A case of severe cytomegalovirus infection after the repair of coarctation of aorta

We report a 2-month-old boy without any immuno-compromised diseases, who suffered from the severe cytomegalovirus (CMV) infection after the subclavian flap aortoplasty and pulmonary artery banding for coarctation complex. He underwent the operation at 2 months old and received 2 units of irradiated packed red blood cells before and after the surgery. His postoperative course was uneventful but the interstitial pneumonitis, until he developed watery diarrhea 10 days after the surgery following hepatitis with the marked hepatomegaly 3 weeks after. Since CMV infection was confirmed as the cause of the pneumonitis, enterocolitis and hepatitis, he was initially treated by gamma-globulin with the high CMV titer at a dose of 200 mg/kg/day for 2 days and ganciclovir at a dose of 10 mg/kg/day for 14 days. Because of the persistent CMV infection, he needed two more treatments of ganciclovir at the same dosage and gamma-globulin once a week for 2 months. He finally recovered from severe CMV infection 5 months after the above treatments. In conclusion, the severe CMV infection can occur by blood transfusion even in the surgical case with normal immune system. If one finds pneumonitis, hepatitis or enterocolitis after any type of surgery with history of blood transfusion, CMV infection should be suspected as the cause of these diseases.     

Radiolabelled monoclonal antibodies (McAb): an alternate approach to the conventional methods for the assessment of cardiomyocyte damage in an experimental brain-death pig model

BACKGROUND: According to the Ministry of Health and Welfare AIDS Surveillance Committee's report on vertically transmitted human immunodeficiency virus (HIV) infection, there have been eight children with acquired immune deficiency syndrome (AIDS) and 18 children with HIV infection in Japan, totalling 26 in all as of February 1997. A search of the literature fails to reveal any report that deals with many cases of vertically transmitted HIV infection in Japan. METHODS: A primary questionnaire survey was taken of the main medical institutions across the country, followed by a secondary questionnaire survey of physicians and pediatricians who treated the disease. A clinical review was made of 19 children with vertically transmitted HIV infection (including eight AIDS children) according to the 1994 Revised Classification System for HIV Infection in Children. RESULTS: The mean age at diagnosis was 14.5 months and the diagnosis was made at less than 18 months of life in approximately 70% of infected children. In the mean observation period of 16 months, six of eight AIDS children (75%), and one child of group B died. The mean period of observation for the seven dead children was 7 months, and six of seven children died by 36 months of life. The survival period after the diagnosis of AIDS was 15 months. The diagnosis of HIV infection was made based on the clinical symptoms of all children with AIDS. Of 11 children, six (45%) presented with symptoms of HIV infection by 6 months of life, and 10 of 11 children (91%) presented with symptoms by 26 months of life. The noteworthy clinical findings included hepatomegaly, splenomegaly, recurrent respiratory tract infection, lymph node swelling, oral candidiasis, hepatitis, wasting syndrome, HIV encephalopathy and severe pneumonia. The favored age for the start of complications and the magnitude of decrease in the HIV helper cell count varied with each case of complications of HIV infection (wasting syndrome, HIV encephalopathy) or opportunistic infections (cytomegalovirus infection, Mycobacterium avium complex infection). Anti-HIV drugs (mainly zidovudine) had been used in five of eight children with AIDS and were effective in two long survivors alone. CONCLUSIONS: Children who are diagnosed with HIV infection, based on their clinical symptoms, carry a poor prognosis. In this respect, early diagnosis and progress in anti-HIV therapy are necessary.     

Manifestation of the Wolff-Parkinson-White syndrome during isoprenaline infusion and carotid sinus massage

Fully susceptible cross-bred calves, six to nine months of age, were immunised by tick-induced Theileria annulata infection treated with chlortetracycline at 16 mg/kg body weight for four, eight or 16 days. The infections were induced with 10 ticks (Hyalomma anatolicum anatolicum) or 30 ticks (H dromedarii). The recovered calves were tested for immunity to homologous severe challenge, 50 or 73 days after the first infection. The reaction of the calves to infections was evaluated by noting the prepatent period, symptoms, degree of anaemia, rate of parasitisation of lymphocytes and erythrocytes. It was observed that untreated calves developed acute theileriasis characterised by typical symptoms and lesions and 56 to 66 per cent mortality. The medicated calves, however, developed a mild form of the disease. Calves which recovered from treated or untreated infections were solidly resistant to subsequent severe homologous infection. Judged from the severity of anaemia in the infected calves, eight day and 16 day medication provided slightly better protection than four day medication. It was concluded that eight day medication afforded adequate protection against the severe immunising infection, and allowed the development of solid resistance to severe homologous challenge.     

Diethylstilbestrol in beef production: what is the risk to consumers?

Acute measles encephalitis with severe sequelae in a 25-year-old man was studied. A transient appearance of oligoclonal IgG in cerebrospinal fluid and of intrathecally produced measles antibodies was found during 2 months after the onset of the disease. On the basis of this finding of local hyperimmunization it is proposed that in the case studied the measles virus infection may have been directly responsible for the disease process in the central nervous system.     

Lamivudine treatment for chronic replicative hepatitis B virus infection after allogeneic bone marrow transplantation

The risk of severe hepatic damage in patients with chronic hepatitis B virus (HBV) infection is well known; more effective treatments for this infection are needed. Lamivudine is being studied in immunocompetent and immunosuppressed HBV infected patients. We report a patient suffering from chronic replicative HBV infection after allogeneic BMT, who responded to lamivudine therapy. A 24-year-old woman with CML received an allogeneic BMT from her HLA-identical sister in June 1992. Before transplant, her HBV status demonstrated viral contact without active infection (HBsAb+, HBcAb+ IgG, HBeAb+). Four months after BMT mild chronic liver GVHD appeared, requiring immunosuppressive treatment. Antibodies to HBV completely disappeared post-transplant. Acute icteric hepatitis occurred 2 years later, with HBsAg+, high level of HBV-DNA, HBeAg+ and HBcAb IgM+. Lamivudine 100 mg/day rapidly reduced transaminase levels and effected HBV-DNA disappearance within 2 months. The treatment was well tolerated; no hematological side-effects occurred. This preliminary observation warrants further investigation of lamivudine treatment in bone marrow transplanted patients with active HBV infection.     

Development of Helicobacter pylori-induced gastric carcinoma in Mongolian gerbils

Helicobacter pylori is classified by IARC/WHO as a definite human gastric carcinogen, despite "inadequate experimental evidence." To obtain direct evidence concerning this relationship, we investigated the histopathological findings of gastric mucosa using a model of H. pylori infection in Mongolian gerbils. The animals were challenged p.o. with H. pylori ATCC-43504 and sacrificed at 6, 12, and 18 months after inoculation for histological examination. All inoculated animals were infected with H. pylori. Severe infiltration of the lamina propria by polymorphonuclear and mononuclear cells appeared in the lesser curvature of the antrum, with an increase in epithelial cell proliferation, and the infiltration extended to the body. Atrophic gastritis and focal intestinal metaplasia also appeared in the lesser curvature of the antral mucosa at 6 months after inoculation. Intestinal metaplasia became severe, with dysplasia, after that. At 18 months after H. pylori inoculation, two of five infected animals showed three well-differentiated gastric cancers. The uninfected control animals showed no abnormal findings throughout the entire observation period. Here, it was confirmed that H. pylori infection alone causes gastric cancer in an animal model.     

A simlified doppler-angiography apparatus for noninvasive diagnosis of carotid stenosis (author''s transl)

Spermiograms of 46 patients were examined 8 days, 4 weeks, 3 months, 6 months and 1 year after acute unilateral non-specific epididymitis. The treatment consisted in 24 cases besides antibiotic treatment with doxycycline in local infiltrations of the spermatic cord with 1% Scandicain solution. Primarily there was found an inhibiting effect on spermatogenesis. In more than 2/3 of the cases a varying oligoasthenospermia was shown 8 days after beginning of the infection. In the further course this disturbance of fertility improves; if local infiltration of the spermatic cord with 1% Scandicain solution is performed, the improvement is more evident. Still, there remain about 20% of the cases in which the fertility disturbance is so severe, that sterility results. One year after the beginning of the infection spermagglutinating antibodies could be shown only in 1 case. The seminal fluid fructose was controlled over 1 year following the beginning of infection and found to be normal in all cases.     

Neuronal activity in MST and STPp, but not MT changes systematically with stimulus-independent decisions

Recurrent infection with hepatitis C virus (HCV) is almost universal following orthotopic liver transplantation although clinical severity varies. Data on 135 patients who underwent transplantation for hepatitis C cirrhosis were reviewed. We describe a progressive, severe cholestatic form of hepatitis occurring in a subgroup of patients with recurrent hepatitis C. Ten patients with severe recurrent hepatitis C were identified; 1 has died, 1 awaits retransplantation, and 8 have undergone retransplantation. All 10 developed severe progressive cholestatic hepatitis, with a mean rise in bilirubin to 24.7 mg/dL at the time of retransplantation. Histology at initial recurrence was of mild hepatitis without evidence of rejection. The failed grafts showed either cirrhosis or confluent hepatic necrosis. The onset of cholestasis preceded retransplantation by less than 5 months. Our study suggests that a minority of patients with recurrent hepatitis C after undergoing liver transplantation develop a severe progressive cholestatic hepatitis and liver failure.     

Cytomegalovirus retinitis in a pediatric AIDS patient

INTRODUCTION: Cytomegalovirus retinitis (CMV) is the most frequently found opportunistic eye infection in adults with AIDS, with mean incidence of 20%-50%. However, only 5% of children with AIDS have this infection. CLINICAL CASE: We present the case of a six year old girl with stage C3 AIDS diagnosed at the age of 20 months, who developed unilateral diffuse retinitis due to CMV. The infection involved the posterior pole of the right eye, with retinal atrophy along the temporal vascular arcodes, and an active advance front in the temporal macula. The optic nerve was not found to be involved although the peripheral areas of the retina were involved leading to rhegmatogenous detachment of the superotemporal retina. In view of the systemic deterioration of the patient, no specific anti-CMV treatment was given. The patient died of respiratory insufficiency a few weeks later. CONCLUSIONS: CMV retinitis in paediatric AIDS patients is usually associated with more severe illness and a poorer general health than the adult population. In view of the absence of symptoms in these patients, periodic ophthalmoscopic examinations should be done in those who have severe immunological deterioration.     

Computer analysis of breast cancer thermograms

3 groups of female children, comprising a total of 169 patients, were followed through successive episodes of urinary tract infection with respect to recurrence of infection. Group A consisted of 66 patients with no evidence of vesico-ureteral reflux. Group B comprised 42 patients with demonstrated vesico-ureteral reflux. The infections in these patients were treated with medical therapy alone and the reflux was not corrected. Group C consisted of 61 children who had surgical correction of vesico-ureteral reflux. While Groups B and C were not strictly comparable, the data indicate that there was no demonstrable difference in the rate of urinary tract infection among the 3 groups. Following short-term specific antibacterial therapy of a new infection, about 20% of children in each group were "cured", i.e., had no further infections during the 12 months or more that they were subsequently followed by the authors. Patients with less severe grades of reflux treated by medication alone (Group B) experienced no greater rate of reinfection than those children presenting with infections in the absence of vesico-ureteral reflux. In those children whose infections could not be adequately controlled by antimicrobial therapy, and those patients with severe (Grade III) reflux, surgery was performed to eliminate the vesico-ureteral reflux. The data also reinforced the concept that correction of reflux does not eliminate the need for constant vigilance and proper treatment of recurrent infections even after successful surgery has been carried out.     

Epidemiology of respiratory syncytial virus infection requiring hospitalization in East Denmark

BACKGROUND: Prophylaxis against infection caused by respiratory syncytial virus (RSV) with high titered RSV immunoglobulin or humanized antibody may soon be available in Europe. OBJECTIVE: To study the epidemiology of RSV infections requiring hospitalization in infants <6 months in East Denmark to provide a rational basis for decisions concerning prophylaxis against RSV. METHOD: Populat ion-based retrospective review of case records of infants <6 months admitted to pediatric departments with RSV infection in East Denmark from November 1, 1995, to April 30, 1996. RESULTS: Data were obtained from 459 infants. Seventy-three had predisposing conditions: prematurity, 49; pulmonary disease, 2; congenital heart disease, 7; neurologic disease, 6; others, 9. One preterm infant had bronchopulmonary dysplasia. The incidence of RSV infection requiring hospitalization in East Denmark among infants <6 months was estimated to be 34/1000/season. It was 32/1000/season among term infants and 66/ 1000/season among preterm infants (P<0.001). Infants with predisposing conditions and/or nosocomial infection (n = 24) had significantly more severe courses than otherwise healthy infants (P<0.01). One-hundred thirty infants received respiratory support by nasal continuous positive airway pressure, but only six required mechanical ventilation. No infants died. CONCLUSION: The course of RSV disease in East Denmark was milder than reported elsewhere, possibly as a result of the low prevalence of bronchopulmonary dysplasia in Denmark. However, RSV constitutes a considerable burden to the Danish pediatric health care system, and therefore prophylaxis against RSV is desirable.     

Neuropsychiatric manifestations of Lyme disease

Lyme disease is a multisystem illness that may affect the central nervous system and subsequently produce mild to severe psychiatric disorders. Physicians who treat patient with Lyme disease need to be aware of its neuropsychiatric symptoms, which may emerge months to years after the initial infection. Prompt diagnosis and effective treatment are needed to avoid the debilitating and possibly irreversible mental illness associated with the neurologic involvement of this spirochetal infection. The author reviews the neuropsychiatric manifestations of Lyme disease and provides diagnostic and therapeutic approaches for the management of the central nervous system disease that may cause them.     

A diagnostic practice study using international classification of epilepsies and epileptic syndromes in 302 cases

A 14-year-old girl who had beta-thalassemia hemoglobin E disease was infected by bacteriologically proven non-01 Vibrio cholerae at 2 months postsplenectomy and died 37 hours after onset of the malady. Postmortem examination disclosed congestion, edema, and hemorrhagic foci of the mucosa of the small and large intestines. The gut mucosa was focally eroded. The gut wall was infiltrated by leucocytes, especially neutrophils, in all coats representing acute purulent and hemorrhagic enterocolitis. There was hyperplasia of lymphoid follicles in the gut mucosa and lymph nodes. It is suggested that morphologic change of the gut in non-01 Vibrio cholerae infection is more severe than in infection caused by Vibrio cholerae.     

Invasive streptococcal infection as a complication of chickenpox

Two girls aged 11 months and 6 years, presented with an invasive group A streptococcal (GAS) infection during the course of primary varicella. The infant had severe cellulitis of the left arm and leg, fever and bacteraemia. She developed osteomyelitis of ulna and tibia. The 6-year-old girl had a fever > 38.5 degrees C, hypotension, an acute respiratory distress syndrome, liver function abnormalities, and positive cultures of blood and joints. Her clinical picture was compatible with a GAS-associated toxic shock syndrome. If during the course of primary varicella persistent fever, secondary fever or pain in one or more extremities occurs, invasive bacterial infection by GAS or Staphylococcus aureus should be considered, even in the absence of skin infection or cellulitis.     

Serologic evolution of neurocysticercosis patients after antiparasitic therapy. Cysticercosis Working Group in Peru

Neurocysticercosis is the main cause of acquired epilepsy in developing countries and is an emerging disease in the United States. Introduction of the immunoblot assay provided a new tool for the diagnosis and monitoring of neurocysticercosis. This study analyzed the relationship between clinical characteristics of cerebral infection (number and type of lesions) plus the baseline response on immunoblot and the changes observed after therapy. Reaction to all 7 diagnostic bands was associated with severe infection (more lesions). Seventeen patients (35%) had no active lesions on computed tomography (CT) 3 months after therapy and were considered cured. Although most cured patients remained seropositive after 1 year, 3 became seronegative before 9 months. In these 3 cases, the lesions had resolved on CT at 3 months. Persistent seropositivity does not necessarily indicate active infection. Serologic follow-up will be clinically helpful only in rare cases in which early antibody disappearance occurs.     

Polymerase chain reaction amplification of Guthrie card deoxyribonucleic acid: extraction of nucleic acid from filter matrices

BACKGROUND: This study was designed to test the association of Chlamydia pneumoniae infection with asthma in a multi-racial population, after adjustments for several potential confounding variables. METHODS: Antibodies to C pneumoniae were measured by microimmunofluorescence in 123 patients with acute asthma, 1518 control subjects admitted to the same hospital with various non-cardiovascular, non-pulmonary disorders, and 46 patients with severe chronic asthma, including some with "brittle" asthma. Acute infection or reinfection was defined by titres of IgG of > or = 512 or IgM > or = 8 or a fourfold rise in IgG, and previous infection by IgG 64-256 or IgA > or = 8. Logistic regression was used to control for likely confounders, including ethnic origin, age, sex, smoking habit, steroid medication, diabetes mellitus and social deprivation, on antibody levels. RESULTS: Antibody titres consistent with acute C pneumoniae infection were found in 5.7% of patients with acute asthma and 5.7% of control patients, while 14.6% of patients with acute asthma and 12.7% of control patients had titres suggesting previous infection. These two groups did not differ significantly. However, titres suggesting previous infection were found in 34.8% of patients with severe chronic asthma: the difference between this group and the control group was statistically significant with an adjusted odds ratio of 3.99 (95% confidence interval 1.60 to 9.97). CONCLUSIONS: These data raise important questions about the previously demonstrated association of C pneumoniae infection with asthma, and suggest that future studies of this association should give particular attention to the presence or absence of a history of severe chronic asthma.     

Effect of splenectomy on HIV-related thrombocytopenia and progression of HIV infection in patients with severe haemophilia

Between May 1983 and September 1991 eleven patients with severe haemophilia underwent splenectomy for HIV-related thrombocytopenia. The sustained complete remission rate (platelets > 100 x 10(9)/l) was 82% over a mean follow-up period of 54 months. The group was compared with 22 age-matched non-thrombocytopenic HIV seropositive haemophiliacs who had not undergone splenectomy. Both groups had equivalent use of factor concentrate and there was no significant difference between the groups in terms of anti-retroviral treatment. Analysis of clinical progression of HIV infection and CD4 positive lymphocyte (CD4+) counts, for the time since splenectomy, revealed no significant difference in progression of HIV infection in the splenectomized group compared with the control group. It is concluded that splenectomy is an effective treatment for HIV-related thrombocytopenia and has no adverse effect on the progression of HIV infection.     

Are there potential non-lipid-lowering uses of statins?

Portal circulation can be evaluated in a relatively noninvasive way by per-rectal portal scintigraphy. We used this method to evaluate portal hemodynamics in patients with chronic liver diseases and underlying hepatic viral infection; the patients did not need surgery or sclerotherapy, or refused it, so changes in the natural course were identified. A solution of Tc-99m pertechnetate was instilled into the rectum, and serial scintigrams were taken while radioactivity curves for the liver and heart were produced. The per-rectal portal shunt index was calculated from the curves. In a longitudinal study, 70 patients (9 with mild chronic hepatitis, 10 with moderate chronic hepatitis, 7 with severe chronic hepatitis, 22 with cirrhosis but without varices, and 22 with both cirrhosis and varices) were examined at least twice at intervals of 12-102 months (mean, 39 months). The shunt index was higher for more severe disorders, increasing in the order of mild chronic hepatitis, moderate chronic hepatitis, severe chronic hepatitis, cirrhosis without varices, and cirrhosis with varices. The mean annual changes in the mean shunt index were 1.0% in mild chronic hepatitis, 4.4% in moderate chronic hepatitis, 6.1% in severe chronic hepatitis, 10.7% in cirrhosis without varices, and 6.2% in cirrhosis and varices. Cirrhotic patients were arbitrarily divided into two groups of roughly equal size on the basis of the shunt index at the first examination. In those with a shunt index of 30% or more, the mean annual change was 4.7%. The patients with a shunt index of less than 30% had a mean annual change of 11.8%. Changes in the portal hemodynamics were not steady. The shunt index rose gradually as disease advanced from mild to moderate and to severe chronic hepatitis and cirrhosis of the liver, after which the index rose rapidly when varices developed, slowing later.     

Psoriatic arthritis: case report of acute HLA-B27 positive polyarthritis preceding the onset of typical skin changes

Psoriasis usually occurs many years before development of arthritis. This is a case report of a patient with acute polyarthritis affecting both peripheral joints and the left sacroiliac joint, preceding the appearance of typical skin manifestations for almost two months. A 44-year-old male mechanic was admitted to our institution for acute additive polyarthritis. Inflammatory synovitis primarily affected large peripheral joints (knees, ankles) in an asymmetrical pattern, with a concomitant development of unilateral sacroiliitis and later with asymmetrical involvement of several proximal and distal interphalangeal joints of the hands and feet. There were also signs of enthesopathy of the right heel. Arthritis was not proceeded by infection of the lower genital or gastrointestinal tract or serological and bacteriological evidences of streptococcal or HIV infection. Laboratory findings showed an erythrocyte sedimentation rate (92 in the first hour), positive histocompatibility antigen HLA-B27 and an increased level of acute phase reactants. Almost two months after affecting the locomotor system a typical psoriatic rash developed, first affecting the scalp and then spreading over the trunk and extremities. It was accompanied by severe onychodystrophy. The patient underwent intensive treatment with methylprednisolone (1.5 mg/kg) and cyclosporine A with significant results.