Outcome of uncorrected CSF leak and consequent recurrent meningitis in a patient: a case presentation and literature review.

Purpose: Post-traumatic CSF leaks are a complication in 2% of all head injuries. Majority of these patients will recover spontaneously. Whilst recent literature has predominantly centred on CSF leaks and their general investigations and management thereof, there is a paucity of information when it comes to those patients who have persistent post-traumatic CSF leaks, as well as the complication of recurrent meningitis. We present a patient with a persistent post-traumatic CSF leak who presented with recurrent bacterial meningitis thirteen times- the highest documented amount in an adult. We reviewed the literature with regards to the above as well.Material and Methods: We reviewed a vast array of journal articles on the topic of CSF leaks from the PubMed resource, and focused this review specifically on those that documented patients who had uncorrected CSF leaks and their outcomes.Results: Complications include meningitis and rhinorrhoea with brain abscesses and pneumocephalus occurring less frequently. Mortality has been documented to be 9% after 1 year. The rates of persistent CSF leaks were within the same range with an average calculated rate of 21%. Whilst meningitis was recorded and is common, it was not stipulated whether the incidences were recurrent.Conclusion: Post-traumatic persistent CSF leaks remain a therapeutic challenge and continued follow-up with early surgical intervention is highly recommended to prevent complications. One of the more serious complications of a persistent leak is meningitis. The long-term outcomes of recurrent meningitis could include cumulative focal neurological deficitis and cognitive impairment.

Burden and predictors of hypertension in India: results of SEEK (Screening and Early Evaluation of Kidney Disease) study.

BACKGROUND: Hypertension (HTN) is one of the major causes of cardiovascular morbidity and mortality. The objective of the study was to investigate the burden and predictors of HTN in India. METHODS: 6120 subjects participated in the Screening and Early Evaluation of Kidney disease (SEEK), a community-based screening program in 53 camps in 13 representative geographic locations in India. Of these, 5929 had recorded blood pressure (BP) measurements. Potential predictors of HTN were collected using a structured questionnaire for SEEK study. RESULTS: HTN was observed in 43.5% of our cohort. After adjusting for center variation (p < 0.0001), predictors of a higher prevalence of HTN were older age ≥ 40 years (p < 0.0001), BMI of ≥ 23 Kg/M2 (p < 0.0004), larger waist circumference (p < 0.0001), working in sedentary occupation (p < 0.0001), having diabetes mellitus (p < 0.0001), having proteinuria (p < 0.0016), and increased serum creatinine (p < 0.0001). High school/some college education (p = 0.0016), versus less than 9th grade education, was related with lower prevalence of HTN. Of note, proteinuria and CKD were observed in 19% and 23.5% of HTN subjects. About half (54%) of the hypertensive subjects were aware of their hypertension status. CONCLUSIONS: HTN was common in this cohort from India. Older age, BMI ≥ 23 Kg/M2, waist circumference, sedentary occupation, education less, diabetes mellitus, presence of proteinuria, and raised serum creatinine were significant predictors of hypertension. Our data suggest that HTN is a major public health problem in India with low awareness, and requires aggressive community-based screening and education to improve health.

Development of a natural model of cutaneous leishmaniasis: powerful effects of vector saliva and saliva preexposure on the long-term outcome of Leishmania major infection in the mouse ear dermis.

We have developed a model of cutaneous leishmaniasis due to Leishmania major that seeks to mimic the natural conditions of infection. 1,000 metacyclic promastigotes were coinoculated with a salivary gland sonicate (SGS) obtained from a natural vector, Phlebotomus papatasii, into the ear dermis of naive mice or of mice preexposed to SGS. The studies reveal a dramatic exacerbating effect of SGS on lesion development in the dermal site, and a complete abrogation of this effect in mice preexposed to salivary components. In both BALB/c and C57Bl/6 (B/6) mice, the dermal lesions appeared earlier, were more destructive, and contained greater numbers of parasites after infection in the presence of SGS. Furthermore, coinoculation of SGS converted B/6 mice into a nonhealing phenotype. No effect of SGS was seen in either IL-4- deficient or in SCID mice. Disease exacerbation in both BALB/c and B/6 mice was associated with an early (6 h) increase in the frequency of epidermal cells producing type 2 cytokines. SGS did not elicit type 2 cytokines in the epidermis of mice previously injected with SGS. These mice made antisaliva antibodies that were able to neutralize the ability of SGS to enhance infection and to elicit IL-4 and IL-5 responses in the epidermis. These results are the first to suggest that for individuals at risk of vector-borne infections, history of exposure to vector saliva might influence the outcome of exposure to transmitted parasites.

Protection against cutaneous leishmaniasis resulting from bites of uninfected sand flies.

Despite the fact that Leishmania are transmitted exclusively by sand flies, none of the experimental models of leishmaniasis have established infection via sand fly bites. Here we describe a reproducible murine model of Leishmania major infection transmitted by Phlebotomus papatasi. Prior exposure of mice to bites of uninfected sand flies conferred powerful protection against Leishmania major that was associated with a strong delayed-type hypersensitivity response and with interferon-gamma production at the site of parasite delivery. These results have important implications for the epidemiology of cutaneous leishmaniasis and suggest a vaccination strategy against this and possibly other vector-borne diseases.

A novel vasodilatory peptide from the salivary glands of the sand fly Lutzomyia longipalpis.

Salivary gland lysates of the sand fly Lutzomyia longipalpis contain a potent vasodilator that aids the fly to feed on the blood of its vertebrate hosts. Chromatographic analysis, antibody reactivity, and data obtained from bioassays of the salivary erythema-inducing factor indicate striking similarity with human calcitonin gene-related peptide. The erythema-inducing factor is, however, at least one order of magnitude more potent than calcitonin gene-related peptide.

Human immunodeficiency virus associated intracranial aneurysms: report of three adult patients with an overview of the literature.

BACKGROUND AND PURPOSE: Aneurysms have been described in HIV infected patients. These involve predominantly extracranial blood vessels with specific histological and clinical features. Intracranial aneurysms are rare and have been identified mainly in children. METHODS: Case reports and literature review. RESULTS: Three black South African HIV positive adult patients with intracranial aneurysms were identified. The clinical, laboratory and radiological features are described. CONCLUSIONS: Intracranial aneurysms occur in both adults and children infected with HIV. More information is required on this association. The frequency in terms of numbers of cases indicates that it is an uncommon association or manifestation of HIV. The characteristics of the aneurysms suggest that they are distinctive and not a chance or coincidental co-occurrence of congenital or arteriosclerotic aneurysms.

Reduced risk of toxoplasma encephalitis in HIV-infected patients--a prospective study from Gauteng, South Africa.

Toxoplasma seroprevalence was determined in 307 consecutive HIV-infected medical inpatients at the Helen Joseph Hospital, Johannesburg, South Africa, using an enzyme linked immunosorbent assay to detect immunoglobulin G (IgG) and IgM antibodies. The mean age of patients was 36 years, with a female to male ratio of 1.3 to 1. The mean CD4 count was 109 cells/mL. Toxoplasma antibodies were detected in 25 patients (8%). Twenty-two of these patients were IgG positive and IgM negative, i.e. reactivation toxoplasmosis. Only two patients (0.65%) had clinical manifestations of toxoplasmosis (one toxoplasma encephalitis and one retinitis). The risk for toxoplasma encephalitis (TE) was 0.33%. These results indicate that the toxoplasma seroprevalence and the TE risk in this population is low. The implication from this study is that in HIV-infected populations where the toxoplasma seroprevalence is low, the TE risk will be low and empiric treatment of focal brain lesions with anti-toxoplasma therapy may be inappropriate.

New-onset seizures associated with HIV infection.

The authors studied new-onset seizures in 60 heterosexual black South African HIV-infected patients who had not used IV drugs. An intracranial space-occupying lesion was identified in 53% of patients, meningitis in 22%, and no additional cause in 25%. Of the patients with an identifiable cause, 64% had probable tuberculosis (tuberculoma or tuberculous meningitis). The majority of patients had late-stage HIV infection (CD4 counts <200/mm(3)).

Mechanisms for inhibition of the generation of thrombin activity by sulfated polysaccharides.

Three mechanisms by which sulfated polysaccharides act as anticoagulants and possibly as antithrombotic agents have been described. These are the two heparin cofactor-dependent mechanisms involving the catalysis of the inhibition of various proteases of coagulation by either antithrombin III or heparin cofactor II. The third is a heparin cofactor-independent mechanism involving the inhibition of formation of prothrombinase and tenase complexes. Four sulfated polysaccharides previously shown to have anticoagulant and antithrombotic effects were assessed to determine which of the three mechanisms operate in the expression of their anticoagulant effects. To do this, [125I]prothrombin was added to undiluted human plasma, and the inhibition of [125I]prothrombin activation, or the catalysis of the formation of thrombin-inhibitor complexes was determined in plasma containing one of the four sulfated polysaccharides. Prothrombin activation was demonstrated by the formation of [125I]prothrombin fragment 1.2 and [125I]thrombin. The effect of the thrombin-specific inhibitor, D-Phe-L-Pro-L-ArgCH2Cl (PPACK), on prothrombin activation was also investigated to determine the role of thrombin-dependent feedback reactions on efficient prothrombin activation. Use of PPACK with sulfated polysaccharides also facilitated estimation of the role of the heparin cofactor-independent effects of sulfated polysaccharides on prothrombin activation. Three concentrations of each of the sulfated polysaccharides were used: 0.66, 6.6, and 66 micrograms/ml of plasma. PPACK (1.0 X 10(-6)M) completely inhibited both intrinsic and extrinsic prothrombin activation. The inhibition of prothrombin activation caused by PPACK was abolished when thrombin was added to the plasma before PPACK. These observations indicate that the presence of trace thrombin activity is critical for efficient prothrombin activation by both the intrinsic and extrinsic pathways. All three concentrations of standard heparin completely inhibited the intrinsic activation of prothrombin. This inhibition was only partially abolished when thrombin was added to the plasma before heparin, indicating that heparin inhibits prothrombin activation both by catalyzing the inhibition of thrombin activity and by a heparin cofactor-independent mechanism. Heparan sulfate did not inhibit intrinsic prothrombin activation but catalyzed the inhibition of the thrombin generated by the formation of thrombin-antithrombin III complex. Dematan sulfate inhibited intrinsic prothrombin activation only at the highest concentration. At the two lower concentrations, dermatan sulfate catalyzed formation of thrombin-heparin cofactor II.(ABSTRACT TRUNCATED AT 400 WORDS)

Maintenance of Toscana virus in Phlebotomus perniciosus by vertical transmission.

Toscana virus was maintained in a laboratory colony of Phlebotomus perniciosus by vertical (transovarial) transmission for 13 consecutive generations over a 23-month period. No significant biological changes were noted in the virus after prolonged vertical passage in the sand flies, and transovarially infected females were able to transmit the agent by bite to susceptible animals. Chronic infection of Ph. perniciosus with Toscana virus had no apparent effect on the insects' rate of eclosion. In the absence of selection and with random matings, the virus infection rates in each subsequent generation of the colony decreased, suggesting that Toscana virus cannot be maintained in Ph. perniciosus by transovarial transmission alone. Alternative mechanisms for virus maintenance are discussed.

Growth and transovarial transmission of Chandipura virus (Rhabdoviridae: Vesiculovirus) in phlebotomus papatasi.

Chandipura virus multipled in sand flies (Phlebotomus papatasi) following intrathoracic inoculation. Within 24 hours, mean virus titers in infected flies increased approximately 4 logs. Experimentally infected P. papatasi transmitted the virus by bite to newborn mice and by transovarial transmission to their progeny. Eight percent of the F1 offspring of experimentally infected female parents were infected with Chandipura virus.

A simple method for experimental infection of phlebotomine sand flies with Leishmania.

Mouse macrophages, grown in continuous cell culture at 37 degrees C, were inoculated with the promastigote stage of various human pathogenic Leishmania species. Under these culture conditions, the parasites rapidly entered the cells and transformed into amastigotes. Two or 3 days after inoculation, the infected macrophages were mixed with washed human erythrocytes and were fed to female sand flies (Phlebotomus papatasi and Lutzomyia longipalpis) through a chick skin membrane. Within 7-10 days after feeding, large numbers of promastigotes were observed in the anterior portion of the insects' guts, indicating that the infected sand flies were capable of transmitting the parasites by bite. This relatively simple and rapid technique should facilitate studies on the biology of Leishmania in their insect vectors. It also eliminates the need for animals as a source of amastigotes.

Studies on the biology of phleboviruses in sand flies (Diptera: Psychodidae). I. Experimental infection of the vector.

This paper describes a series of experiments which were done to determine the behavior of 14 different phleboviruses in laboratory-reared sand flies (Phlebotomus papatasi, P. perniciosus and Lutzomyia longipalpis) after oral and parenteral infection. Most of the viruses replicated in the sand flies after intrathoracic inoculation; however, the insects were quite refractory to oral infection. Six of 11 phleboviruses tested were transovarially transmitted in one or more sand fly species. The percentage of infected F1 offspring produced by parenterally infected female parents ranged from 1.5-60%, depending on the virus type used. These data support the hypothesis that some of the phleboviruses are maintained in sand flies by transovarial transmission.

Host-parasite relationship of Leishmania mexicana mexicana and Lutzomyia abonnenci (Diptera: Psychodidae).

The life cycle of Leishmania mexicana mexicana in the gut of the sand fly, Lutzomyia abonnenci, was studied by light and electron microscopy. Development was suprapylarian with initial establishment of parasites in the bloodmeal (posterior midgut), and anterior migration of parasites to the cardia/stomodeal valve region beginning at 2.5 days post-infection. Flagellates were first observed in the esophagus at 3.5 days, in the posterior armature region of the pharynx at 5 days, and in the anterior pharynx at 7 days; but they were not detected in the cibarium or proboscis. Infection of the pylorus region of the hindgut and of the Malpighian tubules was also commonly observed. Three different morphological forms of L. m. mexicana developed in the gut: nectomonad promastigotes, short promastigotes, and paramastigotes. Nectomonads occurred primarily in the abdominal midgut after bloodmeal digestion, where they were oriented in longitudinal masses in the lumen, or interdigitated with epithelial microvilli via the flagellum. Short promastigotes found in the cardia/stomodeal valve region are described for the first time. These forms were smaller than nectomonads, showed an amplification of the kinetoplast, apposition of kinetoplast and nucleus, and were embedded in a gel-like matrix. To maintain position in the cardia, parasites commonly inserted the flagellum deep into microvilli or cytoplasm of the epithelium; adherence to the cuticular intima of the stomodeal valve was by flagellar modification and formation of hemidesmosome plaques. Paramastigotes occurred in the esophagus, were sometimes degenerated in appearance, and were attached via flagellar hemidesmosomes. Paramastigotes observed in the lumen of the pharynx were commonly degenerated and were not attached to the intima. L. m. mexicana was able to colonize the various gut habitats of Lu. abonnenci by a number of adaptations; this sand fly appears to be a suitable biological host for the parasite.

Detection of promastigote stage-specific antigens on Leishmania mexicana amazonensis developing in the midgut of Lutzomyia longipalpis.

Previously described monoclonal antibodies IX-IF9-D8, IX-2H7-E10 and IX-5H9-C1 recognize promastigote stage-specific determinants present on externally exposed membrane proteins of axenically cultured Leishmania mexicana amazonensis. In the present study, these antigens were demonstrated by indirect immunofluorescence to be present on promastigotes found in the gut lumen of infected Lutzoymia longipalpis. The presence of these antigens on promastigotes found in infected sandflies suggests that the same antigens should be relevant for protective immunity studies and for species identification of Leishmania encountered in epidemiological studies.

Vesicular stomatitis virus, New Jersey serotype: replication in and transmission by Lutzomyia shannoni (Diptera: Psychodidae).

Laboratory-reared female sand flies (Lutzomyia shannoni) were experimentally infected, orally and by intrathoracic inoculation, with the New Jersey serotype of vesicular stomatitis (VSNJ) virus. Virus replication occurred in the insects following infection by both routes. Virus titers greater than 10(4) plaque forming units of VSNJ virus were present in heads of orally infected sand flies 12 days after virus ingestion, confirming that a persistent disseminated infection had occurred. Both orally and parenterally infected Lu. shannoni transmitted VSNJ virus by bite to susceptible rodents and by transovarial transmission to a small percentage of their F1 progeny. The significance of these findings in the epizootiology of VSNJ virus on Ossabaw Island, Georgia, an enzootic focus of this virus, is discussed.

Refractory barriers in the sand fly Phlebotomus papatasi (Diptera: Psychodidae) to infection with Leishmania panamensis.

The life cycle of Leishmania panamensis in Phlebotomus papatasi was studied to characterize barriers limiting parasite colonization, differentiation, migration, and attachment in an unnatural sand fly host. The insects were fed a suspension of L. panamensis-infected macrophages and human erythrocytes, and were examined up to 16 days post-infection by light and electron microscopy. Histologic examination of 401 flies showed the peritrophic membrane to be the first important barrier to parasite establishment in the gut lumen. In most flies, parasites were unable to escape from the closed peritrophic sac, which was either excreted or retained intact in the midgut. After five days, only 31% of the flies were infected; attached parasites colonized the pylorus-ileum and/or colon regions of the hindgut. Anterior migration into the cardia region of the midgut occurred in less than 1% of infected flies; no parasites colonized the foregut. In the bloodmeal and residual bloodmeal, five morphologic forms developed from ingested amastigotes: stumpy, spatulate, elongate, short nectomonad promastigotes, and paramastigotes. Abnormal retention of amastigotes in macrophages and delayed development of promastigote stages was observed. The primary form attached in the hindgut was a pear-shaped haptomonad promastigote. Differentiation of L. panamensis in Ph. papatasi appeared to be similar to that described in natural hosts, except that metacyclic infective forms were not observed, and some forms developed in unusual locations. Phlebotomus papatasi was a partly refractory biological host for L. panamensis. The peritrophic membrane adversely affected the infection rate; rare anterior migration and a lack of metacyclic promastigotes may preclude transmission by bite.

Ultrastructural development of Leishmania chagasi in its vector, Lutzomyia longipalpis (Diptera: Psychodidae).

The development of Leishmania chagasi, etiologic agent of American visceral leishmaniasis, was studied by light and electron microscopy in the gut of the sand fly, Lutzomyia longipalpis, a natural vector. New aspects of suprapylarian Leishmania behavior were elucidated. In the sand fly midgut, amastigotes transformed into promastigotes (division promastigote I) during a first division sequence within the bloodmeal. Secondary division of these promastigotes resulted in a second form (division promastigote II), and these subsequently elongated into nectomonad promastigotes. Nectomonads existed in long and short populations which divided in the bloodmeal and throughout the midgut lumen after escape from the peritrophic membrane. Nectomonads adhered to the midgut cells in a highly organized manner, with their flagella embedded deep into microvilli and cytoplasm. Migration of parasites from the posterior midgut into the cardia/stomodeal valve region at 36 hr was associated with breakdown of the peritrophic membrane anteriorly. Posterior breakdown at 48 hr resulted in a peritrophic tube open at both ends containing some parasites within the digesting bloodmeal for up to 6 days postinfection. At the stomodeal valve, a myriad of slender and rounded promastigotes attached to the intima by flagellar hemidesmosomes; these may represent a transformation sequence from slender nectomonads to pear-shaped haptomonads. Pear-shaped forms appear to be precursors of paramastigotes, which also attached to the valve intima. Both rounded haptomonads and paramastigotes were found in the esophagus, dividing in a complex sequence initiated by posterior cleavage of the cytoplasm producing unique heart-shaped forms. Dividing paramastigotes also colonized the pharynx up to the cibarial valve. The ultrastructure of paramastigotes suggested that they may be infective forms, capable of some motility in the foregut. Free-swimming "infective" promastigotes were observed throughout the midgut and foregut, were attached in the pharynx (armature region), and were associated with the labrum-epipharynx of the proboscis in 3.6% of flies (16 days). The fine structure of hemidesmosomes in the foregut showed regional specializations, including the presence of plasmalemmar bridges in the gap space.

Ultrastructural biology of Leishmania (Viannia) panamensis (=Leishmania braziliensis panamensis) in Lutzomyia gomezi (Diptera: Psychodidae): a natural host-parasite association.

The development of Leishmania (Viannia) panamensis in a natural sand fly host, Lutzomyia gomezi, was studied by light and transmission electron microscopy. New aspects of peripylarian parasite behavior and morphology in the sand fly gut, early bloodmeal stages, and ultrastructural development in the anterior gut were documented. Eight distinct morphological forms were observed in the life cycle of the parasite within the insect. In the bloodmeal, amastigotes (1) transformed into stumpy promastigotes (2) which rapidly multiplied, resulting in spatulate-shaped nectomonad promastigotes (3) and elongate nectomonad promastigotes (4). These latter forms migrated primarily into the hindgut, where both were observed attached (=haptomonad phase) to the cuticular intima by hemidesmosomes within extremely shortened flagella. Spatulate haptomonad promastigotes predominated, colonizing the entire length of the hindgut, with the greatest density at 2 disjunct sites: the pylorus/ileum and the anterior rectum/rectal sac. Paramastigotes and dividing flagellates were rare. Some parasites migrated directly to the cardia/stomodeal valve region without a hindgut phase; however, major movement anteriorly was from the hindgut beginning at 6 days postinfection. In the cardia lumen, dividing short Type A promastigotes (5) predominated, intermixed with short Type B promastigotes with longer flagella (6). Paramastigotes (7) were free-swimming in the lumen as well as attached to the stomodeal valve. The primary colonizers of the valve were pear-shaped haptomonad promastigotes (8), with flagella of variable lengths and multi-segmented hemidesmosomal attachment points to the intima. Promastigotes and paramastigotes colonized the esophagus-pharynx region and attached to the foregut lining by flagellar hemidesmosomes. Both forms may represent infective stages of L. (V.) panamensis; however, no parasites were detected in the cibarium or proboscis. L. (V.) panamensis appeared well-adapted to the gut of Lu. gomezi, multiplying extensively at 2 sites, changing morphological form, and adhering to host surfaces by variously modified flagellar hemidesmosomes.

Experimental infection and transmission of Leishmania major by laboratory-reared Phlebotomus bergeroti parrot.

The ability of colony-reared Phlebotomus bergeroti Parrot to successfully acquire and transmit Leishmania major (strain IPAP/EG 89/SI-177) was demonstrated in the laboratory. Female P. bergeroti were fed naturally on infected mice and artificially on infected blood suspension using a chick-skin membrane apparatus. Groups of sand flies, either infected on mice or by membrane feeding, were dissected and examined using light microscopy at 2-6, 8, 10, and 11 days postfeeding. Heavy promastigote infection of the thoracic and abdominal midgut was observed in 10% (2 of 20) of the naturally infected flies. Promastigote maturation was observed in 87% (81 of 93) of the artificially infected sand flies, with promastigotes observed in the cibarium and mouthparts at five days postinfection, and infective metacyclic stage promastigotes observed at eight days postinfection. Ten days postinfection, 31% (10 of 32) of the remaining artificially infected sand flies refed on an uninfected BALB/c mouse. Twenty-eight days following exposure to the infective sand flies, leishmanial lesions were observed on the pads of the mouse's front feet. The development of lesions on mouse foot pads clearly suggests the potential of P. bergeroti to serve as a vector for L. major.