No abstract

A case of Candida albicans endocarditis is described in which treatment with 5-fluorocytosine was started after aortic valve replacement, but relapse followed discontinuance of treatment. At a second operation the aortic valve was replaced under 5-fluorocytosine cover and treatment was continued with both 5-fluorocytosine and amphotericin-B. There was an initial improvement in signs of heart failure, but on I9 August the shortness of breath increased, and three days later fresh splinter haemorrhages were noted. In view of this, treatment was started with benzyl penicillin 8 mega units intravenously per day, though as yet no organism had been isolated from the cultures of blood or urine. The pyrexia settled, but after 5 days the patient began to suffer sweating attacks, and again his temperature rose. The antibiotic used was changed to cephaloridine 6 g daily, and within one week the patient became apyrexial.On ii September, at IO1.5 p.m., he suddenly developed gross left ventricular failure with a respiratory rate of 50 per minute, and a full length diastolic murmur. A diagnosis of ruptured aortic cusp was made, and emergency valve replacement was performed by Mr. J. E. C. Wright using a Series I200 Starr-Edwards prosthesis (No. ii). At operation the aortic valve was heavily calcified and there were large vegetations involving all three cusps, the non-coronary cusp being destroyed and incompetent. Antibiotic therapy during and shortly after the operation was with the current standard postoperative antibiotic regimen: intravenous gentamycin 40 mg t.d.s. and cloxacillin 500 mg q.d.s.The immediate postoperative course was uneventful, but on I8 September Candida albicans was isolated from blood cultures taken before operation on the ii and 14September. This was sensitive to 5-fluorocytosine at a minimum inhibitory concentration of 0.35 ,ug/ml. Culture of the valve itself grew the same organism, as did three midstream urine specimens taken during this period. One culture from the excised valve also grew actinobacter. Histology of the valve revealed subacute inflammation with lymphocytes and plasma cells, and Gram-positive budding yeasts were demonstrated. Serum contained no precipitins for Candida albicans on 14 September, and the agglutinin titre was less than I: 4. No murmurs were heard at this time.

SUMMARY Computed tomography was undertaken in nine patients (age range 33-69 (mean 48.7) years) with hypertrophic cardiomyopathy. The ventricular septum was demonstrated in each patient and shown to be thickened ( (Conray 420) were then injected into a large peripheral arm vein, 30 ml as a bolus and the remaining 20 ml more slowly during the next 20 s. The first scan was obtained immediately after the bolus, again at full inspiration. Five further contrast enhanced images were then obtained as rapidly as possible during the next minute. Our machine has a 5 s interscan time thus allowing normal respiration between scans. The six postcontrast images were obtained at 5 mm anatomical increments so that there was every chance of getting at least two satisfactory images of the septum. In some patients an attempt was made to align the plane of the scan to the long axis of the heart by gantry angulation after an initial lateral scanogram.Measurements of septal thickness were subsequently made with electronic calipers on the evaluation console. A standard window width (256 Hounsfield Units) was used for viewing. The level was then adjusted until the contrast medium in the chambers was in the middle of the grey scale (often around + 100 HU). ResultsThe