Medicine
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Histoplasmosis is a serious opportunistic infection in patients with AIDS, often representing the first manifestation of the syndrome. Most infections occurring within the endemic region are caused by exogenous exposure, while those occurring in nonendemic areas may represent endogenous reactivation of latent foci of infection or exogenous exposure to microfoci located within those nonendemic regions. However, prospective investigations are needed to prove the mode of acquisition. ⋯ Relapse rates are lower (9 to 19%) in patients receiving maintenance therapy with amphotericin B given at doses of about 50 mg weekly or biweekly than with ketoconazole (50-60%), but controlled trials comparing different maintenance regimens have not been conducted. Until results of such trials become available, our current approach is to administer an induction phase of 15 mg/kg of amphotericin B given over 4 to 6 weeks, followed by maintenance therapy with 50 to 100 mg of amphotericin B given once or twice weekly, or biweekly. If results of a prospective National Institutes of Allergy and Infectious Disease study of itraconazole maintenance therapy document its effectiveness, alternatives to amphotericin B may be reasonable.
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Through a retrospective review, we identified 77 previously unreported cases of coccidioidomycosis during HIV infection. Patients were classified into 1 of 6 categories based on their primary clinical presentation: 20 had focal pulmonary disease (Group 1), 31 had diffuse pulmonary disease (Group 2), 4 had cutaneous coccidioidomycosis (Group 3), 9 had meningitis (Group 4), 7 had extrathoracic lymph node or liver involvement (Group 5), and 6 has positive coccidioidal serology without a clinical focus of infection (Group 6). Coccidioidal serologies were positive on initial testing in 83% of the patients in whom such serologic testing was performed. ⋯ Amphotericin B, ketoconazole, fluconazole, and itraconazole were all used as antifungal therapies. Outcome could not be related to the therapy used. Of note, 3 patients developed coccidioidomycosis while receiving ketoconazole for other conditions.(ABSTRACT TRUNCATED AT 250 WORDS)
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Multicenter Study Clinical Trial
New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases.
Three hundred fifty-nine consecutive patients with community-acquired pneumonia admitted to university, community, and VA hospitals underwent a standardized evaluation, including specialized tests for Legionella spp. and Chlamydia pneumoniae (TWAR). The most common underlying illnesses were immunosuppression (36.3%), chronic obstructive pulmonary disease (32.4%), and malignancy (28.4%). The most frequent etiologic agents were Streptococcus pneumoniae (15.3%) and Hemophilus influenzae (10.9%). ⋯ Mortality was highest for Staphylococcus aureus (50%) and lowest for C. pneumoniae (4.5%) and Mycoplasma pneumoniae (0%). We document that specialized laboratory testing for C. pneumoniae and Legionella spp. should be more widely used rather than reserved for cases not responding to standard therapy. Furthermore, realization that C. pneumoniae and Legionella spp. are common etiologies for community-acquired pneumonia should affect empiric antibiotic prescription.
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We reviewed 149 episodes of septicemia caused by X. maltophilia and Pseudomonas spp. occurring over a 15-year period. The incidence of septicemia caused by these organisms increased in recent years and was most frequently associated with central venous catheterization. ⋯ Although the survival rate was superior to that seen with septicemia caused by other gram-negative organisms, recurrence of infection was significantly more frequent. Removal of central venous catheters is an essential component of therapy of this infection.
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Normoglycemic remission has been observed in black non-insulin-dependent diabetic individuals. Thirty-three patients presented with severe hyperglycemia (mean glucose 682 mg/dl) and were hospitalized for initial treatment. Following intensive outpatient therapy including insulin or sulfonylurea for 0.25 to 96 weeks, they became normoglycemic without pharmacologic treatment. ⋯ Islet cell antibodies were uniformly absent, implying that these individuals did not have an autoimmune form of diabetes. It is not known if remission in non-insulin-dependent diabetes is unique to the black population. Neither the prevalence nor the mechanism of the development of remission is known at this time.