From Long Island Jewish Medical Center, The Long Island Campus for the Albert Einstein College of Medicine, Division of Infectious Diseases, Department of Medicine (WT, CS), Department of Pharmacy (DD), New Hyde Park, New York Address for correspondence: Carol Singer, M.D., Division of Infectious Diseases, Long Island Jewish Medical Center, Staff House, Room 226, 270-05 76th Avenue, New Hyde Park, NY 11040 (Fax: 718-470-0637

From the Division of Infectious Diseases, Department of Medicine, Long island Jewish Medical Center, Albert Einstein College of Medicine, New Hyde Park, New York

Recent advances in methods for the manufacture of inactivated poliovirus vaccines have resulted in increased vaccine immunogenicity. In conjunction with this capability it is important to have available highly sensitive and quantitative potency assays. The potential suitability of enzyme-linked immunoassay (ELISA) was evaluated using animal sera with neutralizing antibodies or neutralizing monoclonal antibodies for antigen detection in potency tests. The monoclonal antibodies developed, which bound D antigen but not C antigen, were neutralizing unless relatively weakly reactive. Those that bound C antigen only were non-neutralizing. Those that bound both C and D antigens were sometimes neutralizing. D-specific and D/C-specific neutralizing monoclonal antibodies against type-2 poliovirus protected mice on passive immunization against paralytic disease and death from the MEF strain virus. Potency measurements by ELISA using either D-specific neutralizing monoclonal antibodies or type-specific goat sera for antigen detection were sensitive and precise. Tests using C-specific monoclonal antibodies for antigen detection indicated that increased C antigen content may result in falsely elevated reactivities of animal sera with some vaccines. Monoclonal antibodies may be useful ELISA reagents for IPV potency testing.

A prospective study was conducted over six months to determine if triple-lumen catheters were associated with a higher rate of infection than single-lumen catheters. A total of 502 central intravascular catheters were prospectively collected from 362 consecutive patients in the adult intensive care units. Semiquantitative and broth cultures were performed on distal and proximal catheter segments, with peripheral blood culture specimens drawn in febrile patients. The overall infection rate for the 502 catheters was 11.8 percent or 2.2 infections per 100 days at risk. The infection rates were: single-lumen lines, 8 percent; triple-lumen lines, 32 percent; and triple-lumen pulmonary artery catheters, 12 percent. When corrected for time at risk, the triple-lumen lines and the triple-lumen pulmonary artery catheters had the same rate of infection, which was three times greater than that of the single-lumen catheters. After correction for confounding variables such as the presence of diabetes mellitus, the use of hyperalimentation, the degree of illness, dialysis, or ultrafiltration, and the use of a guide wire to place a replacement line over a pre-existing one, the risk of infection remained significantly higher for triple-lumen than for single-lumen catheters. The use of a guide wire to place a new line over an old one also was associated with a trend towards an increased risk of infection.

Combined Pneumocystis carinii and Nocardia asteroides pneumonia occurred in a patient with an adrenocorticotropin (ACTH)-producing carcinoid after effective chemotherapy decreased elevated ectopic ACTH and endogenous corticosteroid levels. Implications regarding the pathogenesis of such infections in patients with paraneoplastic tumors are discussed.

Over a two year period, we studied prospectively 80 cases of diffuse pneumonia at Memorial Sloan-Kettering Cancer Center. In 72 per cent of these, the patient had leukemia or lymphoma. Diagnostic procedures consisted of extensive serologic testing for antibody to known respiratory pathogens, including the agent of Legionnaire's disease, and culturing of biopsy specimens for bacteria, viruses, mycoplasmas and fungi. Of 44 cases in which open lung biopsy was performed, a specific cause was found in 61.4 per cent: Pneumocystis carinii in 38.6 per cent, other infections in 9.1 per cent and tumor involvement in 13.7 per cent. There were nonspecific pulmonary changes in 38.6 per cent. Of the 56 cases in which biopsy, autopsy or both were performed, a specific diagnosis was made in 69.7 per cent: P. carinii infection in 37.5 per cent and other infections in 12.5 per cent. In cases in which neither biopsy nor autopsy was performed, a specific infection was diagnosed in 33 per cent; no specific diagnosis was made in the remainder. One patient in the entire group had a significant antibody titer for Legionnaire's disease. Although diagnostic in some cases, extensive serologic testing proved relatively unfruitful. Pneumocystosis was the most frequent diagnosis in this study. The cause of some cases remained obscure, even after lung biopsy.

La aspergilosis pulmonar es una infección micótica causada la mayoría de las veces por la inhalación de esporas de Aspergillus fumigatus. Sin embargo, al hablar de aspergilosis, en realidad nos referimos a un abanico de manifestaciones clínicas y radiológicas que dependen directamente del estado del sistema inmune del paciente, de la existencia de enfermedad pulmonar previa y de la virulencia del organismo. Son 4 los tipos de aspergilosis pulmonar (aspergiloma, aspergilosis broncopulmonar alérgica, aspergilosis necrosante crónica y aspergilosis invasiva), cada uno con hallazgos radiológicos distintos. En este artículo revisamos el espectro de signos de la aspergilosis pulmonar en la tomografía computarizada multidetector y los correlacionamos con los síntomas y la respuesta inmune del paciente. Se abordarán asimismo los principales diagnósticos diferenciales.Pulmonary aspergillosis is a fungal infection usually caused by inhaling Aspergillus fumigatus spores. However, when we talk about aspergillosis, we normally refer to the spectrum of clinical and radiological findings that depend directly on the patient's immune status, on the prior existence of lung disease, and on the virulence of the infective organism. There are four types of pulmonary aspergillosis (aspergilloma, allergic bronchopulmonary aspergillosis, chronic necrotizing pulmonary aspergillosis, and invasive aspergillosis), and each type has its own distinct radiologic findings. We review the signs of pulmonary aspergillosis on multidetector computed tomography and we correlate them with patients’ symptoms and immune responses. Likewise, we discuss the differential diagnoses.

High-frequency jet ventilation is an experimental method of mechanical support, which achieves satisfactory alveolar ventilation and oxygenation at low peak-inspiratory pressures of 5 to 8 cm H2O and low end-expiratory pressures of 3 to 5 cm H2O. This characteristic was used to advantage in 23 patients with cancer, 12 of whom had tracheal or bronchial disruption complicated by pneumonia. Eight patients who could not be supported by conventional means were salvaged.Barotrauma complicated the very high peak airway pressures required to ventilate 8 of 11 patients with respiratory failure associated with diffuse interstitial pneumonia or pulmonary fibrosis. There were only 2 survivors despite temporary normalization of arterial blood gas values in 7 patients.Earlier use of high-frequency jet ventilation in patients with poor compliance may prevent pulmonary disruption in addition to deleterious hemodynamic and systemic effects of conventional high-pressure ventilation. Other applications under study include the role of jet ventilation in resection of the trachea or carina, and in major airway trauma.

Strongyloidiasis is usually a benign illness confined to the gastrointestinal tract. However, dissemination (hyperinfection syndrome) may occur, particularly in patients with impaired cell-mediated immunity. The diagnosis of hyperinfection syndrome is often made postmortem, and mortality is high, even when the disease is recognized during life. Central nervous system involvement with Strongyloides stercoralis has previously been recognized in only a few cases at postmortem examination, and in one case antemortem. We describe a patient with disseminated strongyloidiasis in whom central nervous system involvement was diagnosed antemortem. This patient developed multiple bacterial and fungal systemic and central nervous system infections as a complication of disseminated strongyloidiasis. The natural history of the disease in man, factors predisposing to dissemination, immunologic aspects of helminthic infection, and treatment modalities are discussed.

Cohn's editorial (AmJMed62: 565, 1977) described patients capable of normal activities despite abnormal coronary arteries.A new dimension has been added to this syndrome by rehabilitation programs which raise the patient's fitness to 'cardiac athlete."I participated in footraces in which some 50 post-rehabilitation patients ran distances from 42 to 100 km.The most abnormal angiographic report was triple vessel narrowing of 100 per cent, 95 per cent and 95 per cent, and this patient ran 42 km three times.After myocardial infarction, one patient ran 100 km in 15 hours.This demonstrates Nixon's belief that "human performance may bear no relationship to the appearance of the coronary arteries" [ I].

During a 14 month period there were 364 episodes of bacteremia and fungemia at Memorial Sloan-Kettering Cancer Center. The first nine months of the study were retrospective, and the next five prospective. In patients with leukemia or lymphoma (group 1), Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae and Staphylococcus aureus were the most frequently isolated organisms. The mortality in this group was 40.5 per cent. In the patients with solid tumor (group 2), Esch. coli, Staph. aureus, Bacteroides sp. and Candida sp. were most frequent. Mortality was 27.8 per cent. The source of infection in both groups was often indeterminate. High mortality was associated with pulmonary and intraabdominal infection and with Ps. aeruginosa, K. pneumoniae or polymicrobic sepsis. Factors of prognostic significance were the causative microorganism, source of infection and shock. Although mortality was higher in patients with leukopenia than in those with normal leukocyte counts, the differences were not significant. The mortality in this series was low considering the severity of the underlying diseases and the immunosuppressed state of many of the patients. In a prospective, randomly controlled study, mortality was further diminished by infectious disease consultation at the time the positive blood culture was reported. Severe fungal superinfection, predominantly aspergillosis and candidiasis, was found in 52 per cent of the autopsy patients with leukemia or lymphoma (group 1), but in only 8 per cent of those with solid tumors (group 2).

A case of mucocutaneous leishmaniasis in a patient referred to Memorial Sloan-Kettering Cancer Center, New York, with a presumptive diagnosis of lethal mid-line granuloma is described. The patient had lived in Bolivia and had been treated with antimony during and after which his mucosal lesions progressed. These lesions completely healed with 971 mg of amphotericin B. Mucocutaneous leishmaniasis is endemic in many areas of Central and South America and may occur in patients in the United States who have lived in or traveled to these areas. Organisms may be difficult to identify, and multiple biopsies and cultures may be necessary. The use of amphotericin B for the treatment of leishmaniasis is reviewed. It is an effective alternative to antimony therapy, and in some cases resistant to antimony, it may be the drug of choice.