Why don't we just do what we have to do?

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  • neutropenia, and, therefore, ophthalmological

    Letters to the Editor260References

    1. Porter CJ, Simcock JW, Mackinnon CA. Necrotising fasciitisand cellulitis after traditional Samoan tattooing: casereports. J Infect 2005;50:14952.

    2. Korman TM, Grayson ML, Turnidge JD. Polymicrobial septice-mia with Pseudomonas aeruginosa and Streptococcus pyo-genes following traditional tattooing. J Infect 1997;35:203.

    3. Mathur DR, Sahoo A. Pseudomonas septicaemia followingtribal tattoo marks. Trop Geog Med 1984;36:3012.

    4. Barnham M, Kerby J. A profile of skin sepsis in meat handlers.J Infect 1984;9:4350.

    Tony M. Korman*

    Department of Infectious Diseases, Monash MedicalCentre, 246 Clayton Rd, Clayton, Vic. 3168,

    AustraliaE-mail address: tony.korman@med.monash.edu.au

    M. Lindsay GraysonDepartment of Infectious Diseases, University of

    Melbourne, Austin Hospital, Heidelberg, Vic.,Australia

    John D. TurnidgeDepartment of Microbiology and Infectious

    Diseases, Womens and Childrens Hospital,Adelaide, SA, Australia

    Accepted 23 February 2005

    * Corresponding author. Tel.: C61 3 9594 4563; fax: C61 39594 4533

    Q 2005 The British Infection Society. Published by Elsevier Ltd.All rights reserved.

    doi:10.1016/j.jinf.2005.02.024

    Why dont we just do what we have to do?

    Sir,

    Different series have reported that the incidenceof endophthalmitis in patients with candidaemiahave been as high as 2845%.13 In addition, it iswell know that eye involvement in disseminatedcandidosis may increase morbidity and prolong thenecessity of anti-fungal therapy. Based on theseobservations, it is a consensus that all patients withcandidaemia should have at least one dilatedretinal examination, preferably by an ophthalmol-ogist.4,5 Neutropenic patients may not manifestvisible endophthalmitis until recovery fromexamination should be performed after recoveryof the neutrophil count.4 The aim of this observa-tional study was to retrospectively evaluate theproportion of patients with candidaemia who had afundoscopic examination performed in our medicalcentre. This was a 9-year study (19952003)conducted in Santa Casa Complexo Hospitalar,Brazil. Only patients who had the diagnosis ofsepsis at the time of blood sampling were included.From a total of 210 patients with candidaemia,only 7.6% (nZ16) had an ocular examinationperformed, and neither Candida endophthalmitisnor Candida chorioretinitis was reported. Theinformation of who performed the retinal examin-ation (an ophthalmologist or other medical doctor)was inconsistent in the charts. Fundoscopic exam-ination was more frequently performed in pretermneonates (risk ratio 4.25; CI 1.6810.71), and inpatients receiving parenteral nutrition (risk ratio4.17; CI 1.5810.96). In contrast, the risk ratio fornot-performing retinal examination was 1.12 (CI1.041.20) in cancer patients. When patients werestratified according to severity of candidaemia(APACHE-II in adults and PRISM in children) nodifference in the frequency of ocular examinationwas seen. No difference was also perceived invariables such as admission in the intensive care,invasive mechanical ventilation, shock or neutro-penia. No difference in the mortality rate wasobserved among patients who had an ocularexamination and those who had not. Other resultswere published elsewhere.6 Since, disseminatedcandidosis involving multiple foci is common inneonates,7 this may be the reason for the higherproportion of fundoscopic examination in thesepatients. In addition, many of these patients hadan ophthalmologic consultant to exclude retino-pathy of prematurity. However, the overall lowfrequency of retinal examination among ourpatients with candidaemia has surprised us. Weare not aware of previous studies revealing similarresults, especially in cancer patients. The reasonsfor these findings are obscure. As Santa CasaComplexo Hospitalar is a teaching hospital, diffi-cult access to ophthalmologists cannot be the mainjustification. It is possible that the retrospectivedesign of this study may have led to loose ofinformation, underestimating the real frequency ofretinal examination in this cohort. We wouldfavour the hypothesis that the frequency offundoscopic examination in real life candidaemiapatients may be far different from the datapublished in clinical trials. Continuing medicaleducation seems to be required to our medicalstaff, in order to improve these results.

  • (600900 mg/day) for 6 weeks or doxycycline for 6

    cultures grew Brucella melitensis. Doxycycline(200 mg/day, po) and streptomycin (1 g/day, im)

    Letters to the Editor 261References

    1. Brooks RG. Prospective study of Candida endophthalmitis inhospitalized patients with candidemia. Arch Intern Med 1989;149:22268.

    2. Parke II DW, Jones DB, Gentry LO. Endogenous endophthal-mitis among patients with candidemia. Ophthalmology 1982;89:78996.

    3. Bross J, Talbot GH, Maislin G, Hurwitz S, Strom BL. Riskfactors for nosocomial candidemia: a casecontrol study inadults without leukemia. Am J Med 1989;87:61420.

    4. Pappas PG, Rex JH, Sobel JD, Filler SG, Dismukes WE,Walsh TJ, et al. Guidelines for treatment of candidiasis.Clin Infect Dis 2004;38:16189.

    5. Eggimann P, Garbino J, Pittet D. Management of Candidaspecies infections in critically ill patients. Lancet Infect Dis2003;3:77285.

    6. Pasqualotto AC, Nedel WL, Machado TS, Severo LC. Acomparative study of risk factors and outcome amongoutpatient-acquired and nosocomial candidaemia. J HospInfect; 2005;60:12934.

    7. Chapman RL. Candida infections in the neonate. Curr OpinPediatr 2003;15:97102.

    Alessandro Comaru Pasqualottoa*

    Luiz Carlos SeverobaSchool of Medicine, The University of Manchester,

    1/512 Wilmslow Road, Withington,Manchester M20 4BT, UK

    bSanta Casa Complexo Hospitalar,Porto Alegre, Brazil

    E-mail address:alessandro.pasqualotto@manchester.ac.uk

    Accepted 23 February 2005

    * Corresponding author. Tel.: C44 161 4344528; fax: C44 16127556556

    Q 2005 The British Infection Society. Published by Elsevier Ltd.All rights reserved.

    doi:10.1016/j.jinf.2005.05.011

    Rifampin induced arthritis

    Sir,

    Brucellosis is a zoonosis that is seen in Turkey as inthe other Mediterranean countries. The disease ischaracterized by fever, profuse sweating, malaiseand arthralgia. The diagnosis is made with certaintywhen Brucella are recovered from blood, bonemarrow or other tissues.1 The World HealthOrganization (WHO) recommends regimen oforal doxycycline (200 mg/day) plus rifampinwere started. Fever resolved and the patientimproved on the 7th day of therapy. She wasdischarged with the plan of 6 weeks doxycylineand rifampin (600 mg/day) therapy. On the 6th dayof doxycycline and rifampin therapy she wasadmitted with the complaints of fever and suddenonset of severe pain in her temporomandibulerjoints bilaterally. Swelling, tenderness anderythema were noticed on both temporomandibularjoints in the physical examination. She wasevaluated by otorhinolaryngologists and dentists.No pathology other than temporomandibular jointarthritis was detected. The laboratory values werein the normal ranges. Magnetic resonance imagingcould not be performed because of severe pain. Shewas hospitalized and rifampin was stopped becauseof the suspicion of lupus-like syndrome caused byrifampin.3 Although her anti-nuclear (ANA) levelswere within the normal ranges; fever, pain,swelling and the erythema of the joints resolvedon the 2nd day after rifampin was stopped. Thetherapy was switched to doxycycline and ciproflox-acin (400 mg/day). She is now very well on the 15thday of the last therapy.

    Rifamycin-induced lupus syndrome is one of theadverse reactions caused by these drugs.2,3 Thissyndrome was seen during the treatment oftuberculosis usually in the 311 months of therapy.Also many of the patients were taking medicationsthat were interfering with cytochrome p-450enzyme system. All the patients had positiveantibodies.3 Our patient had been using rifampinfor only 6 days when bilateral temporomandibulararthritis developed and doxycycline was the onlyother drug she was taking. ANA titer was in thenormal ranges. So this clinical presentation seemsto be different from lupus-like syndrome.

    References

    1. Young EJ. Brucella species. In: Mandell GL, Bennett JE,Dolin R, editors. Principles and practice of infectiousdiseases. 6th ed. PA, USA: Elsevier Churchill Livingstone;2005. p. 266974.weeks and streptomycin (1 g/day, intramuscular)for 23 weeks.1 Rifampin and other rifamycins areassociated with many adverse reactions.2 In thisletter, we report a 62-year-old woman who wasadmitted to the hospital with complaints of fever,generalized malaise and lower back pain. Blood

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