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Background Antibody response after high dose influenza vaccine (HDIV) approved for age ≥ 65 years, is superior to a standard-dose vaccine in HIV-infected persons. We report the effectiveness data of HDIV compared to the standard dose quadrivalent vaccine (SDIV) in our HIV clinic. Methods We conducted a retrospective cohort study at the University of Kansas Medical Center to evaluate the effectiveness of HDIV in HIV-infected patients during the 2017–2018 influenza season. A phone survey was utilized to verify vaccination status and interval development of influenza-like illness (ILI). A modified CDC definition of ILI (mCDC ILI = fever and cough, sore throat or shortness of breath (SOB)) and a broader protocol defined ILI (PD ILI = sore throat, cough or SOB with either fever, chills, headache or myalgia) were utilized. The electronic medical record was reviewed to confirm vaccine type and influenza testing when available. Results Of 560 HIV-infected patients in the clinic, 219 (39.1%) were available and willing to participate (197 males, 21 females, 1 transgender female). The median age was 53 years and BMI 27.2 kg/m2. Five percent had CD4< 200 cells/uL, and 13.7% had an HIV viral load > 40 copies/mL. HDIV was given to 119 (54.3%), SDIV to 77 (35.2%) and 23 (10.5%) were not vaccinated (Table 1). A mCDC ILI occurred in 8 (10.4%) in the SDIV group compared to 6 (5.0%) in the HDIV group (p=0.16). A PD ILI was reported in 16 (20.8%) in the SDIV group compared to 12 (10.1%) in the HDIV group (p=0.04). There was no difference in confirmed influenza cases between the two groups (Table 2). On logistic regression only vaccine dose (SDIV OR 2.34 95% CI 1.04–5.37, p=0.04) and age in years (OR 0.97, 95% CI 0.94–1.0, p=0.045) were associated with PD ILI. HDIV remained protective after adjustment for age. Vaccine side effects were mild and occurred in 11/77 (14.3%) in the SDIV group compared to 13/119 (10.9%) in the HDIV group (p=0.5). Conclusion During the 2017–2018 winter season, the CDC reported an influenza attack rate of 14.7% in adults in the US and overall vaccine effectiveness of 38%. Our study demonstrated a 50% reduction in ILI with the HDIV compared to the standard-dose vaccine in HIV-infected patients. A larger prospective randomized control trial is warranted. Disclosures Wissam El Atrouni, MD, ViiV (Advisor or Review Panel member)

In a multicenter, randomized controlled clinical trial, administration of valacyclovir for 90 days following standard intravenous acyclovir therapy for herpes simplex encephalitis did not improve outcomes, as measured by neuropsychological testing at 12 months.

Respiratory viruses cause significant morbidity and mortality in immunocompromised populations such as stem cell transplant and solid organ transplant patients. Few viruses causing respiratory tract infection have an approved therapy, and many of the viruses have no therapeutic options at all. In this article, we describe novel agents under development for treatment options against several respiratory viruses.

Paragonimus kellicotti is an emerging pathogen in the United States with 19 previously reported cases, most in Missouri. Pulmonary symptoms with eosinophilia are most common, though 1 case did involve the central nervous system with few symptoms. We describe the first 2 cases of eosinophilic meningitis due to Paragonimus kellicotti.

Objective To evaluate the effect of intermittent (16 h/d) enteral feeding (IEF) on gastric pH and gastric microbial growth in mechanically ventilated patients. Design Prospective, case-controlled study. Setting Medical ICU and infectious disease research laboratory in a university hospital. Patient population Thirteen mechanically ventilated patients receiving continuous enteral feeding (CEF). Methods Gastric pH and quantitative gastric cultures were obtained while patients received CEF. Each patient's feeding schedule was changed to IEF. Daily gastric pH and quantitative gastric cultures were obtained for 5 consecutive days. Results Gastric microbial growth was found in 85% (11/13) of patients receiving CEF. Implementation of IEF did not clear gastric microbial growth, as only one patient subsequently reverted to negative culture. Similar gastric microbial growth continued in 90% (10/11) of patients after institution of IEF. Gastric pH did not decrease with the administration of IEF (gastric pH with IEF, 3.8±0.6 vs 4.7±0.5 with CEF (not significant [NS]). The amount of microbial growth was also unchanged with IEF (total growth with IEF, 7.8×10 5 ±5.2×10 5 cfu/mL vs 8.7×10 5 ±4.6×10 5 cfu/mL with CEF) (NS). Thirty-eight percent (5/13) of patients developed new Gram-negative rod growth in gastric cultures while receiving IEF. Gram-negative rod isolates increased from 25% of total isolates (CEF) to 40% (IEF). Conclusion Our preliminary data suggest gastric pH was not lowered and existing microbial growth was not cleared in ventilated patients receiving IEF after previously receiving CEF. Further controlled study in a larger group of patients is necessary to determine whether IEF is of benefit in decreasing gastric colonization and nosocomial pneumonia.

Background: A concomitant infection with human immunodeficiency virus (HIV) may alter the natural history of other infections. Several reports indicate that syphilis may behave more aggressively when HIV infection is present.Case: A woman presented with a rash involving her hands and feet and progressive loss of the vision in her right eye. Her serologic tests for syphilis and HIV infection were positive. A diagnosis of neurosyphilis was confirmed by an analysis of cerebrospinal fluid (CSF). She was treated with high-dose intravenous (IV) penicillin. Her skin lesions resolved, but her vision did not improve.Conclusion: The incidence of HIV infection among women is rising. A patient with HIV and syphilis may develop neurosyphilis in a much shorter time than a patient without HIV infection.

Seventy-three immunocompromised patients with disseminated herpes zoster were evaluated in a double-blind controlled trial of acyclovir (n = 37) versus vidarabine (n = 36) therapy. Acyclovir was administered at 30 mg/kg/day at 8-h intervals and vidarabine was given as a continuous 12-h infusion at 10 mg/kg/day for 7 days (longer if resolution of cutaneous or visceral disease was incomplete). No demographic differences existed between treatment groups. No deaths attributable to varicella-zoster virus infection occurred within 1 month of treatment. Neither rates of cutaneous healing, resolution of acute neuritis, and frequency of postherpetic neuralgia nor adverse clinical and laboratory events differed between treatment groups. Acyclovir recipients were discharged from the hospital more promptly than vidarabine recipients (P = .04, log rank test). These data indicate that disseminated herpes zoster is amenable to therapy with either acyclovir or vidarabine; resultant mortality is low.

To the Editor: Leptotrichia spp. have been identified as the cause of various infections. However, the most commonly reported infection is bacteremia in the setting of chemotherapy for hematologic malignancies (1,2). Only recently has L. trevisanii emerged as a cause of infection; case reports are rare (3–5). We recently observed 3 cases of L. trevisanii bacteremia in patients who had recently undergone peripheral blood stem cell transplantation (SCT.) Our goal was to identify possible causes of these infections. The patients were 2 men and 1 woman (ages 53, 56, and 63 years, respectively) who had received myeloablative chemotherapy. The 2 men had multiple myeloma and relapsed follicular non-Hodgkin lymphoma and had neutropenic fever 5 and 4 days post-SCT, respectively. The woman had acute myelogenous leukemia that had arisen from a myelodysplastic syndrome after matched sibling donor SCT failure. She had neutropenic fever on day 13 of induction therapy. Multiple blood cultures from >1 site (peripheral and central venous catheter [CVC] or 2 separate CVCs) obtained from each patient during the initial febrile episode grew L. trevisanii. For the 2 patients with positive cultures for peripheral blood and CVC sites, the peripheral culture was reported as positive before the CVC culture but not before use of the CVC. All subsequent blood cultures and catheter tip cultures from these patients had negative results for bacteria. All organisms were cultured by using the BacT/ALERT 3D blood culture instrument (bioMerieux, Durham, NC, USA) and standard aerobic and anaerobic media. Times to positivity were approximated (range 28–58 hours). Gram staining of isolates from culture media showed large, fusiform gram-negative rods. One isolate had gram-positive beading and was reported as gram variable. A second isolate grew anaerobically from initial subculture on 5% sheep blood agar but grew aerobically in chocolate agar in 5% CO2 on second subculture. A third isolate showed pinpoint growth on initial aerobic culture on sheep blood agar. No isolates were identified by using the RapID ANA II System (Remel, Lenexa, KS, USA). One organism was identified as Sphingomonas paucimobilis by Vitek 2 (bioMerieux), but this result was inconsistent with results of other biochemical tests. The 3 organisms were sent to the Mayo Medical Laboratories (Rochester, MN, USA) for anaerobic bacteria identification and speciation by 16S rRNA gene sequencing. All catheter tips were cultured by rolling a 1-inch segment of the catheter on sheep blood agar and incubating them aerobically in 5% CO2 for 5 days. The reason L. trevisanii has only recently been identified as a cause of bacteremia in neutropenic patients is likely multifactorial. Our findings suggest routine use of 16S rRNA gene sequencing and increased numbers of bone marrow transplants as the major reasons. L. trevisanii was discovered in 1999. More than a decade had passed between the availability of 16S rRNA sequencing and discovery of this bacterium. (5). Some authors suggested that previous lack of recognition may have been caused by fastidious growth requirements, inconsistent staining, or misidentification (3,4,6). No recent major changes in instrumentation, subculture algorithm, or solid media had been made before we isolated this organism, and we had not previously isolated any unidentified organisms with similar appearance and growth patterns typical of L. trevisanii. Unlike some species of Leptotrichia, L. trevisanii grows readily on solid media when subcultured (3). This finding indicates an emergent pathogen rather than a previously undiagnosed cause of bacteremia. We have seen an increase in the number of bone marrow transplants performed, but there has been no major change in myeloablative regimens. We observed 1 case of L. trevisanii bacteremia in each year during 2009–2011, in which our institution performed 185, 189, and 215 transplants, respectively (overall incidence 0.5 cases/100 transplants). This finding might explain why no cases were seen previously. All 3 patients had grades 1–2 mucositis, which in the presence of neutropenia, is a known risk factor for anaerobic bacteremia in patients undergoing chemotherapy for hematologic malignancies (3,7,8). Bacteremia developed in the 3 patients while they were treated with levofloxacin. The 56-year-old man responded to a cephalosporin. The 63-year-old woman did not respond to a carbapenem or vancomycin but did respond to a second carbapenem. The 53-year-old man did not respond to a cephalosporin or metronidazole but became afebrile after treatment with vancomycin. These inconsistencies did not enable us to make specific therapeutic recommendations for treatment of L. trevisanii infection other than to report clinical resistance to levofloxacin. Currently recommended treatment regimens for neutropenic fever do not include treatment for anaerobic infections. Some institutions have altered treatment regimens to include antimicrobial drugs, such as meropenem, because of increases in anaerobic bacteremias (3,9). We do not believe that the number of cases of anaerobic bacteremia at our institution warrants a change in treatment policy. On the basis of our findings, we expect an increase in the number of cases of anaerobic bacteremia after an expected increase in the number of bone marrow transplants performed. Future policies include improved treatment or prevention of mucositis, earlier detection and identification of isolates, and revision of current antimicrobial drug protocols for empiric treatment of neutropenic fever.

Solid tumors rarely present with fever. Among those that do, carcinoma of the colon has been infrequently reported as a primary cause of fever. This patient had carcinoma of the right colon with prolonged fever, but no evidence of infection or gastrointestinal symptoms. At surgical resection, a caecal adenocarcinoma was found with metastases to the mesentery and 10 of 40 lymph nodes. The patient's fever resolved after 3 days. The patient remained healthy during 8 years of follow-up. Right-sided colon cancer is not often considered in the complete evaluation of fever of undetermined cause.

68 patients presented to the Veterans General Hospital, Taipei with nonenterococcal group D streptococcal septicemia in the years 1985-1987. 36 patients (53%) had nonenterococci as part of a polymicrobial bacteremia. The large intestine was not examined in most patients. Five patients (7%) had associated colonic carcinoma, and 17 patients (25%) had colorectal diseases. Only 7/68 patients (10%) were clinically diagnosed as having infective endocarditis by the doctors in charge. The others were regarded as having septicemia. The charts of these patients were reviewed retrospectively to diagnose infective endocarditis based on strict definitions. One (1%) had definite endocarditis proved at autopsy. 16 patients (24%) had probable endocarditis due to the presence of either a new regurgitant murmur or both a predisposing heart disease and embolic phenomena; 39 (57%) had possible endocarditis based on evidence of having either a predisposing heart disease or embolic phenomena; and only 12 (18%) had no evidence of endocarditis. 27 patients (40%) had at least one predisposing heart disease associated with endocarditis. 51 patients (75%) had at least one lesion suggesting embolic phenomena. 30 patients (44%) had electrocardiographic abnormalities. This high incidence of arrhythmia in nonenterococcal septicemia is of particular interest and could be related to cardiac involvement in some patients. The overall mortality, 62% (42/68), was extremely high in our series, but in those who were clinically diagnosed and treated as infective endocarditis, the mortality was low, 14% (1/7). We suggest all patients with nonenterococcal septicemia associated with either heart disease or lesions of CNS, lung, heart, kidney or limbs suggesting embolic phenomena should be regarded as having possible or probable endocarditis. Treating such patients as having infective endocarditis may reduce the mortality in nonenterococcal septicemia.

Fungal endocarditis is considered an absolute indication for valve replacement surgery. We describe the successful medical treatment of recurrent Candida parapsilosis candidemia with sequential treatment with amphotericin B and fluconazole in a patient with probable prosthetic valve endocarditis. Because of the presumed effectiveness of amphotericin B and fluconazole in the treatment of this patient, medical therapy should be considered as potentially useful in the treatment of recurrent C parapsilosis fungemia or endocarditis or both.

To the Editor.— Reflecting on the price of several newer antimicrobial agents in our sample cabinet, a jest was made that the place looked like Fort Knox. As we made actual comparisons, we found that several drugs were at least as precious as gold. We obtained current selling prices from four pharmacies in the Greater Kansas City (Kansas) area for 12 antimicrobial agents. The mean price per tablet and per ounce were calculated (Table). We calculated the number of days of therapy needed to equal the price of an ounce of gold. The mean price was compared with the price of gold ($370.65 per ounce on August 2, 1990). Ratios of the price per ounce of each medication to the price per ounce of gold were calculated. These results show that several common oral antimicrobial agents are, on the basis of weight, more precious than gold.

Prophylactic trimethoprim-sulfamethoxazole (TMP-SMZ) has been shown to reduce the incidence of fever, parenteral antibiotic usage, and infections with gram-negative bacteria in hospitalized patients with neutropenia. Furthermore, TMP-SMZ was found to be equivalent to or better than oral, nonabsorbable antibiotics in direct comparisons and to have an additive effect when given together with other oral, nonabsorbable antibiotics. Adults given TMP-SMZ continuously had fewer readmissions for infection than did controls given TMP-SMZ only while hospitalized. TMP-SMZ used continuously in children with acute leukemia was effective in preventing bacterial and Pneumocystis carinii infections. For prophylaxis in granulocytopenic patients, TMP appeared equivalent to TMP-SMZ both in efficacy and incidence of side effects. However, TMP was less effective in suppressing gastrointestinal flora, including TMP-resistant gram-negative rods. Thus, TMP-SMZ has some role in preventing infections in high-risk patients, but further studies, especially comparisons with untreated patients may still be required. TMP used alone offers little advantage and has the theoretical disadvantage of not preventing infections caused by P. carinii or TMP-resistant gram-negative bacteria.

We determined the concentrations of clindamycin and gentamicin in fluid aspirated from 16 cysts of a surgically excised polycystic kidney. The patient had received both drugs intravenously for seven days before nephrectomy. The cysts were grouped into proximal (pH greater than 6.5) and distal (pH less than 6.5) types according to the pH of the fluid. In nine proximal cysts the mean concentration of gentamicin was 1.3 +/- 0.2 and that of clindamycin was 9.2 +/- 2.3 micrograms/mL. In seven distal cysts the gentamicin concentration was 0.7 +/- 0.2 micrograms/mL and the clindamycin concentration was 34.0 +/- 5.2 micrograms/mL. Plasma gentamicin was 3.8 (peak) and 1.9 (trough) micrograms/mL, and clindamycin was 3.9 micrograms/mL (random). Clindamycin cyst concentrations showed an inverse correlation with cyst fluid pH (r2 = 0.78). These studies confirm that in autosomal dominant polycystic kidney disease (ADPKD), certain cysts develop steep pH gradients between fluid and plasma and indicate that intracystic pH determines the extent to which basic lipophilic antibiotics accumulate in the fluid. Lipid-soluble antibiotics with relatively alkaline pKaS may be useful in the treatment of infected renal cysts.

Nutritional therapy of patients receiving mechanical ventilation includes enteral feeding. To determine the frequency of gastric microbial colonization in patients receiving enteral nutrition, 18 patients with acute respiratory failure receiving ventilation were studied. Multiple sources of tracheal colonization were then evaluated to determine the frequency of tracheal transmission of gastric flora and the relationship of gastric colonization and transmission to nosocomial respiratory infection. The stomach was colonized in every patient who received enteral feeding. Tracheal colonization occurred in 89 percent (16 of 18) of patients. In 12 of these 16 patients, 14 organisms colonized the trachea after transmission from the stomach and/or oropharynx. Thirty-six percent (five of 14) of organisms transmitted to the trachea originated from the stomach, whereas another 36 percent (five of 14) were first recovered from the oropharynx. Four tracheally transmitted organisms were first recovered simultaneously from the stomach and oropharynx. Nosocomial respiratory infection developed in 11 patients (63 percent). Three infections occurred during the six-day study period, one of which was associated with transmission of a gastric organism. Multiple sources of tracheal colonization occur in patients receiving enteral nutrition. The stomach is an important source of tracheal colonization. Enteral nutrition can be associated with gastric flora colonizing the trachea and causing nosocomial respiratory infection.

During the spring of 1971, 103 children with measles vaccine failure were studied. Seventy-six children had typical measles, 15 had mild modified measles, and 12 had an illness resembling the atypical measles syndrome; 6 of these latter 12 patients had previously received only live measles vaccine. Eighty-seven patients had serologic evidence of recent measles infection; 2-mercaptoethanol (2-ME) treatment of the acute-phase sera from these children revealed different antibody patterns by clinical category. The majority of sera from typical measles cases had ≥4-fold reduction in titer with 2-ME treatment, whereas the majority of sera from modified and atypical cases had no reduction in titer with 2-ME treatment. The acute-phase sera of 15 patients with vaccine failure were found to contain only gamma-G measles antibody when separated by sucrose gradient centrifugation. Thirteen of these sera were from children with modified or atypical illnesses. These findings suggest that some vaccine failures occur in patients who were antigenically simulated previously by measles virus and that illness in these children is likely to be less severe.

Amphotericin B methyl ester (AME) has been used to treat fungal infections, most often those caused by Coccidioides immitis. We describe the only patient with disseminated histoplasmosis who has been treated with AME. After having had alarming reactions to amphotericin B, the patient was treated and cured with AME without adverse drug effect or later relapse.

Three patients treated with nafcillin developed granulocytopenia. Only three other such cases have been reported. This complication is most likely due to a direct toxic effect on the bone marrow; markers for an immunologically mediated mechanism have not been found. Nafcillin-associated granulocytopenia usually occurs during the third week of therapy and remits spontaneously with prompt cessation of nafcillin administration.

Clindamycin was used to treat six patients with endocarditis because of allergy to penicillin in five, and an unfavorable clinical response to methicillin in one. Only one patient had an uneventful cure with clindamycin. Two had hepatotoxicity which resolved rapidly after clindamycin was stopped. Two patients, one of whom had an aortic prosthesis, had completed four to six weeks of clindamycin therapy when clinical relapse occurred and blood cultures were again positive for a clindamycin-sensitive isolate. A fifth patient had peptostreptococcal endocarditis. Despite a favorable initial clinical and bacteriologic response, blood cultures taken on the 20th day of therapy again grew the Peptostreptococcus. This relapse pathogen had become resistant to clindamycin and was 100-fold less sensitive than the initial isolate. The few conditions in which clindamycin is indicated for therapy of bacterial endocarditis are outlined.

Eight patients with herpes simplex encephalitis among the 10 cases diagnosed at the University of Kansas Medical Center from 1966 to 1976 were studied with 99mTc early in their diagnostic work-up. The images were unilaterally positive in the temporal lobe area in all 8 patients. Radionuclide studies can suggest herpes simplex as the specific etiology in cases of encephalitis and can also indicate the best site for brain biopsy to confirm the diagnosis by fluorescent antibody techniques. Appropriate antiviral therapy should be instituted as soon as possible to alter the course of this destructive form of viral encephalitis.

Single, intravenously administered doses of cefoxitin and cefamandole did not penetrate into cerebrospinal fluid of normal humans. Multiple-dose administration with or without probenecid facilitated penetration of both antibiotics into the cerebrospinal fluid. Preliminary data showed that cefoxitin penetrated into cerebrospinal fluid of patients with inflamed meninges even when administered in a single dose without probenecid. However, the concentrations of cefoxitin in the cerebrospinal fluid of the individuals studied were not within the therapeutic range.

The plasma and urine concentrations of cefaclor were measured after oral administration of single and multiple doses to volunteers. Cefaclor was rapidly absorbed, rapidly excreted in the urine, well tolerated without toxicity, and failed to accumulate in the plasma with chronic dosing.

A laboratory based epidemiologic study was done to determine the possible relationship of herpesvirus type 2 to carcinoma of the prostate. A total of 305 patients (224 with benign prostatic hypertrophy and 81 with prostatic carcinoma) who underwent transurethral resection of the prostate was studied. Viral cultures were obtained from urethral swabs and urine preoperatively. Prostatic tissue removed at operation was grown as tissue explants, using a monolayer cell culture technique, and examined by specific immunofluorescence and electron microscopy for evidence of herpesvirus type 2. The sera of the patients also were tested for specific antibody to herpesvirus type 2 by the indirect hemagglutination inhibition test. Although herpesvirus was not isolated 5 per cent of the patients had evidence of herpesvirus type 2 antigen in prostatic tissues by specific immunofluorescence. Electron microscopy failed to reveal the presence of viral particles. There was an increased prevalence of herpesvirus type 2 antibody in patients with carcinoma of the prostate compared to the controls with benign prostatic hypertrophy (p less than 0.05). Although marital status was similar the patients with prostatic cancer tended to marry at an earlier age, have more children, more sexual partners and more exposure to prostitutes than their counterparts with benign prostatic hypertrophy. The demonstration of specific herpesvirus type 2 antibody in patients with prostatic cancer supports an etiologic role for herpesvirus type 2 but further studies are needed to describe more definitively the relationship since the indexes of sexual activity are remarkably high in both groups.

Arteriography was performed to determine if similar vascular malformations could be detected in the small bowel. Selective superior mesenteric injection demonstrated the cecal vascular malformation which was supplied by the cecal branch of the ileocolic artery and displayed typical early venous filling. No additional lesions were detected by superior or inferior mesenteric angiographic studies. At operation, the cecal lesion was not found even by careful inspection. Because of the preoperative documentation of a vascular malformation in the cecum, a right hemicolectomy was performed. Gross pathologic inspection was unrewarding, and attempts at arteriography in the resected specimen were unsuccessful. However, the lesion was identified after serial microscopic sectioning. Outpatient followup of the patient for 6 months revealed resolution of the anemia. Neither black nor bloody stools have been noted, and tests for occult blood in the stool have been negative. MORPHOLOGIC FINDINGS The specimen received in the laboratory consisted of a segment of cecum and ascending colon 30 cm in length with a normal appendix and a 4.5 cm segment of terminal ileum. Preliminary inspection showed no mucosal or mural abnormalities throughout. Utilizing information provided by the endoscopist and radiologist, a 3 cm broad crescentic strip of colon over a radius 7 cm from the ileocecal valve was isolated and inspected under a dissecting microscope. This disclosed a 1.2 cm area of faint hypervascularity without mucosal defect. The entire strip of colon was step-sectioned revealing, in this latter region, microscopic evidence of a fairly discrete vascular abnormality. The lesion consisted of a submucosal tangle of dilated arterial and venous, thick-walled blood vessels indicative of marked tortuosity (Figure 2). At one plane of cut, an artery and vein were found in very close juxtaposition, and the possibility of their communicating was suggested strongly. Although a small vein in one section suggested organizing thrombotic material with early angiomatoid formation, no overt embolization was discovered. Irregular and eccentric diffuse hyperplastic sclerosis of the intima of both arteries and veins was noted. Thin-walled vascular channels penetrated the muscularis mucosa terminating in acongeries ofendothelial lined, dysplastic appearing, lake-like spaces throughout the tunica propria in this area. Capillary telangiectasia was noted likewise throughout the muscularis propria and serosa. There was an area of healed erosion of the overlying mucosa. DISCUSSION Previous to the studies reported by Baum and his colleagues7,. a decade ago, reports of vascular lesions of the gastrointestinal tract were rare."g,'0 However, since that Angiodysplasia of the cecum: colonoscopic diagnosis Richard M. Skibba, MD* William A. Hartong, MD Frank A. Mantz, MD Daniel R. Hinthorn, MD James B. Rhodes, MD Department of Internal Medicine and Department of Pathology University of Kansas Medical Center Kansas City, Kansas

Hepatotoxicity has been noted by several investigators during parenteral use of clindamycin, and some have reported that drug half-life is prolonged in the presence of liver disease. We administered 300 mg of clindamycin intravenously at 12-h intervals for 2 days to patients with acute and chronic hepatitis, cirrhosis, and controls to determine whether clindamycin will exacerbate preexisting hepatic dysfunction or whether drug excretion will be delayed in patients with liver disease as compared with controls. Exacerbation of hepatotoxicity was not found in this study. There was a small, but significant, delay in drug elimination between cirrhotics and controls, even after the first dose of clindamycin ( P < 0.05); however, half-lives in all categories were in the range usually considered normal. We conclude that clindamycin can be used in liver disease in some circumstances, if proper precautions are exercised.

The efficacy and safety of imipenem/cilastatin was evaluated in a multicenter study. For 49 of the 78 patients with 79 infections entered into the study, the clinical and bacteriologic efficacy of therapy could be evaluated. Toxicity data were analyzed for all 79 infections. Overall, 35 of 49 infections were cured or improved: 10 of 11 cases of pneumonia; 8 of 15 cases of pyelonephritis; 4 of 5 cases of osteomyelitis; 3 of 4 intravascular infections; 6 of 9 soft tissue infections; and 4 of 5 miscellaneous infections. There were 13 bacteriologic failures; superinfections with resistant organisms (i.e., Candida albicans, methicillin-resistant Staphylococcus epidermidis, and Pseudomonas maltophilia) occurred in three patients; reinfection with sensitive pathogens complicated one urinary tract infection; relapses developed of five urinary tract infections and of one case of endarteritis; and bacteriologic persistence occurred in three soft tissue infections. Infections with Pseudomonas aeruginosa were the most difficult to treat. In only six of 11 P. aeruginosa infections was both bacteriologic and clinical cure achieved. Adverse effects were minimal; no serious hematologic or hepatic toxicity and no adverse renal effects were noted.

A measles epidemic, during which 130 children were hospitalized and six died, occurred in St. Louis City and County during 1970 to 1971. A survey revealed an attack rate of 8.5 per cent in unvaccinated children who had not had natural measles, a rate of 1.7 per cent in children vaccinated after one year of age, but 6.3 per cent for children immunized before age one year. Measles attack rates in vaccinees were independent of time elapsed since immunization. Serum from 8 of 15 children with modified measles had no reduction in acute measles hemagglutination-inhibiting antibody titer after treatment with 2-mercaptoethanol. Twelve children had “atypical measles-rd but six of them had received only live vaccine. Ten per cent of 248 immunized children had hemagglutination-inhibiting titers of

LEGIONELLA pneumophila pneumonia was first recognized after the outbreak that followed the 1976 convention of the Pennsylvania Department of the American Legion in Philadelphia. 1 After the recognition of L pneumophila in causing pneumonia, a respiratory illness without pneumonia termed "Pontiac fever" was shown to be caused by the same agent. 2 Later, L pneumophila was demonstrated in tissues other than the lungs of patients who had pulmonary infiltrates, a finding that suggested hematogenous dissemination. 3 Vascular access sites in patients undergoing renal dialysis may also be infected. 4 From a perirectal abscess in one patient, L pneumophila and anaerobes were isolated. 5 We describe a patient without pneumonia from whom cultures of an open wound showed growth of L pneumophila and Pseudomonas aeruginosa . Apparently the L pneumophila was acquired by the patient from water in a Hubbard tank in which he was receiving daily rehabilitation. Routine disinfection of the

Leg neuralgia is usually caused by nerve root irritation, and is seldom considered of viral origin. Two married couples had recurrent leg pain in a dermatome distribution. In each episode, after one to three days of neuralgia, herpetic vesicles appear on or near the genitalia. Herpesvirus hominis (HVH) was isolated from vesicles or cervix in three patients and was serologically identified as herpesvirus hominis type 2. Prolonged follow-up has not shown progression of the syndrome or any permanent neurologic damage. Treatment with topical neutral red and photoinactivation has not only reduced local lesion healing time and frequency of attacks, but it has also given prompt relief of neuralgia. ( JAMA 236:587-588, 1976)

• Arthritis caused bySporothrix schenckiimay not respond satisfactorily to a full course of intravenous amphotericin B therapy. Left untreated, the fungus continues to be recovered from cultures of joint fluid, and the patient typically has serious joint disability. We have shown In one patient with sporotrichosis of the knee that direct low-dose injections of amphotericin B can be performed safely, resulting in eradication of the fungus. The patient has had continued useful range of motion and weight bearing on the involved knee. (Arch Intern Med1989;149:954-955)

HISTOPLASMA CAPSULATUM may cause several types of cutaneous manifestations. Disseminated histoplasmosis has been most commonly associated with oral mucocutaneous ulcers, 1-3 which may persist longer than three months. The progressive cutaneous form of disseminated histoplasmosis may appear as granulomas, ulcerations, or papulonecrotic lesions. Differentiation of these lesions from other cutaneous ulcers on clinical grounds alone is difficult if not impossible. Etiologic confirmation is determined by isolating H capsulatum , usually from a biopsy specimen. Primary cutaneous histoplasmosis, in which the organism is confined to the skin, is uncommon. To our knowledge, only three verified cases have been reported. 4-6 Furcolow 7 has reviewed previous possible cases. In each of the three verified cases, the infection was self-limited without systemic therapy. The purpose of this report is to present a fourth case of apparent primary cutaneous histoplasmosis. The disease in this immunosuppressed patient differed from previously reported cases of primary cutaneous histoplasmosis in being

Streptococci seldom invade muscle in healthy people with intact integument. However, infection with another agent simultaneously may change this general observation. In a two-week period we encountered dual infections with group A, β-hemolytic streptococci and a picornavirus in each of two hospitalized patients. Both were acutely ill; one died. Renal failure developed in the patient who survived and rhabdomyolysis was demonstrated in the patient who died. Picornavirus titer increases were demonstrated in the patient who survived, and viral inclusions in muscle cells were demonstrated by light microscopy in necropsy specimens and confirmed by electron microscopy in the second patient. We believe that streptococcal invasion of muscle may be facilitated during an outbreak of certain picornavirus infections. ( JAMA 1981;245:1545-1547)

• Eosinophilia as a manifestation of coccidioidomycosis may be found in blood or cerebrospinal fluid. We report on a case of coccidioidomycosis with pleurisy, skin lesions, and meningitis with concomitant striking eosinophilia in both blood and cerebrospinal fluid that resolved promptly after amphotericin B therapy was started. (Arch Intern Med1988;148:895-896)

BOVINE mastitis caused by Streptococcus was recognized long before βhemolytic Streptococcus group B (GBS) was characterized. It was initially termed " S agalactiae " or " S mastitidis " and was believed not to be a human pathogen. Subsequent studies demonstrated that GBS could produce serious infections in postpartum women. During the last decade, GBS has been recognized as causing neonatal sepsis and meningitis, but only recently have adult infections achieved wide recognition. 1 In adults, bacterial endocarditis, septicemia, pneumonia, empyema, peritonitis, meningitis, urinary tract infections, cellulitis, wound infections, and suppurative arthritis have been reported. However, osteomyelitis caused by GBS has only been reported in five neonates 2-4 and there has been one possible adult case. 5 We report the cases of two adult men who had osteomyelitis caused by GBS. One patient had osteomyelitis of the toe associated with diabetes mellitus, and the second patient had frontal sinusitis that resulted in frontal osteomyelitis