Invasive adenovirus (AdV) disease is fatal in >50% of allogeneic hematopoietic stem cell transplant (SCT) recipients. Treatment with cidofovir may improve outcomes based on in vitro susceptibility data and case reports. Six consecutive cases of invasive AdV disease treated with cidofovir were reviewed among 84 allogeneic adult SCT recipients (incidence, 7.1%). Cidofovir was administered intravenously at 5 mg/kg per dose (1-7 doses). All patients received intravenous immune globulin. Blood AdV DNA levels (viral loads, VLs) were monitored with a real-time quantitative polymerase chain reaction assay. Published reports of cidofovir treatment of AdV disease in SCT recipients were critically reviewed. The primary manifestations of AdV disease were hepatitis (n = 3), colitis (n = 2), and nephritis (n = 1). All patients had detectable AdV VLs, with peak values from 5 x 10(5) to 2 x 10(8) copies/mL. All patients received CD34+ selected grafts (n = 3) and/or had graft-versus-host disease (n = 4) and had CD4 counts <100 cells/mm3. Only 1 of 5 patients (20%) who received >or=2 doses of cidofovir died with active AdV disease. Four patients exhibited improvement within days of treatment with cidofovir as documented by clinical criteria and declines in AdV VLs (without a change in immunosuppression). In contrast, 1 patient treated late after onset of AdV disease died after 1 dose of cidofovir. In our review of 70 published cases treated with >or=2 doses of cidofovir, 13 (19%) died from AdV disease. In conclusion, early treatment of AdV disease with cidofovir inhibits viral replication in vivo and reduces mortality in allogeneic SCT recipients compared with historical data.

We report a case of successful, rapid desensitization to enfuvirtide after a hypersensitivity reaction in a man with highly drug-resistant human immunodeficiency virus type 1 infection. The patient was desensitized in a monitored intensive care unit and tolerated the rapid desensitization protocol without any serious adverse effects. This case illustrates the ability to safely desensitize patients with limited treatment options who require enfuvirtide therapy.

A 53-year old man presented to the ED with complaints of fevers and chills for 5 days. Two days prior, he started having generalized arthralgias and a painfully numb left index finger. Similar symptoms had also begun on his left great toe (See Figures D and E, Color Plates page 19). The patient denied recent trauma, although he was unsure if he had sustained an insect bite on the dorsal aspect of his left hand 8 hours prior to the onset of symptoms. Three sets of blood cultures obtained prior to admission were positive for methacillin-sensitive Staphylococcus aureus. The patient was treated with intravenous nafcillin and gentamicin. A transesophageal echocardiography was performed, which showed a friable and perforated left coronary cusp of the aortic valve, resulting in severe aortic insufficiency. The patient was scheduled for emergent aortic valve replacement. It was surmised that the initial site of infection was a badly ulcerated blister located on the patient's right great toe. A Male with Chills and Arthralgias Lo-Ku Chiang MD, PGY-3 Internal Medicine and Ambrish Ojha MD, PGY-5 Infectious Diseases DiscussionThere are numerous peripheral manifestations of bacterial endocarditis. The classic peripheral manifestations are found in up to half of the cases, but the prevalence has decreased in recent years. Janeway lesions are painless erythematous, hemorrhagic, or pustular lesions that are seen on the palms or soles and are often associated with acute bacterial endocarditis. Oslers nodes, which are tender, subcutaneous nodules often located on the pulp of the digits typically seen with subacute bacterial endocarditis. Other vasculitic complications include major arterial emboli, septic pulmonary infarcts, mycotic aneurym, conjunctival petechiae and intracerebral hemorrhages. Immunologic phenomena include glomerulonephritis, a positive rheumatoid factor, Roth spots and superficial retinal hemorrhages. These clinical findings are part of the minor criteria in the Duke classification of diagnosing bacterial endocarditis.Frequently, the presentation of endocarditis is not clear and a high level of clinical suspicion is essential in a patient with fever and systemic symptoms suggestive of infective endocarditis.