Serious infections caused by Streptococcus milleri

Viridans streptococci continue to be the most common etiologic agents in bacterial endocarditis. The spectrum of diseases other than endocarditis caused by these organisms, however, has received sparse attention. Moreover, little clinical information is available concerning the individual viridans streptococcal species. During the 16 months of this study, one species of viridans streptococci, Streptococcus milleri, caused a surprising number of clinically significant suppurative infections. Clinical syndromes included the following: abscesses, 10 cases; peritonitis, four cases; endocarditis, three cases; cholangitis, empyema and cellulitis, one case each. A gastrointestinal source was apparent in eight of these 20 cases. Review of 58 cases of viridans streptococcal endocarditis demonstrated that although Strep. milleri was an infrequent cause of endocarditis, this species was associated with an unusual frequency of suppurative complications. Our experience suggests that Strep. milleri may be more commonly associated with serious suppurative infections than other viridans streptococci and that species identification may be a clinically useful procedure.     

Hemophilus aphrophilus endocarditis: Review of 23 cases

A case of bacterial endocarditis caused by Hemophilus aphrophilus is described, and 22 previously reported cases are reviewed. Eleven patients died and 12 survived; comparison of these two groups reveals that the patients who died were in the older population. The male/female ratio was 3.6:1. The organism was difficult to identify but had a wide range of in vitro bacteriologic sensitivities. This type of endocarditis is frequently associated with emboli and congestive heart failure; each occurred in 9 of 11 fatal cases and 3 of 12 nonfatal cases. Among the nonfatal cases, two patients had both emboli and congestive heart failure, requiring aortic valve replacement despite their precarious clinical condition. Initial drug therapy before results of antibiotic sensitivity tests are known should consist of penicillin combined with streptomycin. When emboli or congestive heart failure appears in Hemophilus aphrophilus endocarditis, early surgical intervention with valve replacement is indicated.     

Subacute and acute endocarditis due to Pseudomonas cepacia in heroin addicts.

Five heroin addicts were treated for endocarditis caused by Pseudomonas cepacia. Two of these infections occurred in patients with no known heart disease whereas the others occurred at sites of previous endocarditis or valve prostheses. Infection was indolent in four patients but was associated with shock and skin lesions suggestive of ecthyma gangrenosum in the fifth. After failure of chloramphenicol and kanamycin, all patients were treated with a combination of sulfamethoxazole, trimethoprim and polymyxin plus heart valve resection or replacement.     

Bacterial endocarditis with ruptured sinus of valsalva and aorticocardiac fistula

A case is presented of bacterial endocarditis with a ruptured sinus of Valsalva and formation of an aorticocardiac fistula from the right coronary sinus into the right atrium and right ventricle. The pathologic, clinical and surgical aspects of bacterial endocarditis complicated by a ruptured sinus of Valsalva and an aorticocardiac fistula are analyzed. This complication of bacterial endocarditis is still uncommon, but alertness to its diagnosis makes possible early and successful surgical treatment.     

Vancomycin therapy of bacterial endocarditis.

Fifteen patients with bacterial endocarditis were treated with vancomycin between 1967 and 1976. The indications for vancomycin therapy were penicillin-cephalosporin allergy in six patients, antibiotic resistant bacteria in six, initial therapy in one and culture-negative endocarditis in two. The causative microorganisms were Staph. epidermidis (four patients), Staph. aureus (two patients), diphtheroids (four patients), viridans streptococci (two patients) and enterococci (one patient). Minimum inhibitory concentrations of vancomycin for these organisms ranged from 0.8 to 3.1 micrograms/ml. The patients received vancomycin for two to 10 weeks (mean five weeks). Cure was achieved in 13 patients, including six with prosthetic valve endocarditis (PVE). Two patients had a relapse of PVE and cultures of blood or heart valve were positive within two months of vancomycin therapy. Vancomycin serum levels did not exceed 50 micrograms/ml, and no serious drug toxicity was encountered in any patient. Three patients had minimal audiogram changes beyond the social hearing range. One patient had mild phlebitis and a rash, and one patient had a transient leukopenia. Vancomycin is an effective nontoxic antibiotic in patients with endocarditis when penicillin or cephalosporin therapy is not appropriate.     

Association of teichoic acid antibody with metastatic sequelae of catheter-associated Staphylococcus aureus bacteremia: a failure of the two-week antibiotic treatment.

A patient with Staphylococcus aureus bacteremia associated with an infected intravenous catheter was treated with oxacillin for two weeks. During that period all blood cultures were sterile, he rapidly became afebrile, and there were no signs of endocarditis or metastatic abscesses. However, serum antibodies against staphylococcal teichoic acid, initially undetectable by the agar gel immunodiffusion technic, became positive during the second week of treatment. Three weeks after discharge, the patient was readmitted to the hospital because of back pain and weakness in the lower extremities. Vertebral osteomyelitis and a spinal epidural abscess caused by Staph. aureus of the same phage type as the bacteremic isolate were demonstrated. This case illustrates the importance of careful follow-up of patients with Staph. aureus bacteremia and the potential value of serial measurement of teichoic acid antibodies in detecting clinically inapparent complications of infection.     

Glomerulonephritis in bacterial endocarditis

The introduction of antibiotic therapy and changing epidemiologic patterns have altered the nature of glomerulonephritis as it occurs during the course of bacterial endocarditis. Observations made predominantly in the pre-antibiotic era suggested that infections with less virulent organisms, by virtue of their indolent subacute course, favored an antibody response predisposing to immune complex glomerulonephritis. Although antibiotic prophylaxis and therapy have reduced the incidence of both Streptococcus viridans bacterial endocarditis and concomitant glomerulonephritis, Staphylococcus aureus has become a major cause of acute bacterial endocarditis with a high incidence of glomerulonephritis. Parenteral drug abuse itself, which has emerged as a major factor predisposing to endocarditis, may also favor the development of glomerulonephritis. The course of glomerulonephritis has been altered in association with these changes in etiology and epidemiology. This review summarizes the clinical and morphologic features of glomerulonephritis as it currently occurs during the course of bacterial endocarditis.     

Oxacillin hepatitis: Two patients with liver biopsy,and review of the literature

Hepatotoxicity associated with intravenous sodium oxacillin therapy is reported in two drug abusers cured of staphylococcal endocarditis. Coincident with the administration of oxacillin, marked increases in hepatic transaminase were observed and liver biopsy showed nonspecific hepatitis. Upon cessation of oxacillin therapy, liver enzyme values returned to(ward) normal.Reports of oxacillin-associated changes in hepatic enzyme levels are reviewed; further observation of oxacillin-associated hepatotoxicity is warranted.     

Nonbacterial thrombotic endocarditis in patients with malignant neoplastic diseases

Seventy-five patients with malignant neoplastic disease and nonbacterial thrombotic endocarditis (NBTE) were studied. The over-all frequency of NBTE was double that observed in other reported autopsy series not limited to patients with cancer. The incidence in autopsy patients with bronchiolar and adenocarcinoma of the lung was twice that of patients with pancreatic and prostatic adenocarcinoma and seven times that of patients with breast cancer. The development of NBTE could not be ascribed to duration of illness or nutritional state. Since 14 patients died of cerebral infarcts and five had major myocardial infarcts resulting from thromboemboli, these and other complications of NBTE should be anticipated particularly in patients with those cancers most often associated with vegetative endocarditis.     

Acute cortical necrosis. Case report and review of the literature

Confluent acute cortical necrosis is a rare but catastrophic disease. Described here is one case which was heralded by abruptio placenta and occurred in concert with a disseminated intravascular coagulopathy (DIC). All causes of acute cortical necrosis share one common denominator: a procoagulant factor capable of activating the coagulation mechanism. This aspect of the pathogenesis, the pathophysiology and clinical aspects of acute cortical necrosis are reviewed and contrasted to acute tubular necrosis and irreversible postpartum renal failure. Preparation for an extended period of treatment is emphasized as recovery from acute cortical necrosis is protracted.     

Immune reactions in infective endocarditis I. Clinical data and diagnostic relevance of antimyocardial antibodies

Clinical data from 72 patients with infective endocarditis (41 with defined pathogen, 31 with no pathogen isolated) were analyzed with respect to the diagnostic relevance of immunologic parameters. In our patients from a rural area, no significant changes in the epidemiology and pathogenesis of infective endocarditis were observed. Antiendocardial and antisarcolemmal (ASA) antibodies were demonstrated in 60% to 100% of cases. Their frequency depended on the endocarditic pathogen and on the clinical course: in subacute or chronic endocarditis these antibodies were found regularly, in acute lethal cases their occurrence was diminished. Whereas antiendocardial antibodies are diagnostic markers of endocarditis, ASA and antimyolemmal antibodies in particular most likely indicate myocardial involvement in endocarditis. Only complement fixing antimyolemmal antibodies induced cytolysis of vital, adult, heterologous cardiac cells. Our data suggest that antibody-mediated cytolysis in vitro may also play a pathogenetic role in vivo.     

Accidental hypothermia in an alcoholic population

Thirty-nine cases of accidental hypothermia are reviewed. Data indicate that mortality varies with the presence of underlying disease rather than with the degree of hypothermia or the methods of rewarming. In 31 patients with hypothermia alone (average temperature 85 °F) mortality was 6.25 per cent. In eight patients with hypothermia and another primary condition (average temperature 84 °F) mortality was 75 per cent.Intractable cardiac arrhythmia has been reported as the primary cause of death in hypothermia. In these patients, death during hypothermia resulted from pulmonary complications. Ventricular arrhythmias, when they occurred, were responsive to routine measures such as electrical cardioversion and myocardial suppressant drugs. Methods of treatment are discussed.     

The syndrome of multiple endocrine gland insufficiency

Addison's disease, when caused by idiopathic atrophy of the adrenal cortex, is frequently associated with other endocrine abnormalities. Primary hypothyroidism and hypogonadism have been reported in association with adrenal insufficiency; understandably, such cases may lead to diagnostic confusion with respect to possible pituitary disease.This case study concerns a woman who exhibited, in sequence and over a period of 17 years, hypogonadism, hypoadrenalism, diabetes mellitus and, finally, hypothyroidism. Originally misdiagnosed as having Sheehan's syndrome, she eventually became hyperpigmented. The true nature of her illness was then revealed to be primary insufficiency of multiple endocrine glands, with the demonstration of elevated levels of several pituitary hormones.Because multiple endocrine insufficiencies may coexist or develop with time, we suggest that a patient with a single documented endocrine deficiency be investigated initially and serially for additional glandular deficiencies.     

Noninvasive methods for detection of valve vegetations in infective endocarditis

To determine the optimal noninvasive method for the demonstration of endocarditic vegetations, 35 consecutive episodes of clinically diagnosed endocarditis in 33 patients were studied with M mode and two dimensional echocardiography, and with gallium-67 citrate and technetium-99m stannous pyrophosphate cardiac scanning. Clinical criteria for the diagnosis of endocarditis were: temperature higher than 38 ° C; sustained bacteremia with at least three positive blood cultures; no extracardiac focus of bacteremia; and known underlying heart disease, a new or changing murmur or a history of intravenous drug abuse with radiologic evidence of septic pulmonary emboli. M mode echocardiography detected 18 vegetations in 17 of the 35 episodes of endocarditis studied (49 percent positive); two dimensional echocardiography detected 30 vegetations in 28 of the 35 episodes studied (80 percent positive). In contrast, no vegetations were detected with technetium-99m stannous pyrophosphate scanning, and only two gallium-67 citrate scans were positive. The advantage of the two dimensional echocardiographic technique over all others tested was particularly notable for the identification of aortic and tricuspid valve vegetations.     

Transient functional asplenism in sickle cell-C disease

During a painful crisis, the spleen of a patient with sickle cell-C disease failed to visualize with 99^m Tc-sulfur colloid although it was significantly enlarged by palpation. At that time, the peripheral blood smear showed numerous sickle cells, normoblasts and erythrocytes containing Howell-Jolly bodies. After therapy with hypotonic saline solution and with clinical improvement, the enlarged spleen was completely visualized on repeat scanning. The normoblasts and erythrocytes containing Howell-Jolly bodies also decreased in number. This case of transient asplenism is similar to the cases previously reported only in children with homozygous sickle cell disease. The significance of this phenomenon with respect to increased susceptibility to infection is discussed.     

Outbreak of toxoplasmosis in a family and documentation of acquired retinochoroiditis

An outbreak of toxoplasmosis in one household is described. It demonstrates the potential for a common source infection with Toxoplasma gondii to cause multiple cases. Six of seven members of a household investigated for toxoplasmosis demonstrated high antibody titers consistent with recent infection; five of these members (83%) were symptomatic. The most common manifestations were fever and lymphadenopathy, which developed from seven to 18 days (mean 11 days) after a common source ingestion of infected meat. Since inadequately cooked lamb, pork and beef are probably the most common sources of infection in the United States, outbreaks of multiple cases may occur more frequently than is generally appreciated. As more outbreaks of febrile illnesses are examined, especially in families and closed communities, it is likely that more common source epidemics of toxoplasmosis will be recognized. Retinochoroiditis is an unusual manifestation of adult acquired toxoplasmosis. In the index case in this epidemic the patient manifested vision threatening retinochoroiditis 129 days after infection with toxoplasmosis. He represents the ninth well-documented case of toxoplasma retinochoroiditis associated with adult acquired disease.     

Lupus erythematosus-like disease due to hydrazine

A case of systemic lupus erythematosus-like disease due to occupational exposure to hydrazine is described. The patient had four of the 1982 revised criteria for SLE (malar rash, photosensitivity, antinuclear antibody, and antibody to nDNA) and genetically is a slow acetylator with the HLA DR2,3 phenotype. Many of her healthy family members had antibodies to nuclear constituents. Lymphocytes from the patient and an identical twin sister, but not from three normal control subjects, showed inhibition of pokeweed mitogenstimulated IgG synthesis after five daily exposures of each subject to hydrazine. Chemicals such as hydrazine in the environment can induce cases of SLE-like disease in predisposed persons.     

Histoplasma Endocarditis Diagnosed by Thrombus Aspiration

Negative cultures in endocarditis often lead to delays in targeted life-saving therapies. We present the case of a 68-year-old man who presented with culture-negative endocarditis, which was complicated by coronary embolization resulting in anterior ST-elevation myocardial infarction (STEMI). Aspiration thrombectomy led to the diagnosis of fungal endocarditis, one of the most serious causes of culture-negative presentation.     

Methyldopa hepatitis: A report of six cases and review of the literature

Six cases of methyldopa hepatitis, including two in which the patients died are reported; and 77 cases from the literature are reviewed. Patients in whom severe hepatotoxic reactions to methyldopa develop usually complain of prodromal symptoms typical of hepatitis, often with fever, one to four weeks after therapy is initiated. Jaundice, when it occurs, is usually manifest within three months.

Asymptomatic, transient elevations of serum transaminase levels may occur in patients receiving methyldopa. However, since the clinical and histologic features of hepatic injury from methyldopa are indistinguishable from viral hepatitis, it is suggested that the incidence of this iatrogenic disease is higher than generally appreciated.

Serum transaminase levels should be determined at the initiation of therapy with methyldopa and four weeks later. Moreover, any patient who has unexplained fever or the prodromal symptoms of hepatitis should undergo liver chemistry studies immediately.     

Disseminated paracoccidioidomycosis (South American blastomycosis) in the United States

Paracoccidioidomycosis or South American blastomycosis (SAB) is a systemic mycosis endemic to South America but rarely recognized in North America. Visceral dissemination has not been described in the eight cases previously reported from the United States. The patient we describe represents the first case of visceral disseminated SAB, with testicular, adrenal and probable hepatic involvement, diagnosed in the United States. The pathogenesis, clinicopathologic manifestations and therapy of SAB, with particular attention to disseminated paracoccidioidomycosis with adrenal insufficiency, is reviewed.