CORRESPONDENCE

and glutathione. Forty percent of Japanese patients with insulin autoimmune syndrome had tak- en medication such as sulfhydryl compounds [9].

YASUKO UCHIGATA, 10. YUKIMASA HIRATA, MB.

YASUE OMORI, M.D. Tokyo Women’s Medical College

Tokyo, Japan 1. Lurch HB, Clement S, Sokol MS, Lanclry F. Reac-

tive hypoglycemic coma due to insulin autoimmune

syndrome: case report and literature review. Am J

Med 1992; 92: 681-5.

2. Hirata Y, lshiizu H, Ouchi N, et al. Insulin autoim-

munity in a case of spontaneous hypoglycemia. J

Jpn Diabetes Sot 1970; 13: 312-20.

3. Hirata Y. Arimichi M. Insulin autoimmune syndro-

me-the second case. J Jpn Diabetes Sot 1972;

15: 187-92.

4. WasadaT, EguchiY.TakayamaS.YaoK. HirataY.

lshi S. Insulin autoimmune syndrome associated

with benign monoclonal gammopathy. Diabetes

Care 1989; 12: 147-50.

5. Uchigata Y, Yao K, Takayama-Hasumi S, Hirata Y.

Human monoclonal lgG1 insulin autoantibody from

insulin autoimmune syndrome directed at determi-

nant at asparagine site on insulin B-chain. Diabetes

1989: 38: 663-6.

6. Uchigata Y. Takayama-Hasumi S. Hirata Y. In-

ducement of antibody that mimics insulin action on

insulin receptor by insulin autoantibody directed at

determinant at asparagine site on human insulin B

chain. Diabetes 1991; 40: 966-70. 7. Uchiita Y. Eguchi Y, Takayama-Hasumi S, Hir-

ata Y. The immunoglobulin class, the subclass and

the ratio of k:X lit chain of autoantibodies to hu-

man insulin in insulin autoimmune syndrome. Auto-

immunity 1989; 3: 289-97.

6. Uchiita Y. Kuwata S, Tokunaga K. et a/. Strong

association of insulin autoimmune syndrome with

HLA-DR4. Lancet 1992; 339: 393-4.

9. Hirata Y, Uchigata Y, Eguchi Y, Takayama-Ha-

sumi S. Omori Y. Clinical characteristics of 190 pa-

tients with insulin autoimmune syndrome in Japa-

nese. Manuscript in preparation.

10. lnoko et al. Central data analysis. In: Tsuji et al.

HLA 1991. Vol 1 or Vol2. New York: Oxford Universi-

ty Press (in press).

11. Wasada T. Eguchi Y, Takayama S, Yao K. Hirata

Y. RP-HPLC analysis of circulating insulin in the insu-

lin autoimmune syndrome. J Clin Endocrinol Metab

1988; 66: 153-8.

Submitted August 20. 1992, and accepted in

revised form September 28, 1992

RENAL ASPERGILLOMA IN AIDS

To the Editor: We were interested in the report by Halpern et al [l] describing the occurrence of an isolated re-

Figure 1. CT scan of the abdomen upon admission of the patient.

Figure 2. Photomicrograph of the excised kidney showing the presence of fiia-

ments of A. fumigatus (Gomori-Grocott stain).

nal aspergilloma in a patient with the acquired immunodeficiency syndrome (AIDS). We have re- cently observed a similar case in a 30-year-old non-intravenous drug user. Pneumocystis carinii pneumonitis had been the initial presentation of AIDS in this pa- tient 9 months prior to the onset of fever and hematuria, without lumbar pain. The computed tomographic (CT) scan revealed a large abscess of the upper pole of the right kidney with peri- nephretic extension (Figure 1).

A nephrectomy was performed, which was followed by apyrexia and improvement of accompany- ing general symptoms. Analysis of pus identified the presence of Aspergillus fumigatus (Gomori- Grocott stain) (Figure 2). The same fungus was found in the sputum, although there were no signs of pulmonary involvement on thoracic radiograph and CT scan. The patient was treated with 400 mg/d of itraconazole. No fungicidal plasma concentrations were achieved with this dose, nor

May 1993 The American Journal of Medicine Volume 94 957

CORRESPONDENCE

with escalating doses of the drug of 600,800, and 1,000 mg/d. One month after surgery, the CT scan showed the presence of a fluid collection in the right renal bed. The patient had fever, weight loss, and pain; multiple fistulas developed at the site of the ne- phrectomy incision. The culture grew A. fumigutw. Local irriga- tions with amphotericin B were performed for 6 weeks without any improvement. Administra- tion of intravenous amphotericin B was then started and itracona- zole was discontinued. The pa- tient has now been treated with 1 mg/kg/d of amphotericin B for 3 weeks. His condition remains poor.

After the preliminary report of Salomon et al [2] and the article by Halpern et al [l], this is the third report of an isolated renal aspergilloma complicating the course of AIDS. Our observations emphasize the need for monitor- ing the fungicidal levels of itra- conaxole and suggest that thera- peutic concentrations of the drug may be difficult to reach in pa- tients with AIDS, possibly be- cause of decreased absorption of the drug secondary to gastric hy- pochlorhydria [3]. The time of nephrectomy may not be as im- portant in this rare complication of AIDS as actually achieving ef- ficient concentrations of antifun- gal drugs in plasma.

CHRISTOPHE PIKETTY, M.D. FRANCOISE GEORGE. M.D.

LAURENCE WEISS; M.D. VERONIQUE LAVARDE, M.D.

ANNE HERNIGOU, M.D. MICHEL D. KAZATCHKINE, M.D.

Hopital Broussais Paris, France

1. Halpem M, Szabo S, Hochberg E, et a/. Renal

aspergilloma: an unusual cause of infection in a pa-

tient with the acquired immunodeficiency syn-

drome. Am J Med 1992; 92: 437-40

2. Salomon N, Penman DC, Salztman BR, et al. In-

vasive aspergillosis in AIDS: clinical manifestations

and predisposing factors [abstract]. International

Conference on AIDS, 1989; 5: 236.

3. Aouizerat J. Pradier C. Montoya M, eta/. Hypoch-

lorhydria and HlVinfection [abstract]. Third Europe-

an Conference on Clinical Aspects and Treatment of

HIV Infection, 1992: 184.

Submitted May 25, 1992. and accepted in revised

form October 26, 1992

ACKNOWLEDGMENT: We thank Dr. E. Baviera for

making the histopathologic material available.

ASSOCIATION OF INFLAMMATORY BOWEL DISEASE AND BACTERIAL ENDOCARDlTlS

To the Editor: Kreuzpaintner and co-workers [l] report that among 213 pa- tients with native valve endocar- ditis, 6 had active inflammatory bowel disease. They postulate a “44-fold overrepresentation of inflammatory bowel disease” in this group of patients with endo- carditis. I reviewed 95 consecu- tive patients with native valve endocarditis seen at our institu- tion, in a search for antecedent gastrointestinal instrumentation [2]. These patients were also re- viewed for concomitant condi- tions that would make them more susceptible to endocarditis; 56% had known heart lesions, and 32% had events that could cause bac- teremia within 2 months of endo- carditis (including two cases with fiberoptic sigmoidoscopy, one of which was associated with multi- ple additional events capable of causing bacteremia, but the other of which seems likely to have re- sulted from endoscopy [3]). None of the 95 patients had inflamma- tory bowel disease.

These data do not support Kreuzpaintner and colleagues’ thesis that patients with inflam- matory bowel disease are prone to endocarditis. I would like to point out to your readers that the American Heart Association has substantially revised [4] their recommendations since the 1984 reference cited by Kreuxpaintner et al.

Further data are needed before it can be concluded that patients with active inflammatory bowel disease are more susceptible to and need special attention against infectious endocarditis.

ROBERT G. NORFLEET, M.D. Marshfield Clinic

Marshfield, Wisconsin

1. Kreuzpaintner G. Horstkotte D. Heyll A, L&se B,

Strohmeyer G. Increased risk of bacterial endocar-

ditis in inflammatory bowel disease. Am J Med

1992; 92: 391-5.

2. Norfleet RG. Infective endocarditis and infections

of orthopedic and vascular prosthesis followinggas-

trointestinal endoscopy and dilation [letter]. Gas-

trointest Endosc 1990; 36: 546-7.

3. Norfleet RG. Infectious endocarditis after fiberop-

tic sigmoidoscopy: with a literature review. J Clin

Gastroenterol 1991; 13: 448-51. 4. Dajani AS, Bisno AL, Chung KJ, eta/. Prevention

of bacterial endocarditis: recommendations by the

American Heart Association. JAMA 1990; 264:

2919-22.

Submitted June 5, 1992, and accepted November

16, 1992

The Reply: As has been pointed out in our article [l], the true coincidence between infective endocarditis and inflammatory bowel disease as well as colorectal tumors is completely unknown so far and may only be calculated from large epidemiologic studies. Bacter- emia is an essential condition for the development of infective en- docarditis. An increased inci- dence of bacteremia and conse- quent infective endocarditis in patients with inflammatory bow- el disease can easily be under- stood and may be supported by our recent findings.

Therefore, inflammatory bow- el disease may be considered an independent risk factor for bac- terial endocarditis. This hypoth- esis was examined by investiga- tion of bacteremia during colon- oscopy in three different groups of patients. These were patients with active (n = 5; mean age f SD = 33 f 11 years; range, 22 to 48 years) or inactive (n = 9; mean age f SD = 39 f 12 years; range, 23 to 59 years) inflammatory

558 May 1993 The American Journal of Medlclne Volume 94