthotopic liver transplantation

A 25-year-old male, who received an orthotopic liver transplant for fulminant hepatic failure resulting from hepatitis B, had disseminated Trichosporon beigelii infection develop. Of the 55 cases of disseminated T. beigelii that have been reported in the English-language medical literature, most have occurred in patients who were both neutropenic and had compromised cell-mediated immunity. Mortality has ranged from 60 to 78%. Outcome appears to depend significantly on leukocyte recovery. Histologically, Trichosporon can be confused with Candida; however, recognition of the arthroconidia and pleomorphic hyphae and pseudohyphae of Trichosporon should allow their differentiation.

Cartilage proteoglycan depletion in acute and chronic antigen-induced arthritis

We examined the kinetics of proteoglycan (PG) depletion in rabbits with antigen-induced arthritis. There was a rapid loss of PG from arthritic cartilage, reaching 35-40% at day 7. Thereafter, the rate of PG depletion declined, and by day 42, the maximum loss was 55-60%. The initial loss of PG was accompanied by the appearance of large amounts of sulfated glycosaminoglycans (GAGs) in the joint fluid (measured as total sulfated GAGs by dye binding and as keratan sulfate by radioimmunoassay). However, by day 14, the levels of sulfated GAGs in arthritic joint fluid declined to control levels, even though the cartilage demonstrated a sustained depletion of PG. The cartilage PG degradation observed in antigen-induced arthritis could also be produced in normal animals by a single intraarticular injection of recombinant interleukin-1. The acute loss of cartilage PG occurred independently of neutrophil accumulation, both in the case of antigen-induced arthritis and after injection of interleukin-1.

[Investigations on the etiology of sepsis by using experimental mouse model with leukocytopenia. 1. Influence of antibiotics]

Investigation on the etiology of septicemia occurring among the immunocompromised patients was performed by using experimental model of the mouse with leukocytopenia. The ddY conventional mice of 4 weeks of age were inoculated with cyclophosphamide (CPM) intraperitoneally 3 to 5 times every other day with a dose of 3 mg/mouse once to make an agranulocytic status. Then, intraperitoneal administrations of various antibiotic regimens consisting of ampicillin (ABPC) alone, ABPC + ceftazidime (CAZ), ABPC + CAZ + cloxacillin (MCIPC), ABPC + CAZ + MCIPC + minocycline (MINO) and saline as a control to these immunosuppressed mice were begun once every day for 10 days after the second inoculation of CPM. The mortality rate of the mice given saline as a control was very high with a frequency of 43.3% and there were significant differences between the saline group and another antibiotic groups other than ABPC (p less than 0.01). On the other hand, the mortality rate of the group given APBC showed the highest rate of 70% and it was significantly higher than that of the saline control group (p less than 0.05). The main cause of most of the dead mice was septicemia due to P. aeruginosa and which were isolated from the feces of all these mice and serotype of the strains isolated from the heart blood and feces in the same host corresponded to each other. Moreover, intestinal bacterial flora in mice treated by saline and ABPC which highly showed Pseudomonas sepsis, was occupied dominantly by P. aeruginosa, although P. aeruginosa was not detectable from the experimental environments.(ABSTRACT TRUNCATED AT 250 WORDS)

Methazolamide-associated temporary leukopenia and thrombocytopenia

A three-week course of methazolamide therapy for chronic open-angle glaucoma resulted in marked leukopenia and thrombocytopenia. Prompt discontinuation of therapy resulted in complete recovery of white blood cell and platelet counts within five days. The recommendations for patients receiving carbonic anhydrase inhibitors for blood count control at six-month intervals are discussed.

Leukopenia with neutropenia associated with teicoplanin therapy

The first case report of leukopenia with neutropenia due to the new glycopeptide antibiotic teicoplanin is described. The side effect occurred in a 73-year-old man hospitalized because of subacute bacterial endocarditis caused by Streptococcus faecalis. Leukopenia with neutropenia (white blood cells 2000/mm3, neutrophils 46%) developed after 20 days of teicoplanin therapy. After stopping teicoplanin white blood cell and neutrophil counts reverted to normal, but dropped again on rechallenge. A review of 1500 records of patients treated with teicoplanin alone or in combination with other drugs was also performed. Five cases were found in which leukopenia was possibly (four cases) or probably (one case) related to teicoplanin therapy. From these preliminary data the incidence of leukopenia related to teicoplanin seems to be low.

Hematologic aspects of human immunodeficiency virus infection: laboratory and clinical considerations

Hematologic abnormalities are common in patients with HIV infection. This review will focus on HIV-associated cytopenias and coagulation abnormalities. Their occurrence, laboratory evaluation, and clinical significance and the mechanisms underlying their development are discussed. Therapeutic modalities are presented, with an emphasis on treatment strategies for HIV-associated thrombocytopenia.

White blood cell aplasia associated with thymoma

A limited number of cases of acquired hypoplastic neutropenia or pure white blood cell aplasia (PWCA) associated with thymoma have been reported, in contrast to the well-documented association of pure red blood cell aplasia and thymoma. The mechanism of the aplasia in these disorders is unclear. The authors report a case of PWCA (with total absence of all granulopoietic elements in the bone marrow) in a patient with metastatic spindle cell thymoma, in which suppression of autologous granulocyte-macrophage colony-forming units by the patient's serum could be demonstrated. This finding suggests a humoral autoimmune mechanism for the pathogenesis of PWCA in this patient and lends support to the possibility that all hematologic phenomena associated with thymoma may have an autoimmune basis.

Comparative activities of ciprofloxacin and ceftazidime against Klebsiella pneumoniae in vitro and in experimental pneumonia in leukopenic rats

The antibacterial activities of ciprofloxacin and ceftazidime against Klebsiella pneumoniae in vitro and in vivo were compared. Although there was only a minor difference between the MBCs of both drugs, the bacterial killing rate of ciprofloxacin in vitro was very fast in comparison with that of ceftazidime. Similarly, the intravenous administration of ciprofloxacin at 1 h after bacterial inoculation resulted in effective bacterial killing in the lungs of leukopenic rats. This killing was dose dependent, in contrast to the dose-independent bactericidal effect of ceftazidime. The high antibacterial activity of ciprofloxacin in the lungs as compared with that of ceftazidime was also reflected in its therapeutic efficacy in K. pneumoniae pneumonia and septicemia in leukopenic rats when these infections were treated at 6-h intervals over 4 days, starting at 5 h after bacterial inoculation. Concentrations of ciprofloxacin and ceftazidime in lung tissue were not significantly different. Regarding the antibacterial activity of both drugs against K. pneumoniae in relation to the bacterial growth rate in vitro and in the lungs of leukopenic rats, ciprofloxacin killed K. pneumoniae organisms that were not actively growing, whereas ceftazidime did not. In addition, it was demonstrated that when the intravenous administration of antibiotic was delayed from 1 h up to 24 h after bacterial inoculation, ceftazidime lost its antibacterial activity in the lungs and blood of leukopenic rats, whereas ciprofloxacin was still very effective. These data suggest that the capacity of an antibiotic to kill bacteria at a slow growth rate may be relevant for its therapeutic effect in established infections, in which slowly growing bacteria form a substantial part of the total bacterial population.

Long-term prophylaxis of infection by selective decontamination in leukopenia and in mechanical ventilation

The autochthonous anaerobic bacterial flora in the mucosal layer of the gastrointestinal tract limits colonization by aerobic potential pathogens. This effect is called colonization resistance. Colonization of the digestive tract by potentially pathogenic microorganisms precedes infection in patients with leukopenia and in cases of mechanical ventilation and can be prevented by long-term administration of antimicrobial agents that spare the autochthonous anaerobic bacterial flora of the mucous membranes, a concept known as selective decontamination. Antimicrobial agents active against anaerobic flora reduce colonization resistance, permitting colonization by and overgrowth of potentially pathogenic microorganisms and possibly leading to infections with resistant microorganisms. A distinction can be made between antimicrobial agents that reduce colonization resistance and those that leave it intact by examining the effect of antimicrobial agents on aerobic intestinal flora of mice and humans.

Combination of amikacin and ceftazidime as empiric treatment of febrile leukopenic patients affected by solid tumors

A combination of amikacin and ceftazidime was used as initial empiric therapy for the treatment of 25 evaluable febrile episodes (temperature greater than or equal to 38.5 degrees C) in leukopenic adult patients (wbc less than or equal to 1,000/mm3) with solid tumors, characterized by poor prognosis because of low performance status (median Karnofsky score: 50) and progressive disease (76% of cases). Nineteen (76%) of the 25 episodes responded to the initial empiric antibiotic combination. In the microbiologically documented infections, there was no significant difference in the response rate between bacteremia (67%) and localized infections (81%). The response in localized infections caused by gram-negative organisms (81%) was similar to that obtained in gram-positive organisms (82%), whereas gram-positive bacteremia responded better than gram-negative (100 vs 50%). No serious side effects were observed. Reversible nephrotoxicity occurred in 12% and hypokalemia in 20% of the patients treated. This antibiotic combination is a safe and efficacious empiric therapy for infections in leukopenic patients with solid neoplasia.

Septicemia, rash, and pulmonary infiltrates secondary to Corynebacterium group JK infection

This report describes a leukemic patient undergoing induction therapy in whom a Corynebacterium JK infection developed while he was leukopenic. The clinical triad of perirectal inflammation, skin lesions, and interstitial lung infiltrates, which has not previously been reported, is discussed. Characteristics of the organism and postulated routes of infection as well as treatment are explored.

Spectrum of HTLV-III infection in a hemophilic cohort treated with blood products from a single manufacturer

One hundred fifty-eight hemophilia A, B, and von Willebrand disease (VWD) patients treated with clotting factor concentrates from a single manufacturer were tested for antibody to the human T-lymphotropic virus type III (HTLV-III). Antibody was detected in 63% and 40% of those with severe hemophilia A and B, respectively, 12% and 0% of those with mild hemophilia A and B, and two patients with recessive VWD. Forty-two antibody-positive and 20 antibody-negative patients were studied for clinical and laboratory features of infection. Eleven seropositive patients had clinical signs of infection including Pneumocystis carinii pneumonia, lymphadenopathy, splenomegaly or diarrhea; however, only one patient had developed acquired immune deficiency syndrome (AIDS), and only two had significant impairment of their performance status. Thirty-one patients remained totally asymptomatic. Eight patients had a history suggestive of acute HTLV-III infection. Thrombocytopenia was observed in 18% of seropositive patients, lymphopenia in 60%, depressed T-helper cells in 43%, reduced T-helper:T-suppressor ratios (TH:TS) in 33%, and elevated platelet-bound immunoglobulin in 53%. The antibody-negative group had normal T-helper cell levels (except one patient) and TH:TS ratios, and normal platelet immunoglobulin levels. Both groups demonstrated a significant elevation of immunoglobulin levels and a high prevalence of antinuclear factor and antismooth muscle antibodies. The mean level of IgG was significantly higher in the antibody-positive group. This study confirms the correlation between HTLV-III infection and reduced T-helper cells in hemophiliacs but demonstrates a low incidence of clinical symptomatology. There was evidence of polyclonal B-cell hyperactivity in the antibody-negative group as well as the seropositive group.