Monitoring women at risk for preterm labor

Candida arthritis is infrequent in patients who are not intravenous drug users. We describe a patient who was not an intravenous drug user and without other predisposing factors who developed knee arthritis caused by Candida albicans. We believe that this is the first report of such a case.     

The treatment of Eikenella corrodens soft tissue infection in an injection drug user

Despite the frequent occurrence of mucosal candidiasis in patients infected with HIV, systemic candidiasis is uncommon and usually associated with intravenous catheters, parenteral nutrition, or antibiotics and neutropenia. Most of the fungal isolates are usually Candida albicans, Candida tropicalis or Candida parapsilosis. The authors report a case of infective endocarditis due to Candida zeylanoides that occurred in a patient infected with HIV in the absence of the usual risk factors for systemic candidiasis.     

Chronic neutrophilic meningitis caused by Candida albicans

Meningitis caused by Candida albicans is a very infrequent entity. We present 3 intravenous drug users with chronic neutrophilic meningitis caused by Candida albicans. The clinical, microbiological and radiological features of the 3 patients are reviewed. The interval between the onset of the disease and the diagnosis was long (from 4 to 12 months). Candida albicans was cultured from cerebrospinal fluid (CSF) in the 3 patients. All of them developed hydrocephalus, meanwhile arachnoiditis was disclosed in two. The therapy with amphotericyn, 5-flucytosine and fluconazole produced clinical improvement and the sterilisation of the CSF in all the 3 cases. Clinicians should be aware of this entity because of diagnosis may be delayed in several months.     

Pharmacokinetics of oral fluconazole in premature infants

Systemic infections with Candida albicans in neonates are a frequent and well recognized problem. The therapeutic gold standard in this situation is the combined intravenous antimycotic treatment with amphotericin B and flucytosine. Potential adverse effects of this regimen have encouraged the search for desirable alternatives. We report on the use of oral fluconazole in neonates with Candida albicans septicaemia. Three premature infants were treated with four courses of therapy. Pharmacokinetic studies were performed during each course. At oral doses of 4.5-6 mg/kg once a day, serum levels of fluconazole were within the therapeutic range during the entire dosage interval. Follow up showed microbiological and clinical cure in all patients with no side-effects. In one patient a dosage of 4 mg/kg per day lead to a microbiological relapse with sub-therapeutic serum levels. CONCLUSIONS: Oral fluconazole seems to be a safe and effective treatment for Candida albicans septicaemia even in premature infants.     

Cholestatic hepatitis associated with piroxicam use. Case report

A 81-year-old man who complained of fever and disturbance of consciousness was admitted to our hospital. Listeria monocytogenes type 1/2aA was cultured from only the blood. He was treated with gamma-globrine and sensitive antibiotics (PAPM/BP, EM) immediately after admission, and recovered in spite of multiple organ failure due to septic shock. He was not an immunocompromised host and did not have complication of meningitis, but had rhabdomyolysis and liver dysfunction.     

Candida fungemia in neonates treated with fluconazole: report of forty cases, including eight with meningitis

PURPOSE OF THE STUDY: To assess efficacy and safety of fluconazole in neonates with Candida fungemia. STUDY DESIGN: Multicenter prospective protocol of all fungemias appearing between January 1, 1993, and December 31, 1997, in four major university hospitals. RESULTS: Forty neonates, 28 of them with very low birth weight (<1500 g; 30.5 median gestation week), with documented Candida albicans fungemia were treated with intravenous fluconazole in a daily dosage of 6 mg/kg once daily for 6 to 48 days. Thirty-four received fluconazole as monotherapy and 6 received it in combination with amphotericin B. Thirty-two (80%) were cured; 4 of them relapsed despite at least 14 days of therapy, but they were ultimately cured without sequelae. Eight other neonates died, 4 because of fungal infection and 4 because of prematurity or hemorrhage or lung failure, with fungemia (20% overall and 10% attributable mortality). Two neonates had elevated liver enzymes during fluconazole therapy and 2 others had elevated serum creatinine during fluconazole monotherapy. In none of them did these abnormalities necessitate discontinuation of antifungal therapy. In 8 neonates fungal meningitis developed as a complication of fungemia. All but 3 fungemias were C. albicans; 3 were Candida parapsilosis. CONCLUSIONS: Fluconazole was safe and effective antifungal therapy even in complicated or Candida fungemia in neonates and in infants with very low birth weight.     

Pappataci fever

Sandfly fever virus is known to cause pappataci fever. The sandfly fever virus belongs to the Genus Phlebovirus (family: Bunyaviridae) and is endemically found in areas of South Europe, Asia and Africa. In Germany, pappataci fever is only described in connection with travelling to endemic areas. We report on a 15 year-old girl suffering from sandfly fever virus infection after vacation in Turkey. The initial symptoms started with fever for about three days, frontal headache, nausea and arthralgia. After a short time of clinical improvement symptoms recurred and our patient entered hospital with signs of severe meningitis. Liquor analysis showed a lymphocytic meningitis. Due to multiple insect bites on her legs sandfly fever was suspected. Blood analysis confirmed an acute infection with sandfly virus Sicilian from which she completely recovered. ELISA and immunoblot analysis revealed an infection with sandfly virus serotype Sicilian, which was not encountered with meningitis so far. Our case report illustrates that due to increased tourism sandfly fever virus infection has to be considered as a cause of aseptic meningitis in travellers.     

Role of ultrasound and harness treatment in the management of developmental dysplasia of the hip

INTRODUCTION: Pustular candidiasis in heroin addicts is a rare entity in dermatology. We report a case. CASE REPORT: A 29-year-old female heroin addict developed a painful pustular growth on the scalp. There was no fever. Multiple follicular pustulae measuring 2 to 3 mm were associated with hyperesthesia of the scalp and painful cervical nodes. Biopsy showed acute ostiofolliculitis with a few blastospores and mycelial filaments. Candida albicans was isolated from the pustulae and the buccal cavity. Candida serology was positive (indirect immunofluorescence 1/100, coelectrosyneresis: 4 archs). Search for other localizations and HIV serology were negative. The last injection of brown heroin had been taken 15 days earlier; lemon had been added. Treatment with flucanazole (400 mg/d) led to improvement within 48 hours. DISCUSSION: Sudden development of pustulae or nodules in pilous zones in a heroin addict should suggest the diagnosis. Outcome depends on early treatment after diagnosis and search for other localizations. Our case presented two particular aspects: ostiofollicular localization of the pustulae and a long delay (15 days) between the (presumably) last injection and the development of the lesion. Folliculitis develops almost exclusively in addicts who use brown heroin. Contamination by Candida albicans results from the lemon used to improve solubility at injection.     

Unexpected candidemia complicating ureteroscopy and urinary stenting

Two elderly patients with obstructive renal calculi who developed Candida albicans bloodstream infection within 12 h following ureteroscopy and ureteral stenting are described. Both patients were treated with prolonged courses of broad-spectrum antibiotics and were found to have urine cultures positive for Candida albicans prior to the urologic procedures. One patient also developed bilateral candidal endophthalmitis. The clinical presentation was indistinguishable from bacteremia complicating manipulation of the urinary tract. The patients were successfully treated with systemic antifungal therapy. Candiduria may present a risk for dissemination during invasive, relatively simple urologic procedures.     

Racemose angiomatosis. Comments on the article of D.E. Matsko and I.A.Sokolova. Racemose angioma of the nervous system: tumor or developmental defect? Vopr. onkol. 1966. V.42, No.6. p.91-96

Diversion colitis is thought to result from nutritional deficiencies secondary to fecal diversion. Symptoms include hemorrhagic purulent rectal discharge, abdominal pain, and tenesmus. 5-Aminosalicylic acid (5-ASA) and N-butyrate enemas have been reported to help this condition non-spinal cord injury (SCI) patients. We report the case of a 49-year-old C6 ASIA B tetraplegic man who had received colostomy because of intractable ileus 10 years earlier. He presented with a 2-week history of rectal pain and bleeding. Abdominal and rectal examination on admission were unremarkable. Colonoscopy showed a partial stricture 70cm proximally to the rectum. The colonic mucosa appeared granular and friable with evidence of linear ulceration. Histopathologic study was consistent with colitis. The patient developed fever, abdominal distention, and extensive retroperitoneal air after endoscopy, suggesting colonic perforation. He was treated with daily 5-ASA suppository and total parenteral nutrition for the presumed diagnosis of diversion colitis, and intravenous antibiotics for perforated colon. After 6 weeks of treatment with 5-ASA, the patient had decreased rectal pain and bleeding. This experience suggests that diversion colitis may be a cause of abdominal discomfort in SCI patients and that 5-ASA may be used in the management of diversion colitis.     

Recurrent pyogenic granuloma or Warner and Wilson-Jones syndrome

Here we report a case of pneumococcal meningitis with bilateral sensorineural hearing loss at the onset. The patient was a 60-year-old man who a few days before visiting our hospital experienced common cold-like symptoms, and then he suddenly developed bilateral hearing loss. Examination of the cerebrospinal fluid (CSF) on the day of admission revealed pleocytosis and his CSF culture demonstrated pneumococci. Otorhinolaryngological examinations disclosed bilateral severe sensorineural hearing loss due to cochlear impairment. Many cases of bacterial meningitis concomitant with hearing loss have been reported, but a case of meningitis starting with sudden hearing loss is rare.     

Gut colonization of mice by yeast: effects of methylprednisolone and antibiotics

BACKGROUND/AIMS: This study evaluated the effects of broad spectrum antibiotics and methylprednisolone on the gut colonization of mice by C. albicans. METHODOLOGY: Male Crl:CD1 (ICR) BR mice, 3 months of age, were fed chow containing Candida albicans, while similar mice were fed regular chow. The gut of the Candida-fed mice was colonized by yeast. Groups of mice were subsequently treated for 10 days, with either ceftriaxone, ticarcillin-clavulanic acid, or methylprednisolone, each alone or with the combination of methylprednisolone and each antibiotic. Other Candida-colonized mice received normal saline, and non-colonized mice, serving as controls, received the same drugs and drug combinations or saline. RESULTS: Candida-colonized mice treated with each antibiotic alone had significantly higher yeast counts in their stool, while those treated with methylprednisolone alone did not. Colonized mice treated with the combination of each antibiotic with methylprednisolone had similar stool concentrations of Candida as mice treated with each antibiotic alone. Saline did not change Candida in the stool concentration. Yeast was not found in the stool of non-colonized mice treated with the drugs under investigation or saline. Dissemination of Candida did not occur in any mouse. CONCLUSIONS: Ceftriaxone and ticarcillin-clavulanic acid significantly increase gut colonization of mice by yeast, while methylprednisolone, either alone or in combination with these antibiotics, does not.     

Candida endocarditis in the first year of life

Candida is an increasing problem as a causal agent of nosocomial infection in neonates and infants. We report 15 cases of infective endocarditis caused by Candida spp treated at the Hospital Infantil de Mexico between 1980 and 1991. The diagnosis of endocarditis was established by the identification of Candida in at least two blood cultures and echocardiographic assessment. From 110 cases of systemic candidiasis during the eleven years period of study, fifteen patients presented endocarditis (13.6%), all had a central venous catheter. Three had antecedent of congenital heart disease. Candida isolation was obtained an average of 28 days after admission. The major clinical findings were: fever in 13 patients, respiratory distress and cardiac murmurs observed in nine respectively. Thrombocytopenia was present in eight children. The echocardiographic evaluation showed vegetations located in the superior vena cava in six, right atrium in five, tricuspid valve in two, inferior vena cava and right ventricle in one respectively. Three cases were subjected to surgical treatment. Nine patients died for a case fatality rate of 60%. The echocardiographic evaluation practiced in all patients with suspicion of systemic candidiasis is critical for the prognosis. The identification of endocardiac involvement coupled with the opportune administration of antifungal therapy and surgical treatment may improved the survival.     

Disseminated miliary cerebral candidiasis

We present a case of disseminated intracranial infection by Candida albicans in a 5-year-old girl who had fever and a change of consciousness after surgery for complex congenital heart malformation. MR imaging revealed multiple small ring-enhancing hemorrhagic abscesses. One year after antifungal treatment, the abscesses and ventriculomegaly were almost completely resolved. The patient was discharged in a stable but vegetative condition.     

Intravenous injection of Candida-derived mannan results in elevated tumor necrosis factor alpha levels in serum

Intravenous injection of Candida albicans into mice produced elevated serum tumor necrosis factor alpha (TNF-alpha) levels. We hypothesized that immunostimulants released in vivo from C. albicans during fungal sepsis might contribute to the elevated levels of TNF-alpha in serum. We tested this hypothesis in mice with C. albicans mannan (CAM). Increased serum TNF-alpha levels were observed following intravenous and intraperitoneal injections of CAM. Injection of CAM into mice resulted in increased serum TNF-alpha concentrations that reached 1,200 pg/ml of blood, compared with 2,400 microg/ml of blood following injection of 10 microg of endotoxin. The response to CAM was concentration dependent, requiring a minimum dose of 20 microg of CAM per g of body weight. Sera from mice were tested 30, 60, 90, and 120 min after intravenous injections with CAM. TNF-alpha concentrations were minimal 30 and 120 min after intravenous injection and maximal 60 and 90 min after CAM injection. The relative distribution of CAM in vivo in decreasing order was determined to be as follows: blood > liver > lung > spleen, 90 min following injection of a single 5-mg dose of CAM. CAM was confirmed as the stimulating substance by utilizing anti-CAM antibodies in vivo to block the response. Rabbit anti-mannan antibodies administered by intraperitoneal injection 24 h before CAM injection significantly suppressed (P < 0.05) the accumulation of TNF-alpha in the sera. Dexamethasone administered to mice before intravenous injection of mannan significantly reduced (40 to 90% reduction; P < 0.05) the concentrations of TNF-alpha in the sera of treated mice. Thus, when in vivo CAM clearance mechanisms are exceeded, sufficient CAM may become available to stimulate TNF-alpha production, making CAM an important part of pathogenesis in Candida sepsis.     

Candidemia in the neonatal intensive care unit

The hospital records of 18 infants (9 males & 9 females) with one or more positive cultures for Candida species were studied retrospectively in an attempt to define the characteristics, associated factors and treatment for candidemia in the neonatal intensive care unit. The number of patients have increased recently and the mortality rate is 56% (10/18). The Candida species isolated from blood were Candida albicans in 16 cases and Candida parapsilosis in 2 cases. Fever, not-doing-well, and abdominal distention were the most common presentations, prompting us to the initial impression of bacterial sepsis and/or necrotizing enterocolitis. Eleven associated factors for candidemia were relating to the measures and therapy in the neonatal intensive care unit, such as prolonged use of broad-spectrum antibiotics, parenteral hyperalimentation etc. All of these 18 patients were treated with intravenous amphotericin B. Six patients were given adequate total dose (> 25 mg/Kg), while 12 patients underwent inadequate treatment (3.7 +/- 2.9 mg/Kg). The 10 fatal patients belonged to the inadequate treatment group. As there is continual progress in neonatal intensive care units, candidemia is becoming an increasing common problem and which deserves attention.     

Acute bacterial meningitis in adults: a clinical and developmental analysis of 100 cases

BACKGROUND: Characterize clinical findings and outcome of acute bacterial meningitis (ABM) in adults, with special emphasis on nosocomial meningitis and meningitis in the elderly. METHODS: We reviewed the charts of all persons 14 years of age or older in whom ABM was diagnosed in our hospital during a 12 and a half-year period. RESULTS: Ninety-seven patients were treated for 100 episodes of ABM, of which 23 percent were nosocomial and 27 percent occurred in elderly persons. Predisposing factors were present in 59 percent of the episodes. Fifty-four percent had the classic triad of fever, nuchal rigidity, and change in mental status. Cerebrospinal fluid pleocytosis with a neutrophilic predominance, hypoglycorrhachia, and elevated protein levels were present in 62 percent of the episodes. A pathogen was identified in 62 percent of the cases, in a higher frequency in elderly persons (p < 0.05) and in patients who had not received antibiotics before the lumbar puncture (p < 0.05). Causal agents more frequently identified were: Streptococcus pneumoniae (27 percent) in community-acquired meningitis, coagulase-negative Staphylococci (35 percent) in nosocomial meningitis, and Strep. pneumoniae (33 percent) in elderly persons. Central nervous system (CNS) complications occurred in 18 percent of episodes, and 15 percent developed systemic complications. The overall mortality rate was 9 percent, higher among patients in whom CNS complications began within 24 hours of admission (p < 0.05). CONCLUSIONS: A high proportion of cases of ABM in adults are nosocomial, or affect elderly persons. The fatality rate is high, particularly among those who develop CNS complications at the onset of the disease.     

Legionella longbeachae pneumonia in a gardener

A 52-year-old male gardener, who traveled to Guam Island several days ago, was admitted to our hospital with fever, cough and dyspnea. His chest X-ray showed bilateral infiltration and he was severely hypoxic and hypotensive on admission. He died of multiple organ failure in spite of intensive treatment with mechanical ventilation antibiotics including erythromycin. Legionella longbeachae serotype 1 was isolated from his sputum and was regarded as the etiologic agent. Legionella longbeachae was not isolated from the same type of leaf mold that he used as potting soil. This is the first case of Legionella longbeachae pneumonia from whom the organism was isolated in Japan.     

Candida infection of a silicone metacarpophalangeal arthroplasty

Fungal infections following joint arthroplasty are extremely rare. Only 16 cases of Candida prosthetic infections have been reported, involving the hip, knee or shoulder joints. We report a case of a silicone metacarpophalangeal joint replacement complicated by a Candida albicans infection.