Caspofungin is a new echinocandin drug with comparable in vitro activity against azole-susceptible and -resistant isolates of Candida that could provide a less toxic alternative to amphotericin B for ...the management of esophageal candidiasis with clinical or laboratory evidence of decreased susceptibility to fluconazole. The authors retrospectively analyzed its efficacy in adults with endoscopically documented Candida esophagitis from four Phase II and III studies using two definitions of resistance to fluconazole1) clinically refractory infection based on failure of esophageal symptoms to improve despite at least 1 week of ≥200 mg/d of fluconazole; or 2) microbiologically resistant infection with either “susceptible dose-dependent” or “resistant” Candida isolates based on MICs of 16 to 32 and ≥64 μg fluconazole/mL, respectively. A favorable response required resolution of all symptoms and substantial improvement in endoscopic findings. Seven of 11 patients (64%) who had been clinically refractory to fluconazole had favorable responses to caspofungin. Eleven of 14 patients (79%) whose Candida isolates had decreased susceptibility to fluconazole had favorable responses to caspofungin, including 5 (83%) of 6 patients infected by isolates with MICs of ≥64 μg fluconazole/mL. Caspofungin appeared to be efficacious therapy for some patients with esophageal candidiasis who were clinically refractory to fluconazole or infected by Candida with reduced susceptibility to fluconazole in vitro.
Coinfection with the human immunodeficiency virus (HIV) and Treponema pallidum may predispose to accelerated neurosyphilis. The mechanism underlying this interaction is undefined, but usually ...presumed to result from HIV-induced suppression of cell-mediated immunity as reflected in the CD4 T-lymphocyte count. We report a patient infected with HIV who developed aggressive neurosyphilis despite a CD4 count of 1000/mm3. The CD4 cells constituted 17% of his total lymphocytes. Our case suggests that while severe neurosyphilis can occur in HIV-infected persons with normal absolute CD4 counts, the percentage of CD4 cells may be a better indicator of the risk of neurosyphilis. These observations are relevant to designing treatment strategies for patients coinfected with HIV and T pallidum based on measures of their immunocompetence.
The management of patients with bacterial endocarditis complicated by atrioventricular block is based on uncontrolled data, mostly from retrospective surgical and autopsy series. It is difficult to ...advance broad recommendations on the basis of such a biased population. Nevertheless, it is the firm opinion of many experienced clinicians that heart block developing as the result of aortic endocarditis signals myocardial abscess formation, and thereby is an indication for early surgery. I present a patient with aortic and mitral endocarditis in whom first degree heart block developed and then disappeared over five days; she was successfully managed with medical therapy alone. This case illustrates that some patients with endocarditis and heart block will not require surgery. In this setting, I propose the following guidelines in selecting patients for operation: 1) the observed appearance or progression of heart block; 2) the presence of aortic valve involvement; 3) the persistence of heart block, despite at least one week of optimal antibiotics; and 4) the elimination of other potential causes of conduction abnormalities.
Necrotizing fasciitis is an uncommon severe infection involving subcutaneous tissues and advancing along fascial planes. Group B streptococcal infections occur disproportionately in diabetics and ...pregnant women. Although fasciitis secondary to group B streptococcus has been described in infants and adult women in the postpartum period, we report the first case, to our knowledge, of group B streptococcal necrotizing fasciitis in an adult diabetic unrelated to obstetric complications.
