562
Correspondence
therapy. It is interesting to note that the rash was manifested on a day that the dose of the steroids was reduced. The failure of diphenhydramine to prevent this local reaction may be the result of inadequate dosing or a nonhistamine-mediated mechanism. We conclude that this type of reaction is distinct from chemical phlebitis by virtue ofits complete reversibility. Whereas subsequent doses of pentamidine can reproduce the localized reaction in the same or different vein, no serious adverse reaction ensued despite administration of 10 more doses.
Robert S. Jones, Jr., Cheryl Collier-Brown, and Byungse Suh Section of Infectious Diseases. Department of Medicine. Temple University Health Sciences Center. Philadelphia. Pennsylvania
SIR-Lupatkin and colleagues reported on five patients with AIDS who had tuberculous abscesses [I] and noted that 10 cases of tuberculous abscess formation in patients with AIDS had been previously reported. These abscesses were located in unusual places such as the liver, pancreas, testicles, prostate, spleen, psoas muscle, abdominal wall, and the mediastinum. I
Correspondence: Dr. Kwan Kew Lai, Division of Infectious Disease and Immunology, Department of Medicine, University of Massachusetts Medical Center. 55 Lake Avenue North. Worcester, Massachusetts 01655.
Clinical Infectious Diseases 1992;15:562-3 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1503-0034$02.00
References l. Walzer PD. Perl DP, Krogstad DJ. Rawson PG. Schultz MG. Pneumocvstis carinii pneumonia in the United States. Ann Intern Med 1974;80:83-93. 2. Gerger TGH. Tappero JW. Leoung GS. Jacobson MA. Aerosolized pentamidine and cutaneous eruptions [letter]. Ann Intern Med 1989;110: 1035-6. 3. Leen O. Mandai BK. Rash due to nebulised pentamidine [letter]. Lancet 1988;2: 1250-1. 4. Wang JJ. Freeman AI, Gaeta JF. Sinks LF. Unusual complications of pentamidine in the treatment of Pneumocystis carinii pneumonia. J Pediatr 1970;77:311-4. 5. Webster LT Jr. Drugs used in the chemotherapy of protozoal infections. In: Gilman AG. Rail TW. Nies AS. Taylor P. eds. Goodman and Gilman's the pharmacological basis of therapeutics. New York: Pergamon Press, 1990:) 008-) 7.
wish to report the case ofa patient with AIDS who had probable tuberculous abscesses in the gluteal and retroperitoneal areas. A 35-year-old man with a history of intravenous drug use, AIDS, and Mycobacterium tuberculosis and candidal infections ofthe right supraclavicular nodes was treated initially with isoniazid, rifampin, pyrazinamide, and a course of antifungal therapy. His CD4 cell count was 200 cells/rnrrr', After 2 months, rifampin therapy was discontinued because of nausea, and therapy with ethambutol was substituted. Three months later, he developed a 6-cm fluctuant tender mass over the left sacrum. The previous biopsy site at the right supraclavicular area became fluctuant and drained spontaneously. Computed tomographic examination (figure I) of the abdomen and pelvis showed a left gluteal abscess measuring 3.5 X 3 X 2.5 em centered in the gluteal meatus with extension of the inflammatory process up into the left side of the retroperitoneum. There were multiple
Figure 1. Computed tomographic image of the pelvis that shows an abscess in the left gluteal area (arrow).
Downloaded from http://cid.oxfordjournals.org/ at University of Otago on July 18, 2015
Tuberculous Abscess in a Patient with AIDS
C1D 1992; 15 (September)
CID 1992; 15 (September)
Correspondence
563
This patient presented with localized swelling in the gluteal and retroperitoneal areas 3 months after receiving therapy for M. tuberculosis infection of the right supraclavicular area, where an abscess also developed that spontaneously drained. M. tuberculosis did not grow in cultures of specimens from the abscesses, most likely because the patient had been receiving antituberculous therapy. These acid-fast bacilli were unlikely to be Mycobacterium avium complex (MAC) as the patient was not receiving antituberculous agents to which MAC was susceptible. Because of the polymicrobial nature of this patient's abscess, the question ofgastrointestinal involvement with perforation and subsequent abscess formation was raised. However. the patient refused any further investigation. M. tuberculosis abscesses may develop in patients with AIDS while they are receiving appropriate antituberculous therapy.
Clarithromycin-Induced Thrombocytopenia
causes for thrombocytopenia and the reversal of this condition when clarithromycin was discontinued provide strong evidence for a causal relation. In September 1989, a human immunodeficiency virus-related Hodgkin's nodular sclerosing lymphoma was diagnosed in a previously healthy 30-year-old homosexual man. The patient was treated with an ABVD (Adriamycin [doxorubicin], bleomycin, vinblastine, and dacarbazine) chemotherapeutic protocol from September 1989 through May 1990. He tolerated the regimen well, and the lymphoma was in complete remission after chemotherapy. A representative complete blood cell count at the completion of therapy showed a white blood cell count of 3,900/mm 3 , a hematocrit of 36.9%, and a platelet count of 231,000/mm 3 . The patient received maintenance therapy with zidovudine (500 mg/d) and aerosolized pentamidine (once a month) until August 1991. At that time, he had relative pancytopenia (white blood cell count, I,900/mm 3 ; hematocrit, 28.9%; platelet count, 82,000/mm 3 ) that was associated with daily fevers (temperature to 39°C) and a rapid, unexplained weight loss. A biopsy of bone marrow revealed no evidence of recurrent Hodgkin's disease. Maturation of all cell lines was consistent with previously described changes associated with antiretroviral therapy [5]. Acid-fast smears of the bone marrow and subsequent mycobacterial cultures of the bone marrow and blood were diagnostic of MAC infection. The results ofall other bacterial and fungal cultures were negative. Therapy for disseminated MAC infection with amikacin (7.5 mg/kg iv every 12 hours), clofazimine (200 mg/d), and clarithromycin (2,000 mg/d) was begun. The patient tolerated treatment well and had a generalized sense that his condition had improved. The patient's daily fevers resolved promptly, and he gained weight steadily throughout his clarithromycin therapy. After 4 weeks of treatment, the patient's platelet count de-
SIR-Clarithromycin, a new oral macrolide recently approved by the U.S. Food and Drug Administration, has equal or better activity when compared with erythromycin against many grampositive organisms, anaerobic organisms, Chlamydia trachomatis. Moraxella catsrrhalis. and Legionella pneumophila. It has a longer half-life, better absorption, and fewer gastrointestinal adverse effects. Most recently, it has generated much interest as a possible agent for the treatment of serious infections due to the Mycobacterium avium complex (MAC) in patients with AIDS. In vitro susceptibility data support its bactericidal activity [I], and in a limited clinical study, a marked decrease in bacillemia in patients with AIDS and disseminated MAC infection was noted [2]. Clinical trials are under way with regimens including clarithromycin for the treatment of patients with AIDS and disseminated MAC infection. The known adverse effects, including gastrointestinal upset and elevations in levels of liver-associated enzymes, are usually mild and reversible when therapy is interrupted [3, 4]. To our knowledge, thrombocytopenia associated with the use of clarithromycin has not been reported. We describe a patient with AIDS and disseminated MAC disease who developed reversible thrombocytopenia while receiving therapy with clarithromycin. The absence of other definable
Correspondence: Dr. Carmelita U. Tuazon, Division of Infectious Diseases, Department of Medicine, The George Washington University Medical Center, 2150 Pennsylvania Avenue, N.W., Suite #5-403. Washington, D.C. 20037. Clinical Infectious Diseases 1992;15:563-4 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1503-0035$02.00
Kwan Kew Lai Division ofInfectious Disease and Immunology. Department ofMedicine, University ofMassachusetts Medical Center, Worcester. Massachusetts
Reference I. Lupatkin H, Brau N. Flomenberg P, Simberkoff MS. Tuberculous abscesses in patients with AIDS. Clin Infect Dis 1992: 14: 1040-4.
Downloaded from http://cid.oxfordjournals.org/ at University of Otago on July 18, 2015
microabscesses in the spleen. Findings ofa bone scan were negative. A chest roentgenogram showed lingular atelectasis and a decrease in the size of the right hilar mass when compared with his previous roentgenogram. Cultures of recent bronchoalveolar lavage specimens were negative for M. tuberculosis. The patient underwent surgical drainage of the abscess, which, in culture, yielded a mixture oforganisms including Candida albicans. viridans streptococci, Haemophilus parainfluenzae, and anaerobic bacteria. all ofwhich the microbiology laboratory was unable to grow in culture for further identification. Fluorochrome and Ziehl-Neelsen smears of multiple samples of the gluteal and supraclavicular area abscess were positive for acid-fast bacilli. but these organisms did not grow in culture. The patient was treated with ceftazidime, clindamycin, and amphotericin B, and treatment with antituberculous agents was continued. He had intermittent fever while receiving therapy. Repeated cultures of specimens of the gluteal abscess after 2 weeks of therapy yielded enterococci and non-aureus Staph ylococcus. Acid-fast bacilli were no longer seen, and mycobacterial cultures were negative. After 36 days of hospitalization, the patient's condition improved, and he was discharged to a hospice while continuing to receive antituberculous therapy with fluconazole and clindamycin. He died 6 months later.
Correspondence
therapy. It is interesting to note that the rash was manifested on a day that the dose of the steroids was reduced. The failure of diphenhydramine to prevent this local reaction may be the result of inadequate dosing or a nonhistamine-mediated mechanism. We conclude that this type of reaction is distinct from chemical phlebitis by virtue ofits complete reversibility. Whereas subsequent doses of pentamidine can reproduce the localized reaction in the same or different vein, no serious adverse reaction ensued despite administration of 10 more doses.
Robert S. Jones, Jr., Cheryl Collier-Brown, and Byungse Suh Section of Infectious Diseases. Department of Medicine. Temple University Health Sciences Center. Philadelphia. Pennsylvania
SIR-Lupatkin and colleagues reported on five patients with AIDS who had tuberculous abscesses [I] and noted that 10 cases of tuberculous abscess formation in patients with AIDS had been previously reported. These abscesses were located in unusual places such as the liver, pancreas, testicles, prostate, spleen, psoas muscle, abdominal wall, and the mediastinum. I
Correspondence: Dr. Kwan Kew Lai, Division of Infectious Disease and Immunology, Department of Medicine, University of Massachusetts Medical Center. 55 Lake Avenue North. Worcester, Massachusetts 01655.
Clinical Infectious Diseases 1992;15:562-3 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1503-0034$02.00
References l. Walzer PD. Perl DP, Krogstad DJ. Rawson PG. Schultz MG. Pneumocvstis carinii pneumonia in the United States. Ann Intern Med 1974;80:83-93. 2. Gerger TGH. Tappero JW. Leoung GS. Jacobson MA. Aerosolized pentamidine and cutaneous eruptions [letter]. Ann Intern Med 1989;110: 1035-6. 3. Leen O. Mandai BK. Rash due to nebulised pentamidine [letter]. Lancet 1988;2: 1250-1. 4. Wang JJ. Freeman AI, Gaeta JF. Sinks LF. Unusual complications of pentamidine in the treatment of Pneumocystis carinii pneumonia. J Pediatr 1970;77:311-4. 5. Webster LT Jr. Drugs used in the chemotherapy of protozoal infections. In: Gilman AG. Rail TW. Nies AS. Taylor P. eds. Goodman and Gilman's the pharmacological basis of therapeutics. New York: Pergamon Press, 1990:) 008-) 7.
wish to report the case ofa patient with AIDS who had probable tuberculous abscesses in the gluteal and retroperitoneal areas. A 35-year-old man with a history of intravenous drug use, AIDS, and Mycobacterium tuberculosis and candidal infections ofthe right supraclavicular nodes was treated initially with isoniazid, rifampin, pyrazinamide, and a course of antifungal therapy. His CD4 cell count was 200 cells/rnrrr', After 2 months, rifampin therapy was discontinued because of nausea, and therapy with ethambutol was substituted. Three months later, he developed a 6-cm fluctuant tender mass over the left sacrum. The previous biopsy site at the right supraclavicular area became fluctuant and drained spontaneously. Computed tomographic examination (figure I) of the abdomen and pelvis showed a left gluteal abscess measuring 3.5 X 3 X 2.5 em centered in the gluteal meatus with extension of the inflammatory process up into the left side of the retroperitoneum. There were multiple
Figure 1. Computed tomographic image of the pelvis that shows an abscess in the left gluteal area (arrow).
Downloaded from http://cid.oxfordjournals.org/ at University of Otago on July 18, 2015
Tuberculous Abscess in a Patient with AIDS
C1D 1992; 15 (September)
CID 1992; 15 (September)
Correspondence
563
This patient presented with localized swelling in the gluteal and retroperitoneal areas 3 months after receiving therapy for M. tuberculosis infection of the right supraclavicular area, where an abscess also developed that spontaneously drained. M. tuberculosis did not grow in cultures of specimens from the abscesses, most likely because the patient had been receiving antituberculous therapy. These acid-fast bacilli were unlikely to be Mycobacterium avium complex (MAC) as the patient was not receiving antituberculous agents to which MAC was susceptible. Because of the polymicrobial nature of this patient's abscess, the question ofgastrointestinal involvement with perforation and subsequent abscess formation was raised. However. the patient refused any further investigation. M. tuberculosis abscesses may develop in patients with AIDS while they are receiving appropriate antituberculous therapy.
Clarithromycin-Induced Thrombocytopenia
causes for thrombocytopenia and the reversal of this condition when clarithromycin was discontinued provide strong evidence for a causal relation. In September 1989, a human immunodeficiency virus-related Hodgkin's nodular sclerosing lymphoma was diagnosed in a previously healthy 30-year-old homosexual man. The patient was treated with an ABVD (Adriamycin [doxorubicin], bleomycin, vinblastine, and dacarbazine) chemotherapeutic protocol from September 1989 through May 1990. He tolerated the regimen well, and the lymphoma was in complete remission after chemotherapy. A representative complete blood cell count at the completion of therapy showed a white blood cell count of 3,900/mm 3 , a hematocrit of 36.9%, and a platelet count of 231,000/mm 3 . The patient received maintenance therapy with zidovudine (500 mg/d) and aerosolized pentamidine (once a month) until August 1991. At that time, he had relative pancytopenia (white blood cell count, I,900/mm 3 ; hematocrit, 28.9%; platelet count, 82,000/mm 3 ) that was associated with daily fevers (temperature to 39°C) and a rapid, unexplained weight loss. A biopsy of bone marrow revealed no evidence of recurrent Hodgkin's disease. Maturation of all cell lines was consistent with previously described changes associated with antiretroviral therapy [5]. Acid-fast smears of the bone marrow and subsequent mycobacterial cultures of the bone marrow and blood were diagnostic of MAC infection. The results ofall other bacterial and fungal cultures were negative. Therapy for disseminated MAC infection with amikacin (7.5 mg/kg iv every 12 hours), clofazimine (200 mg/d), and clarithromycin (2,000 mg/d) was begun. The patient tolerated treatment well and had a generalized sense that his condition had improved. The patient's daily fevers resolved promptly, and he gained weight steadily throughout his clarithromycin therapy. After 4 weeks of treatment, the patient's platelet count de-
SIR-Clarithromycin, a new oral macrolide recently approved by the U.S. Food and Drug Administration, has equal or better activity when compared with erythromycin against many grampositive organisms, anaerobic organisms, Chlamydia trachomatis. Moraxella catsrrhalis. and Legionella pneumophila. It has a longer half-life, better absorption, and fewer gastrointestinal adverse effects. Most recently, it has generated much interest as a possible agent for the treatment of serious infections due to the Mycobacterium avium complex (MAC) in patients with AIDS. In vitro susceptibility data support its bactericidal activity [I], and in a limited clinical study, a marked decrease in bacillemia in patients with AIDS and disseminated MAC infection was noted [2]. Clinical trials are under way with regimens including clarithromycin for the treatment of patients with AIDS and disseminated MAC infection. The known adverse effects, including gastrointestinal upset and elevations in levels of liver-associated enzymes, are usually mild and reversible when therapy is interrupted [3, 4]. To our knowledge, thrombocytopenia associated with the use of clarithromycin has not been reported. We describe a patient with AIDS and disseminated MAC disease who developed reversible thrombocytopenia while receiving therapy with clarithromycin. The absence of other definable
Correspondence: Dr. Carmelita U. Tuazon, Division of Infectious Diseases, Department of Medicine, The George Washington University Medical Center, 2150 Pennsylvania Avenue, N.W., Suite #5-403. Washington, D.C. 20037. Clinical Infectious Diseases 1992;15:563-4 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1503-0035$02.00
Kwan Kew Lai Division ofInfectious Disease and Immunology. Department ofMedicine, University ofMassachusetts Medical Center, Worcester. Massachusetts
Reference I. Lupatkin H, Brau N. Flomenberg P, Simberkoff MS. Tuberculous abscesses in patients with AIDS. Clin Infect Dis 1992: 14: 1040-4.
Downloaded from http://cid.oxfordjournals.org/ at University of Otago on July 18, 2015
microabscesses in the spleen. Findings ofa bone scan were negative. A chest roentgenogram showed lingular atelectasis and a decrease in the size of the right hilar mass when compared with his previous roentgenogram. Cultures of recent bronchoalveolar lavage specimens were negative for M. tuberculosis. The patient underwent surgical drainage of the abscess, which, in culture, yielded a mixture oforganisms including Candida albicans. viridans streptococci, Haemophilus parainfluenzae, and anaerobic bacteria. all ofwhich the microbiology laboratory was unable to grow in culture for further identification. Fluorochrome and Ziehl-Neelsen smears of multiple samples of the gluteal and supraclavicular area abscess were positive for acid-fast bacilli. but these organisms did not grow in culture. The patient was treated with ceftazidime, clindamycin, and amphotericin B, and treatment with antituberculous agents was continued. He had intermittent fever while receiving therapy. Repeated cultures of specimens of the gluteal abscess after 2 weeks of therapy yielded enterococci and non-aureus Staph ylococcus. Acid-fast bacilli were no longer seen, and mycobacterial cultures were negative. After 36 days of hospitalization, the patient's condition improved, and he was discharged to a hospice while continuing to receive antituberculous therapy with fluconazole and clindamycin. He died 6 months later.
