Resolution of multiply recurrent and multifocal diverticulitis after fecal microbiota transplantation.

BACKGROUND: The exact pathophysiology of diverticulitis is not well understood and may be multifactorial. Recent studies highlight dysbiosis as a plausible mechanism. FMT is a safe strategy to restore commensal colon microbiota and has proven to be an effective treatment for gastrointestinal dysbiosis such as Clostridium difficile infection (CDI). There have been no studies reporting the treatment of diverticulitis with FMT. Our aim was to describe the novel application of fecal microbiota transplantation (FMT) for the treatment of recurrent diverticulitis. CASE: We report a case of a 63-year-old woman who had a 13-year history of multiply recurrent and multifocal diverticulitis previously treated with numerous short courses of intravenous and oral antibiotics for acute flares, two segmental colon resections, and suppressive antibiotic therapy for recurrent disease. Secondary to multiple courses of antibiotics , the patient developed CDI. She was treated with a single round of FMT and subsequently stopped all antibiotics at the time of FMT. RESULTS: In 20 months of follow-up, the patient has had no further recurrence of diverticulitis or CDI. CONCLUSIONS: FMT could prove to be a novel therapy for refractory diverticulitis but requires further investigation.

Imported rickettsial disease: clinical and epidemiologic features.

PURPOSE AND METHODS: The rickettsioses continue to constitute major health problems in many parts of the world. With increasing international travel, recognition of rickettsial diseases by physicians is becoming more important. The clinical features of four cases of rickettsial disease imported into Canada over a five-year period are presented; two patients with tick typhus (Rickettsia conorii), one patient with scrub typhus (R. tsutsugamushi), and one patient with murine typhus (R. typhi). We also present the North American data over the past 10 years from the Centers for Disease Control (CDC) (Atlanta). RESULTS: Since 1983 in the United States, three cases of imported scrub typhus, all after travel to India, were confirmed, as well as six cases of murine typhus after travel to southeast Asia. At the CDC, 67 imported cases of tick typhus have been confirmed by indirect fluorescent antibody test since 1976; most illnesses occurred after travel to Africa. CONCLUSION: Rickettsial diseases are underrecognized by physicians, who should consider these diagnoses in travelers returning from endemic areas. Since effective treatment is available, prompt diagnosis and treatment are important. In all cases, specific serologic confirmation should be obtained.

A comparison of the complement fixation, indirect fluorescent antibody, and microagglutination tests for the serological diagnosis of rickettsial diseases.

Three techniques for the serological diagnosis of Rocky Mountain spotted fever were compared by testing 417 sera from 178 patients who very probably did not have rickettsial infections and 88 sera from 41 patients who very probably had Rocky Mountain spotted fever (SF). The techniques were complement fixation (CF), indirect fluorescent antibody (IFA), and microagglutination (MA). To avoid possible degradation during unnecessary purification, the antigens were prepared by methods that were as simple as possible. In the CF tests of 417 sera from patients with nonrickettsial diseases there was only one titer of 8 and none at higher dilutions, whereas with the IFA and MA tests 4-8% of the sera reacted with SF antigens and 4-20% reacted with murine typhus (MT) antigens; the evidence indicated that these reactions were not caused by specific rickettsial antibody. With the SF sera, it could be seen that the IFA test was the most sensitive and the MA test was the least sensitive at each interval after infection. Moreover, the IFA results showed the least number of confusing cross-reactions with MT antigens and the MA test showed the most. The relative advantages of the three tests in serodiagnosis of rickettsial diseases are discussed.

Evidence of Rickettsia prowazekii infections in the United States.

From January 1976 through January 1979 serum specimens from 1,575 individuals were received at the Center for Disease Control and tested for antibodies to rickettsiae. Of these, sera from eight persons gave serological results indicative of recent infections with epidemic typhus rickettsiae (Rickettsia prowazekii). Five of the persons were from Georgia, and one each was from Tennessee, Pennsylvania and Massachusetts. The illnesses occurred during the winter, chiefly in persons living in a rural environment. The clinical picture was compatible with louse-borne epidemic typhus. There was no apparent contact with human body or head lice, and no cases occurred in patient contacts, indicating that infection was not associated with the classic man-louse-man cycle of epidemic typhus. Two of the eight patients had contact with flying squirrels suggesting that they became infected from this known extrahuman reservoir of R. prowazekii.

LC determination of octreotide acetate in compound formulations of Sandostatin and diamorphine hydrochloride.

The determination of octreotide acetate in compound formulations of Sandostatin and diamorphine hydrochloride by RP-LC is described. Octreotide acetate, diamorphine hydrochloride and their respective degradants, [des-Thr-ol8]-octreotide and 6-O-acetylmorphine, were baseline resolved using a Lichrospher-60 RP-select B column with a mobile phase composition of acetonitrile/phosphate buffer (pH 7.4, 20 mM) (35:65 v/v) with UV detection at 210 nm. The method is simple, selective, precise and suitable for the determination of octreotide acetate in admixture.

Diagnosis of rickettsial diseases: a perspective.

Rickettsioses have nonspecific clinical manifestations, making them difficult to diagnose in a clinical setting. Laboratory testing is usually needed to confirm the diagnosis. Rickettsial isolation is a sensitive and specific diagnostic technique, but the hazards associated with handling pathogenic rickettsiae usually preclude isolation attempts in most laboratories. Rickettsiae can also be detected in infected tissues by fluorescein-labeled antisera or by immunoperoxidase staining, but these techniques lack sensitivity, except when applied to postmortem tissue specimens. However, rickettsial DNA can be detected in acute phase blood specimens by polymerase chain reaction (PCR) technology, and this technique offers the prospect of prompt diagnosis and treatment. Serologic testing remains the most frequently used approach to diagnosis, although antibody tests usually fail to identify rickettsioses early enough to affect the management of individual patients. Available serologic techniques vary considerably in their sensitivity and specificity. Enzyme-linked immunosorbent assays (ELISA) are extremely sensitive, but the general unavailability of specific diagnostic antigens reduces the specificity of this and other serologic techniques. Molecular characterization of rickettsial antigens may soon allow the production of peptide antigens that are specific for each species and could maximize the specificity of test results. No diagnostic technique has any value unless it is applied successfully to the appropriate patient population. Improved surveillance of rickettsial diseases is urgently needed to identify specific areas in which rickettsioses are endemic. Such surveillance data would promote awareness of rickettsioses among local physicians and increase the probability that individual patients with rickettsioses would be identified promptly and receive appropriate therapy early in the course of their illness.

Ehrlichiosis--a disease of animals and humans.

Ehrlichiae are one of several kinds of obligate intracellular bacteria. Taxonomically, they are grouped with rickettsiae, but they can be distinguished by their unique tropism for circulating leukocytes. Ehrlichia canis causes a pancytopenia in dogs that becomes chronic if untreated. Certain breeds develop severe infections, characterized by fever, anorexia, dramatic weight loss, marked pancytopenia, anemia, peripheral edema, and hemorrhage. Ehrlichia risticii, a recently discovered species, is the cause of a serious diarrheal disease of horses. Other species of ehrlichiae have been documented as being veterinary pathogens. Recent data indicate that E. canis or a closely related species causes an acute febrile illness in humans. Clinically, the disease is similar to Rocky Mountain spotted fever, except that most patients do not have a rash. Human ehrlichiosis appears to be tickborne and is prevalent primarily in the southern Atlantic and south-central states. A mild from of ehrlichiosis has also been documented.

Determination of antibiotic susceptibility of Rickettsia by the plaque assay technique.

Plaque formation by various rickettsiae was completely inhibited by commercial antibiotic discs impregnated with tetracycline, chloramphenicol, nitrofurantoin, and erythromycin; partial inhibition was observed around discs containing nalidixic acid and sulfisoxazole, but no inhibition was seen around discs containing cephalothin, ampicillin, oxacillin, kanamycin, polymyxin B, streptomycin, or penicillin.

Flying squirrels and their ectoparasites: disseminators of epidemic typhus.

Information gathered during the past decade indicates that the eastern flying squirrel, Glaucomys volans, is a zoonotic reservoir of Rickettsia prowazekii - causative agent of louse-borne (epidemic) typhus. The sporadic cases o f typhus that have occurred in the USA in association with flying squirrels provide evidence that flying squirrels can transmit R. prowazekii infection to humons. Strains of R. prowazekii, isolated from flying squirrels multiply readily in human body lice, but flying squirrel lice, although readily infected, are very host specific and tend not to bite humans. It may be that the infection is spread to humans in infective ectoporasite faeces aerosolized when the flying squirrels groom themselves. As Joseph McDade emphasizes in this article, current concepts of typhus epidemiology and control must be re-evaluated to take into account this zoonotic aspect.

Plaque assay for Q fever and scrub typhus rickettsiae.

The plaque assay procedure developed for spotted fever and typhus group rickettsiae is also appropriate for scrub typhus and Q fever rickettsiae. The plaque titers of suspensions of Rickettsia tsutsugamushi and Coxiella burnetii compared favorably with end points obtained by titrations in mice.

Virulent to avirulent conversion of Legionnaires' disease bacterium (Legionella pneumophila)--its effect on isolation techniques.

Suspensions of the Legionnaries' disease bacterium (Legionella pneumophila; LDB) were prepared from the yolk sacs of infected egg embryos, the spleens of infected guinea pigs, and cultures of the organism propagated on enriched Mueller-Hinton agar. Each suspension was titrated to determine the number of bacterial colonies (cfu), yolk sac 50% lethal doses (YSLD50), guinea pig 50% infectious doses (GPID50), and guinea pig 50% lethal doses (GPLD50) produced by 1 ml of inoculum. The numbers of cfu/YSLD50, GPID50, and GPLD50 were then calculated for each suspension. The suspension from yolk sacs had 1 cfu/YSLD50 and 10 cfu/GPID50. The suspension from spleens of guinea pigs also had 1 cfu/YSLD50. Organisms propagated on Mueller-Hinton agar, however, had greater than 10(7) cfu/YSLD50 and 10(5) cfu/GPID50. Thus, the LDB lost virulence when it was cultivated on agar. Guinea pigs vaccinated either subcutaneously or intraperitoneally with LDB grown on Mueller-Hinton agar resisted challenge with virulent LDB.

Prevalence and distribution of spotted fever and typhus infections in Sierra Leone and Ivory Coast.

A serosurvey for evidence of rickettsial infections was conducted in the rural populations of several tropical rain forest areas in Sierra Leone and Ivory Coast. Seropositivity rates were surprisingly high in both countries, with more than 7% of the individuals in some districts having antibodies to spotted fever-group rickettsiae. No significant difference was found in the overall prevalence of diagnostic antibody titers to spotted fever-group rickettsiae in Sierra Leone (5.3%) and Ivory Coast (6.2%). However, there was a significant difference (p less than 0.001) in the prevalence of diagnostic antibody titers to typhus rickettsiae in the two countries. There were no marked geographic differences within either country in overall prevalence of rickettsial infections, but there were possible area differences in specific seropositivity rates to typhus- and spotted fever-group rickettsiae in Sierra Leone. In both countries, age and sex differences were important in determining seropositivity, but there was no indication of an age-sex interaction. In Sierra Leone, 59 of the 80 positive sera (73.8%) were from persons age 15 or above (p less than 0.001), and 50 of the 80 (62.5%) were from males (p = 0.05). In Ivory Coast, 33 of the 37 positive sera (89.2%) were from the greater than or equal to 15-age group, and 28 of the 37 (75.7%) were from males (p less than 0.001 for both age and sex). The identification of specific areas endemic for these rickettsial diseases should facilitate the diagnosis and treatment of patients with rickettsial illnesses in West Africa.

Legionnaires' disease bacterium isolated in 1947.

The results of serologic, cultural, and DNA relatedness studies have shown that the Legionnaires' disease (LD) bacterium and an unclassified agent isolated in 1947 are the same species. Both organisms grew on charcoal-yeast extract agar, enriched Mueller-Hinton agar, and F-G agar, but neither grew on blood agar, trypticase soy agar, or in thioglycollate broth. Both agents reacted with convalescent sera from patients with Legionnaires' disease and convalescent sera from guinea pigs infected experimentally with the LD bacterium. The percentage of guanine plus cytosine in DNA preparations from each organism was ascertained by thermal denaturation to be 39%. In DNA hybridization reactions the 1947 isolate showed the same degree of relatedness to Philadelphia 1 strain of the LD bacterium as did three recent isolates of the bacterium. The LD bacterium was also shown to be antigenically related to another unclassified organism isolated in 1959.