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Rare and emerging opportunistic fungal pathogens are a serious and growing concern for immunosuppressed patients. Macrophomina phaseolina, an important soilborne plant pathogen in tropical and subtropical soil, should be considered in this category. It may be evident as a localized cutaneous cellulitis or as an ocular keratitis. We describe a 42-year-old diabetic male originally from India in whom a soft tissue mass of the foot proved to be an M. phaseolina cellulitis and review the literature. To our knowledge, only four individuals have been documented with infections with this organism, three of whom were immunocompromised.

The nontropical diabetic hand syndrome merits recognition as a serious hand infection and diabetic complication. Initially recognized in the tropics and called tropical diabetic hand syndrome, this entity has not been previously delineated in temperate regions. Due in part to its unremarkable initial presentation, nontropical diabetic hand syndrome is neglected in temperate zones of the world yet it can result in severe morbidity and mortality among diabetic patients. It is poorly understood, needs recognition, and mandates expedited treatment since its clinical presentation is often overlooked until serious consequences occur. Inner city diabetic patients with poor glycemic control appear to be particularly susceptible to developing nontropical diabetic hand syndrome. We review this new entity and differentiate it into three clinical presentations: (Stage I) superficial erosion and ulceration; (Stage II) cellulitis and necrosis; and (Stage III) gangrene. The treatment of this new diabetic syndrome involves aggressive glycemic control and possible surgical intervention. We stress the importance of recognizing the diabetic hand syndrome as a potentially disabling and life-threatening disorder in diabetics worldwide.

We report a rare case of Mycobacterium haemophilum presenting as an intraventricular granulomatous mass with loculated hydrocephalus and seizures in a patient with human immunodeficiency virus. M. haemophilum, a slow-growing mycobacteria, causes localized and disseminated disease among immunocompromised hosts. Central nervous system infection with M. haemophilum is extremely rare. Preoperative laboratory testing of our patient for tuberculosis, toxoplasmosis, sarcoidosis and histoplasmosis were negative. Surgical resection of the mass revealed a caseating granuloma that stained positive for acid-fast bacillus suggesting possible tuberculoma. Despite negative testing for tuberculosis, a polymerase chain reaction analysis was ultimately performed from the resected mass which revealed M. haemophilum. To our knowledge, this is the first case of M. haemophilum presenting as an intraventricular mass. We review the clinical manifestations of this pathogen and discuss the medical and surgical management.

18-Fluorine fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) has been shown to have use in the diagnosis of inflammatory and infectious diseases in addition to its primary use in cancer. We describe a case of early neurosyphilis that initially presented as symmetric, generalized lymphadenopathy on PET/CT. We conclude that PET/CT may play a role in evaluating targeted diagnostic interventions, disease extent, and treatment efficacy for disseminated syphilis.

Leishmaniasis is an emerging disease in HIV-infected persons; visceral leishmaniasis is an AIDS-defining opportunistic infection. The parasite that causes this infection is usually transmitted by the sandfly and occasionally by nonsterile needles among intravenous drug users. Diffuse cutaneous leishmaniasis (DCL) is a rare anergic variant of leishmanial infection with the characteristic presentation of numerous nonulcerating nodules with an abundant parasite load, lack of visceral involvement, negative reaction to the leishmanin skin test, and a chronic course with incomplete response to treatment and frequent relapses. We report a case of DCL that developed in the context of the immune reconstitution inflammatory syndrome (IRIS) in a man with AIDS following initiation of antiretroviral therapy. We also review DCL to emphasize the importance of recognizing and treating this evolving disease in the growing population of patients on immunorestorative therapy.

A 20-year old man who had sex with men (MSM) presented with destructive osteomyelitis of the sternal bone and diffuse maculopapular rash. During laboratory evaluation he was found to have secondary syphilis and HIV with viral load of 28,000 copies per milliliter and CD4 count of 251 cells per microliter. Surgical debridement and biopsy of the sternal bone was performed. The biopsy examination demonstrated bone necrosis with perivascular infiltration of plasma cells and lymphocytes and rare hystiocytes. No granulomatous lesions were identified and acid-fast, fungal, silver, and Gram's stains did not show any organism. All cultures were negative. Real-time polymerase chain reaction (PCR) using probes targeting a pathogen-specific and highly conserved TpN47 gene of Treponema pallidum was performed on the DNA, extracted from the biopsy specimen and T. pallidum amplicons were detected. Patient was initially treated empirically with vancomycin, piperacillin/tazobactam and intravenous aqueous penicillin G. After confirming the diagnosis he completed 2 weeks of intravenous aqueous penicillin G treatment with resolution of osteomyelitis confirmed at follow-up visit after 6 weeks. Osteomyelitis is a rarely described manifestation of secondary syphilis. To the best of our knowledge, this is the first case of using T. pallidum DNA PCR to confirm the diagnosis of syphilitic osteitis. We suggest that osteomyelitis may be an underrecognized problem in patients with secondary syphilis, especially in HIV-coinfected individuals and PCR seems to be a valuable method in confirming the diagnosis.

Leishmaniasis is endemic in 98 countries and territories, with 1.2 million new cases per year, making it a worldwide concern. The deadly visceral form is a leading cause of death from tropical parasitic infections, second only to malaria. Leishmaniasis appears to be increasing in many countries because of extended urbanization. The disease reservoir includes small mammals; parasite transmission occurs via bite of the female phlebotomine sandfly. Disease manifestations vary and largely depend upon the Leishmania species acquired. It may be first evident with a range of findings-from a localized cutaneous ulcer to diffuse painless dermal nodules-or, in the mucocutaneous form, ulceration of the oropharynx. In the potentially deadly visceral form, the internal organs and bone marrow are affected.

The diagnosis of leishmaniasis can be challenging because it mimics both infectious and malignant conditions. A misdiagnosis may lead to an unfavorable outcome. Using culture, histologic, and/or polymerase chain reaction study results, a diagnosis of leishmaniasis can be established and treatment initiated. Appropriate management requires an accurate diagnosis, which often includes identification of the specific etiologic species. Different endemic areas have varying sensitivities to the same medication, even within individual species. Species identification may be of practical value, because infections with select species have a substantial risk of visceral involvement. In addition, HIV and otherwise immunocompromised patients with leishmaniasis have a propensity for diffuse cutaneous leishmaniasis. For most New World Leishmania species, parenteral antimonial drugs remain the first line of therapy, while Old World species are easily treated with physical modalities. Historically, live organism vaccination has been used and is effective in preventing leishmaniasis, but results in an inoculation scar and an incubation period that may last for years. A more effective method of vaccination would be welcome.

objective: To determine the most efficient approach to the diagnosis of infective endocarditis (IE) in febrile parenteral drug users (PDUs) and evaluate possible effects of human immunodeficiency virus (HIV) infections or acquired immunodeficiency syndrome (AIDS) on susceptibility to IE and final outcome. design: A prospective study of appropriate patients admitted on 149 random sampling days during a 14-month period and review of past experience with IE, HIV, and AIDS admissions to hospital. setting: An urban university hospital patients: Prospectively, 121 febrile PDUs plus an additional 16 found to have IE on nonsampling days during the study period. Retrospectively, all PDUs with IE from 1985 to 1991 and all patients with HIV infections with or without AIDS from July 1990 through December 1991. measurements: Physical examination, hemograms, urinalysis, blood cultures (plus other body fluids when indicated), echocardiography, laboratory testing for HIV status. main results: Five categories of patients were identified: L Infective endocarditis (n = 16); II. Other infections with bacteremia (n = 21); III. Bacteremia with unidentified source of infection (n = 14); IV. Infections without bacteremia (n = 52); V. Fever of unknown origin (n = 18). Physical findings and standard laboratory testing did not differentiate Group I from any of the other diagnostic categories. Adding additional IE cases from nonstudy days brought the total to 32. Vegetations were found on echocardiography in 94%; blood cultures, available in 30 of 32 instances, were all positive. HIV or AIDS status was not found to alter susceptibility to IE or influence mortality. While hospital admissions for HIV and especially AIDS have continued to increase among PDUs, the number of cases of IE has decreased since 1988 to 1989. conclusions: Based on the high incidence of blood culture positivity and the sensitivity of echocardiography in detecting vegetations in IE, a simple algorithm has been developed for the initial diagnostic management of febrile PDUs admitted with the possible diagnosis of IE. HIV infection, with or without full-blown AIDS, does not appear to affect the incidence or outcome of IE among these patients. Current practices among PDUs may be effecting a decline in IE but not HIV infections.

Crohn's disease is a chronic, relapsing, inflammatory disorder which may involve any segment of the bowel from mouth to anus. The mucocutaneous manifestations of Crohn's disease in the orofacial region are multiple, including oral Crohn's disease, metastatic Crohn's disease in sites noncontiguous with the bowel system, and reactive disorders such as pyoderma gangrenosum. Clinicians should be familiar with these extraintestinal manifestations and include this important and often serious disease in the evaluation of patients with selected orofacial disorders. The recognition of these manifestations may help prevent misdiagnosis and unnecessary treatment, and facilitates timely diagnosis, palliation and definitive therapy.

Bacillary angiomatosis is an unusual systemic vascular proliferation seen predominantly in patients with the acquired immunodeficiency syndrome. These vascular lesions are due to infection with a Bartonella species, most commonly B. henselae, but sometimes B. quintana. It is treatable and often curable, but without therapy may be life-threatening. Clinically, the disorder often resembles several different vascular disorders, particularly pyogenic granuloma and Kaposi's sarcoma. We now report a clinically typical patient with bacillary angiomatosis who was HIV seronegative, but who had idiopathic thrombocytopenic purpura, was status-post splenectomy and to whom long-term systemic prednisone had been administered.

Ten patients developed infections after alloplastic implantation (nine silicone, one gelatin film [Gelfilm] implant) for orbital floor fracture repair. Infection resulted from the following: (1) dental surgery, (2) upper respiratory infection, (3) inferior extrusion of a retained implant into the maxillary sinus with a fistulous tract into the inferior conjunctival fornix, (4) rhinoplasty, (5) snorting cocaine and other drugs, (6) postoperative infection after orbital floor repair, and (7) medial implant migration resulting in chronic dacryocystitis. In all ten patients, implants were removed because of orbital abscess, recurrent infection, or chronic low-grade infections. Microbiologic culture of removed implants disclosed Staphylococcus aureus, S. epidermidis, Serratia marcescens, and Pseudomonas aeruginosa as the offending organisms. The main complication of infection included severe cicatricial ectropion of the lower eyelid in three patients. The final globe position was not adversely affected by implant removal performed from five months to 20 years after insertion. Guidelines for prevention and management of orbital implant infections based on these ten patients are presented.

Histoid lepromas are a rare eruption in patients with lepromatous leprosy. A 59-year-old man from India with lepromatious leprosy who developed histoid lepromas and who was dapsone resistant was studied. These tumors resembled cutaneous metastases. This Indian man is to our knowledge the first patient to be reported with this rare disorder in the continental United States.

Neuropathologic changes are described in eight fatal cases of the acquired immunodeficiency syndrome (AIDS), including four subjects who were i.v. drug abusers (two women, two men), two Haitian men, one bisexual man, and one women who had no known risk factors for AIDS. All cases had significant infections of the brain, with examples of bacterial, fungal, protozoal, and viral disease in the group. Combined infections were observed in three cases, including one case of previously unreported central nervous system (CNS) abscess due to Nocardia (combined with Salmonella). The most frequent CNS pathogen was Toxoplasma gondii, which in both Haitian subjects co-existed with systemic tuberculosis, leading to diagnostic difficulty. Only one case of "subacute encephalitis" was represented, although in other cases microglial nodules were associated with Toxoplasma and Cryptococcus organisms, as well as probable cytomegalovirus. Non-infectious complications included a cerebral infarct (one case), central pontine myelinolysis (one case), and diffuse microcystic change of the white matter (one case).

The total number of cases of heroin-induced endocarditis occurring over a four-year period were reviewed in order to explain an increase in the number of cases in the last year studied (1975). Brown heroin was noted to be used more frequently by addicts during the period of increased incidence. Cultures of "street samples" of brown and white heroin as well as cocaine were obtained in order to elucidate a possible relationship between the increased use of brown heroin and the increased number of endocarditis cases. Despite frequent contamination of both white and brown heroin, none of the common endocarditis-causing pathogens were isolated from the samples. Staphylococcus aureus, the most common etiological agent, frequently resulted in tricuspid endocarditis. That the accepted criteria for tricuspid endocarditis may be present without actual cardiac valve involvement is demonstrated by a most unusual case of hepatic vasculature infection.

The failure to diagnose tuberculosis during life is largely due to the decline in the index of clinical suspicion which has accompanied the reduction in prevalence of tuberculosis and to failure to appreciate changes in the epidemiological pattern of the disease. Ten patients with extra-pulmonary tuberculosis seen in one hospital during a 4-yr period illustrate contemporary diagnostic problems. In each, a diagnosis of tuberculosis was not considered initially because of lack of suspicion and consequent failure to utilize proven and accepted laboratory methods. Along with high index of clinical suspicion, some simple laboratory and diagnostic studies are of immense value. If tuberculin tests are negative in the initial phase, and become positive during the course of an illness with non-specific symptoms, this may indicate a tuberculous etiology. Equally significant is the unexplained rise in alkaline phosphatase resulting from granulomatous involvement of the liver. With modern chemotherapeutic drugs available, tuberculosis is now usually a curable disease. Physicians, therefore, must be aware of the problem of undiagnosed tuberculosis, particularly in elderly patients and must pursue proper investigations so that chemotherapy can be initiated early in the course of the illness.

Two patients hyperinfected with Strongyloides stercoralis (an intestinal nematode) are described. Both were both in Puerto Rico and had left the island six to 15 years previously; both were receiving adrenal steroids (one for Hodgkin's disease and the other for Goodpasture's syndrome). One died shortly after diagnosis, but the other survived the hyperinfection syndrome and complicating bacterial sepsis and meningitis. In addition to our case reports, 103 previously described cases of presumed strongyloides hyperinfection are reviewed. Among 89 patients immunocompromised by therapy or disease, the mortality rate was 86%; bacterial sepsis often contributed to the fatal outcome. In most cases, infection was acquired in an endemic area, sometimes long before the hyperinfection syndrome occurred. The few patients who had never been to an endemic area had a history of prolonged contact with highly soiled material, an observation suggesting cross infection from a contaminated person. When administered in time, thiabendazole, the drug of choice for strongyloidiasis, was effective in 70% of cases. If intestinal infection with S. stercoralis is detected and treated before immunosuppressive therapy is initiated and if a high index of suspicion for the hyperinfection syndrome is maintained while immunosuppressive therapy is given, the mortality from this disease should decrease.

A case of purulent meningitis in an adult caused by Streptococcus MG-intermedius, also known as Streptococcus milleri, is described. The intriguing taxonomical history of this organism and its association with mycoplasma pneumoniae pulmonary infections is reviewed. The incidence of central nervous system infections due to this organism is also discussed.

Septicemia due to Pseudomonas putrefaciens was found in an elderly man with chronic leg ulcers. This organism is rarely cultured from human material and has been reported to cause skin and ear infections in only a few patients. Its potential for invasiveness is documented in this case for the fourth time.

Superinfection in the compromised host often poses a diagnostic and therapeutic dilemma for the physician who is concerned that a perplexing array of microorganisms might be involved. We believe that the differential diagnosis list can often be narrowed considerably by separating superinfection in the compromised host into five convenient categories: (1) infections due to the underlying disease itself; (2) infections due to the underlying disease plus therapy for that disease; (3) infections due solely to medicaments, operations, or procedures; (4) infections increased in severity but probably not in incidence; and (5) societally related infections. Use of this or a similar categorization should result in a more rational approach to differential diagnosis, should encourage a more focused diagnostic work-up, should reduce the necessity for invasive procedures, should provide the microbiology laboratory information about specific organisms that should be sought sedulously, and should permit the selection of a more rational antimicrobial regimen prior to the availability of definitive microbiologic information.

Specimens from 300 patients were studied using five to nine aerobic and anaerobic culture media, including five that were hypertonic, Groups studied included fever of unknown origin, suspected endocarditis, endocarditis during therapy, bacteremia during therapy, abscess and cellulitis, presumed infectious arthritis, renal transplantation during rejection, collagen disease, sarcoidosis, lymphoma, and colitis. Isolates in hypertonic media were reverted to parent form by agar passage. In only 5% of these selected cases were organisms found in hypertonic, but not conventional, media that appeared on the basis of repeated isolation and/or serological studies to come from the patient. Nine of the 16 appeared to be of major significance. The two groups in which use of highly enriched, hypertonic media seemed most helpful were suspected endocarditis and undefined meningitis with negative cultures using standard media. The most effective of the hypertonic media used was 0.3 M sucrose in brain heart infusion with 20% horse serum. In most instances, the organism grew only in the hypertonic sucrose, and in most cases it appeared in conventional rather than aberrant form. Hypertonic media, especially 0.3 M sucrose, are of substantial helpin a small number of carefully selected cases.

Massive hemoptysis in patients with tuberculosis is reported infrequently and then virtually always in association with cavitary disease or aspergilloma. In contrast, we describe herein five cases characterized by hemoptysis on admission, bilateral pulmonary disease, samples of sputum positive for acid-fast bacilli by Ziehl-Neelsen stain, and no obvious cavitary disease. In each, hemoptysis subsided and then suddenly recurred in prodigious amounts, leading to death, probably from asyphyxiation. In patients hospitalized with tuberculous hemoptysis of any amount, with or without an obvious cavity, aggressive diagnostic evaluation, including bronchoscopic examination, may define the site of bleeding, thus permitting rapid surgical intervention if the hemoptysis increases.

Thirty patients with presumed anaerobic pleuropulmonary infection were treated with clindamycin hydrochloride. Diagnoses of anaerobic infections were made primarily on clinical evidence, including history of aspiration, fetid sputum, and x-ray findings of pulmonary infiltrates, frequently with cavity formation. All patients were treated with clindamycin hydrochloride by mouth for 10 to 28 days in a dosage of 150 to 300 mg four times a day. Twenty-six patients showed a favorable response, although 6 also required closed thoracotomy with tube drainage of the pleural space. No serious side effects were encountered, although one patient developed transient neutropenia, and another showed elevation of hepatic enzyme levels. There were no cases of clinical superinfection, and only four patients acquired Gram-negative enteric pathogens in the sputum in low titers. Clindamycin given orally thus appears to be an effective initial antibiotic in the treatment of anaerobic pneumonias.

During the first week of March 1974, a hospitalized patient being evaluated for hyperproteinemia and hypertension experienced fever, chills, and myalgia and showed pulmonary signs consistent with diffuse pneumonia. Subsequently, the findings from serologic tests confirmed that the patient had viral influenza. Seven other compromised hosts on the same ward developed symptoms of pneumonic influenza, and serologic data on three of the seven confirmed influenza A2. Additionally, a previously healthy young adult admitted with acute respiratory distress died of nonbacterial complications and was shown to have community-acquired influenza. The unusual features of the epidemic were the intrahospital localization of the epidemic in compromised hosts, the high rate of pneumonic complications, the low rate of secondary bacterial infection, and the severity of the viral pneumonia in the community-acquired case.

A patient admitted to the hospital with diarrhea due to Salmonella heidelberg subsequently developed fatal disseminated salmonellosis, despite vigorous antimicrobial treatment. Beginning five weeks after the initial patient's death, nine patients developed hospital-acquired S heidelberg infections characterized by diarrhea (in seven) and bacteremia (in two). A careful search for salmonellosis among patients and hospital staff revealed two asymptomatic excretors. Extensive culturing of samples from the environment did not show any contaminated objects or reservoirs. The epidemic ended after initiation of an energetic handwashing campaign and isolation procedures. The strain of S heidelberg isolated was resistant to chloramphenicol, ampicillin, and gentamicin. Especially interesting in the epidemic were the prolonged time between death of the index case and the appearance of nosocomial cases, the high fatality rate, and the marked antibiotic resistance. ( Arch Intern Med 136:968-973, 1976)

Candida endocarditis was first described in 1939 by Freedman and Donaldson as an unidentified yeast on the aortic valve. Since then, numerous reports have been published. No effective treatment was available before the introduction of amphotericin B, although Harrell and Thompson did report successful treatment with nystatin in one case. 1 The following cases prompted us to review the literature regarding the management of this disease. PATIENT SUMMARIES Patient 1.— A 17-year-old male heroin user entered the Martland Hospital in May 1973, with a two-week history of increasing shortness of breath, anorexia, and vomiting. Fever with chills supervened five days prior to admission. He had experienced rheumatic fever at the age of seven years, and seven years later he was found to have mitral stenosis and incompetence. Three years before admission, the mitral valve was replaced by a Starr-Edwards prosthesis. Thereafter, the patient was unavailable for follow-up and did not

Four parenteral drug abusers with the acquired immunodeficiency syndrome had nonmycobacterial actinomycetales infections. Three patients had nocardiosis and one developed a streptomyces lymphadenitis. There was pericardial involvement in two patients, and two patients died. Presumptive diagnoses were often incorrect, highlighting the risks of empiric therapy in these patients. Four of the nine patients with the acquired immunodeficiency syndrome and nocardia or streptomyces infections whose cases were reported to the Centers for Disease Control also had mycobacterial disease. A common susceptibility to these agents may exist in these immunosuppressed patients.