1/374. Spontaneous remission in myelodysplastic syndrome. A 73-year-old man was admitted for investigation of pancytopenia. His physical examination was unremarkable and the bone marrow aspirate was compatible with myelodysplastic syndrome (RAEB). cytogenetic analysis of the bone marrow revealed a trisomy 21. The patient received transfusions of packed red cells, and his condition remained stable for the next 7 months. He was then admitted with a chest infection and was treated with broad-spectrum antibiotics with satisfactory response. During his hospitalization there was a gradual increase in his complete blood count values, which persisted, resulting in a normal peripheral blood after 3 months. A bone marrow aspirate performed at that time revealed normal findings with no karyotypic abnormalities, indicating a spontaneous remission. The patient remained stable for the next 6 months; then he recurred with 20% blasts in his bone marrow and reappearance of trisomy 21 in 42% of the metaphases examined. Several hematologic malignancies with spontaneous remissions have been described to date, but they have generally been short and recurrence is the rule, as in the case described. The role of endogenous cytokines in triggering these spontaneous remissions is under question, as the exact mechanism is unknown. ( info) |
| This case illustrates 2 main points. Firstly, fetal infection can mimic exactly both the immediate and delayed signs of perinatal asphyxia. Secondly, the placenta may hold the key to the diagnosis of sepsis which may be made difficult in the neonate by labour ward practices such as the use of intrapartum and immediate newborn antibiotics. We strongly support the recommendation that newborn blood and fetal membrane cultures should always be obtained in babies with a diagnosis of 'intrapartum asphyxia and fetal distress' (1). To this we would add the recommendation that placental histology be performed in these circumstances. ( info) |
3/374. Pneumonitis secondary to the influenza vaccine. We report a 58-year-old man who developed respiratory distress and interstitial shadowing on chest X-ray 10 days after receiving the influenza vaccine. He failed to respond to intravenous antibiotics but his clinical condition, hypoxia and chest X-ray changes improved dramatically on oral steroids. The clinical diagnosis was pneumonitis secondary to recent influenza vaccination. ( info) |
4/374. corynebacterium pseudodiphtheriticum: an easily missed respiratory pathogen in hiv-infected patients. Despite being a well-known respiratory pathogen for immunocompromised patients, corynebacterium pseudodiphtheriticum has uncommonly been reported to occur in persons with infection attributable to hiv virus. We report three cases of respiratory tract infection attributable to C. pseudodiphtheriticum in hiv-infected patients and review the four previous cases from the medical literature. All of them were male with a median cd4 lymphocyte count of 110 cells/mm3 (range, 18-198/mm3); five of the seven cases occurred in persons for whom AIDS was diagnosed previously. The onset of symptomatology was usually acute and the most common radiographic appearance was alveolar infiltrate (six patients) with cavitation (two patients) and pleural effusion (two patients). In five of the seven cases, C. pseudodiphtheriticum was isolated from bronchoscopic samples and in the remaining two cases was recovered from lung biopsy (one patient) and sputum (one patient). In the three patients reported herein and in one previous case from the medical literature, quantitative culturing of bronchoscopic samples obtained through either bronchoalveolar lavage or protected brush catheter procedures yielded more than 10(3) CFU/mL. All the strains tested were susceptible to penicillin and vancomycin. Resistance to macrolides was common. Recovery was observed in six of the seven patients. C. pseudodiphtheriticum should be regarded as a potential respiratory pathogen in hiv-infected patients. This infection presents late in the course of hiv disease and it seems to respond well to appropriate antibiotic treatment in most of the cases. This easily overlooked pathogen should be added to the list of organisms implicated in respiratory tract infections in this population. ( info) |
5/374. Prolonged respiratory failure in chlamydia pneumoniae pneumonia. We describe a 65-year-old man, who had cardiomyopathy and developed acute respiratory failure requiring ventilator treatment. Acute pneumonia caused by chlamydia pneumoniae was diagnosed based on PCR positivity of bronchoalveolar lavage. Gas exchange did not improve in response to appropriate antibiotic therapy, and the patient died. ( info) |
6/374. indium-111 pentetreotide lung uptake in infectious lung disease. Bilateral diffuse lung uptake of In-111 pentetreotide (OCT) was observed during a whole-body scan performed in a 68-year-old woman with Cushing's syndrome and suspected ectopic adrenocorticotropic hormone secretion. A few days later, she was found to have bilateral bacterial pneumonia (of mixed anaerobic origin). Cushing's syndrome was finally proved to be of pituitary origin. The OCT lung uptake in pneumonia probably resulted from tracer binding by somatostatin receptors on the inflammatory leukocytes. Although the rapid wash-out from experimentally induced abscesses does not make OCT a suitable tracer for detecting acute infections, the images and data here reported suggest that infectious lung disease should be excluded before diagnosing lung involvement by neuroendocrine tumors. ( info) |
7/374. Acid fast filaments in stool samples from an AIDS patient. The presence of filamentous bacteria morphologically similar to Nocardia in a fresh stool sample from an AIDS patient with pulmonary nocardiosis is here reported. The material was submitted to our laboratory for a parasitologic examination and was stained by the Kinyoun method, revealing numerous delicate, irregularly stained, branching acid-fast filaments. nocardia asteroides had been isolated from sputum samples of this patient. The patient was a 32 year-old hiv female admitted to our center on June 1997 because of productive cough, right-sided thoracic pain and weight loss. Chest X rays showed the presence of right superior lobe excavated pneumonia. This was the first time we had observed filamentous bacteria similar to Nocardia in a stool sample submitted to parasitologic examination. For similar cases, and when its presence was not detected in other specimens collected from the same patient, intestinal endoscopy and biopsy should be performed for eventual lesions and smear examination repeated with Kinyoun stain and cultures for Nocardia. ( info) |
| pseudomonas aeruginosa is an uncommon cause of community acquired pneumonia in immunocompetent hosts. We report two cases that did well once appropriate and prolonged antimicrobial therapy was initiated. They had no evidence of immune deficiency. The initial consideration was pulmonary tuberculosis in both cases given the subacute presentation, significant weight loss, and findings on chest roentgenogram. ( info) |
9/374. Fulminant psittacosis requiring mechanical ventilation and demonstrating serological cross-reactivity between legionella longbeachae and chlamydia psittaci. chlamydia psittaci infection typically causes a mild respiratory illness in humans. Severe respiratory failure requiring mechanical ventilation or intensive care therapy is an uncommon development. The aetiological agents causing severe community acquired pneumonia often remain undetermined. Serological tests may aid in diagnosis. We present two cases of fulminant psittacosis, one demonstrating early cross-reactivity with legionella longbeachae. ( info) |
10/374. In-hospital management of adults who have community-acquired pneumonia. The initial in-hospital management of adult patients with community-acquired pneumonia can be divided into five major steps: an early recognition of the patient with presumptive pneumonia, assessment of the severity of illness, establishment of an etiologic diagnosis, supportive therapy, and decision regarding initiation of empirical therapy. In most European recommendations, the empirical antibiotic treatment is directed against "the most likely pathogen," based on epidemiological, clinical, and laboratory data, and on the severity of illness. In contrast, newer North American guidelines have focused on the severity of illness of community-acquired pneumonia. As a consequence, the use of a broader initial antibiotic coverage, including extended-spectrum cephalosporins and combinations, seems to be more common in north america than in europe. ( info) |