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PubMed1995

Rocky Mountain spotted fever: a seasonal alert.

Rocky Mountain spotted fever occurs during seasonal tick activity. A history of exposure to tick-containing habitats within the 3- to 12-day incubation period is a key epidemiological factor. The signs of fever, headache, myalgia, nausea, vomiting, and anorexia at onset of infection are difficult to distinguish from those of self-limited viral infections. Rash usually appears later and, if present, progresses through a sequence of stages and distribution that are never pathognomonic. The effects of disseminated Rickettsia rickettsii infection of endothelial cells include increased vascular permeability, edema, hypovolemia, hypotension, prerenal azotemia, and, in life-threatening cases, pulmonary edema, shock, acute tubular necrosis, and meningoencephalitis. In severe cases, fluid management is a challenge. The clinical diagnosis, which is difficult, is rarely assisted by laboratory findings because antibodies are usually detected only in convalescence, and immunohistologic methods for detection of rickettsiae are unavailable in most clinics. Doxycycline is the treatment of choice except for pregnant or allergic patients, who are treated with chloramphenicol.

Humans↗

PubMed1996

Bacteremia due to Citrobacter species: significance of primary intraabdominal infection.

From 1982 to 1994, 45 patients (1.22 episodes per 10,000 discharged patients) were treated for citrobacter bacteremia at National Taiwan University Hospital (Taipei). All patients had at least one underlying disease. Citrobacter bacteremia most commonly occurred in patients with malignancies (48.9%) or hepatobiliary stones (22.2%). Intraabdominal tumors comprised the majority (59.1%) of malignancies. Bacteremia commonly originated from sites such as the abdominal cavity (51.1%), urinary tract (20%), and lung (11.1%). Polymicrobial bacteremia was diagnosed in 15 patients (33.3%); for nine (60%) of these patients, the source of the infection was intraabdominal. Prior treatment with a third-generation cephalosporin was significantly associated (P < .01) with the development of multidrug resistance among the isolates. The mortality associated with citrobacter bacteremia was 17.8%. Poor prognostic factors included pneumonia, altered mental status on presentation, hypothermia, oliguria, septic shock, deterioration in mental status, hyperbilirubinemia, azotemia, and thrombocytopenia. Combination therapy, as compared with other regimens, improved the outcome of citrobacter bacteremia.

Adolescent↗

PubMedDate not supplied

Pentamidine: a review.

Pentamidine, recently released for clinical use, is effective in therapy for the hemolymphatic stage of Gambian trypanosomiasis, antimony-resistant leishmaniasis, and Pneumocystis carinii pneumonia. The mechanism of action is unclear and may differ for different organisms. Trypanosomes actively transport pentamidine intracellularly, and the drug may then interfere with DNA biosynthetics. However, pentamidine appears to kill nonreplicating P. carinii. The mechanism of killing is unexplained. The pharmacokinetics of pentamidine has been incompletely studied in humans. The estimated volume of distribution is 3 liters/kg. Levels in plasma of pentamidine range from 0.3-1.4 microgram/ml after standard 4 mg/kg dosing, with no appreciable increase in drug levels on successive dosing and no correlation between levels and creatinine clearance or adverse reactions. The drug appears to be concentrated in the kidney and excreted in the urine, with levels detectable six to eight weeks after cessation of therapy. Immediate adverse reactions have included hypotension, nausea, and vomiting. Local pain or abscess formation at an injection site, mild azotemia, leukopenia, abnormal findings from liver function tests, and hypoglycemia may also occur.

Amidines↗

PubMed1995

Reduced renal response to low-dose dopamine infusion in the elderly.

BACKGROUND: Increasing age is associated with a number of changes in renal function, including a diminished capacity to excrete salt and water loads and an increased susceptibility to acute renal failure. Dopamine is a renal autocoid important in diuresis and natriuresis and may also serve to protect against ischemic renal injury. The aim of this study was to assess the renal response to a low-dose dopamine infusion in healthy young vs elderly individuals. METHODS: Five healthy young (28 +/- 2 yr) and elderly (68 +/- 3 yr) subjects underwent evaluation of renal function and blood pressure before, during, and after a 3-hour infusion of dopamine (1 microgram/kg/min) in the Clinical Research Center of Beth Israel Hospital. RESULTS: Renal plasma flow, estimated by clearance of para-aminohippurate clearance, was significantly lower in the elderly than in the young subjects, but both groups increased estimated renal plasma flow by approximately 30% during dopamine infusion. Endogenous creatinine clearance was also significantly lower in the elderly. During dopamine infusion, creatinine clearance rose significantly only in the young. Both young and old had a similar natriuretic response to dopamine although urine flow and free water clearance were significantly lower in the old. Neither group had significant changes in blood pressure or heart rate. CONCLUSIONS: Resistance to the actions of dopamine on creatinine clearance in the elderly may reflect an inability to respond to endogenous dopamine at times of physiologic stress with resulting susceptibility to azotemia.

Adult↗

PubMed1976

Comparison of amphotericin B and amphotericin B methyl ester: efficacy in murine coccidioidomycosis and toxicity.

The methyl ester of amphotericin B was compared with the parent compound, amphotericin B, in terms of therapeutic efficacy in experimental murine coccidioidomycosis and of toxicity. Infections were established by intraperitoneal or intratracheal inoculation with arthrospores. The mice were given either intraperitoneal or intravenous injections of drug for 30 days, according to several dosage schedules. At low doses, amphotericin B methyl ester was less effective therapeutically than was amphotericin B; however, at higher doses, amphotericin B was directly lethal and/or nephrotoxic, whereas the methyl ester was therapeutically effective and nontoxic. In contrast to amphotericin B, the methyl ester did not cause either azotemia or histopathologic changes in the kidneys.

Amphotericin B↗

PubMed1977

Comparison of amikacin and tobramycin in the treatment of infection in patients with cancer.

Two new aminoglycoside antibiotics, tobramycin and amikacin, were compared in a randomized study of the treatment of infections in patients with cancer. For the identified infections, the response rate for tobramycin was 60% and for amikacin was 64%. Pneumonia, urinary tract infection, and septicemia were the most frequent infections. Most (78%) of the identified pathogens were gram-negative bacilli; Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa were the most frequently isolated organisms. When only infections due to gram-negative bacilli were considered, 67% responded to tobramycin and 69% responded to amikacin. All infections except pneumonias had at least a 50% response rate to either antibiotic. The major form of toxicity of both antibiotics was azotemia and occurred in 22% of cases treated with tobramycin and in 20% treated with amikacin. Tobramycin and amikacin are equally effective in the treatment of gram-negative infections and have similar toxicity.

Adolescent↗

PubMed1978

Pharmacokinetics of cephalosporins in patients with normal or reduced renal function.

The pharmacokinetic distribution of 10 cephalosporin compounds, cephalothin, cephaloridine, cephaloglycine, cephalexin, cefazolin, cephapirin, cephradine, cephacentrile, cefoxitin, and cefamandole, in patients with various degrees of renal function was reviewed. The mean serum half-life (t1/2) of each cephalosporin compound was calculated from reported data in patients grouped according to their degree of renal function, as determined by the rate of creatinine clearance. Mean t1/2 values in patients with normal renal function were compared with t1/2 values for the same cephalosporin in patients with moderate renal failure and severe renal azotemia. The effect of hemodialysis and peritoneal dialysis on the mean serum t1/2 of each cephalosporin was also determined. The mean serum t1/2 of each cephalosporin progressively increased as the rate of creatinine clearance decreased. Hemodialysis decreases the t1/2 of cephaloridine, cephalexin, cefazolin, and cephacetrile but only minimally influences the t1/2 of cephalothin and cefamandole. Peritoneal dialysis reduces the t1/2 of cephalothin and cephaloridine but only minimally influences the t1/2 of cefazolin and cefamandole.

Cephalexin↗

PubMed1987

Platelet-mediated bleeding caused by broad-spectrum penicillins.

One hundred fifty-six hospitalized adult patients treated with ticarcillin, piperacillin, mezlocillin, or cefotaxime (control) were prospectively observed for determination of frequencies of platelet dysfunction and bleeding. Increases in bleeding times (greater than or equal to 5 min above pretreatment values) occurred in 73% of patients receiving ticarcillin, 43% receiving piperacillin, 25% receiving mezlocillin, and 17% receiving cefotaxime (P less than .0001); chemotherapy, thrombocytopenia, age of greater than or equal to 60 years, dose of greater than or equal to 12 g per day, and duration of treatment of six or more days were significant covariables. Significant bleeding occurred in 34% of patients treated with ticarcillin, 17% with piperacillin, 2% with mezlocillin, and 5% with cefotaxime (P = .0005); chemotherapy, thrombocytopenia, primary marrow disorders affecting platelet function, prolonged prothrombin time, and azotemia were significant covariables. Bleeding was associated with an elevated pretreatment bleeding time, an increase in bleeding time during treatment, and the maximal observed bleeding time during treatment (P less than .0001).

Adult↗

PubMed1989

Melioidosis: a major cause of community-acquired septicemia in northeastern Thailand.

In a prospective study of all patients with Pseudomonas pseudomallei infections admitted to a large provincial hospital in northeastern Thailand, 63 cases of septicemic melioidosis and 206 patients with other community-acquired septicemias were documented during a 1-y period. Apart from P. pseudomallei, the spectrum of bacteria isolated from blood cultures and the overall mortality (32%) were similar to those previously reported elsewhere. Death from septicemia was associated with failure to develop a leukocytosis or pyrexia over 38 degrees C, azotemia, hypoglycemia, and jaundice. Septicemic melioidosis presented mainly in the rainy season, occurred predominantly in rice farmers or their families, and was significantly associated with preexisting diabetes mellitus or renal failure (P = .03). Blood-borne pneumonia and visceral abscesses were common and the mortality was high (68%; P less than .001). The response to appropriate treatment was slow (median fever clearance time 5.5 d) and the median duration of hospital stay was 4 w. Septicemic melioidosis is a major cause of morbidity and mortality in northeast Thailand.

Diabetes Complications↗

PubMed1992

A recalcitrant, erythematous, desquamating disorder associated with toxin-producing staphylococci in patients with AIDS.

Although staphylococcal infections are common in patients with AIDS, staphylococcal toxin-related disorders have rarely been described. Five cases of a staphylococcal toxin-associated syndrome characterized by prolonged erythema, extensive cutaneous desquamation, hypotension, tachycardia, and multiple organ involvement are described in patients with AIDS. These illnesses were recurrent and recalcitrant with a mean duration of 50 days. Toxic shock syndrome toxin-1-producing staphylococci were isolated from three and staphylococcal enterotoxins B and A from one patient each. Sources of organisms were blood, one patient, and soft tissues and nasal accessory sinuses, two patients each. Three of the five patients died of renal failure and central nervous system abnormalities. One survivor required intubation for respiratory failure. All individuals manifested a marked diminution of CD4+ cells. Other laboratory abnormalities included azotemia and prolongation of partial thromboplastin time. Oliguria occurred in three patients. Thus, this recalcitrant erythematous desquamative disorder appears to be a variant of staphylococcal toxic shock syndrome in certain subsets of immunocompromised individuals.

Acquired Immunodeficiency Syndrome↗

PubMed1995

Adverse events associated with trimethoprim-sulfamethoxazole and atovaquone during the treatment of AIDS-related Pneumocystis carinii pneumonia.

Atovaquone was compared to trimethoprim-sulfamethoxazole (TMP-SMZ) for the relationship of time receiving therapy, plasma drug concentrations, and incidence of adverse reactions in patients with AIDS-associated Pneumocystis carinii pneumonia. Treatment-limiting adverse events occurred in 9% of atovaquone-treated patients and 24% of TMP-SMZ-treated patients. Adverse events usually did not occur before day 7 for either treatment. Only the incidence of rash increased with increasing plasma concentrations of atovaquone. The incidence of anemia, neutropenia, and azotemia increased with increasing trimethoprim plasma concentration, while other adverse events (gastrointestinal disorders, rash, fever, and liver function abnormalities) were independent of plasma drug concentration.

AIDS-Related Opportunistic Infections↗

PubMed1997

Mitomycin-C induced hemolytic uremic syndrome: a case report and literature review.

Hemolytic uremic syndrome spontaneously arises in a few patients with advanced cancer, but it is more commonly related to the use of certain chemotherapeutic agents. Mitomycin-C is, etiologically, the most common causative agent inducing hemolytic uremic syndrome, in a dose dependent manner. We report this syndrome, attributable to mitomycin-C at a cumulative dose of 40 mg/m2, in a gastric cancer patient. A 42-year-old female with stage III gastric cancer underwent radical gastrectomy and was given mitomycin-C at 10 mg/m2 intravenously every four weeks as adjuvant therapy. Hemolytic uremic syndrome was diagnosed three months after the last dose of mitomycin-C administration. The most prominent symptoms included pallor, hypertension and anasarca, with laboratory evidence of microangiopathic hemolytic anemia, azotemia and hyperkalemia. Her disease was progressive, but fortunately stabilized after staphylococcus column A dialysis. Her disease remained in remission for 24 months from the time of diagnosis, and then relapsed in the form of peritoneal carcinomatosis with partial intestinal obstruction.

Adenocarcinoma↗

PubMed1996

Long-term successful management of refractory congestive cardiac failure by intermittent ambulatory peritoneal ultrafiltration.

Despite advances in the pharmacological management of cardiac failure, some patients remain refractory to this therapy. However, improved understanding of the physiology and technique of peritoneal dialysis has recently allowed ambulatory peritoneal ultrafiltration to be applied to the treatment of patients with intractable heart failure. We report the management of three such patients with New York Heart Association (NYHA) class IV cardiac failure, each with a left ventricular ejection fraction < 20%. They had become unresponsive to maximum pharmacological management with inotropes, diuretics and ACE inhibitors. All patients had biochemical evidence of pre-renal azotemia. Initially, patients received aggressive ultrafiltration by continuous veno-venous haemofiltration (CVVH) or one- to two-hourly peritoneal dialysis exchanges until they achieved an optimal dry body weight. Once stabilized, they were converted to an intermittent ambulatory peritoneal ultrafiltration (IAPU) regimen of one to three exchanges per 24 h according to their individual needs. During an 18 +/- 10-month follow-up, their duration of hospital confinement was reduced by 85% and all three patients improved from class IV to class II cardiac failure. IAPU may have a useful role in the long-term management of intractable heart failure in a selected group of patients.

Chronic Disease↗

PubMed1983

Cis-platinum in the treatment of advanced or recurrent adenocarcinoma of the ovary. A phase II study of the Gynecologic Oncology Group.

Thirty-seven patients with advanced or recurrent adenocarcinoma of the ovary no longer amenable to control with surgery, radiation therapy, or higher prior chemotherapy were treated with cis-platinum, 50 mg/m2 intravenously every 3 weeks. Among the 37 patients, three patients had a clinical complete response (8%) and six had a partial response (16%). Twenty-three demonstrated stable disease (62%), while five demonstrated rapidly increasing disease (14%). Median response duration was 5 months and median survival was 10+ months. Responders survived longer than nonresponders (p = 0.01). Adverse effects included leukopenia (26/37), thrombocytopenia (19/37), nausea and vomiting (35/37), and azotemia (19/37). Adverse effects were generally mild to moderate and tolerable. Cis-platinum thus appears to be highly active in the treatment of adenocarcinoma of the ovary at the dose and schedule tested.

Adenocarcinoma↗

PubMed1984

Phase II trial of cisplatin as second-line chemotherapy in patients with advanced or recurrent endometrial carcinoma. A Gynecologic Oncology Group study.

Twenty-five patients with advanced or recurrent endometrial carcinoma no longer amenable to control with surgery, radiotherapy, hormonal therapy, or higher-priority chemotherapy were treated with cisplatin 50 mg/m2 intravenously every 3 weeks. Only one objective response, a partial response, was observed among the 25 patients (4%). Twenty patients (80%) exhibited stable disease for more than 1 month, while four patients (16%) progressed less than 1 month after initiating chemotherapy. Adverse effects included leukopenia (28%), thrombocytopenia (40%), nausea and vomiting (74%), and azotemia (37%). Only one patient experienced life-threatening toxicity. Cisplatin thus appears tolerable but only minimally active when given at the dose and schedule tested to patients with endometrial carcinoma who have previously demonstrated progression of disease on chemotherapy with known activity.

Aged↗

PubMed1984

Phase II trial of piperazinedione (NSC 135758) in the treatment of advanced or recurrent carcinoma of the ovary. A Gynecologic Oncology Group study.

Thirty-eight patients with advanced or recurrent epithelial ovarian cancer no longer amenable to management with surgery, radiotherapy, or chemotherapy with known activity were given piperazinedione 9 mg/m2 intravenously every 3 weeks. Of the 31 patients evaluable for response, only one achieved a partial response of disease (3%), while there were no complete responses. Fourteen (45%) experienced progression of disease less than 1 month after starting therapy. Adverse effects consisted primarily of myelosuppression (81%), nausea and vomiting (32%), and azotemia (29%) with three patients (10%) having life-threatening thrombocytopenia. While adverse effects were tolerated, the drug at the dose and schedule tested has only minimal activity at best and should not be considered for further trials in epithelial ovarian cancer.

Adenocarcinoma↗

PubMed1987

Pilot study of combination 5-fluorouracil, cisdiamminedichloroplatinum II, and radiation therapy for grade III and IV astrocytomas.

Nineteen patients with biopsy-proven high-grade astrocytomas received as initial treatment whole-brain radiation and combination chemotherapy with 5-fluorouracil (5-FU), 1,000 mg/m2/24 h as a continuous infusion for 96 h, and bolus cisdiamminedichloroplatinum II (CDDP), 100 mg/m2. Chemotherapy cycles were repeated on day 21, then every 28 days until progression or completion of six cycles. All 19 patients completed one cycle of chemotherapy. Toxicity was moderate, with cytopenias, nausea, vomiting, diarrhea, stomatitis, and reversible azotemia. Survival ranged from 2 to 160+ weeks, with a median of 35 weeks. The survival of the pilot group was compared with historical controls treated with radiation plus 1,3,-bis(2-chloroethyl)-1-nitrosourea (BCNU). Controls were similar in histology, age, performance score, and survival, without statistically significant differences. The combination of radiation therapy, continuous-infusion 5-FU, and bolus CDDP as described here for high-grade astrocytomas is moderately toxic and appears to offer no survival advantage compared with radiation therapy plus BCNU.

Adolescent↗

PubMed1992

Phase II study of combination therapy with high-dose cisplatin, etoposide, and mitomycin in patients with advanced non-small-cell lung cancer.

Forty-six patients with metastatic non-small-cell lung cancer (NSCLC) were treated with a combination of high-dose cisplatin, etoposide, and mitomycin. Thirty-four patients (74%) had a performance status of 1, and 39 patients (85%) had adenocarcinoma. Of the 42 patients evaluable for response and toxicity, four achieved a partial response (10%); no patient achieved a complete response. Seven patients who had received prior chemotherapy showed no major response. The median survival of all 42 patients was 23 weeks. Myelosuppression was the major dose-limiting toxicity for this regimen, and 12 of 46 patients (26%) developed neutropenic fever requiring hospitalization and parenteral antibiotics. Of the 12 patients with severe neutropenic fever, one patient died because of toxicity. Nonhematologic toxicities, including azotemia, peripheral neuropathy, nausea, vomiting, and hearing loss were transient and modest. We conclude that high-dose cisplatin combined with etoposide and mitomycin is a relatively toxic regimen with a low response rate. Further evaluation of the combination as given in this trial is not warranted.

Adult↗