Fungal endophthalmitis in a tertiary care cancer center: a review of 23 cases

Few data exist on the etiology, presentation, prognosis, and management of fungal endophthalmitis (FE) in cancer patients. FE cases were identified by reviewing the ophthalmology reports and microbiology cultures of patients at The University of Texas M. D. Anderson Cancer Center. We retrospectively reviewed the medical records and obtained information related to malignancy, fungal infection and its management, visual outcome, and mortality. We compared FE caused by Candida spp. (CE) to FE caused by molds (ME). Of the 102 cancer patients with a fungal infection for whom an ophthalmology consult was requested, 23 met the criteria for definite (N = 6) or probable (N = 17) FE (8 with CE, 15 with ME). All of the patients with ME had hematologic malignancies, whereas half of the patients with CE had solid tumor (P = .008). Only patients with CE had a history of surgery within 30 days of FE diagnosis (38%, P = .03). Fungal pneumonia [17 (74%)] and disseminated infection [14, (61%)] were common. The most common presenting symptoms were decreased vision [16 (70%)] and ocular pain [14 (61%)]. All treated patients received systemic antifungals (combination therapy in 72% of the cases). Seven patients (30%) underwent vitrectomy. Only one patient received intraocular injection of amphotericin B along with systemic antifungals. Four-week mortality was high [13 (57%)], especially in ME (73%, P = .04). Among the eight surviving patients where visual acuity could be assessed, visual outcome improved or remained stable in five (63%). FE in cancer patients occurs in the setting of severe, frequently disseminated opportunistic mycoses, is caused predominantly by hyalohyphomycetes, and is a marker for high 4-week mortality.     

Serious complications of vascular catheter-relatedStaphylococcus aureus bacteremia in cancer patients

Over the period 1986 to 1989, 53 cancer patients were identified with catheter-relatedStaphylococcus aureus bacteremia at the University of Texas M.D. Anderson Cancer Center. Septic thrombosis was diagnosed in 12 (23 %) patients and was suspected in another 3 (6 %). Of the 12 patients, five developed deep-seated infections (septic emboli, endocarditis, meningitis, abscess), compared with 2 of the 38 other patients with no septic thrombosis (p<0.01). Fever persisted for more than three days after antibiotic initiation in 52 % of the patients with complications (septic thrombosis and/or deep-seated infections), compared with 19 % of those without complications (p<0.02). Of the three patients with complications who were treated for 14 days with intravenous antistaphylococcal antibiotics, two relapsed; in contrast, all of the nine patients with complications who were treated for more than 14 days (mean 4 weeks) were cured, and none relapsed (p<0.05). Of the nine patients with complications who were treated with a long course of therapy, only one required surgery. The possibility of septic thrombosis and/or deep-seated infections should be considered in all cancer patients with catheter-relatedStaphylococcus aureus bacteremia, and if present, the condition should be treated with appropriate intravenous antibiotics for at least four weeks.     

The significance of blood cultures positive for emerging saprophytic moulds in cancer patients

The significance of blood cultures positive for emerging saprophytic moulds (e.g., Scedosporium apiospermum, Scedosporium prolificans, Paecilomyces spp.) was evaluated in 30 cancer patients (1996-2002). Diagnostic criteria proposed previously for evaluation of aspergillaemia were used. Blood cultures positive for emerging saprophytic moulds represented 1% of all positive fungal cultures. One case of catheter-related fungaemia was excluded. The remaining 29 cases consisted of true (n = 5), probable (n = 1), indeterminate (n = 7) fungaemia, and contamination (n = 16). True fungaemia was seen only in leukaemia patients and allogeneic bone marrow transplant recipients. S. apiospermum and S. prolificans were the commonest causes of true fungaemia.     

“Pulmonary tongue” a right ventricle phase abnormality in muga studies in patients with pulmonary hypertention

Pulmonary hypertension (PH) produces strain followed by hypertrophy and later dilatation of the right ventricle (RV) and pulmonary artery. The signs and symptoms are nonspecific. There is a need for a noninvasive sensitive way to diagnose PH. The purpose of this study is to evaluate phase abnormalities in radionuclide MUGA studies of patients with referred diagnosis of PH. In a retrospective analysis of 44 patients who had a radionuclide multigated study (MUGA) and contrast ventriculography (CV), 19 had high mean pulmonary pressure (over 20 mmHg) and a high pulmonary vascular resistance index (over 2.0). In 15 patients, a delayed phase segment in the RV corresponding to the pulmonary infundibulum and pulmonary conus was noted The Pulmonary Tongue sign (PT), 12 had PH (True positive) and 3 did not (false positive) on CV. No PT was seen in the remaining 29 patients, only 7 of them had PH (False negative). The sensitivity, specificity and accuracy of the PT sign in detecting PH was 80%, 72% and 77% respectively. The number of patients was too small to calculate the correlation of the grade of PT with the severity of PH. We conclude that The Pulmonary Tongue sign on a MUGA study is clinically useful in detecting PH.This project is supported by research project MLNO13 and funded by research Council, Kuwait University     

Antimicrobial activity and durability of a novel antimicrobial-impregnated bladder catheter

The main objective of this study was to examine the antimicrobial activity and durability of a novel indwelling bladder catheter impregnated with minocycline and rifampin. Thirty antimicrobial-impregnated bladder catheters were inserted transurethrally in spinal cord-injured patients and removed, in six groups of five catheters each, at 3, 7, 10, 14, 17 or 21 days. Removed catheters had detectable zones of inhibition against two different clinical isolates of each of the 10 tested uropathogens (Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella pneumoniae, Enterobacter cloacae, Citrobacter diversus, Enterococcus faecalis, Enterococcus faecium, Staphylococcus saprophyticus and Candida albicans) for greater than 14 days after catheter insertion. The residual zones of inhibition and levels of antimicrobial agents in removed catheters were both inversely related to the duration of catheter placement. Minocycline and rifampin were undetectable in serum and urine. These results support the ongoing efforts for examining the clinical efficacy of these experimental bladder catheters.     

Antibiotic susceptibility of staphylococcal isolates from patients with vascular catheter-related bacteremia: potential role of the combination of minocycline and rifampin

The antimicrobial susceptibility to ten antibiotics of 197 staphylococcal isolates recovered over a 10-year period from patients with vascular catheter-related bacteremia was examined. Isolated organisms induced methicillin-sensitive Staphylococcus aureus (95 isolates), methicillin-resistant S. aureus (42 isolates) and methicillin-resistant S. epidermidis (60 isolates). A microtiter assay was used to determine the MIC and MBC of individual antibiotics and to conduct time-kill studies of certain drug combinations. The activity of clidamycin, cefamandole and oxacillin was generally restricted to methicillin-sensitive organisms, whereas daptomycin, novobiocin, teicoplanin and vancomycin exhibited bactericidal activity against all tested staphylococcal species. Bacterial resistance to ciprofloxacin was detected among the more recent isolates of methicillin-resistant staphylococci. Minocycline and rifampin demonstrated bacteriostatic and bactericidal activity, respectively, against all groups of organisms. The interaction of rifampin with minocycline, vancomycin, or novobiocin was generally indifferent. The results of this study support the ongoing efforts for evaluation of the antimicrobial efficacy of vascular catheters coated with the combination of minocycline and rifampin.