We describe a hypothetical case of an HIV-positive dentist without cognitive impairment who uses proper infection control procedures. The dentist's physician notifies the medical officer of health without the dentist's consent. Although HIV-positive health care workers, including dentists, have been identified in the past, proven HIV transmission to patients is very rare. Most authorities recommend that an HIV-positive health care worker be monitored by an expert panel, which could then, if necessary, refer to the regulatory body to revoke or restrict the person's license to practice. Mandatory HIV testing is not required for health care workers because they generally do not pose a risk for infecting their patients; they are, however, ethically and legally obligated to report their HIV status to their profession's regulatory body.

We describe ten cases of aortitis due to Salmonella that were treated at the University of Toronto-affiliated Hospitals between 1978 and 1997. Predisposing conditions included hypertension, diabetes mellitus, and myelodysplastic syndrome. Main presenting symptoms were fever and abdominal and back pain. The most frequent site involved was the abdominal aorta, followed by the thoracic aorta. All but one patient were treated with intravenous bactericidal antibiotics; seven also underwent surgery, four with axillobifemoral grafts and three with in situ grafts. Four of seven patients died within 1 month of the surgical procedure (three patients with in situ grafts and one patient with axillobifemoral graft). We also reviewed the pathogenesis, clinical and laboratory characteristics, and treatment of 140 cases of aortitis due to Salmonella reported in the literature since 1948. The use of bactericidal antibiotics, together with early surgical intervention and long-term suppressive antibiotic therapy, has led to improved survival.

OBJECTIVE: To report two patients with AIDS and cytomegalovirus retinitis who developed iritis after receiving intravenous cidofovir. Both experienced recurrent symptoms upon rechallenge. CASE SUMMARIES: Two HIV-positive patients with cytomegalovirus retinitis infections previously controlled with intravenous ganciclovir or foscarnet were treated with intravenous cidofovir. Symptoms of iritis developed after the second or third dose of cidofovir. One patient experienced symptoms unilaterally, while the other patient had bilateral symptoms. In both patients, the iritis resolved with topical ophthalmic therapy, but recurred following subsequent infusions of cidofovir. Therapy with cidofovir was discontinued, and no further recurrences of iritis were noted. One patient had post-inflammatory fixed dilated pupils. CONCLUSIONS: Iritis can uncommonly occur in patients receiving intravenous cidofovir and oral probenecid. With prompt drug discontinuation and administration of topical corticosteroids and/or mydriatic agents, symptoms are usually reversible.

The etiology of the Chronic Fatigue Syndrome (CFS) is unknown but it is usually considered to be postinfectious or postviral. Many infecting agents have been suspected as causative but none has been proven. We investigated precipitating factors in 134 CFS patients through the use of a questionnaire, interview, clinical examination and serology for infecting agents; 35 healthy controls completed a similar questionnaire. CFS started with an apparently infectious illness in 96 (72%) but a definite infection was only found in seven of these 96 (7%). Thirty-eight (28%) had no apparent infectious onset: 15/38 (40%) had noninfectious precipitants (trauma, allergy, surgery). There was no apparent precipitating event in 23/38 (61%). Immunization was not a significant precipitant. Stressful events were very common in the year preceding the onset of CFS (114/134, 85%) but these occurred in only 2/35 (6%) of the controls (p < .0001). The onset of CFS may be associated with preceding stressful events and multiple other precipitants. An infectious illness is not uniformly present at the onset and no single infectious agent has been found; CFS is most likely multifactorial in origin.

The Chronic Fatigue Syndrome is a chronic debilitating illness associated with severe fatigue as well as a variety of other complaints, CFS is often considered to be postinfectious and many etiologic agents have been suggested but no consistent infecting agent has been found. Other theories of causation abound but none is clearly favoured by the scientific evidence. Numerous studies confirm the presence of depressive and anxiety syndromes during or even preceding the onset of CFS, Routine blood tests are generally normal but a variety of inconsistent immunologic abnormalities are reported. Cognitive dysfunction is frequently subjectively reported but difficult to confirm objectively. Many treatments have been reportedly useful in CFS but none is consistently effective. Cognitive behavioural treatment has demonstrated excellent results. Full recovery is very unusual but many subjects improve over time. CFS overlaps with other conditions such as fibromyalgia and depression. The information amongst the general public and popular press differs from that in the scientific literature; there is a need for education of physicians, patients and patient groups with respect to current scientific evidence. CFS is an often misunderstood illness and is a credible area for research.

There is a sound body of scientific literature on chronic fatigue syndrome [CFS] yet many questions remain. Current evidence does not favor a single infecting agent as the cause. There are probably many factors contributing to the onset and maintenance of CFS. Psychological symptoms are frequent and may be important in the pathogenesis. Minimal investigations are suggested. No single therapy is definitely useful and a multidisciplinary approach is favored. Most patients improve considerably over a period of years.

We report the successful treatment of three cases of infection due to Exophiala species. These organisms belong to the heterogeneous group of dematiaceous (darkly pigmented) fungi. Two cases of infection occurred in organ transplant recipients who were receiving immunosuppressive medications. Both of these infections remained localized to the subcutaneous tissues and were successfully treated with surgical excision of the lesions. We also describe what is to our knowledge the first reported case of prosthetic valve endocarditis due to Exophiala castellanii that was managed with a combination of medical and surgical therapies. Exophiala species remain an uncommon cause of infection. However, as the population of immunocompromised patients continues to grow and further improvements in the microbiological techniques for identification of these fungi occur, these organisms will be recognized with increasing frequency as a cause of human disease.

We report the clinical and microbiological characteristics of 11 cases of Aeromonas hydrophila infection of skin and soft tissue, and we review the English-language literature on such infections. Of our 11 patients, seven (64%) presented to the hospital between the months of May and September (inclusive). Three patients (27%) had an underlying systemic illness, and two (18%) had nosocomially acquired infection. The nine patients with community-acquired infection had all experienced antecedent trauma, and seven (78%) of these nine reported recent exposure to freshwater. All patients had clinical evidence of soft-tissue inflammation, and nine (82%) had fever. Four wounds were characterized by a foul odor. The infection was polymicrobial in nine cases (82%). Treatment included the administration of antibiotics in nine instances, but empirical antimicrobial therapy provided coverage against Aeromonas in only two cases. Ten patients required surgical management of their wounds. Posttraumatic wound infections with a history of freshwater exposure should alert the clinician to the possible presence of A. hydrophila. Prompt surgical evaluation of wounds in combination with appropriate antibiotic therapy is recommended for the management of these infections.

The prevalence and characteristics of hepatitis C virus (HCV) infection in 226 patients who were seropositive for human immunodeficiency virus (HIV) were determined. Antibody to HCV (anti-HCV) was detected by enzyme immunoassay (EIA), and positive results were confirmed by a neutralization EIA or recombinant immunoblot assay. The prevalence of anti-HCV was 8%. Intravenous drug use was the most common risk factor for HCV infection (61.1% of patients), and 52.4% of intravenous drug users were seropositive for anti-HCV (HCV+). Only 16.7% of HCV+ patients had AIDS, as compared with 37.4% of anti-HCV-seronegative (HCV-) patients (P = .04). The prevalence of hepatitis B virus markers in patients with and without anti-HCV was similar. The CD4+ lymphocyte counts were higher for HCV+ patients than for HCV- patients (P = .001), and the prevalence of anti-HCV decreased in parallel with CD4+ counts. Elevated liver function test values were more common for HCV+ patients than for HCV- patients (61.1% vs. 26.0%; P < .01), but abnormalities were usually slight (< 2-fold elevation in values). HCV viremia was detected by the polymerase chain reaction in 88.2% of HCV+ patients. Despite the coexistence of HIV and HCV infection, liver disease appeared to be mild, and HCV infection did not appear to increase the severity of HIV infection. Serological tests for HCV appear to underestimate the prevalence of HCV infection in patients with advanced HIV infection or AIDS.

A t the Eighth International Conference on AIDS, held in Amsterdam, July 1992, media attention was drawn to reports of a number of unusual cases of marked CD4+ T-lymphocytopenia with opportunistic infections but no evidence of HIV infection. Public health officials at the US Centers for Disease Control and Prevention (CDCP), Atlanta, immediately investigated the nature of the newly designated syndrome, idiopathic CD4+ T-lymphocytopenia (ICL).' Patients with ICL typically have (a) an absolute CD4+ T-lymphocyte count of less than 300 (according to the CDCP) or 400 (according to the Laboratory Centre for Disease Control [LCDC], Ottawa) x 106/L, or a CD4+ count that constitutes less than 20% of the total number of T cells, on more than one occasion over 6 months, (b) no serologic evidence (as determined by enzyme-linked immunosorbent assay [ELISA] and Western blot assay) of HIV infection, (c) opportunistic infection and (d) no evidence of defined immunodeficiency or therapy associated with depressed levels of CD4+ T cells." 2 Since 1983 at least 66 cases, including 47 from the CDCP, have been reported.', '6 Recently, the epidemiologic, clinical, immunologic and virologic aspects of ICL have been extensively described.'36 The epidemiologic features are quite different from those of HIV-related AIDS. No clustering of cases around any age group or geographic area has been observed. Smith, Neal and Holmberg'3 reported that 62% of the patients they reviewed did not have identifiable risk factors for HIV infection. Thirteen percent had a history of blood transfusions, 13% engaged in homosexual activities, and 15% had hemophilia. Sexual partners and household contacts all had normal CD4+ counts. Forty percent of the patients had AIDS-defining illnesses, including pulmonary and extrapulmonary Mycobacterium avium complex, pulmonary tuberculosis, Pneumocystis carinii pneumonia and mycotic and herpes-type viral infections. Interestingly, Kaposi's sarcoma was not present in the CDCP cases. Fifty-three percent of the patients had other, non-AIDS-defining illnesses, and 6% were asymptomatic. Extensive virologic studies, including polymerase-chain-reaction (PCR) assay, failed to show evidence of a retroviral infection such as that involving HIV type 1 (HIV-1) or type 2 (HIV-2) or human T-lymphotropic virus type I (HTLV-I) or type II (HTLV-II).'-'6 To our knowledge, only two cases of ICL have been reported in Canada.'7 We describe two additional cases of AIDS-defining illnesses with low CD4+ counts and no laboratory evidence of HIV infection. A description of the methods used in the laboratory investigation of these cases is in Appendix 1.

Chronic fatigue syndrome (CFS) is a severely disabling illness of uncertain aetiology. It is characterized by a chronic, sustained or fluctuating sense of debilitating fatigue without any other known underlying medical conditions. It is also associated with both somatic and neuropsychological symptoms. Both physical and laboratory findings are usually unremarkable. Regional cerebral blood flow (rCBF) was assessed in 60 clinically defined CFS patients and 14 normal control (NC) subjects using 99Tcm-hexamethylpropyleneamine oxime (99Tcm-HMPAO) single photon emission computed tomography (SPECT). Compared with the NC group, the CFS group showed significantly lower cortical/cerebellar rCBF ratios, throughout multiple brain regions (P < 0.05). Forty-eight CFS subjects (80%) showed at least one or more rCBF ratios significantly less than normal values. The major cerebral regions involved were frontal (38 cases, 63%), temporal (21 cases, 35%), parietal (32 cases, 53%) and occipital lobes (23 cases, 38%). The rCBF ratios of basal ganglia (24 cases, 40%) were also reduced. 99Tcm-HMPAO brain SPECT provided objective evidence for functional impairment of the brain in the majority of the CFS subjects. The findings may not be diagnostic of CFS but 99Tcm-HMPAO SPECT may play an important role in clarifying the pathoaetiology of CFS. Further studies are warranted.

Letters1 April 1992Why Was Treatment of Cytomegalovirus Retinitis Randomized?Irving E. Salit, MD, CMIrving E. Salit, MD, CMSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-116-7-604 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptTo the editors:Palestine and colleagues (1) examined the role of foscarnet in the treatment of cytomegalovirus retinitis in the acquired immunodeficiency syndrome (AIDS). They conducted a randomized, controlled trial in which the patients in one study arm initially received no treatment. What was the rational for having such a control group? Cytomegalovirus retinitis is the most common intraocular infection and the most common cause of blindness in patients with AIDS. Both ganciclovir and foscarnet have been shown to be approximately 90% effective in arresting retinitis, at least during the induction phase (2-4). It is also well known that, despite...References1. PalestinePolisDe Smet AMM. A randomized, controlled trial of foscarnet in the treatment of cytomegalovirus retinitis in patients with AIDS. Ann Intern Med. 1991;115:665-73. LinkGoogle Scholar2. FelsensteinD'AmicoHirsch DDM. Treatment of cytomegalovirus retinitis with 9-[2-hydroxyl-l-(hydroxymethyl)ethoxymethyl] guanine. Ann Intern Med. 1985;103:381-2. LinkGoogle Scholar3. WalmsleyChewRead SES. Treatment of cytomegalovirus retinitis with trisodium phosphonoformate hexahydrate (foscarnet). J Infect Dis. 1988;157:569-72. CrossrefMedlineGoogle Scholar4. FanningReadBenson MSM. Foscarnet therapy of cytomegalovirus retinitis in AIDS. J Acquir Immune Defic Synd. 1990; 3:472-9. MedlineGoogle Scholar1. PalestinePolisde Smet AMM. A randomized, controlled trial of foscarnet in the treatment of cytomegalovirus in patients with AIDS. Ann Intern Med. 1991;115:665-73. LinkGoogle Scholar2. HochsterDieterichBozzette HDS. Toxicity of combined ganciclovir and zidovudine for cytomegalovirus disease associated with AIDS. Ann Intern Med. 1990;113:111-7. LinkGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byResearch Ethics Committees 1 April 1992Volume 116, Issue 7Page: 604-605KeywordsAIDSBlindnessCytomegalovirus infectionRetinitis ePublished: 1 December 2008 Issue Published: 1 April 1992 PDF downloadLoading ...

Postinfectious neuromyasthenia (PIN) is a clinical syndrome of protracted and incomplete recovery after an apparent viral-like illness. Medical investigation yields few abnormalities which might account for the symptomatology. A substantial number of PIN patients complain of cognitive changes. Specific complaints include impaired attention, concentration and abstraction skills. This study was designed to systematically investigate whether the aforementioned subjective complaints could be quantified objectively using standard neuropsychological instruments. Results indicated that on all tests but one, the subjects' performances were significantly higher than those of their age matched groups in the normative data. Specifically, PIN patients scored significantly better than their age matched norms on tests of concentration, attention and abstraction. What is most striking is the discrepancy between the subjective complaints of cognitive impairment and the objective results of the subjects' performances on all tests. These findings suggest that psychological factors may play an important role in the cognitive functioning of individuals diagnosed with postinfectious neuromyasthenia.

The fibrillar Dr hemagglutinins expressed by two uropathogenic Escherichia coli isolates were mechanically sheared from whole cells and subsequently purified by using anion-exchange high-pressure liquid chromatography. The isolated hemagglutinins were proteins with apparent subunit molecular masses of 14,500 daltons by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and isoelectric points of 5.4 in denaturing isoelectric focusing gels. The two proteins were serologically related to each other but distinct from P fimbriae, as assessed by bacterial agglutination and immunoblotting. The amino acid compositions of the two hemagglutinins were highly similar both to each other and to other Dr hemagglutinins. N-terminal amino acid sequencing of the major hemagglutinin subunit proteins demonstrated homology with afimbrial E. coli adhesins.

P pilus filaments are important in binding to globoside through an adhesin located at the tip of the pilus. There is considerable antigenic variation among P pili, and the immunologic response is usually serotype specific. We purified denatured pilin subunits and used them as immunogens to prepare more broadly cross-reactive antisera. Although antifilament antisera (AFA) detected predominantly the homologous strain, antisubunit antisera (ASA) prepared from two different strains detected P pili in 16 of 16 and 14 of 16 P-piliated strains by Western blotting (immunoblotting). The binding of ASA to the homologous pilus filament was inhibited by only 3 of 17 strains. ASA agglutinated only two of nine heterologous strains and immunoprecipitated pili from one of three heterologous strains. By immunoelectron microscopy ASA was seen to bind to pilus filaments but not as strongly as AFA. Antiserum raised to the denatured pilin subunit was not substantially more reactive with pilus filaments derived from heterologous strains than was AFA. ASA was, however, a very useful probe for detecting most P pilins.