Medicine
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To our knowledge, an institutional review of systemic histoplasmosis has not been conducted in the United States since the major outbreaks in Indianapolis in 1978-4982. We conducted a retrospective review of all patients with systemic histoplasmosis diagnosed at Mayo Clinic over a 15-year period. The case definitions employed were based on an international consensus statement by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group (EORTC/IFICG) and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (MSG). ⋯ The relapse rate was 9%, with a median relapse-free survival of 857 days. Systemic histoplasmosis should be suspected in patients who have lived in endemic areas with fever, bone marrow suppression, and elevated hepatic enzymes, particularly if they are immunocompromised. Evaluation including a combination of Histoplasma serologic screening, urine antigen assay, and fungal culture will secure the diagnosis in most cases.
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Comparative Study
Comparison of clinical manifestations and outcome of community-acquired bloodstream infections among the oldest old, elderly, and adult patients.
Valid studies comparing the clinical characteristics among adult, elderly, and the oldest old bacteremic patients are lacking. We conducted a prospective, observational study in the emergency department (ED) of a university medical center between June 2001 and June 2002. All patients >18 years of age who registered in the ED with a clinically significant, culture-positive, bloodstream infection (BSI) were enrolled. ⋯ Elderly patients had significantly less tachycardia (p = 0.001), but more acute respiratory (p = 0.007) and renal failure (p = 0.037); the oldest old patients had more afebrile episodes (p = 0.006), leukocytosis (p = 0.012), and more patients developed respiratory failure (p = 0.009), acute renal failure (p = 0.011), septic shock (p = 0.022), and altered mental status (p = 0.013). Urinary tract infections were the main source of BSI for both the elderly and oldest old, while the oldest old patients had significantly more pneumonia than the elderly or adults. As a group, older patients had fewer signs and symptoms of BSI, but a higher risk of organ failure and a worse prognosis than younger patients.
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Streptococcus pneumoniae infections can cause serious systemic disease in patients following hematopoietic stem cell transplantation (HSCT), and the response to pneumococcal vaccine is inadequate in most HSCT recipients. We evaluated the clinical spectrum of pneumococcal disease and vaccine-breakthrough infections in HSCT recipients at our cancer center in a retrospective analysis of all consecutive episodes of S. pneumoniae infection from 1989 through 2005. During the study period, 7888 patients underwent HSCT at our center; we identified 47 HSCT recipients with 54 S. pneumoniae infections. ⋯ All 5 (11%) patients who developed vaccine-breakthrough S. pneumoniae infection (546 +/- 732 d following vaccination) had pneumonia, and in 4 patients concurrent bacteremia also occurred. A serious S. pneumoniae infection in HSCT recipients occurred more commonly in patients with lymphoma and patients receiving high-dose systemic corticosteroid therapy. It is noteworthy that there were no cases of extrapulmonary organ infection in HSCT recipients who presented with S. pneumoniae infection at our institution.
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Susac syndrome is characterized by the clinical triad of encephalopathy, hearing loss, and retinal artery branch occlusions, mostly in young women. To our knowledge, long-term outcome and impact of pregnancy have not been specifically addressed. We report a series of 9 patients (7 female, 2 male) followed at the same institution, with special emphasis on clinical outcome including pregnancy and long-term sequelae. ⋯ In conclusion, at the end of follow-up, most patients had returned to work and none had severe impairment. Pregnancy may affect the course of Susac syndrome, with relapse of encephalopathy postpartum. Our main finding was that the course of Susac syndrome is not self-limited as previously thought, since isolated retinal arteriolar involvement may occur as a very late manifestation.
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Severe community-acquired pneumonia (CAP) requiring admission to an intensive care unit (ICU) has been inadequately studied. We compared characteristics and outcomes of patients with CAP who were admitted to the ICU with those of patients managed on the ward. Of the 3675 patients hospitalized with CAP, 374 (10%) were admitted to the ICU. ⋯ The following factors were predictive of ICU admission on multivariable analysis: younger age, smoker, limitation of functional status, absence of cough or pleurisy, presence of chronic obstructive pulmonary disease, substance abuse, elevated serum creatinine, abnormal serum glucose concentration, and a respiratory rate of <16 or >24 breaths per minute. Patients with low Pneumonia Severity Index scores and low CURB-65 scores were admitted to the ICU based on clinical judgment that appeared to supersede objective scoring. Severe CAP requiring admission to the ICU is common, and the decision about which patients to admit often requires clinical judgment that in many cases appears at odds with various validated pneumonia severity scoring systems.