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Onchocerciasis was diagnosed when a skin biopsy specimen immersed in saline revealed microfiliariae. The patient was a 22-year-old student from Cameroon, West Africa, complaining of small, recurrent, pruritic papules on his thighs. Chemotherapy with ivermectin, an established antiparasitic agent with newly recognized anti-onchocercal potential, was well tolerated, and microfilariae were not detected in post-therapy skin biopsy specimens. The diagnosis of onchocerciasis should be entertained in individuals returning or emigrating from endemic areas.

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New therapies for vancomycin-resistant Enterococcus faecium (VREF) infections are urgently needed. We describe the treatment of 15 patients with VREF infection with quinupristin/dalfopristin (RP 59500), a new injectable streptogramin antibiotic. Primary infections treated were bacteremia (4), urinary tract (4), intraabdominal (5), otitis externa (1), and meningitis (1). Minimum inhibitory concentrations for quinupristin/dalfopristin ranged from 0.5 microgram/ml or less to 2 micrograms/ml, and minimum bactericidal concentrations were greater than 64 micrograms/ml for all VREF isolates tested. Peak serum inhibitory titers following infusion of quinupristin/dalfopristin ranged from 1:8 to 1:64; all bactericidal titers were less than 1:2. Development of resistance to quinupristin/dalfopristin during therapy was not observed. The only drug-related adverse effect noted was phlebitis in 4 patients; all had received quinupristin/dalfopristin by peripheral venous infusion. Three patients had clinical and bacteriologic cures. Relapses occurred in 5 patients with recovery of VREF from infected sites in post-treatment cultures. Ten patients died of severe underlying disease; VREF was believed to contribute directly to the death of only 1 patient. While evaluation of clinical efficacy was complicated by the severity of underlying disease in patients with VREF infection, our experience suggests that quinupristin/dalfopristin is a safe and potentially useful agent for the treatment of VREF infections.

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Septicemia due to Pseudomonas putrefaciens was found in an elderly man with chronic leg ulcers. This organism is rarely cultured from human material and has been reported to cause skin and ear infections in only a few patients. Its potential for invasiveness is documented in this case for the fourth time.

IS6110-Based PCR Methods for Detection of Mycobacterium tuberculosis Kent et al. (3) detected Mycobacterium tuberculosis by a nested PCR test that amplified a 181-bp target located in insertion sequence IS6110, but they also encountered many false-positive results when the test was applied to isolates of mycobacteria that do not belong to the M. tuberculosis complex. Because the investigators attributed the false positives to homology between IS6110 and genomic DNA of the other mycobacterial species, they warned that false-positive PCR results could be a problem with some IS6110-based methods for detection of M. tuberculosis complex. Our recent experience in using IS6110-based amplifications for detection of M. tuberculosis complex is informative on this issue. We selected two such amplifications that others had developed, with respective 123-bp (2) and 317-bp (1, 4) targets, and after slightly modifying the procedures incorporated them into a dual-PCR clinical protocol that we applied to mycobacterial colonies grown on Löwenstein-Jensen or Middlebrook 7H11 medium. The modifications that we made included use of dUTP (rather than dTTP) in both reaction mixes and use of a cycling program that was the same for both amplfications (30 cycles; cycle 1: 94ЊC for 5 min, 68ЊC for 45 s, 72ЊC for 90 s; cycles 2 through 30: 94ЊC for 45 s, 68ЊC for 45 s, 72ЊC for 90 s). The two amplifications were performed in separate tubes in a single thermal-cycler run, and the two amplified products were then electrophoresed in separate lanes of the same ethidium bromide-stained 2% agarose gel. In initial validation studies and in subsequent routine clinical examinations, we used this dual-PCR procedure in blindly testing 116 mycobacterial isolates, all of which were also identified to the species (or complex) level by the Mycobacteriology Laboratory of the New Jersey State Department of Health on the basis of their colony characteristics, chemical reactions, patterns shown on highpressure liquid chromatography, and DNA-rRNA hybridizations. The results produced by the dual-PCR procedure and the final identifications by the state laboratory were in total agreement for all 116 isolates: they were positive for M. tuberculosis complex in 46 cases and negative in the remaining 70. Identifications made by the state laboratory on the 70 isolates negative for M. tuberculosis complex were as follows: M. avium-M. intracellulare complex, 50; M. xenopi, 7; M. gordonae, 7; M. fortuitum, 5; and M. kansasii, 1. (In the entire series of 116 cultures, there was a single specimen for which the initial PCR results were discrepant, i.e., the 123-bp target was amplified but the 317-bp target was not. An advantage of the dual-PCR approach was demonstrated in th is case, in that duplicate repeats with the two sets of applicable primer pairs produced amplification of both targets, thus identifying the culture as positive for M. tuberculosis complex. This diagnosis was later confirmed by the state laboratory.) Kent et al.'s call for careful validation of any IS61...