High-dose Intravenous Penicillin Research Articles

Pulmonary Actinomycosis Associated with Poor Oral Hygiene: A Case Report

Pulmonary actinomycosis, a rare and chronic infection caused by Actinomyces species, involves anaerobic gram-positive bacteria that are part of the oral cavity’s normal flora. Thoracic involvement, accounting for approximately 15% of all actinomycosis cases, typically results from aspiration of oropharyngeal secretions. We report the case of a 36-year-old man with poor oral hygiene and severe dental decay who presented with a month-long history of chronic cough, hemoptysis, malodorous sputum, weight loss, and pleuritic chest pain. Imaging identified a cavitary lesion in the left upper lobe, initially raising concern for infectious or malignant etiologies. Bronchoscopic sampling confirmed pulmonary actinomycosis through histological identification of sulfur granules. The patient responded favorably to high-dose intravenous penicillin followed by oral antibiotics. This case underscores the diagnostic challenges of pulmonary actinomycosis, the importance of oral hygiene as a modifiable risk factor, and the need for a multidisciplinary management approach.

Syphilitic retinitis presentations: punctate inner retinitis and posterior placoid chorioretinitis.

To describe two distinct presentations of syphilitic fundus features in a series of patients with ocular syphilis. This is a retrospective, interventional case series of 22 eyes from 16 serology confirmed cases. Clinical examination, fluorescein angiography, and optical coherence tomography were performed at presentation and following high-dose intravenous penicillin G. In our cohort, the mean age was 47.6years (range 24-59years) and 14 patients were male (87.5%), 11 patients were positive for human immunodeficiency virus (68.8%), and 6 had bilateral involvement (37.5%). Mean best-corrected visual acuity improved from 0.99 ± 0.79 logarithm of the minimal angle of resolution (LogMAR) at the time of presentation to 0.29 ± 0.36 LogMAR on final visit (P < 0.01). Posterior segment examinations in eyes with retinitis showed two distinct types (1) discrete, placoid lesions in the macula consistent with acute syphilitic posterior placoid chorioretinitis or (2) punctate inner retinitis with corresponding fluorescein pooling in a segmental pattern. These findings rapidly resolved after antibiotic therapy. In the era of resurgence, ocular syphilis may present with two phenotypes of discrete retinal lesions. Recognition of the characteristic ocular features may help make the diagnosis and monitor treatment response.

Meningitis Caused by Enterococcus gallinarum in an Immunocompetent Host

Introduction: Enterococci are unusual etiological agents of bacterial meningitis. Meningitis caused by Enterococcus gallinarum, especially those that occur in immunocompetent hosts, is extremely rare. Moreover, community-acquired E. gallinarum meningitis might be extremely unexpected for a clinician and therefore easily misdiagnosed and mistreated. Case Presentation: A 12-year-old boy presented with an acute onset of fever, headache and vomiting. The cerebrospinal fluid culture from lumbar puncture yielded an isolate that was identified as E. gallinarum. The therapeutic regimen was a combination therapy of rifampicin and high-dose intravenous penicillin. One day after starting treatment, the patient became afebrile. A repeated lumber puncture two weeks later showed few white blood cells in the CSF and no bacterial growth. Conclusions: This case reveals an incident of meningitis caused by E. gallinarum in an immunocompetent host. The combined therapy of rifampicin and high-dose intravenous penicillin might be effective for treatment in such a case.

Results from the Survey of Antibiotic Resistance (SOAR) 2011-13 in Turkey.

Data are presented from the Survey of Antibiotic Resistance (SOAR) for respiratory tract infection pathogens collected in 2011-13 from Turkey. MICs were determined using Etest(®). Susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) interpretive criteria. Rates of antibiotic susceptibility were very low among 333 isolates of Streptococcus pneumoniae tested: penicillin 38% using CLSI (oral) and EUCAST breakpoints; erythromycin 51% using CLSI and EUCAST criteria; and cefuroxime 64.6% using CLSI and PK/PD and 46.9% using EUCAST. Of the isolates, >90% were susceptible to amoxicillin/clavulanic acid, ceftriaxone (except using EUCAST criteria: 76%), levofloxacin and high-dose intravenous penicillin. Among 339 Haemophilus influenzae isolates, 6.8% were β-lactamase positive while 9.1% were β-lactamase negative but ampicillin resistant (BLNAR) by CLSI (14.7% by EUCAST) criteria. Amoxicillin/clavulanic acid susceptibility was ∼90% by CLSI (with or without BLNAR adjustment, EUCAST and high-dose PK/PD) but lower, at 82.9%, by EUCAST with BLNAR adjustment. Levofloxacin susceptibility was 96% using all three breakpoints. Dramatic differences in rates of susceptibility, depending on the breakpoints used, were seen for cefaclor [94% by CLSI (86.4% BLNAR adjusted), 23% by PK/PD] and cefuroxime [97% by CLSI (89.1% BLNAR adjusted), 85% by PK/PD, 15% by EUCAST (13.0% BLNAR adjusted)]. Streptococcus pyogenes (n = 222) and Moraxella catarrhalis (n = 40) isolates remained highly susceptible to amoxicillin/clavulanic acid, cephalosporins and levofloxacin, with only erythromycin susceptibility dropping below 95% for S. pyogenes. Overall, amoxicillin/clavulanic acid and levofloxacin were the most active antibiotics based on all three breakpoints against these pathogens. Although susceptibility was not universally low in Turkey, high resistance rates were found in S. pneumoniae and, when using PK/PD and EUCAST breakpoints, in other respiratory pathogens.

Bilateral papillitis and unilateral focal chorioretinitis as the presenting features of syphilis

BackgroundSyphilis is a multisystem bacterial infection caused by Treponema pallidum. The incidence of infection in the United States has risen by more than 75% since the year 2000, when it was at a low of 2.1 per 100,000 people. Ocular involvement may occur in any stage of infection and may present in a variety of ways, with posterior uveitis being the most common manifestation. We report a case of ocular syphilis infection with an unusual presentation of bilateral non-granulomatous panuveitis with papillitis and unilateral focal chorioretinitis.FindingsThis is a retrospective case report with literature review. A 39-year-old Caucasian female presented with a 2-week history of bilateral ocular flashes and left eye pain. Dilated fundus examination revealed mild optic disc edema in both eyes, the right eye more than the left. In the left eye, there was an area of retinal elevation and whitening involving the peripheral retina. Fluorescein angiography, B-scan ultrasonography, and ocular coherence tomography were performed, and laboratory tests were ordered based on the clinical presentation. After rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-Abs) were positive, syphilitic uveitis was confirmed, and the patient was admitted for a 14-day course of high-dose intravenous penicillin G.ConclusionsThe first signs and symptoms of syphilis may be ocular, which can lead to a diagnostic challenge. A high index of suspicion is the key for early diagnosis of ocular syphilis. Prompt treatment with intravenous penicillin G is highly effective in resolving the infection.

Antitoxin treatment for liver abscess caused byClostridium perfringens

To the Editor, We read with great interest the article 'A case of emphysematous hepatitis with spontaneous pneumoperitoneum in a patient with hilar cholangiocarcinoma' by Jung Ho Kim et al.1 The authors described fatal case of emphysematous hepatitis caused by C. perfringens, but did not mention the hemolysis or disseminated intravascular coagulopathy (DIC) during hospital course. Laboratory data on admission revealed anemia (hemoglobin 9.3 mg/dL), severely elevated aspartate transaminase (AST) level (882 IU/L), and high total bilirubin level (17.9 mg/dL), but alanine transaminase (ALT) level was elevated moderately (257 IU/L). Although clinical data was limited, this disproportion between AST and ALT may suggest the intravascular haemolysis caused by C. perfringens. Van Bunderen et al retrospectively reviewed 40 cases of C. perfringens septicaemia that rapidly progressed to intravascular haemolysis and metabolic acidosis and led to death within a few hours after admission.2 The mortality rate was >80% despite treatments with high-dose intravenous penicillin and surgical debridement to eliminate the focus of infection. Therefore, we must redefine conventional treatments by reexamining the pathophysiology of such infections. Alpha toxin secreted by C. perfringens is responsible for intravascular haemolysis followed by severe anemia, acute renal failure, DIC and multi-organ failure. Therefore, specific antitoxic globulins (antitoxin) should be administered with antibiotics as early as possible to neutralise the toxin. In fact, the antitoxin against the alpha toxin of C. perfringens has been used for decades for the treatment for gas gangrene (myonecrosis) caused by C. perfringens.3 However, this product is no longer available in the United States because of poor efficacy and severe allergic reactions.4 Aggressive surgery, including amputation and repeated debridement, constitute the mainstay of treatment of myonecrosis caused by C. perfringens. On the other hand, the efficacy of antitoxin treatment for liver abscess caused by C. perfringens has not been evaluated. Unlike gas gangrene, C. perfringens septicaemia rapidly causes haemolysis followed by multi-organ failure; therefore, surgical intervention is not attempted in many cases. We recently introduced the use of the antitoxin against the C. perfringens alpha toxin to cease haemolysis and prevent multi-organ failure.5 Here we confirmed that the antitoxin effectively neutralises the alpha toxin secreted by C. perfringens; however, it does not possess antibacterial activity or the capacity to prevent bacterial growth and cannot restore organ function. Therefore, we propose that the optimal treatment for C. perfringens septicaemia should combine the antitoxin, antibiotics and surgical intervention.

Neurosyphilis with dementia and bilateral hippocampal atrophy on brain magnetic resonance imaging

BackgroundThis article reports a rare case of active neurosyphilis in a man with mild to moderate dementia and marked hippocampal atrophy, mimicking early onset Alzheimer’s disease. Few cases have so far described bilateral hippocampal atrophy mimicking Alzheimer’s disease in neurosyphilis.Case presentationThe patient presented here is a 33 year old Bulgarian male, whose clinical features include progressive cognitive decline and behavioral changes over the last 18 months. Neuropsychological examination revealed mild to moderate dementia (Mini Mental State Examination score was 16/30) with impaired memory and attention, and executive dysfunction. Pyramidal, and extrapyramidal signs, as well as dysarthria and impairment in coordination, were documented. Brain magnetic resonance imaging showed cortical atrophy with noticeable bilateral hippocampal atrophy. The diagnosis of active neurosyphilis was based on positive results of the Venereal Disease Research Laboratory test/Treponema pallidum hemagglutination reactions in blood and cerebrospinal fluid samples. In addition, cerebrospinal fluid analysis showed pleocytosis and elevated protein levels. High-dose intravenous penicillin therapy was administered. At 6 month follow up, improvements were noted clinically, on neuropsychological examinations, and in cerebrospinal fluid samples.ConclusionThis case underlines the importance of early diagnosis of neurosyphilis. The results suggest that neurosyphilis should be considered when magnetic resonance imaging results indicate mesiotemporal abnormalities and hippocampal atrophy. Neurosyphilis is a treatable condition which requires early aggressive antibiotic therapy.

Göz Kapağında Deri Şarbonu

Anthrax is an infectious disease caused by Bacillus anthracis. Cutaneous, respiratory and gastrointestinal involvements can be seen. The face and eyelids are the most commonly involved areas in cutaneous anthrax. If eyelid anthrax is not promptly treated, it may cause severe deformities of eyelids including cicatrization and ectropion. In this study, a 38-year-old male presenting with right eye palpebral cutaneous anthrax was reported. There was periorbital edema and a black eschar on right eyelid leading to closed eye. Gram-positive rods were seen in the microscopic examination of scrapings taken from the lesion. The patient received high dose intravenous penicillin G (16 million units/day) for 10 days. The lesion healed within 10 days, leaving no clinical evidence of any eyelid deformity. No eyelid deformity was observed during one-year follow-up period. Observing this case suggested that early diagnosis and treatment can prevent development of potential antrhax eyelid complications.

Şarbon: Preseptal Sellülitin Nadir Bir Sebebi

Anthrax, caused by the spore-forming bacterium Bacillus anthracis, is rarely seen in industrial nations but is common in developing countries. In this case report, a 36-year-old male farmer who was diagnosed with preseptal cellulitis initially, was presented. Gram-positive rods were found in the microscopic examination of the scraped material obtained from the lower edge of the necrotic area. The patient was managed with high dose intravenous penicillin G. On the third day of treatment, edema began to decrease on the right eyelids. A patch of black necrotic eschar tissue developed on the whole surface of left eyelids. At the final examination of the case, six months after the completion of the treatment, the cutaneous lesion was healed without any eyelid pathology. Despite its rarity in developed parts of the world, anthrax should be considered in the differential diagnosis of preseptal and orbital cellulitis.

When infections collide—gummatous syphilis in an HIV-infected individual

Syphilis and HIV are both transmitted sexually and have emerged as important co-pathogens with reciprocal augmentation in transmission and disease progression. HIV-positive patients tend to experience more aggressive symptomatology due to syphilis and are at greater risk of developing neurological disease. Similarly, standard therapy for syphilis may be inadequate in HIV-positive individual suggesting intensified treatment regimens may be required along with close follow-up. We report here the case of a 50-year-old HIV-positive male presenting with an unusual constellation of neurological findings. Although he had been treated appropriately 10 years previously for primary syphilis, investigations revealed multiple current intracranial gummas. Treatment with high-dose intravenous penicillin G resulted in clinical and radiographic resolution. Given the broad differential for HIV-positive patients presenting with neurological symptoms, the clinician must maintain a high index of suspicion for syphilis known for its varied and at times unusual manifestations. Further, prior treatment of syphilis does not ensure cure and so syphilis must be considered irrespective of treatment history.

Actinomyces in Chronic Granulomatous Disease: An Emerging and Unanticipated Pathogen

Chronic granulomatous disease (CGD) is a rare inherited disease of the phagocyte NADPH oxidase system that causes defective production of toxic oxygen metabolites, impaired bacterial and fungal killing, and recurrent life-threatening infections, mostly by catalase-producing organisms. We report for the first time, to our knowledge, chronic infections with Actinomyces species in 10 patients with CGD. Actinomycosis is a chronic granulomatous condition that commonly manifests as cervicofacial, pulmonary, or abdominal disease, caused by slowly progressive infection with oral and gastrointestinal commensal Actinomyces species. Treatment of actinomycosis is usually simple in immunocompetent individuals, requiring long-term, high-dose intravenous penicillin, but is more complicated in those with CGD because of delayed diagnosis and an increased risk of chronic invasive or debilitating disease. Actinomyces was identified by culture, staining, 16S ribosomal DNA polymerase chain reaction, and/or a complement fixation test in 10 patients with CGD. All 10 patients presented with a history of fever and elevated inflammatory signs without evident focus. Diagnosis was delayed and clinical course severe and protracted despite high-dose intravenous antibiotic therapy and/or surgery. These results suggest an unrecognized and unanticipated susceptibility to weakly pathogenic Actinomyces species in patients with CGD because these are catalase-negative organisms previously thought to be nonpathogenic in CGD. Actinomycosis should be vigorously sought and promptly treated in patients with CGD presenting with uncommon and prolonged clinical signs of infection. Actinomycosis is a catalase-negative infection important to consider in CGD.

Extracranial infected carotid artery aneurysm

Infected aneurysms of the extracranial carotid arteries are rare. This is a case report of a 63-year-old female who developed an infected internal carotid artery aneurysm due to group B Streptococcus ten days after a dental procedure. She was successfully treated with excision of the aneurysm and common to internal carotid artery bypass with greater saphenous vein.

Anthrax meningoencephalitis — Declining trends in an uncommon but catastrophic CNS infection in rural Tamil Nadu, South India

Introduction Anthrax, a cattle-born zoonosis has been a serious infectious disease and its meningoencephalitic form remains a rapidly fatal illness even now. Aim The aim of this paper is to evaluate the incidence and clinical profile of anthrax meningoencephalitis admitted to a teaching hospital predominantly serving a rural population in South India. Materials and methods We made a systematic study of the case records of patients with microbiologically confirmed diagnosis of anthrax meningoencephalitis admitted over a 20-year period. We searched the internet and office records for the anthrax outbreaks and the preventive strategies in place in India. Results The admissions occurred in two clusters, four during 1992–1994 and six in 1998–2000; with no further detection unto August 2008. All patients were adult males with agriculture related occupation. Three of the 10 patients had no evidence of primary focus of infection. Majority were in coma at admission and had documented evidence of septicemia. CSF was haemorrhagic and death was the uniform outcome despite high dose intravenous penicillin G; maximum duration of hospital survival being 48 h. Comment Anthrax is a rare, but catastrophic cause of meningoencephalitis. Improvement in education and life styles as well as livestock vaccination in rural areas appear to have effectively decreased the incidence of this dreaded acute zoonosis in the South Indian states of Tamilnadu and Puducherry.

High-dose intravenous-penicillin in neurosyphilis: effect on intrathecal synthesis of IgG, IgM, IgA and IgD

We evaluated occurrence and levels of intrathecal synthesis of IgG, IgM, IgA and IgD by calculating corresponding index values in 8 patients with definite and 4 with suspected or possible neurosyphilis, prior to, during and after high-dose intravenous penicillin therapy. Four patients with active neurosyphilis displayed intrathecal synthesis of IgG, IgM and IgA. Only 2 of them showed elevated IgD index, and both had taboparesis, pleocytosis and positive VDRL in CSF, and simultaneous elevation of the IgG, IgA and especially of the IgM indices. This suggests that intrathecal synthesis of IgD may occur in patients with severe CNS inflammation in response to diffuse CNS treponemal damage. Penicillin therapy incited transitory elevation of one or more of the immunoglobulin index values in most patients, possibly in response to massive treponemal lysis inside the CNS. Thereafter, the values became mostly normalized but exceptions occurred, including one patient who had elevated IgG and IgM index which persisted 31 months after therapy. Our data indicate that determinations of immunoglobulin indices performed on consecutive specimens from individual patients with neurosyphilis may be helpful in the evaluation of treatment.

Neurosyphilis presenting with dementia, chronic chorioretinitis and adverse reactions to treatment: a case report

Neurosyphilis results from infection of the brain, meninges or spinal cord by Treponema pallidum and develops in about 25%-40% of persons who are not treated for syphilis. This article reports a rare case of active neurosyphilis with mild dementia, chronic chorioretinitis, and hearing loss. During the treatment with Penicillin, a rare combination of complications such as Jarisch-Herxheimer and Hoigné reactions were observed.The clinical feature is characterized by a slow progressive cognitive decline and behavior changes for the last 2 years. Neuropsychological examination revealed mild dementia (MMSE = 23) with impaired memory and attention and executive function. Left sided chronic chorioretinitis and hearing loss were documented. High dose intravenous penicillin therapy was complicated by Jarisch-Herxheimer and Hoigne reactions. During the follow up examinations at 6 and 12 months, the clinical signs, neuropsychological examination, and cerebrospinal fluid (CFS) samples showed improvement of dementia, CSF findings, and hydrocephalus.In conclusion, this atypical presentation of neurosyphilis in combination with rare complications of treatment is worthy of attention. Neurosyphilis should be part of the differential diagnosis of each patient showing cognitive deterioration and behaviour disturbances.

CARACTeRÍSTICAS CLÍNICAS Y TRATAMIeNTo De LA NeURoSÍFILIS eN UN HoSPITAL PÚBLICo, CALLAo 1997-2007

Objectives. To describe clinical features, cerebrospinal fluid (CSF) changes, and therapy of patients with neurosyphilis (NS). Material and methods. This is a retrospective study including patients older than 14 years who met criteria for defining a confirmed or probable case of neurosyphilis according to the Centers for Disease Control and Prevention (CDC) and who were admitted to a public hospital in Callao, Peru, between 1997 and 2007. Results. Twenty-five patients met criteria for defining NS (22 for confirmed cases and 3 for probable cases). Median age was 40 years, 24 patients (96%) were men, four (16%) had a past history of syphilis, and 15 (60%) had HIV infection. Twenty-one patients (84%) developed symptomatic NS, of which fourteen (67%) had early forms, and this pattern was most commonly seen in HIV-infected patients (p=0.001). Of those patients with CSF data available, 64% (14/22) had pleocytosis and 73% (16/22) high protein levels, and there were no significant differences between patients with and without HIV infection. CSF VDRL tests were reported as reactive in 88% (22/25) of patients. Median CSF VDRL titers were lower in HIV-infected patients (p=0.006), and a higher proportion of HIV-negative patients had CSF VDRL titers ≥1:4 (p=0.02). 72% of patients received high-dose intravenous aqueous crystalline penicillin G. Conclusions. The majority of patients with NS had HIV infection. Early NS was more common than late NS and the CSF VDRL titers were lower in HIV-infected patients. High-dose intravenous penicillin was the most frequently used therapy.

Oral doxycycline for neuroborreliosis

Community-acquired bacterial meningitis (eg, pneumococcal meningitis) and other serious CNS infections are life-threatening and rapidly progressive, and curing them is dependent on achieving bactericidal concentrations of antibiotics at the sites of infection. The general reluctance to treat such infections with oral antibiotics has several causes, such as unreliable drug absorption from the gastrointestinal tract (due to nausea and vomiting or haemodynamic instability), the fact that blood and CSF drug concentrations achievable with many oral agents are much lower than those possible with parenteral antibiotic preparations, and the scarcity of clinical experience with oral antimicrobials for these indications. Consistent with this approach, parenteral antibiotic therapy has commonly been used to treat neuroborreliosis. 1 Steere AC Pachner AR Malawista SE Neurologic abnormalities of Lyme disease: successful treatment with high-dose intravenous penicillin. Ann Intern Med. 1983; 99: 767-772 Google Scholar , 2 Dattwyler RJ Halperin JJ Volkman DJ Luft BJ Treatment of late Lyme borreliosis—randomized comparison of ceftriaxone and penicillin. Lancet. 1988; 1: 1191-1194 Scopus (0) Google Scholar Oral doxycycline versus intravenous ceftriaxone for European Lyme neuroborreliosis: a multicentre, non-inferiority, double-blind, randomised trialOral doxycycline is as efficient as intravenous ceftriaxone for the treatment of European adults with Lyme neuroborreliosis. Full-Text PDF

Therapy for Lyme arthritis: Strategies for the treatment of antibiotic‐refractory arthritis

Lyme arthritis, caused by the tick-borne spirochete Borrelia burgdorferi (1), typically causes intermittent or persistent arthritis in a few large joints, especially the knee, for several years (2). Treatment recommendations have changed over time. In the early 1980s, 3 intramuscular injections of benzathine penicillin or a 10-day course of high-dose intravenous (IV) penicillin cured only 35–55% of patients (3). In the late 1980s, treatment with IV ceftriaxone for 2 weeks was effective in 90% of patients (4,5); slightly better results were achieved with 4 weeks of therapy (6), but adverse events occurred more frequently. During the same period of time, a 4-week course of oral doxycycline or amoxicillin was also effective in 90% of patients with Lyme arthritis (7). However, joint swelling in some patients remained unresponsive to oral therapy and re-treatment with a 2-week course of IV ceftriaxone (7). To date, little information is available about therapy for such patients. One non–antibiotic-treated patient had resolution of joint swelling following hydroxychloroquine therapy (8). Sixteen of 20 patients with persistent arthritis despite antibiotic therapy experienced resolution after arthroscopic synovectomy (9). In 2000, an expert panel from the Infectious Diseases Society of America (IDSA) presented guidelines for the treatment of Lyme disease (10). The panel recommended initial treatment with oral doxycycline or amoxicillin for 4 weeks for patients with Lyme arthritis and no concomitant neurologic abnormalities. Results of a cost–benefit analysis suggested that such therapy is as effective as IV therapy, is safer than IV therapy, and is considerably less expensive (11). For patients in whom arthritis is persistent despite receiving 4 weeks of oral antibiotic therapy, the panel recommended re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of IV ceftriaxone. However, in a small percentage of patients, proliferative synovitis (12,13) persists for months to several years, even after 2 months of treatment with oral antibiotics, 1 month of treatment with IV antibiotics, or both, which we have termed antibiotic-refractory (or slowly resolving) Lyme arthritis.

Actinomycoses and Nocardia pulmonary infections

Actinomycosis and nocardiosis are uncommon pulmonary infections with distinct morphologic features. Both infections most commonly present as chronic, debilitating illnesses with radiographic manifestations simulating lung cancer or tuberculosis. Immunocompromised hosts, however, may develop fulminant disease resembling acute bacterial pneumonia. The purpose of this review is primarily to review the clinical features, diagnosis, and management of actinomycosis and nocardiosis. Treatment of actinomycosis is usually simple, requiring long-term, high-dose intravenous penicillin. Short-course chemotherapy, however, has recently been reported to be successful. Pulmonary nocardiosis is an important cause of opportunistic infection in immunosuppressed patients, and the incidence of this infection is increasing. The sulfonamides are still first-line agents in the management of nocardiosis, but resistance is most common among N. farcinica and N. otitidiscaviarum isolates. Carbapenems should be used as an alternative treatment for severely ill patients. Broth microdilution, E-test (AB Biodisk, Solna, Sweden) and BACTEC (Becton Dickinson, Sparks, Maryland, USA) radiometric method may be more useful in the routine clinical laboratory for antimicrobial testing of aerobic actinomycetes. The practical distinction between the two diseases is in the matter of therapy. Diagnosis depends on a high degree of suspicion so as to alert the microbiology and pathology laboratories to employ special methods to identify the organisms. Early recognition and prompt treatment usually results in complete cure.

The "Great Imitator." Syphilis as Causative Agent of Isolated, Concurrent, Acute Hepatitis and Meningitis

The first described case of acute concurrent hepatitis and meningitis as the isolated mode of presentation of syphilis in an HIV-infected homosexual man undergoing antiretroviral therapy is presented and discussed, on the ground of literature evidences and relevant epidemiological, diagnostic, therapeutic, and public health implications. A negligible epidemiological and medical history and the absence of other signs and symptoms of syphilis delayed the diagnosis, which was later confirmed through associated positive serum and cerebrospinal fluid syphilis serology. Histopathologic studies of the liver were also performed, as well as brain computed tomography scan. High-dose intravenous penicillin administration led to a rapid cure of both complications. When facing young patients with some signs and symptoms of hepatic and meningeal involvement, a syphilitic etiology should not be underestimated, especially when concurrent conditions (HIV disease and antiretroviral therapy in our case) may render differential diagnosis even more difficult. The recent resurgence of syphilis also focuses important public health issues, as a sign of a reduced attention to barrier preventive measures against sexually transmitted diseases.