Papers by Brian Wispelwey
41st Annual Meeting, Oct 8, 2003
Pediatric Infectious Disease Journal, Dec 1, 1989
Aids Research and Therapy, Jun 8, 2009
Two HIV-1 infected patients developed signs and symptoms consistent with adrenal suppression afte... more Two HIV-1 infected patients developed signs and symptoms consistent with adrenal suppression after being exposed to intra-articular triamcinolone acetate while also receiving ritonavir as part of their highly active antiretroviral therapy. Laboratory evaluation confirmed secondary adrenal suppression in both cases. Both patients recovered without the need for chronic replacement steroids. Adrenal suppression has been described as an adverse outcome in patients treated with fluticasone and concomitant ritonavir. In the reported cases, the adrenal suppression likely developed as a result of increased systemic concentrations of triamcinolone due to an inhibition of cytochrome p450 3A4 metabolism. Practitioners of HIV medicine should be aware of the potential negative interaction of injected triamcinolone and ritonavir.
Case reports in infectious diseases, 2017
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing sy... more Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome (SUNCT) is a type of trigeminal autonomic cephalalgia. Its etiology is generally idiopathic, though rarely it has been associated with viral infections. We describe the fourth case reported in the literature of SUNCT in association with viral meningoencephalitis.
Journal of Clinical Gastroenterology, Apr 1, 1996
Drug Safety, 1990
With the advent of the acquired immunodeficiency syndrome (AIDS), the therapeutic importance of p... more With the advent of the acquired immunodeficiency syndrome (AIDS), the therapeutic importance of pentamidine isethionate has greatly increased. This review summarises its pharmacology, its toxicity and clinical experience in the treatment of Pneumocystis carinii pneumonia (PCP). Data are conflicting as to whether pentamidine is more or less effective than cotrimoxazole (trimethoprim-sulfamethoxazole) for the treatment of PCP in individuals with AIDS, but due to its toxicity and expense, it is considered as second-line therapy by many authorities. Hypoglycaemia has been encountered in up to 27% of treatment courses with pentamidine, and nephrotoxicity in 25%. In an attempt to circumvent the toxicities associated with parenteral administration, aerosolised delivery has been evaluated for both therapy and prevention of PCP. Aerosolised pentamidine, on the basis of early clinical results, convenience and low toxicity, may become the drug of choice for prevention of PCP in individuals at high risk. However, its role in the treatment of PCP remains to be defined. Preliminary studies suggest that it is effective, but the data are insufficient to support its use outside of clinical trials.
Diagnostic Microbiology and Infectious Disease, Mar 1, 1990
Infectious Disease Clinics of North America, Dec 1, 1990
Bacterial meningitis continues to be an important cause of morbidity and mortality despite the av... more Bacterial meningitis continues to be an important cause of morbidity and mortality despite the availability of effective bactericidal antibiotics. Penicillin or ampicillin remains the drug of choice for meningitis caused by Streptococcus pneumoniae and Neisseria meningitidis. The third generation cephalosporins have revolutionized the treatment of gram-negative meningitis. Future therapy for bacterial meningitis will use recent developments in the understanding of pathogenic and pathophysiologic mechanisms underlying this disease.
Strategies to optimally use fluoroquinolones in the hospital setting are reviewed. Summary: Fluor... more Strategies to optimally use fluoroquinolones in the hospital setting are reviewed. Summary: Fluoroquinolones possess broad-spectrum antimicrobial coverage and are widely used to treat a variety of infections including some serious, life-threatening conditions. Overuse and inappropriate use of fluoroquinolones has led to rapid emergence of fluoroquinolone-resistant organisms as well as multidrug-resistant pathogens. Preserving the fluoroquinolone class is important, especially given the lack of new antibiotics currently in clinical development. Maintaining the fluoroquinolone class as a therapeutic option requires the successful implementation of guidelines to promote appropriate, optimal use of these agents. Among many recommendations to control the growing problem of antimicrobial resistance, antimicrobial stewardship programs offer the most comprehensive solution to gain appropriate antimicrobial prescribing. Effective programs include selection of the most effective agents, specific dosages, frequency of administration, routes of administration, and duration of therapy. Additionally, a dual fluoroquinolone formulary, which typically incorporates one respiratory fluoroquinolone and ciprofloxacin, has been employed to increase the diversity of fluoroquinolone treatment and thus reduce the selective antimicrobial pressure. A combination of antimicrobial stewardship programs and a dual formulary option has been demonstrated to be a good approach to optimize the use of fluoroquinolones in the hospital. Two successful experiences in applying such strategies have been reported; in both cases the empiric fluoroquinolone prescribing was reduced. Conclusion: Implementation of aggressive optimization strategies such as the combined use of antimicrobial stewardship programs and a dual fluoroquinolone formulary may maintain the efficacy of fluoroquinolones and preserve their utility for future patients.
Journal of Clinical Investigation, Oct 1, 1988
The factors responsible for blood-brain barrier (BBB) injury during bacterial meningitis are inco... more The factors responsible for blood-brain barrier (BBB) injury during bacterial meningitis are incompletely defined. We evaluated the role of Haemophilus influenzae type b (Hib) lipopolysaccharide (LPS) in the alteration of blood-brain barrier permeability (BBBP) in an adult, normal and leukopenic, rat model of meningitis. Intracisternal inoculation of Hib LPS resulted in (a) dose-dependent increases in BBBP from 2 pg to 20 ng, with significant attenuation in the peak response after challenge with 500 ng and 1 ,ug, (b) time-dependent increases in BBBP, with a delayed onset of at least 2 h, maximum alteration at 4 h, and complete reversal at 18 h; (c) greater BBBP than after challenge with the live parent strain; (d) and a close correlation (r = 0.86) between CSF pleocytosis and BBBP at 4 h. The LPS effect was significantly inhibited by preincubation with Polymyxin B and neutrophil acyloxyacyl hydrolase, however two different oligosaccharide-specific monoclonal antibodies did not inhibit activity. No change in BBBP after inoculation with Hib LPS occurred in leukopenic rats. Hib LPS, in the setting of an intact leukocyte response, exerts profound effects on BBBP.
Cambridge University Press eBooks, Mar 6, 2013
Case Reports in Clinical Medicine, 2013
Acute HIV infection (AHI) is often marked by nonspecific and vague complaints, which make detecti... more Acute HIV infection (AHI) is often marked by nonspecific and vague complaints, which make detection difficult. An 18-year-old man presented with one week history of subjective fevers with chills, nonproductive cough and generalized body aches. He was found to have rhabdomyolysis due to AHI. This report adds the most thoroughly investigated case of AHI-associated rhabdomyolysis to date, having ruled out erlichia, legionella, parainfluenza, adenovirus, enterovirus, metapneumovirus, RSV and DILS.
Blood, Nov 29, 2018
Introduction Clostridium difficile infection (CDI) is a major cause of morbidity and mortality in... more Introduction Clostridium difficile infection (CDI) is a major cause of morbidity and mortality in hospitalized patients. In autologous stem cell transplant (ASCT) recipients the national estimated incidence is approximately 5% to 10%. The use of antibacterial agents, such as ciprofloxacin, which historically has been used as a prophylactic agent in our autologous stem cell transplant population, is considered to be a risk factor for developing CDI. However, there have been few studies that have investigated the relationship of prophylactic antibiotics in the ASCT population and the development of CDI. One study, Satlin et al, found fluoroquinolone prophylaxis in ASCT patients decreased the rate of febrile neutropenia and blood stream infections and also a possible increase in the rate of CDI. Methods To attempt to decrease the incidence of CDI, our institution made a change to our standard of practice and suspended the utilization of CIP (500 mg twice daily beginning on the day zero and continued until engraftment or antibiotic escalation) for antibacterial prophylaxis in our ASCT population. All patients received antiviral and antifungal prophylaxis at baseline and broad-spectrum anti-pseudomonal antibacterial agents at the first recorded febrile event or as clinically necessary. CDI testing was completed when patients had three or more liquid stools in a 24-hour period along with other symptoms (i.e., fever, abdominal pain). Patients were found to have a CDI when the stool sample resulted positive while experiencing correlative symptoms. Stool samples were assessed for Clostridium difficile with the Cepheid GeneXpert NAAT. We retrospectively collected data on patients who received CIP prophylaxis from June 2016 - June 2017 and compared it to patients who did not receive CIP prophylaxis from July 2017 - June 2018. Data were analyzed using Chi-squared and T-tests were used to assess for significance and logistic regression was utilized to assess for possible associations between patient characteristics (age, race, sex, diagnosis, and conditioning regimen) and CDI. Results A total of 116 ASCT patients were analyzed; the median age was 57 years old and the most common diagnoses were multiple myeloma, non-Hodgkin's lymphoma, and Hodgkin's lymphoma; 57 patients received CIP antibacterial prophylaxis and 59 patients received no antibacterial prophylaxis. The most common conditioning regimens include melphalan (60%) and BEAM with or without rituximab (22%). CDI occurred in 15% of patients who did not receive CIP prophylaxis and 18% of patients who received prophylaxis (p=0.739). Of note, 88% of patients in both groups were tested for CDI. Neutropenic fever occurred significantly more often in patients who did not receive prophylaxis, 64% vs 35% (p=0.003). The rates of bacteremia were also found to be significantly higher in the non-CIP group, 32% vs. 12% (p=0.01). Gram-negative bacteria blood isolates were increased in patients not receiving CIP prophylaxis, 19% vs. 7% (p=0.062). Interestingly, there was also an increase in the occurrence of gram-positive bacteremia isolates, 19% vs. 5% (p=0.03). The average length of hospital stay was 19 days for both groups and intensive care unit admissions were similar between the two groups, 14% vs. 11% (p=0.616). Conclusion The lack of CIP prophylaxis in ASCT did not significantly decrease the rate of CDIs. With the removal of antibacterial prophylaxis, there was a significant increase in the rate of neutropenic fever and bacteremia, specifically gram-positive bacteremia. Hospital length of stay and admissions to the intensive care unit were similar between the groups. No additional risk factors were determined to be associated with the development in CDI in the patient population. Based on the results of this study, our institution reinstituted the utilization of CIP prophylaxis. Future studies include the utilization of antibody prophylaxis for CDI and also assessing Clostridium difficile colonization and its effect on developing an active clinical infection. Disclosures No relevant conflicts of interest to declare.
Infectious Diseases in Clinical Practice, Sep 1, 2011
Persistent hiccups in patients with human immunodeficiency virus/acquired immunodeficiency syndro... more Persistent hiccups in patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) are most often associated with opportunistic infections or HIV-associated illnesses. There have been no described cases of hiccups due to highly active antiretroviral medications. We report a case of persistent hiccups likely due to fixed-dose tenofovir and emtricitabine and review etiologies of persistent and intractable hiccups in patients with HIV and common gastrointestinal disturbances linked to the fixed-dose formulation.
Case reports in infectious diseases, 2012
Cutaneous manifestations of cytomegalovirus (CMV) in patients without human immunodeficiency viru... more Cutaneous manifestations of cytomegalovirus (CMV) in patients without human immunodeficiency virus remain rare. Perianal CMV may be observed due to periodic fecal shedding but may be confused for other pathogens, and definitive diagnosis requires histopathologic examination. An instructive case is described, and the literature reviewed.
Case reports in infectious diseases, Oct 20, 2020
Gradenigo's syndrome (GS) classically involves a triad of ear pain due to acute or chronic otitis... more Gradenigo's syndrome (GS) classically involves a triad of ear pain due to acute or chronic otitis media (OM), facial or retro-orbital pain in the distribution of the trigeminal nerve, and an abducens nerve palsy. e simultaneous presentation of all three components has become less common in cases of GS reported in the literature, particularly in the era of antibiotics effective against typical organisms attributed to OM and petrous apicitis. In addition to infectious petrous apicitis arising directly from OM, more recent cases of GS are attributed to the compression of the same traversing cranial nerves in the presence of various expansile petrous apex (PA) lesions, both benign and malignant. We report a case of a 24-year-old male who presented initially with nausea, fever, photophobia, left-sided retro-orbital pain, and headache. He was diagnosed with bacterial meningitis by lumbar puncture and treated with empiric antibiotics, with CSF eventually revealing nontypeable Haemophilus influenzae. Several days into his course, he developed diplopia with leftward gaze. Brain imaging revealed an expansile, erosive PA cholesterol granuloma with associated contiguous dural and leptomeningeal enhancement. e patient improved with antibiotics and eventually underwent surgical intervention. is atypical presentation of GS with a rare complication of meningitis in the setting of a PA granuloma demonstrates the importance of early recognition of this syndrome, as well as consideration of added surgical intervention in patients with pre-existing petrous lesions at potentially higher risk of dangerous complications of GS.
The American Journal of the Medical Sciences, Apr 1, 2017
BMC Infectious Diseases, May 22, 2018
Background: Mycobacterium Avium Complex (MAC) is an established microbiologic cause of pulmonary ... more Background: Mycobacterium Avium Complex (MAC) is an established microbiologic cause of pulmonary disease, lymphadenitis, and disseminated disease in cases of advanced immune suppression. However, MAC manifesting as vertebral osteomyelitis is less common, and is particularly rare in the absence of Acquired Immunodeficiency Syndrome (AIDS). Prompt diagnosis of MAC vertebral osteomyelitis is challenging, but necessary to prevent serious morbidity or mortality. Case presentation: We report a case of MAC osteomyelitis of the lumbar spine in a 70-year-old woman on extended duration corticosteroid therapy for systemic lupus erythematosus who presented with progressive back pain. Upon presentation, imaging revealed osteomyelitis of the lumbar spine with associated paraspinal abscess. Cultures from the surgical evacuation of the paraspinal abscess yielded no pathogen growth and she was therefore treated with empiric antibacterial therapy. Two weeks after her initial hospital discharge she represented with severe back pain and radiologic evidence of progressive disease in her lumbar spine. Two additional vertebral biopsies were required during her first 2 weeks of admission. MAC eventually grew from culture 14 days after collection. She was treated with ethambutol and rifampin and her symptoms resolved in 2 weeks, though therapy was continued for 12 months. Conclusions: MAC is an unusual cause of vertebral osteomyelitis in patients with AIDS, but is exceedingly rare in those without severe immune compromise. Despite its rarity, it must be considered in cases of vertebral osteomyelitis that do not respond to empiric antibiotic therapy. Multiple biopsies may be necessary to obtain a diagnosis and avoid destructive infectious complications of an untreated infection.
Annals of Internal Medicine, Apr 15, 1990
To review recent advances in the understanding of pathogenic and pathophysiologic mechanisms unde... more To review recent advances in the understanding of pathogenic and pathophysiologic mechanisms underlying bacterial meningitis that may lead to the development of adjunctive strategies for treating this disorder. Studies published from 1975 to 1989 were identified using Index Medicus and by reviewing the bibliographies of identified articles. We reviewed the experimental and human studies evaluating pathogenesis, pathophysiology, and antimicrobial treatment of bacterial meningitis, as well as those reviews that have contributed to our understanding of meningitis. We evaluated the data on the pathogenesis, pathophysiology, and treatment of bacterial meningitis and considered in depth the information from animal models that may have potentially important applications in the treatment of human disease. Penicillin and ampicillin remain the drugs of choice for meningitis caused by Streptococcus pneumoniae and Neisseria meningitidis. The third-generation cephalosporins have revolutionized the treatment of gram-negative bacillary meningitis; one such agent, ceftazidime, is also useful for treating Pseudomonas aeruginosa meningitis. Modification of subarachnoid space inflammation by anti-inflammatory agents may lessen many of the pathophysiologic consequences of bacterial meningitis. A recent study of adjunctive dexamethasone therapy in infants and children with bacterial meningitis showed that the incidence of long-term neurologic sequelae was lower in the corticosteroid group. Future therapy for bacterial meningitis will use recent developments in the understanding of pathogenic and pathophysiologic mechanisms underlying this disease. Additional studies using monoclonal antibodies against specific virulence factors and investigations into the production of inflammatory cytokines in response to bacterial cell products may lead to additional treatments that decrease the high morbidity and mortality in patients with bacterial meningitis.
Case reports in infectious diseases, 2016
Clostridium perfringens bacteremia is an uncommon yet serious clinical syndrome that typically ar... more Clostridium perfringens bacteremia is an uncommon yet serious clinical syndrome that typically arises from a gastrointestinal source. However, clinicians should consider nongastrointestinal sources as well. We present a rare case of C. perfringens bacteremia of urinary origin that required surgical intervention for definitive treatment. A 61-year-old male presented with acute nausea and vomiting, altered mental status, and chronic diarrhea. His physical exam revealed right costovertebral tenderness and his laboratory work-up revealed acute renal failure. Percutaneous blood cultures grew C. perfringens. Cross-sectional imaging revealed a right-sided ureteral stone with hydronephrosis, which required nephrostomy placement. On placement of the nephrostomy tube, purulent drainage was identified and Gram stain of the drainage revealed Gram-variable rods. A urinary source of C. perfringens was clinically supported. Although it is not a common presentation, nongastrointestinal sources such as a urinary source should be considered in C. perfringens bacteremia because failure to recognize a nongastrointestinal source can delay appropriate treatment, which may include surgical intervention.
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Papers by Brian Wispelwey