Archive for the ‘Pneumonia’ Category

Rhodococcus equi Pneumonia: Discussion

Feb 13, 2015 Author: Walter Mcneil | Filed under: Pneumonia

Rhodococcus equi Pneumonia: DiscussionThe incidence of infection with R equi, although low, appears to be increased in patients with HIV infection. Our cases bring to four the number of reports of pulmonary disease due to R equi in patients with HIV-related illnesses. As our two patients illustrate, infection with this organism can be an early manifestation of immune dysfunction related to HIV. Although experience with R equi is limited, the characteristics of these four cases are remarkably similar and should suggest the diagnosis. Both of the cases of R equi pneumonia previously reported in association with HIV infection had a left upper lobe cavitary infiltrate. One of these patients developed an empyema, and the other had associated pleural thickening. Our two cases also presented with cavitary infiltrates and pleural effusion. Therefore, all cases of R equi in these patients have had cavitary pneumonia with pleural disease. This presentation with a subacute illness with an upper lung field cavitary infiltrate and an associated pleural effusion at some time in the course is sufficiently unusual in AIDS that we think the possibility of infection with this organism should be considered in the differential diagnosis of such a patient. Although the location of the infiltrate might suggest tuberculosis, Pitchenik and colleagues observed that Mycobacterium tuberculosis rarely produced cavitation in AIDS patients. (more…)

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  • Rhodococcus equi Pneumonia: Case Reports

    Feb 12, 2015 Author: Walter Mcneil | Filed under: Pneumonia

    Case 2
    A previously healthy 45-year-old homosexual white man first presented to another hospital with a four-day history of fever, chills, right pleuritic chest pain, and cough productive of gray blood-tinged sputum. Physical examination revealed a temperature of 40°C and respiratory rate of 28/minute. Rhonchi, egophony, and dullness were noticed at the right base. His white blood cell count was 7.4 x 109/L. His chest radiograph demonstrated a dense right lower lobe infiltrate. Sputum cultures and smears, blood cultures, pleural fluid cultures, bone marrow biopsy, open lung biopsy, and viral titers were negative, although HIV positivity was documented. After a two-month hospital course which included respiratory failure requiring intubation, mechanical ventilation, and therapy with multiple parenteral antibiotics, he defervesced and was discharged. (more…)

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  • Rhodococcus equi Pneumonia

    Feb 11, 2015 Author: Walter Mcneil | Filed under: Pneumonia

    Rhodococcus equi PneumoniaAn Unusual Early Manifestation of the Acquired Immunodeficiency Syndrome (AIDS)
    Rhodococcus equi is an aerobic Gram-positive weakly acid-fast nonmotile nonsporeforming pleomorphic bacillus which has been identified as a source of cavitary pneumonia, pleural effusions, brain abscesses, and subcutaneous nodules in immunocompromised hosts. Initially recognized as a pathogen in animals, Rhodococcus equi (formerly known as Corynebacterium equi) was first reported as a human pathogen by Golub et al in 1967 in a patient with a lung abscess. In 1983, Van Etta et al2 summarized findings in the ten cases in the literature and added two of their own. Since then, four additional cases have been reported, two of which occurred in patients with the acquired immunodeficiency syndrome (AIDS). We report two additional cases of cavitary pneumonia with pleural effusion due to Rhodococcus equi presenting in one month to Parkland Memorial Hospital in patients infected with the human immunodeficiency virus (HIV). Recognition of this pathogen as a cause of pneumonia and/or pleural effusion in the growing population of patients with HIV-associated illness has important therapeutic implications regarding both choice and duration of antibiotic therapy. Because R equi very rarely infects normal hosts, we feel that this infection in patients positive for HIV should be regarded as sufficient for a diagnosis of AIDS. (more…)

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  • Antibiotic Studies in Pneumonia: Conclusion

    Nov 29, 2014 Author: Walter Mcneil | Filed under: Pneumonia

    Antibiotic Studies in Pneumonia: ConclusionThe end points for the classification of cure should be explicit. We suggest a new criterion: clinical cure is defined as resolution of presenting symptoms and signs (for example, defervescence, return of normal respiratory rate, clearing of cough and sputum, etc) at a fixed time (for example, five-seven days) following discontinuation of the test antibiotic. Bacteriologic eradication based on post-therapy sputum cultures would be of secondary importance given the aforementioned difficulties in interpretation. The current requirement of the Food and Drug Administration for sputum sterilization by the antibiotic in declaring a patient as “cured” should be re-evaluated. Reading here

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  • Antibiotic Studies in Pneumonia: Outcome

    Nov 28, 2014 Author: Walter Mcneil | Filed under: Pneumonia

    Given the difficulties in interpretation of sputum culture, we suggest subclassifying etiologies into two categories: “definitive” and “presumptive.” Definitive etiology might include any of the following: (a) blood or pleural fluid cultures yielding a pathogen; (b) open lung biopsy results yielding a pathogen; (c) broncho-alveolar lavage findings revealing Pneumocystis carinii; (d) positive sputum culture for Legionella, Mycoplasma, or TWAR; or (e) fourfold rise in antibody titer for Legionella, Mycoplasma, TWAR, Q-fever or influenza A. Presumptive etiology might include growth of a bacterial pathogen in sputum culture in which Gram stain revealed a predominant bacterium compatible with the culture result. Even when the sputum is considered to be an excellent specimen, any organism isolated cannot be considered as the “definitive” etiology, since the specimen may still fail to yield the actual pathogen. other

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  • Antibiotic Studies in Pneumonia: Test antimicrobial

    Nov 27, 2014 Author: Walter Mcneil | Filed under: Pneumonia

    Antibiotic Studies in Pneumonia: Test antimicrobialGiven the proliferation of antibiotic studies reported in peer-review journals, “throw-away” journals, and pharmaceutical-produced literature, how does one evaluate the relative merits of these studies? We offer some guidelines for consideration by practicing physicians to use in evaluating studies of this type. First, prospective, randomized, comparative trials of the new agent to an established standard is an obvious minimal requirement. This separates Khans study from other “open” studies of ciprofloxacin in pneumonia. A double-blind format would be ideal, since criteria for cure in pneumonia includes subjective evaluation. (more…)

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  • Antibiotic Studies in Pneumonia: Study of ciprofloxacin

    Nov 26, 2014 Author: Walter Mcneil | Filed under: Pneumonia

    The quinolones are a new group of antimicrobial agents that have been proposed for the treatment of pneumonia because of their activity against Gram-positive and Gram-negative aerobic bacteria, relatively high penetration into lung tissue, small number of serious side effects, and convenience of oral therapy. They also have activity in vitro against Mycoplasma, Chlamydia, and Legionella. Although it has been emphasized that the spectra of quinolones do not include anaerobic bacteria, evidence exists that they may be active against oropharyngeal flora (which may be pathogenic in the context of aspiration pneumonia). Preliminary studies suggest that quinolones are efficacious for pneumonia, but there have been few comparative studies. (more…)

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  • Antibiotic Studies in Pneumonia

    Nov 25, 2014 Author: Walter Mcneil | Filed under: Pneumonia

    Antibiotic Studies in PneumoniaPitfalls in Interpretation and Suggested Solutions
    “Pneumonia continues to offer a major diagnostic and therapeutic challenge for the clinician. Lower respiratory tract infections constitute a major usage group for antibiotics, and the commercial success of a new agent virtually requires that it carries an indication for these infections. Consequently, many new antimicrobial agents continue to be introduced for lower respiratory tract infections with a corresponding number of clinical studies being performed, making it increasingly difficult for the practicing physician to select the appropriate antimicrobial with confidence. read only

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