Inner ear and facial nerve complications of acute otitis media with focus on bacteriology and virology.

CONCLUSION: Among 20 patients with inner ear complications and/or peripheral facial palsy secondary to acute otitis media (AOM) a proven or probable bacteriological cause was found in 13 (65%). In seven patients (35%), a proven or probable viral cause was found. Only two of the patients (10%), with a proven bacterial AOM and a clinical picture of a purulent labyrinthitis in both, together with a facial palsy in one, had a substantial degree of dysfunction. Although the number of patients in this study is relatively low our findings show that inner ear complications and facial palsy due to AOM can be of both bacterial and viral origin. Severe sequelae were found only where a bacterial origin was proven. OBJECTIVES: Inner ear complications and/or peripheral facial palsy secondary to AOM are rare. The general understanding is that they are due to bacterial infections. However, in some of these patients there are no clinical or laboratory signs of bacterial infections and they have negative bacterial cultures. During recent years different viruses have been isolated from the middle ear or serologically proven in AOM patients and are thought to play a pathogenetic role. We suggest that in some cases of AOM complications from the inner ear and the facial nerve can be caused by viruses. The purpose of our study was to analyze infectious agents present in patients with inner ear complications and/or facial palsy arising from AOM. PATIENTS AND METHODS: The medical records of 20 patients who had inner ear complications and/or facial palsy following AOM ( unilateral in 18, bilateral in 2) between January 1989 and March 2003 were evaluated. Bacterial cultures were carried out for all patients. Sera from 12 of the patients were stored and tested for a battery of specific viral antibodies. In three patients, investigated between November 2002 and March 2003, viral cultures were also performed on samples from the middle ear and nasopharynx. RESULTS: Nineteen patients had inner ear symptoms. Eight of them had a unilateral sensorineural hearing loss and vertigo, three had vertigo as an isolated symptom and one, with bilateral AOM, had bilateral sensorineural hearing loss. Seven patients had a combination of facial palsy and inner ear symptoms (unilateral sensorineural hearing loss in three, unilateral sensorineural hearing loss and vertigo in two, bilateral sensorineural hearing loss and vertigo in one, with bilateral AOM, and vertigo alone in one). One patient had an isolated facial palsy. Healing was complete in 11 of the 20 patients. In seven patients a minor defect remained at follow-up (a sensorineural hearing loss at higher frequencies in all). Only two patients had obvious defects (a pronounced hearing loss in combination with a moderate to severe facial palsy (House-Brackman grade 4) in one, distinct vestibular symptoms and a total caloric loss in combination with a high-frequency loss in the other. Eight patients had positive bacteriological cultures from middle ear contents: Streptococcus pneumoniae in two, beta-hemolytic Streptococcus group A in two, beta-hemolytic Streptococcus group A together with Staphylococcus aureus in one, Staph. aureus alone in one and coagulase-negative staphylococci (interpreted as pathogens) in two. In the 12 patients with negative cultures, there was a probable bacteriological cause due to the outcome in SR/CRP and leukocyte count in five. In four patients serological testing showed a concomitant viral infection that was interpreted to be the cause (varicella zoster virus in two, herpes simplex virus in one and adenovirus in one.) In three there was a probable viral cause despite negative viral antibody test due to normal outcome in SR/CRP, normal leukocyte count, serous fluid at myringotomy and a relatively short pre-complication antibiotic treatment period.

Oxybuprocaine induces a false-positive response in immunochromatographic SAS Adeno Test.

OBJECTIVE: To investigate whether a solution of oxybuprocaine hydrochloride, 0.4%, results in a false-positive response in an immunochromatographic SAS Adeno Test. DESIGN: Experimental study. CONTROLS: Physiologic saline and 2% lidocaine. TESTING: Each chemical (100 microl) was diluted in a transport medium. Five drops (200 microl) of the resultant solution were dispensed into the round sample well of a test device. Fifteen samples were tested in each group. MAIN OUTCOME MEASURES: Ten minutes after the start of the test, a colored line in the "specimen" portion of the test membrane was visually read as positive or negative by a masked technician. RESULTS: No positive reaction was observed in the control groups (physiologic saline and lidocaine). A false-positive reaction was observed in six samples (33.3%) in the oxybuprocaine group. The positive rate was significantly higher in the oxybuprocaine group compared with those in control groups (P = 0.0062, Fisher's extract probability test). CONCLUSIONS: Oxybuprocaine may induce a false-positive reaction in an immunochromatographic SAS Adeno Test. We recommend the use of lidocaine, instead of oxybuprocaine, for local anesthesia in taking eye swabs from patients with suspected adenovirus infection.

Epidemic spread of adenovirus type 4-associated acute respiratory disease between U.S. Army installations.

A large outbreak of adenovirus type 4-associated acute respiratory disease (ARD) occurred at Fort Jackson, South Carolina, in 1997. A laboratory-based ARD surveillance program was initiated at Fort Gordon, Georgia, where advanced individual training was heavily populated with Fort Jackson soldiers. Adenovirus type 4 was isolated from 50% of 147 trainees hospitalized with ARD. Most (88%) introduced cases were in trainees from Fort Jackson.

Aspects on the interaction of Streptococcus pneumoniae and Haemophilus influenzae with human respiratory tract mucosa.

Haemophilus influenzae and Streptococcus pneumoniae are common causes of respiratory tract infections. H. influenzae attach to receptor epitopes in mucins and in epithelial cell membranes. Attachment is followed by an epithelial cell cytokine response. Secreted cytokines then initiate inflammation, upset the integrity of the mucosal barrier, and lead to disease. S. pneumoniae do not bind to mucins but attach to respiratory tract epithelial cells. Attachment is increased by viral infection of the epithelial cells. Unlike H. Influenzae, S. pneumoniae induce apoptosis in epithelial cells, thus disrupting the mucosal barrier. Attachment and persistence is counterbalanced by antiadhesive as well as bactericidal molecules in secretions such as human milk. These examples illustrate the balance between host defenses and microbial virulence as it has coevolved to maintain the health of the respiratory mucosa.

Surveillance and control of epidemic keratoconjunctivitis.

PURPOSE: The purpose of this study was to determine if the implementation of a formal set of infection-control policy and procedures (ICPPs) can reduce the number of outbreaks of epidemic keratoconjunctivitis (EKC) and the number of nosocomially infected patients in a large teaching eye institute. METHODS: A retrospective and prospective study of the incidence of EKC and the number of affected patients was performed for the years 1984 through 1991. Infection-control measures (ICPPs) were formulated in 1992 with regulations implemented for patient control and management, hand washing, instrument disinfection, medication distribution, and employee furloughs. Two levels of ICPPs were established on the basis of nonepidemic or epidemic conditions. After implementation of ICPPs, a prospective 4-year study (1992 through 1995) and statistical analysis were performed to determine whether the number of outbreaks of EKC and affected patients significantly decreased. RESULTS: The incidence of institutional EKC epidemics per year was at least one and as many as three from 1984 through 1991. After implementation of a formal set of ICPPs, no epidemics occurred in 2 of 4 years studied. The number of epidemics and affected patients was significantly less when the years before and after implementation of ICPPs were compared by chi-square analysis (P < .01 and P <. 01, respectively). CONCLUSIONS: In this first prospective study of institutional outbreaks of EKC, the implementation of ICPPs was demonstrated to be an effective means to decrease the number of EKC outbreaks and nosocomially infected patients for this particular institution. Although several reports of institutional outbreaks of EKC have described infection-control measures that eventually controlled an outbreak well under way, this study provides policies and procedures that may effectively decrease the number and size of nosocomial epidemics of adenoviral conjunctivitis in large teaching eye institutions.

Neonatal adenovirus infection: a case report with in situ hybridization confirmation of ascending intrauterine infection.

Adenovirus infection is a rare, but serious infection, during the neonatal period. The actual model of infection at birth is currently unknown, however, several mechanisms have been proposed. We describe a case of fatal neonatal adenovirus pneumonia in a 25-wk gestational age infant. Adenovirus was confirmed by electron microscopy and by in situ hybridization. The maternal cervical/endocervical smear taken prior to the delivery contained epithelial cells with changes suggestive of adenovirus, which was confirmed by in situ hybridization on the smear. These findings suggest that ascending viral infection is a factor in the pathogenesis of neonatal adenovirus infection. The identification and reporting of adenovirus may be important during pregnancy in order to avoid delay in delivery of the fetus once membranes have ruptured.

Adenovirus myocarditis: retrospective diagnosis by gene amplification from formalin-fixed, paraffin-embedded tissues.

Understanding the pathogenesis of viral myocarditis is linked to the availability of sensitive assays to detect viruses in clinical material. Recent advances in molecular techniques permit direct detection of viral-specific nucleic acid in tissue samples. This report describes a protocol for DNA extraction and amplification of adenovirus genome from formalin-fixed, paraffin-embedded human tissues that detects as little as 10 copies of viral genome in a background of 0.5 micrograms of human DNA. This sensitive assay permitted the examination of archived tissues to establish a retrospective diagnosis of adenoviral myocarditis in two pediatric patients.

Restriction endonuclease analysis of adenovirus isolates from sporadic and epidemic ocular infections: experience in a clinical laboratory.

Adenovirus isolates from 52 patients with ocular infection over a 3-year period were typed by restriction endonuclease analysis in a clinical laboratory. The results indicated that adenovirus type 8 was the most common cause of adenovirus eye infection during this period, being responsible for 42 (81%) of the 52 cases. Of 42 adenovirus type 8 isolates, 22 showed variant patterns by restriction endonuclease analysis and required multiple enzyme digests for identification. These isolates were readily identified by neutralisation tests.

Recognition of adenovirus types in faecal samples by southern hybridization in South Australia.

The distribution of adenovirus types in faecal samples of patients with suspected viral gastroenteritis from South Australia was determined during the 12-month period, July 1991-June 1992. There were 3299 samples tested and 226 (6.9%) were positive for adenovirus by enzyme immunoassay. Of these 226 samples, 154 (68%) were typed directly using virus DNA extracted from the faecal samples according to the Sma I, Hind III and BstE II restriction patterns and Southern hybridization analysis with pooled viral genomic DNA probes. In this group, 86% of the samples were from patients who were < 3 years of age. Enteric adenovirus types 40 and 41 accounted for 20 and 40% respectively, of these samples, and types 1, 2, 3, 5, 6, 7 and 31 comprised the remainder. Type 40 was detected mainly in the winter and spring periods, and type 41 predominated in the autumn period. The majority of the non-enteric types were found during the late winter and spring periods.

Adenovirus infection induces loss of HLA class I and CD3 antigens, but does not induce cell surface presentation of the La (SS-B) autoantigen.

Antibodies to the RNA polymerase III transcription termination factor La are frequently found in the serum of patients with various autoimmune diseases. The mechanisms by which autoimmune responses are evoked remain largely obscure, but the presentation of autoantigens on the cell surface during stress conditions has been reported as a possible factor. In this study we analysed the effects of adenovirus infection on the binding of anti-La antibodies to the surface of several human cell lines and on the levels of the membrane-expressed glycoproteins HLA class I, CD44 and the CD3 complex. In addition, we studied the relative amount and the intracellular distribution of the La protein as well as its association with the major species of non-coding virus-associated (VAI) RNA. While immunofluorescence patterns revealed a redistribution and possibly cell surface expression of the La protein during infection, this could not be confirmed by other techniques. In contrast, surface levels of HLA class I proteins and CD3 complex were severely affected. The data suggest that the subcellular distribution of the La protein is not detectably influenced by adenovirus infection.

Restriction endonuclease analysis of adenovirus type 3 isolated in Norway from 1970 to 1991.

Forty-three strains of adenovirus type 3 isolated from patients in Norway between 1970 and 1991 were analyzed with four restriction endonucleases. Bg1 II was the most discriminative enzyme. Five genotypes were identified and one of these has not been described before (Ad3a12). During both the epidemics in this period, new genotypes were introduced into the population. The same genotypes were identified in Norway as have previously been found in the northern parts of Europe, America and the Soviet Union.

Six-year longitudinal analysis of adenovirus type 3 genome types isolated in Yamagata, Japan.

Five hundred eighty-seven adenovirus type 3 (Ad3) isolates were established from children with acute respiratory infections (ARI) from 1986 to 1991, in Yamagata, Japan. Ad3 could be found in almost all the months during the 6 years when two epidemics occurred, in 1987 and 1989. A molecular epidemiological study was done on 346 of the 587 isolates, using restriction endonucleases; BamHI, HindIII, SmaI, and BgIII were used. The Ad3 isolates were classified into seven genome types. The genetic differences among the seven genome types were < 0.9%, and their phylogenetic tree, estimated by the neighbor-joining method, correlated highly with their monthly distribution. One genome type predominated for 56 months, while the other six related genome types cocirculated for a short period. These results suggested that the predominant genome type of Ad3 might have been endemically perpetuated in the Yamagata area with minor genomic variations. Furthermore, the outbreaks of Ad3 may have been due not to the appearance of a new genome type but rather to the endemic genome type.

Genome type analysis of Chilean adenovirus strains isolated in a children's hospital between 1988 and 1990.

In a study designed to evaluate the genetic variability of adenovirus strains associated with infantile cases of respiratory disease requiring hospitalization, a collection of 136 adenovirus isolates obtained in the Roberto del Rio Children's Hospital of Santiago, Chile between June 1988 and November 1990 was studied by restriction enzyme analysis. Nasopharyngeal aspirates were obtained on admission from children under 2 years. During the study period a total of 227 adenovirus respiratory infections (ARI) were diagnosed at the ward for ARI by immunofluorescence, representing 23% of all admissions. Fifty percent of the 136 typed strains were found to belong to subgenus B, and the other 50% corresponded to subgenus C. Digestion with a set of seven enzymes allowed the identification of nine different genome types of subgenus C, three of which had not been previously described, exhibiting novel restriction patterns with either BgI II or BstEII. Ad7h, identified in 66 isolates, was the predominant genome type and was associated with the nine cases requiring mechanical respiratory assistance and with the two fatalities recorded during the 29 months. No differences were found between the age and sex distribution of subgenus B and C genomic variants, but the mean length of hospital stay (X +/- 2 SE) recorded among patients infected with subgenus B types was significantly higher (17.72 + 4.52 days (n = 55) vs. 7.54 + 1.70 days (n = 53); F = 17.22; P < 0.0001).

Sequence and functional analysis of the human adenovirus type 7 E3-gp19K protein from 17 clinical isolates.

The adenovirus (Ad) early region 3 (E3) glycoprotein of 19K (gp19K) binds major histocompatibility (MHC) class I antigens in the endoplasmic reticulum (ER), and the gp19K-class I complex is retained in the ER through an ER retention signal at the C-terminus of gp19K. This retention of class I antigens blocks cytolysis of gp19K-expressing cells by cytotoxic T lymphocytes (CTL). Animal models infected with Ad mutants lacking gp19K support a role for gp19K in counteracting a CTL response. Gp19K binds with different avidities to different class I antigens, and portions of the gp19K sequence are highly variable among Ad serotypes in different subgroups (Ad3, 11, and Ad35 in subgroup B; Ad2 and Ad5 in subgroup C); this raises the possibility that certain human individuals may be more susceptible to productive or persistent infection by particular serotypes of Ad, depending on the haplotype of the individual and the type of Ad. To begin to address this possibility, the gp19K gene from 17 very diverse Ad7 (subgroup B) clinical isolates was amplified by the polymerase chain reaction, and the DNA sequences were determined. The Ad7 gp19K sequence was 98% identical to that of Ad3. Surprisingly, we found complete conservation of the amino acid sequence of gp19K from all but one of the clinical isolates; one isolate had a conservative Ala to Val substitution. Gp19K from Ad7 clinical isolates representing distinct Ad7 genotypes co-immunoprecipitated with class I antigens. Our data indicate that there is very strong evolutionary pressure to maintain the sequence of gp19K in Ad7. The only known function for gp19K from different Ad serotypes is binding to class I antigens. It is interesting to consider, therefore, what selective pressure operates to maintain the sequence of gp19K among serotypes within a subgroup, and yet allows for very significant divergence in the sequence of gp19K among serotypes in different subgroups. The possible role of MHC class I antigens in this selection process is discussed.

Epidemic keratoconjunctivitis in a chronic care facility: risk factors and measures for control.

OBJECTIVE: To study patterns of transmission of epidemic keratoconjunctivitis (EKC) in a chronic care facility and to assess control measures and prevent future outbreaks in this setting. DESIGN: A retrospective cohort study. SETTING: A 120-bed, four-unit, skilled nursing facility. PATIENTS: Residents and employees of the above facility. INTERVENTIONS: Increased frequency of cleaning; use of bleach disinfectant; universal precautions in handling eye secretions from residents with conjunctivitis; cohorting residents by unit; suspension of new admissions; closure of common gathering areas. MEASUREMENTS: Resident demographics; possible risk factors for infection among residents (including mobility, underlying illness, medications, involvement in social activity, level of confusion) and among employees (including co-morbid illnesses and eye conditions, exposures to persons with conjunctivitis, visits to eye care specialists, use of contact lenses or glasses); testing of conjunctival specimens from symptomatic persons for viral and bacterial agents. RESULTS: Of 95 residents on three chronic care units, 47 (attack rate 49%) had onset of eye symptoms consistent with EKC between September 14 and December 7, 1990. Thirty-eight (81%) of these had onset following the onset of symptoms in a resident with dementia who, despite habitual eye-rubbing and wandering into other residents' rooms, was not isolated or restricted in any way. Attack rates were higher (though not statistically significant) among more mobile residents (60% for ambulatory residents) and among those considered by staff to be confused (56%). Rapid antigen detection and culture confirmed adenovirus type 37 as the etiologic agent. CONCLUSIONS: Transmission of infection with adenovirus type 37 was successfully interrupted following strict infection control, suspension of new admissions, cohorting of residents by unit, and change to a disinfectant that inactivates adenovirus. Recognition of conjunctivitis as an appropriate reason for restricting movement of an infected resident may have prevented extensive viral transmission in this outbreak.

Nosocomial adenovirus infection: molecular epidemiology of an outbreak.

Nosocomial transmission of adenovirus type 3 associated with fatalities in infants has not been frequently reported. This report describes the nosocomial spread of adenovirus types 2 and 3 among infants with bronchopulmonary dysplasia in a chronic (transitional) care facility. The index case developed pneumonia with a clinical deterioration in respiratory status 8 days after admission. Within the next 10 to 30 days 9 other infants and 2 health care personnel became ill with respiratory symptoms. Three of these 10 infants had progressive respiratory failure and 2 of them died. All of these infants had underlying chronic lung disease of bronchopulmonary dysplasia. The overall attack rate was 30% (10 of 33). Further spread of adenovirus was prevented by using barrier precautions and masks while performing tracheostomy care. Adenovirus isolates were serotyped as Ad3 in 4 patients and 1 staff member, as Ad2 in 3 patients, and as a combination of Ad2 and Ad3 in 1 patient. Two fatalities were associated with Ad3 infection. Three isolates from 2 patients and 1 staff member were not available for typing. Restriction endonuclease analysis was performed on all of these isolates of Ad3 and Ad2. There was no genetic heterogeneity in the isolates, suggesting a common source.

Disseminated adenoviral infection presenting as acute pancreatitis.

Adenoviruses are gradually being recognized as a significant source of morbidity and mortality in the immunocompromised patient population. We report a bone marrow transplant patient who developed severe abdominal pain accompanied by marked elevations in serum pancreatic and hepatic enzyme levels. She died shortly thereafter. Autopsy revealed hemorrhagic pancreatitis and fulminant hepatic necrosis. Both the pancreas and liver contained intranuclear inclusions consistent with adenovirus; electron microscopy confirmed that there were, indeed, adenoviral particles. This report of adenoviral pancreatitis emphasizes the diversity of manifestations seen with adenoviral infection.

The polymerase chain reaction for detecting adenovirus DNA in formalin-fixed, paraffin-embedded tissue obtained post mortem.

The polymerase chain reaction (PCR) was used to detect adenovirus DNA in formalin-fixed, paraffin-embedded tissue obtained post mortem. Adenovirus DNA was successfully amplified from specimens of lung and liver from two patients with disseminated adenovirus infection confirmed by virus isolation, electron microscopy and/or immunohistochemistry. Negative results were obtained for specimens of lung from two patients with cytomegalovirus pneumonia. The specificity of the adenovirus PCR was confirmed by means of a digoxigenin-labelled probe generated in a separate PCR. Detection of viral nucleic acid by PCR in tissues obtained post mortem has considerable diagnostic potential.

Isolation of adenovirus type 11 from the brain of a neonate with pneumonia and encephalitis.

We describe a fatal case of adenovirus pneumonia accompanied by encephalitis in a neonate who showed lethargy on the 6th day and died on the 12th day. Adenoviral particles as well as viral intranuclear inclusions were noted in pulmonary alveolar epithelium cells. Neuropathological examination revealed diffuse oedema, perivascular cuffing and gliosis in the white matter. Adenovirus type 11 was isolated from lung, hilar lymph node, and brain tissue. This is the first instance of adenovirus isolation from brain tissue in a newborn infant. The virological and neuropathological findings suggest the invasion of neural tissue by adenovirus and substantiate the significance of neurological symptoms observed in neonatal adenovirus infection.