Corticosteroids for the management of severe intracranial hypertension in meningoencephalitis caused by Cryptococcus gattii: A case report and review

Immune reconstitution inflammatory syndrome in meningitis caused by Cryptococcus gattii in immunocompetent patients after initiation of antifungal therapy appears to be the result of paradoxical antifungal treatment-induced clinical deterioration due to improved local immune responses to cryptococcal organisms. Recent anecdotal reports have suggested a favorable clinical response to corticosteroids in select patients with C. gattii central nervous system (CNS) infections. In this report, we describe a 65-year-old patient with meningoencephalitis caused by C. gattii who developed persistent intracranial hypertension and was successfully managed with antifungal therapy, repeated lumbar puncture and corticosteroids. Our observations suggest a possible benefit of dexamethasone in the management of select cases of C. gattii CNS infection with intracranial hypertension. Further studies are necessary to evaluate the long-term use of steroids in select patients with C. gattii with intracranial hypertension.

Cutaneous mucormycosis with subsequent visceral dissemination in a child with neutropenia: a case report and review of the pediatric literature

Primary cutaneous mucormycosis is a rare opportunistic fungal infection that is usually limited to the skin. We describe a primary cutaneous Rhizopus infection occurring at a site occluded by a sterile adhesive dressing in which the disease was viscerally disseminated at the time fo diagnosis. Mucormycosis should be considered in all ecthyma-like lesions in immunocompromised patients. It may be rapidly diagnosed by examination of hematoxylin-eosin and PAS-stained sections of the eschar base and a culture of a leading edge tissue aspirate. We review 21 cases of primary cutaneous mucormycosis in children and compare them with the present case.

Mechanism of gastric emptying of a nondisintegrating radiotelemetry capsule in man

We studied the mechanism of gastric emptying of a pH-sensitive radiotelemetry capsule with respect to phases of the interdigestive migrating motor complex (IMMC) in fasting normal volunteers and the effect of the Heidelberg capsule (HC) on the duration or timing of the IMMC phases. A manometric catheter with eight mounted solid-state strain gauges was passed transnasally and positioned fluoroscopically in the duodenum and jejunum in four normal, fasted male volunteers, in their right lateral position. The HC was administered orally following the establishment of one complete IMMC cycle (defined by the recording time between the end of two subsequent phase III activity fronts) and during the beginning of Phase I of the next cycle. The gastric residence time (GRT) of the HC was measured as the time of a gastric pH rise of greater than or equal to 3.0 units. In three subjects, GRT of the HC lasted to within 5 min of the onset of the next duodenal phase III of the IMMC, while in the fourth subject, the HC passed during the second phase III activity front. There were no significant differences in the duration of each phase of duodenal IMMC in the presence or absence of the HC (Phase I, 54 +/- 9.3 vs 31.6 +/- 10.1; Phase II, 22 +/- 8.1 vs 58.9 +/- 32; Phase III, 5.3 +/- 0.7 vs 4.2 +/- 0.7 min; mean +/- SE; P greater than 0.1 in all phases). In addition, the HC had no effect on motility index or patterns of contractions.(ABSTRACT TRUNCATED AT 250 WORDS)

A controlled study of the nephrotoxicity of mezlocillin and gentamicin plus ampicillin in the neonate

The nephrotoxicity of the aminoglycoside gentamicin was evaluated in an open, controlled study of newborn infants randomly allocated to receive either combination drug therapy with gentamicin and ampicillin or single drug therapy with mezlocillin for treatment of presumed neonatal sepsis. There were no significant differences in initial clinical characteristics between the groups. Neonates receiving gentamicin, in contrast to those receiving mezlocillin, had significant nephrotoxicity manifested by a smaller postnatal fall in mean serum creatinine concentration (-9%, P NS vs -21%, P less than 0.005, respectively) and a diminished postnatal rise in mean creatinine clearance (+ 21%, P NS vs + 51%, P less than 0.01, respectively). In neonates with a fall in creatinine clearance, the mean decline was significantly greater in those receiving gentamicin (44% vs 20%, P less than 0.01). There was no relationship between the incidence of gentamicin nephrotoxicity and either peak or trough gentamicin levels. For treatment of presumed neonatal sepsis, gentamicin proved more nephrotoxic than mezlocillin.

A controlled study of the nephrotoxicity of mezlocillin and amikacin in the neonate

The nephrotoxicity of the aminoglycoside amikacin sulfate was evaluated in an open, controlled study of newborns with presumed neonatal sepsis. One hundred twelve neonates were randomly allocated to receive either amikacin-ampicillin or mezlocillin, a semisynthetic penicillin. Neonates receiving amikacin, in contrast to those receiving mezlocillin, showed significant nephrotoxicity as evidenced by a delayed postnatal fall in mean serum creatinine level (82 to 80 mumol/L [0.93 to 0.90 mg/dL] vs 84 to 72 mumol/L [0.95 to 0.82 mg/dL]) and a delayed postnatal rise in mean creatinine clearance per kilogram of body weight (12% vs 38%). Furthermore, 40% of neonates receiving amikacin-ampicillin compared with 19% of neonates receiving mezlocillin had a decline in creatinine clearance (greater than 25%). There was no relationship between amikacin nephrotoxicity and either peak or trough amikacin levels. In summary, in a controlled study of the use of amikacin and mezlocillin in neonates, the combination of amikacin and ampicillin proved more nephrotoxic to the newborn kidney.

Kinetic nephelometric determination of transthyretin and retinol-binding protein in neonatal serum

We have developed a kinetic immunonephelometric method for the determination of retinol-binding protein and modified the method of Jacob et al (Clin Chem 1983; 29: 564) for the determination of transthyretin (prealbumin) in neonatal serum specimens from small, premature infants. The methodologies allow detection of 17.5 mg/l transthyretin and 1.7 mg/l retinol-binding protein in 25 microliter of serum. Between-run precision studies using pooled neonatal serum gave CV values of 3% and 5-6% for transthyretin and retinol-binding protein, respectively. Results obtained for neonatal specimens using this method agreed well with those obtained for the same specimens using radial immunodiffusion. Mean (SD) serum concentrations for 39 neonatal specimens were 100.4 (46.6) and 26.3 (10.8) mg/l for transthyretin and retinol-binding protein, respectively.

Prediction of cerebral death by cranial sector scan

Real-time cranial ultrasonography (cranial sector [CS] scan) was prospectively evaluated for its usefulness in identifying irreversible cerebral injury in critically ill children admitted to the neonatal and pediatric ICUs at our institution. Absence of pulsatile movement of the anterior and middle cerebral arteries was determined to represent absent cerebral perfusion and thus profound irreversible injury. Of 800 consecutive patients representing 1900 CS scans, 12 met the criteria. Six were neonates and 6 were older infants. Mechanisms of injury included severe hypoxia, head trauma, and CNS infection. Absence of brain function by clinical examination and EEG confirmed CS findings in 11 who expired. One neonate survived with intact brainstem function but no identifiable cerebral function or growth. No false positives were demonstrated. We found the CS scan to be a reliable bedside adjunct in the determination of irreversible cerebral injury or cerebral death.