All News

Bronchiectasis, part 2: Management

Systemic antibiotics are the mainstay of the managementof acute exacerbations of bronchiectasis. Antibiotic selection should include coverage for Streptococcus pneumoniaeand Haemophilus influenzae; particular attention alsoshould be paid to the presence of Staphylococcus aureus andPseudomonas species. There is some evidence that long-termlow-dose macrolide therapy can reduce the incidence of acuteexacerbations and decrease sputum production. There alsomay be a role for the use of inhaled antibiotics in the treatmentof bronchiectasis. Airway clearance strategies, such as chestpercussion and postural drainage, are clearly useful in patientswith cystic fibrosis and may be useful in managing bronchiectasisin other patients. Surgical resection can be considered if apatient has localized disease that is refractory to medical managementor if he or she is unwilling to undergo long-term medicaltherapy. (J Respir Dis. 2008;29(1):20-25)

A 45-year-old man with intralobar bronchopulmonary sequestration

Bronchopulmonary sequestrationis a rare congenitallung malformation characterizedby an abnormal segmentof bronchopulmonary tissuesupplied by an anomaloussystemic artery. The diagnosismay be easily missed in adults,since many are asymptomatic;moreover, symptoms, whenpresent, often overlap withthose of other pulmonaryprocesses. Surgical resectionprovides definitive managementand is usually reservedfor patients with symptoms.We present a case of intralobarbronchopulmonary sequestrationthat presented duringadulthood.

Does nasal allergy contribute to secretory otitis media in adults?

This study from the Netherlands lends support to the hypothesis that nasal allergy plays a role in chronic secretory otitis media in adults. Nasal allergen challenge combined with tympanometry appears to be a valuable diagnostic tool in this setting.

The challenges of antibiotic resistance: Key findings from recent studies

The emergence of antimicrobial resistance has increasingly impeded the management of a number of clinically important infections. Noteworthy examples include infections caused by penicillin-resistant Streptococcus pneumoniae, methicillin-resistant Staphylococcus aureus (MRSA), antibiotic resistant Pseudomonas aeruginosa, vancomycin-resistant enterococci (VRE), and fluoroquinolone-resistant Clostridium difficile.

Pulmonary nocardiosis mimicking empyema necessitatis

Nocardia asteroides is a rarecause of pulmonary or disseminatedinfection in immunocompetentpersons. Pleuralcompromise is common, butempyema necessitatis is veryrare. The authors describe anapparently immunocompetentpatient with N asteroides infectionwho had chest wallcompromise mimicking empyemanecessitatis.

How to handle progressive disseminated histoplasmosis

Progressive disseminated histoplasmosis (PDH) ismost likely to occur in patients with AIDS. Typical signs andsymptoms include fever, night sweats, anorexia, malaise, dyspnea,weight loss, hepatosplenomegaly, lymphadenopathy, skinlesions, and neurological deficits. The diagnosis of histoplasmosiscan be confirmed by tissue culture and stains and byserological studies. Bronchoscopy with bronchoalveolar lavage(BAL) often plays a pivotal role in the workup, particularly inpatients with respiratory symptoms and abnormal chest radiographicfindings. In some cases, transbronchial biopsy in conjunctionwith BAL can improve the diagnostic yield. Liposomalamphotericin B or amphotericin B lipid complex is recommendedfor the initial treatment of moderately severe to severePDH. Itraconazole may be appropriate for those with mild tomoderate PDH and is recommended for maintenance therapy.(J Respir Dis. 2008;29(1):37-40)

Economic Evaluation of a Prior Authorization Program for Biologic Response Modifiers

Specialty medications constitute the fastest-growing segment of drug spending under the pharmacy benefit. This study evaluated the impact of a specialty pharmacy prior authorization (PA) program on prescription drug costs for biologic response modifiers (BRMs) used in the treatment of persons with rheumatoid arthritis, juvenile rheumatoid arthritis, Crohn disease, ankylosing spondylitis, psoriatic arthritis, psoriasis, and other spondyloarthropathies. A retrospective, case-control, one-to-one matching approach based on patient age, sex, and client characteristics was used. Case clients were enrolled in the specialty pharmacy PA program from January 1 through December 31, 2005. The control group consisted of clients who were not enrolled in the program during this time. The average costs per eligible member per month (PMPM), for the total, plan, and member were $1.32, $1.29, and $0.03, respectively, in the case group, and $1.44, $1.41, and $0.03, respectively, in the control group. Clients who implemented the specialty pharmacy PA program for BRMs saved an estimated total cost of $0.12 PMPM. Implementing a specialty pharmacy PA program reduced BRM costs. (Drug Benefit Trends. 2008;20:26-31)

Melanoma Within a Congenital Nevus

A 48-year-old Hispanic man had a tender, bleeding growth within a darkly pigmented plaque on the right flank. The pigmented lesion had been present since birth; it was previously asymptomatic. The tumor arose out of the mainly flat patch 6 months earlier and had slowly enlarged. The patient worked indoors, wore sunscreen daily, and generally avoided outdoor activities. He had no family history of skin cancer.

Prophylactic Oseltamivir for Prevention of Nosocomial Influenza A Virus Infection

The effectiveness of oseltamivir in preventing nosocomialinfluenza (influenza Avirus infection) during an influenzaepidemic was carried out in several wards of a universityhospital. Asurvey conducted during the 2005 influenza seasonidentified 30 staff members (nurses and doctors) and 3hospitalized patients who met the case definition for influenza.Adefinitive influenza diagnosis was made in 17 staff members(57%) and in 2 inpatients (66%) based on the results of a rapiddiagnostic test. Most of the 30 symptomatic staff membershad been vaccinated for influenza. Symptomatic staff memberswere sent home for 1 week, and the infected inpatients wereisolated. Oseltamivir (75 mg/d for 5 days) was administered to99 staff members and 2 inpatients who had close contact withthe infected patients. Although a relatively large number of thestaff had an influenza virus infection, the use of oseltamivirmay have effectively prevented a nosocomial outbreak.[Infect Med. 2008;25:49-50a]

Gloves-and-Socks Rash With Eosinophilia

A 25-year-old woman presented with a rash of 4days' duration, fever, arthralgia, and headache.The rash, which was localized to the hands, feet,and elbows, was intensely pruritic and was associatedwith swelling and pain in the hands and feet.

Differentiating Loxoscelism From Cutaneous Anthrax and Lyme Erythema Migrans

Loxoscelism is often misdiagnosed, in part because the clinical presentation of loxoscelism is similar to that of other conditions, such as cutaneous anthrax and Lyme erythema migrans (EM). Differentiating these disorders is important because some of these conditions require early treatment to achieve the best clinical outcomes. Unfortunately, using geography to make or exclude a diagnosis is becoming less reliable.

Disseminated Intravascular Coagulation as an Unusual Presentation of Acute Retroviral Syndrome

Multiple atypical presentations of acute retroviral syndromehave been reported in the literature, but rarely has acute retroviralsyndrome been associated with disseminated intravascularcoagulation (DIC). We detail a case of a 19-year-old manadmitted to the hospital with initially unexplained severe DICthat on workup was found to be secondary to acute retroviralsyndrome. [Infect Med. 2008;25:24-28]

Cryptococcal Meningitis: Review of Current Disease Management

The incidence of cryptococcal infections in the HIV-infectedpopulation has diminished because of the effectiveness of anti retroviraltherapy, whereas the incidence in non–HIV-infectedhosts has grown. Despite improvements in antifungal therapy,successful outcomes in the management of cryptococcalmeningitis are dependent on a high index of clinical suspicion,appropriate use of diagnostic assays, early and aggressiveantifungal therapy, and recognition of complications such asincreased intracranial pressure and immune reconstitutionsyndromes. Published guidelines for the care of patients withcryptococcal meningitis are available and may be adapted toindividual patient requirements. Basic and clinical studies areneeded to further define the components of immune protection,optimal therapy in special patient populations, and the recognitionand treatment of complications of cryptococcal meningitis.[Infect Med. 2008;25:11-23]

Thank you, ACS!

Breathable indoor air has become so commonplace in the United States (and, increasingly, worldwide) that many forget that it has been less than a quarter century since the major push to limit indoor smoking really began to have an impact.

Trimeris, Roche Pull No-Needle Fuzeon Bid, Obesity a Problem in HIV Population

Trimeris and its partner Roche said they are withdrawing an application to sell their injectable AIDS drug Fuzeon (enfuvirtide) in a needle-free device. "While the device has shown potential benefit for some patients, we don't believe it's the real alternative delivery option for all patients," said Michelle Zupancic, vice president, HIV, at Roche (Vollmer S. News & Observer [Raleigh]. October 4, 2007).

Women and HIV

In 1985, only 7% of AIDS cases occurred among female adults and adolescents older than 13 years, but by 2005, they represented 27% of US AIDS cases.