Septicemia due to Yersinia enterocolitica

Despite the increasing number of reports of Yersinia enterocolitica infection in humans, septicemia with this organism has remained a rare complication. A 73-year-old woman presented with fever, jaundice, hepatomegaly and cellulitis. Microorganisms isolated from both skin lesion and blood were biochemically and serologically identified as Yersinia enterocolitica, biotype 4, serotype 3 and lysotype 9b. High agglutinating titres against this organism were demonstrated in the patient''s serum. Complete recovery followed a course of gentamicin sulfate. A household pet was considered, but not proved, to be the source of this infection.     

Septicemia due to coagulase-negative Staphylococcus in a community hospital.

The experience with septicemia due to coagulase-negative Staphylococcus at a 623-bed primary care hospital between 1980 and 1984 was reviewed. A total of 38 episodes in 37 patients were documented; data were available on 37 episodes in 36 patients. The organism accounted for 3.8% of all cases of septicemia and 6.7% of cases of nosocomial septicemia and was associated with 0.03% of all admissions. The incidence remained stable over the 5 years. The rate of survival 28 days after the episode was 78%. Most of the episodes (31) originated from infected vascular access sites. Of the 37 isolates 15 (41%), all S. epidermidis, were slime producing. S. epidermidis accounted for 33 of the isolates; of the 33, 5 were methicillin-resistant and slime producing. Various in-vitro susceptibility testing methods and testing for beta-lactamase production yielded conflicting results. Methicillin resistance, slime production and speciation as S. epidermidis were not confirmed as virulence markers. Five patients with methicillin-resistant organisms were treated with cephalosporins, and all recovered. These findings as well as examination of the literature do not support the recommendations that laboratories report such isolates as resistant to all beta-lactam agents and that vancomycin be given in all such infections. The different case mix in community hospitals as compared with university centres results in different patterns of nosocomial infection. Since the community hospital patient population is much larger, more information on the patterns of infections in these centres is needed.     

Septicemia due to Streptococcus mitis in neutropenic patients with acute leukemia

Eight neutropenic patients with acute lymphocytic or nonlymphocytic leukemia had septicemia due to different strains of Streptococcus mitis (St. mitis), a microorganism not commonly recognized as a special pathogen in leukemic patients. Four of the patients had been treated with high-dose cytosine arabinoside as part of the cytostatic regimen, six had a central venous line and four patients had oral lesions prior to the infection. Selective gut decontamination consisted of co-trimoxazole/colistin in five patients and quinolones in three patients. The first three patients died, either due to interstitial pneumonia with the adult respiratory distress syndrome (ARDS), or due to infection-triggered disseminated intravascular coagulation despite prompt empiric antibiotic therapy including vancomycin. The other patients improved after empiric supplementation of penicillin G (30 Mega/day) to the antibiotic regimen. Beginning ARDS in two of these patients dramatically responded to high-dose steroids. We conclude that St. mitis is a major pathogen in neutropenic leukemic patients. Infection appears to occur independently of acute leukemic cell type, regimen of selective gut decontamination, venous access, visible oral lesions or treatment with high-dose cytosine arabinoside. The clinical course of our patients raises questions about the value of commonly recommended empiric antibiotic regimens, which were clearly ineffective to control infections with St. mitis in this patient group. Our data indicate that immediate antibiotic therapy with penicillin G is indicated and may be life-saving for suspected St. mitis infections in neutropenic leukemic patients.     

Secondary extramedullary plasmacytoma of sigmoid colon in a patient with multiple myeloma: a case report

Background

Extramedullary plasmacytoma is an uncommon tumor that most often involves the nasopharynx or upper respiratory tract. Extramedullary plasmacytoma is a type of plasma cell neoplasm that can present as a primary tumor or secondary to another plasma cell neoplasm, such as multiple myeloma. Secondary extramedullary plasmacytoma is usually noted in the advanced stages of the disease. Involvement of the gastrointestinal tract occurs in approximately 10% of cases.

Case presentation

A 71-year-old Caucasian woman with known diverticular disease of the colon and multiple myeloma diagnosed 3 years previously, with monoclonal bands of immunoglobulin A, lambda light chains, and multiple osteolytic lesions, presented to our hospital with abdominal pain, abdominal discomfort, and pneumoperitoneum. She underwent left colectomy for diverticulitis with perforation, and an extramedullary secondary colonic plasmacytoma was found in histopathological examination of the sigmoid colon.

Conclusions

Plasmacytoma is known to occur in extraosseous sites. The stomach and small intestine are the most commonly involved sites in the gastrointestinal tract. Secondary extramedullary plasmacytoma of the colon is rare. Colonic plasmacytoma may have varying clinical presentations, such as inflammatory bowel disease and multiple colonic strictures. Although these cases are rare, treating physicians as well as radiologists, pathologists, and surgeons should be aware of this entity.

     

Acquired hemophilia in a patient with myeloma.

The generally accepted indications for stress testing in patients with coronary artery disease include confirming the diagnosis of angina, determining the limitation of activity caused by angina, assessing prognosis in patients with known coronary artery disease, assessing perioperative risk, and evaluating responses to therapy. In patients with a clinical scenario strongly suggestive of angina, testing is not necessary to diagnose coronary artery disease. The exercise treadmill-electrocardiogram test is the oldest and most extensively used stress test and can be reliably performed in patients who are clinically stable and who have an interpretable resting electrocardiogram. The addition of myocardial imaging agents such as thallium 201, technetium Tc 99m sestamibi, and technetium Tc 99m teboroxime increases the sensitivity and specificity for detecting coronary disease. Pharmacologic agents such as dipyridamole, adenosine, and dobutamine may be used in patients who cannot exercise adequately. Myocardial ischemia can also be evaluated by echocardiography, computed tomography, or magnetic resonance imaging, especially when additional information such as left ventricular and valvular function is desired. We review the indications for the noninvasive evaluation of coronary artery disease and the rationale for selecting a diagnostic test.     

Intravenous infusion of pituitary adenylate cyclase-activating polypeptide (PACAP) in a patient with multiple myeloma and myeloma kidney: a case study

We have recently shown significant renoprotective effects with the administration of pituitary adenylate cyclase-activating polypeptide (PACAP) in models of myeloma kidney. PACAP markedly inhibited the production of proinflammatory cytokines stimulated by immunoglobulin light chains in human renal proximal tubule epithelial cells and in the kidneys of rats infused with myeloma light chains. PACAP was also shown to suppress the proliferation of human kappa and lambda light chain-secreting multiple myeloma-derived cells. In this case study, an 81-year-old male patient with active multiple myeloma and myeloma kidney was infused intravenously with synthetic human PACAP38 at a rate of 4 pmol/kg/min for 120 min. The continuous infusion increased the level of PACAP38 in blood, with a plateau at about 0.2 nM during the infusion. The level of PACAP in the blood rapidly declined after the cessation of administration with a half-life of about 5-10 min. The continuous infusion did not significantly alter the basal glucose level, blood gases or blood pressure. There was a large reduction in free lambda light chains in urine after the start of the treatment with PACAP. These studies show that PACAP can be safely used in humans and suggest that it could be used as a novel therapeutic agent for the treatment of multiple myeloma and myeloma kidney.     

Human bone marrow stroma-dependent myeloma sister cell lines MOLP-6 and MOLP-7 derived from a patient with multiple myeloma

Human bone marrow stroma (BST)-dependent myeloma sister cell lines MOLP-6 and MOLP-7 were established from the peripheral blood of a multiple myeloma (MM) patient with IgA kappa type MM (stage IIIB). The growth of the cell lines is constitutively dependent on BST cells; none of the cytokines tested nor the culture supernatant of the BST cells could support the growth. Both cell lines showed typical plasma cell morphology with abundant cytoplasm and one to four nuclei under Wright staining. The immunoprofiles of MOLP-6 and MOLP-7 correspond to that seen typically in primary MM cells: positive for cytoplasmic immunoglobulin (Ig) chains, a heavy and kappa light chains, CD9, CD28, CD40, CD44, CD45, CD56, and PCA-1; the cells were negative for surface Igs and various other B-cell, T-cell and myelomonocyte associated markers. Both cell lines also expressed adhesion molecules including HCAM (CD44), VLA-4 (CD49d/CD29), VLA-6 (CD49f/CD29), ICAM-1 (CD54), NCAM (CD56), LFA-3 (CD58) and L-selectin (CD62L). The doubling time of MOLP-6 and MOLP-7 was 48 and 168 hours, respectively. In addition to this growth characteristic, the maximum cell density of each cell line was obtained at 1.7 x 10(6) cells/ml and 9.7 x 10(5) cells/ml, respectively. The characteristics of each cell line may reflect intraclonal variation of the proliferative capacity. The MOLP-6 together with the MOLP-7 sister will be useful model systems for the investigation of the biology of myeloma.     

Genetic predisposition to multiple myeloma

Genetic myeloma risk research relied on genome-wide association studies to identify 24 common but lowimpact germline predisposition alleles that account for an estimated one eighth of the heritable myeloma risk in Caucasians. Next-generation sequencing, particularly whole-exome sequencing, uncovered a handful of rare but high-impact myeloma risk loci that convey intriguing clues about etiology. The recent discovery of NCOA1 as a myeloma susceptibility gene in Han Chinese has set the stage for the more complete elucidation of the genetic myeloma risk across ethnic barriers. Validating individual myeloma risk loci at the functional level and integrating predisposition genes in genetic networks and biological pathways are important research tasks going forward. Candidate pathways that are currently emerging include plasma cell development, autophagy, telomere maintenance, and cell cycle regulation. An outstanding knowledge gap in the area of gene-environment interaction concerns the possibility that tumor-promoting effects of myeloma susceptibility alleles depend on specific environmental or occupational exposures. An implicit promise of myeloma risk research is the detection of new molecular targets for myeloma treatments and preventions. A related outcome is new biomarkers for patient stratification, prognostication, and development of individualized treatment plans.     

Enteric Infection and Subsequent Septicemia due to Attaching and Effacing Escherichia coli in a Chinchilla

An adult male chinchilla (Chinchilla lanigera) presented with severe lethargy and tachypnea; the physical examination was otherwise unremarkable. Due to the animal''s clinical condition, it was submitted for necropsy but died immediately prior to euthanasia. Clinicopathologic findings included leukocytosis with a left-shift neutrophilia and lymphopenia, azotemia, hyperphosphatemia, hyperglycemia, hyperlipemia, electrolyte imbalance, cholestasis, and hepatocellular damage. Neutrophilic enteritis with gram-negative bacterial colonization, hepatic lipidosis, interstitial pneumonia, suppurative tubulonephritis, erosive gastritis, cerebral edema, and lymphoid depletion were present microscopically. Attaching and effacing, eae-positive, Escherichia coli characterized by the presence of the intimin virulence factor was isolated from both the kidney and spleen. The cause of death was attributed to acute E. coli septicemia and subsequent disseminated intravascular coagulation.Abbreviations: AEEC, attaching and effacing E. coli.A black-gray, adult (age, unknown) male, experimentally naïve chinchilla (Chinchilla lanigera) purchased (Moulton Chinchilla Ranch, Rochester, MN) approximately 1 y previously, presented with extreme lethargy and tachypnea during daily health rounds. The chinchilla was group housed with 2 cage mates in accordance with the Guide for the Care and Use of Laboratory Animals⁹ in an AAALAC-accredited facility. A total of 12 nonSPF chinchillas were acquired together from the same vendor. The chinchillas were housed in a self-contained isolation cubicle within a diverse-species room, which included mice, rats, guinea pigs, and gerbils. The cubicle was maintained at negative pressure with regard to the room. Housing consisted of a modified stainless steel chicken brooder (Alternative Design Manufacturing and Supply, Siloam Springs, AR). The chinchilla was fed a daily ration of pelleted diet (Mazuri Chinchilla Diet 5M01, PMI Nutrition International, Richmond, IN) and maintained on filtered chlorinated municipal water via a glass bottle with a rubber stopper and stainless steel sipper. Caging, feeding bowls, and water bottles were sent to the cage washing area for sanitation. Cage components were sanitized in a rack washer (Better Built Rack Washer, Northwest Systems, Delta, Canada) that provided a 180 °F final water rinse. A blend of organic and inorganic acid detergent (Acidulate 28, Quip Labs, Wilmington, DE) was used during the wash cycle to remove urine deposits and proteinaceous debris. Environmental enrichment included the provision of hide boxes, biweekly dust baths (Critter Bath Powder, Central Garden and Pet, Walnut Creek, CA), certified wood gnawing blocks (Bio-Serv, Frenchtown, NJ), and western timothy hay (Oxbow Animal Health, Murdock, NE). Room conditions included 18.3 to 20.0 °C (65 to 68 °F), 35% to 40% relative humidity, and a 12:12-h light:dark cycle. Routine health monitoring consisted of daily observations by the husbandry and veterinary technical staff for clinical signs of illness. No deviations in appetite or other gross abnormalities were noticed prior to the animal''s illness.On physical examination, the chinchilla was moribund and responsive only when prodded. Copious fecal pellets were palpated on abdominal examination. The animal weighed 560 g and was in good body condition. The chinchilla was submitted immediately for necropsy but died prior to euthanasia. Subsequently, approximately 2 mL of blood was withdrawn by cardiocentesis for hematology and chemistry. Chinchilla-specific reference intervals were not available from the laboratory; therefore, published reference intervals were used as a guide for interpretation of the hematology and clinical chemistry results.²⁴     

Systemic lambda light-chain deposition in a patient with myeloma.

Systemic lambda light-chain deposition occurred in a 73-year-old man with myeloma. An initial renal biopsy specimen showed the features of myeloma kidney. When he died 22 months later lambda light chains were detected by immunofluorescence in kidneys, liver, spleen, and heart. They were probably responsible for cardiac dysfunction and the fatal arrhythmia. It is suggested that in this patient deposition was due to a structural alteration of the light chains, possibly induced by cyclophosphamide.     

Lemierre's Syndrome: Two Cases of Septicemia due to Fusobacterium necrophorum

Two cases of Lemierre's syndrome are reported. The first patient presented with septic shock, multiple pulmonary infiltrates and thrombophlebitis of the right internal jugular vein. The second patient had septicemia due toFusobacterium necrophorum and Peptostreptococcus micros with multiple pulmonary abscesses, cholestatic liver dysfunction and severe thrombocytopenia. Clinical course, radiological and laboratory findings and therapy are discussed.     

Steroid-carrier proteins in patients with multiple myeloma

Patients with multiple myeloma have transcortin levels lower than normal. This is due in essence to a subgroup of patients producing IGG heavy chains with lambda light chains. Patients producing IGG with predominantly kappa light chains have almost normal transcortin levels. On the other hand, the binding activity of the steroid binding beta globulin (SB beta G) of the kappa type of multiple myeloma is significantly higher than the steroid binding of the lambda type of multiple myeloma. The serum levels of vitamin D binding protein (DBP) fall in the normal range.