1 despite a 21-year search for a diagnosis, the patient's illness remains hazy. The diagnosis is most obviously hereditary coproporphyria. The patient and her brother were both affected.The patient had a 21-year history of recurrent abdominal pain, with neither clinical nor surgical peritonitis and in the absence of remarkable sequelae. There was evidence of autonomic disturbances: a rapid pulse, an episode of urinary retention, and decreased peristalsis with dilated loops on a plain film of the abdomen. There was also evidence of neuropsychiatric phenomena: anxiety, myalgia, and an episode of transient hemianopia, a form of focal seizure, and a postictal headache, which was misinterpreted as a conversion reaction. There was a history of intolerance of amitriptyline, isoniazid, and rifampin, which are considered unsafe in patients with porphyria. The coincidental findings of dry cough and splenomegaly probably amount to a red herring and did not contribute to the patient's illness.Several quantitative tests of spot urine samples from the patient revealed a threefold to fivefold elevation in the level of porphobilinogen, and her brother had a value that was at the upper limit of the normal range. Coproporphyrin III excretion in feces and coproporphyrinogen oxidase in leukocytes and cultured skin fibroblasts were not assayed. The erythrocyte porphobilinogen deaminase activity was normal, as one would have predicted, since it is characteristically normal in patients with hereditary coproporphyria. 2 M ARWAN S. A KASHEH , M.D. Amman, Jordan P.O. Box 9668 Instructions for Letters to the Editor Letters to the Editor are considered for publication (subject to editing and abridgment), provided they are submitted in duplicate, are typewritten and triple-spaced, and do not exceed 400 words of text, a maximum of five references, and one figure or table. Letters should have no more than three authors, and all should sign the letter. Please include a word count, your telephone number, and your fax number (if available).Letters should not duplicate similar material being submitted or published elsewhere, and they should not contain abbreviations. Financial associations or other possible conflicts of interest should always be disclosed. Submission of a letter constitutes permission for the Massachusetts Medical Society, its licensees, and its assignees to use it in the Journal 's various editions (print, data base, and optical disk), in anthologies, revisions, and any other form or medium.Letters referring to a recent Journal article must be received within four weeks of the article's publication. To expedite receipt of such letters, we encourage authors outside the United States to communicate by fax (617-739-9864 or 617-734-4457).We are unable to provide prepublication proofs, and unpublished material will not be returned to authors unless a stamped, self-addressed envelope is enclosed. Receipt of letters is not acknowledged, but correspondents will be notified when a decision is made.

Among the adhesin-encoding virulence operons associated with uropathogenic Escherichia coli, only pap (pyelonephritis-associated pilus)-related gene clusters typically exhibit variation in their structure and chromosomal copy number. To access further such variability, we compared pap restriction fragment length polymorphisms (RFLPs) with those detected among rRNA (rrn) operons, which encode an essential host function unrelated to virulence. To place such findings in a phylogenetic perspective, the E. coli isolates were also characterized by using multilocus enzyme electrophoresis. Variation in the rrn RFLP profiles correlated with evolutionary divergence resolved by multilocus enzyme electrophoresis; isolates with identical rrn profiles represented the same or closely related electrophoretic types. In contrast, such isolates frequently had different pap-related RFLPs, indicating that these genetic variations have developed recently relative to the changes associated with essential rrn operons or metabolic enzymes. Despite such fluctuations, two lines of evidence indicate conditions under which the pap-related RFLPs can be stably maintained. First, for each of 20 patients with urosepsis, both the primary urinary tract isolate and the concurrent blood isolate were identical. Second, although obtained from different patients, some isolates representing the same electrophoretic type also had identical pap-related RFLPs. Thus, the genotypic diversity of this virulence adhesin operon was not generated during the course of acute infection or during laboratory manipulations. Since fecal E. coli isolates frequently carry chromosomally encoded pap-related gene clusters, these findings suggest that the intraand interchromosomal recombination events generating the polymorphisms associated with the pap-related sequences likely occur among the E. coli of the commensal reservoir.Escherichia coli cause the substantial majority of urinary tract infections (33). As a group, such uropathogenic isolates exhibit properties that are not prevalent among commensal E. coli isolates found in the intestinal flora (40). Prominent among these phenotypes is the expression of adhesins that mediate bacterial attachment to the human uroepithelium and thereby confer a selective advantage in ascending colonization of the upper urinary tract by allowing the bacteria to resist the cleansing effect of urine flow in the ureters (29). pap (pyelonephritis-associated pili) and prs (pap-related sequence) are two structurally and functionally related operon clusters that have been cloned from E. coli J96 and shown to express adhesin pili (9,21,22). pap encodes a P-fimbrial adhesin that specifically recognizes the globoseries of glycolipids present on both human erythrocytes bearing the P blood group antigen and uroepithelial cells (19,21,22). prs encodes an F adhesin that preferentially binds to the Forsmann antigen, which is a major constituent of sheep erythrocyte membranes and is also present on the cells of the human renal pelvis (21,22).In a recent s...

Although Streptococcus pneumoniae remains the most common cause of community-acquired bacterial pneumonia, its involvement in skin infection is notably infrequent. A review of the literature uncovered only 13 cases of pneumococcal cellulitis in adults. Distinguishing features of skin infection by S. pneumoniae included the presence of bullae, brawny erythema, and a violaceous hue in the affected skin area. Most patients with pneumococcal cellulitis had chronic illnesses or were immunocompromised because of drug or alcohol abuse. Even with appropriate antimicrobial therapy, many patients required prolonged hospitalizations and surgery for cure. We report a case of primary pneumococcal cellulitis with secondary bacteremia in an alcoholic patient who required extensive surgical therapy and whose course was additionally complicated by acute glomerulonephritis.

Fluconazole, a triazole compound with potent activity against many medically important fungi, undergoes rapid oral absorption, and has been shown in healthy volunteers to exhibit virtually complete bioavailability. The purpose of this study is to evaluate the bioavailability of fluconazole administered via a feeding tube with concomitant enteral feeds in intensive care unit patients. Once prescribed by the attending physician, fluconazole was administered either as an intravenous infusion over 1 h or the tablet was crushed and given via a feeding tube with concomitant enteral feeds. Once blood samples were obtained (not before the fifth dose) of the first regimen, the patient could be switched over to the alternate route and blood samples were again obtained after at least five doses. All patients had normal gastrointestinal motility, normal renal, and hepatic function. Serum concentrations were determined by a validated HPLC method. The area under concentration-time curve (AUC) was calculated using the trapezoidal rule; bioavailability was determined from the ratio of AUC(tube)/AUC(intravenous). The bioavailability for five patients was calculated to be 97.2 +/- 9.8%. Fluconazole retained excellent bioavailability when crushed and administered via a feeding tube with or without concomitant enteral feeding in critically ill patients. This alternative route of administration promotes cost savings and decreases the chance for secondary infection from indwelling intravenous catheters.