One-year follow-up of patients of the ongoing Dutch Q fever outbreak: clinical, serological and echocardiographic findings.

PURPOSE: In 2007, a large goat-farming-associated Q fever outbreak occurred in the Netherlands. Data on the clinical outcome of Dutch Q fever patients are lacking. The current advocated follow-up strategy includes serological follow-up to detect evolution to chronic disease and cardiac screening at baseline to identify and prophylactically treat Q fever patients in case of valvulopathy. However, serological follow-up using commercially available tests is complicated by the lack of validated cut-off values. Furthermore, cardiac screening in the setting of a large outbreak has not been implemented previously. Therefore, we report here the clinical outcome, serological follow-up and cardiac screening data of the Q fever patients of the current ongoing outbreak. METHODS: The implementation of a protocol including clinical and serological follow-up at baseline and 3, 6 and 12 months after acute Q fever and screening echocardiography at baseline. RESULTS: Eighty-five patients with acute Q fever were identified (male 62%, female 38%). An aspecific, flu-like illness was the most common clinical presentation. Persistent symptoms after acute Q fever were reported by 59% of patients at 6 months and 30% at 12 months follow-up. We observed a typical serological response to Coxiella burnetii infection in both anti-phase I and anti-phase II IgG antibodies, with an increase in antibody titres up to 3 months and a subsequent decrease in the following 9 months. Screening echocardiography was available for 66 (78%) out of 85 Q fever patients. Cardiac valvulopathy was present in 39 (59%) patients. None of the 85 patients developed chronic Q fever. CONCLUSIONS: Clinical, serological and echocardiographic data of the current ongoing Dutch Q fever outbreak cohort are presented. Screening echocardiography is no longer part of the standard work-up of Q fever patients in the Netherlands.

Hepatitis B virus infected health care workers in The Netherlands, 2000-2008.

In response to the confirmed transmission of hepatitis B virus (HBV) from a surgeon to several patients in the Netherlands, a 'Committee for Prevention of Iatrogenic Hepatitis B' was established in 2000. During the years 2000-2008, the committee reviewed 99 cases of HBV-infected health care workers. Fifty of them were found to perform exposure prone procedures (EPPs). Because of high levels of HBV DNA (>100,000 copies/ml), a ban on performing EPPs was applied in 11/50 cases; 25/50 low-viremic health care workers were allowed to continue EPPs while their HBV load was being monitored; and 14/50 cases had stopped working or changed profession. In five restricted workers who started oral antiviral treatment, HBV replication was persistently suppressed, enabling the ban on EPPs to be lifted. Throughout the European Union different levels of HBV viremia have been chosen, above which health care workers are not allowed to perform EPPs. It remains unknown how this affects the safety of patients. Application in the Netherlands of a European or a British guideline would have, respectively, doubled or tripled the number of restricted health care workers.

Bacteraemia caused by Stomatococcus mucilaginosus in a granulocytopenic patient with acute lymphocytic leukaemia.

A patient undergoing chemotherapy for acute lymphoblastic leukaemia developed bacteraemia caused by Stomatococcus mucilaginosus while he was granulocytopenic. The organism may have been selected from the upper respiratory tract flora during prophylaxis with oral ciprofloxacin and then translocated to the blood stream via the mucosa. The strain produced an API-Staph profile indistinguishable from that of Micrococcus kristinae. Since a catalase-negative reaction is highly suggestive of S. mucilaginosus, the test should be performed routinely if this organism is not to be overlooked.

Conjunctival and corneal colonization by Pseudomonas aeruginosa in mechanically ventilated patients. A prospective study.

In patients on mechanical ventilation the eyes may be colonized with P. aeruginosa. This study was designed to establish an association between endotracheal suctioning and this colonization. During the study period from January to August 1996, ten out of twenty-eight (36%) patients who were mechanically ventilated for than 3 days developed colonization of the respiratory tract with P. aeruginosa. In seven out of these ten patients (70%) conjunctival colonization with P. aeruginosa could be established. Subsequently three patients (11%) developed a clinical eye infection. In all patients the eye on the side corresponding to the position of the ventilator, the suction device and the location of the nurse during suctioning procedures, was colonized first. Contamination of the conjunctiva probably occurs by aerosol exposure during disconnection of the intubation tube from the ventilator for tracheal suctioning. Patients on mechanical ventilation may have an increased risk for eye infections.

Detailed analysis of health status of Q fever patients 1 year after the first Dutch outbreak: a case-control study.

BACKGROUND: Q fever is a zoonosis caused by the obligate intracellular bacterium Coxiella burnetii. The two long-term complications, after primary infection, are chronic Q fever in ∼1% of patients, and a chronic fatigue syndrome in 10-20%. However, the existence of a protracted decreased health status after Q fever remains controversial. AIM: To determine the health status of the patients of the Q fever outbreak in The Netherlands in 2007, 1 year after primary infection. DESIGN: Cross-sectional case-control study. METHODS: Health status of the patients from the 2007 Dutch Q fever outbreak was compared to age-, sex- and geographically matched and Q fever seronegative controls. Health status of both patients and controls was assessed with the Nijmegen Clinical Screening Instrument (NCSI). RESULTS: Fifty-four Q fever patients provided 34 years of age- and sex-matched controls from the same neighbourhood. Eleven controls had positive Q fever serology and were excluded. Q fever patients had significantly more problems on the subdomains of symptoms and functional impairment. Overall quality of life was decreased in both patients and controls, 59% vs. 39%, respectively, ns). Severe fatigue levels were present in 52% of patients vs. 26% in controls (P < 0.05). CONCLUSION: These data support a sustained decrease in many aspects of health status in Q fever patients in The Netherlands, 1 year after primary infection.

Procalcitonin kinetics in Legionella pneumophila pneumonia.

Little is known about procalcitonin (PCT) levels in patients with community-acquired pneumonia (CAP) caused by Legionella pneumophila. The aim of the present study was to investigate this infection marker in patients admitted with L. pneumophila pneumonia in relation to conventional inflammatory parameters, severity of pneumonia upon admission and clinical outcome. Eighteen patients admitted with CAP caused by L. pneumophila serogroup 1 were retrospectively examined. PCT measurements were carried out during the first week of admission in addition to measurements of C-reactive protein (CRP), white blood cell (WBC) count and registration of severity of pneumonia upon admission (CURB-65 score). The mean PCT level upon admission in patients with L. pneumophila pneumonia was 13.5 ng/mL (range 0.3-55.7 ng/mL). Mean CRP level was 397 mg/L (range 167-595 mg/L) and mean WBC count 11.7 x 10(9)/L (range 4.5-20.4 x 10(9)/L). Initial high PCT levels were indicative of more severe disease as reflected by prolonged intensive care unit (ICU) stay and/or in-hospital death. Patients admitted to the ICU showed significantly higher PCT levels compared with the remaining patients [26.7 ng/mL (range 4.6-55.7 ng/mL) vs. 6.9 ng/mL (range 0.3-29.3 ng/mL); p 0.019]. There was a significant correlation between Acute Physiology and Chronic Health Evaluation-II scores upon ICU admission and initial PCT levels upon hospital admission (r = 0.86; p 0.027). Persistently increased PCT levels during treatment were indicative of unfavourable clinical outcome. Conventional inflammatory parameters (CRP and WBC) and the CURB-65 score lacked this discriminatory capacity in our study population. PCT may therefore be a valuable tool in the initial clinical assessment and follow-up of patients with L. pneumophila pneumonia.

Specific and sensitive detection of Neisseria gonorrhoeae in clinical specimens by real-time PCR.

Early diagnosis of Neisseria gonorrhoeae infections is important with regard to patients' health and infectivity. We report the development of a specific and sensitive TaqMan assay for the detection of N. gonorrhoeae in clinical samples. The target sequence is a 76-bp fragment of the 5' untranslated region of the opa genes that encode opacity proteins. A panel of 448 well-defined N. gonorrhoeae isolates was used to evaluate and optimize the assay. The method employs two minor-groove binding probes, one of them recognizing a newly identified sequence in the opa genes. Testing a large panel of related and unrelated microorganisms revealed that other Neisseria strains and other microorganisms tested negative in the opa test. With a lower detection limit of one genome per reaction, the opa test appeared more sensitive than both the COBAS AMPLICOR (Roche Diagnostics Nederland BV, Almere, The Netherlands) and a LightCycler 16S rRNA test. Analysis of a panel of 122 COBAS AMPLICOR-positive samples revealed that 68% were negative in both the 16S rRNA test and the opa assay (confirming that the COBAS AMPLICOR test produces false positives), while 30% were positive in both assays. Three samples were opa positive and 16S rRNA negative, which may be due to the higher sensitivity of the opa assay. We conclude that the opa gene-based real-time amplification assay offers a sensitive, specific, semiquantitative, and reliable assay suitable for the detection of N. gonorrhoeae in clinical specimens and/or for confirmation of less specific tests.

Comparison of seven coagulase tests for identification of Staphylococcus aureus.

Four coagglutination tests for the identification of Staphylococcus aureus were compared with the ordinary slide and tube coagulation tests using two groups of staphylococcal strains (one isolated in the authors' laboratory and the other identified by a reference laboratory). The correct identification rate in the two groups was respectively for slide test 96.9% and 92.7%, tube coagulation (citrate plasma) 99.0% and 94.8%, tube coagulation (EDTA plasma) 99.0% and 91.7%, API Staphase III 100% and 91.7%, Staph Rapid 97.9% and 91.3%, Staphyslide 99.0% and 94.6%, Staphaurex 96.9% and 92.7%. The sensitivity of Staph Rapid, Staphyslide and Staphaurex was slightly higher than that of the other tests. These three tests and the slide test were considerably more rapid as regards identification than the other tests.

Candida tropicalis arthritis in a patient with acute myeloid leukemia successfully treated with fluconazole: case report and review of the literature.

The case of a 77-year-old woman with acute myeloid leukemia who developed Candida tropicalis septic arthritis of the knee after remission-inducing chemotherapy is reported. A literature review of C. tropicalis non-prosthetic arthritis is included. The isolate was susceptible to fluconazole (MIC 0.25 mg/l). She was treated with fluconazole (400 mg orally) and frequent relieving synovial aspirations. After 1 month of antifungal therapy the synovial fluid became culture negative. Fluconazole concentration in the synovial fluid and serum were 20 mg/l and 19.4 mg/l, respectively. The patient was treated for a total of 7 months and made a full recovery. This is the first report of the successful use of fluconazole in the treatment of septic arthritis due to C. tropicalis.

Mycobacterium xenopi infection in an immunosuppressed patient with Crohn's disease.

A 48 year old patient with active Crohn's disease presented with bilateral nodules over his lungs resembling malignant metastasis. Bronchoscopic and pathological examination of the airways and sputum did not show any malignancy. After 6 weeks Mycobacterium xenopi was cultured from his bronchial washings while all other cultures remained negative. Treatment was started with rifampicin, ethambutol, and clarithromycin and, after 9 months of treatment, there was an almost complete resolution of his chest radiograph.