Optimal treatment for asymptomatic neurosyphilis.

In the pre-penicillin era, patients with asymptomatic neurosyphilis (ANS) were more likely to develop long-term neurological sequelae than those patients with normal cerebrospinal fluid (CSF). Although benzathine penicillin G cannot achieve treponemicidal levels in the CSF, decreased rates of neurological complications of syphilis and non-treponemal titre serological responses are usually observed after treatment with this antibiotic. We here a homosexual man with ANS successfully treated with benzathine penicillin G. This case suggests that reconsideration on the necessity of a lumbar puncture in HIV-infected patients with ANS is warranted.

Expression of matrix metalloproteinases and their tissue inhibitors in the serum and cerebrospinal fluid of patients with meningitis.

Meningitis is associated with an imbalance between matrix metalloproteinases (MMPs) and endogenous tissue inhibitors of MMP (TIMPs). Serum and CSF were collected prospectively from all patients with meningitis between January 2008 and December 2008 to measure the concentrations of MMP/TIMP in those patients who underwent a lumbar puncture for a presumptive diagnosis of meningitis. A total of 199 patients were enrolled into the study. The concentrations of CSF MMP-9 and TIMP-1 were significantly higher in the meningitis group compared with the control group (p 0.032 and p <0.001, respectively). However, the CSF TIMP-4 levels were significantly lower in the meningitis groups compared with the control groups (p <0.001). Patients with bacterial meningitis had higher CSF MMP-9 and TIMP-1 levels than those who had aseptic meningitis and controls. Patients with various infectious meningitis etiologies tended to have higher CSF MMP-9 expression by gelatin zymography when compared with the controls. In conclusion, MMP/TIMP system dysregulation was found in patients with meningitis, and CSF MMP and TIMP might act as novel indicators in patients with meningitis.

Reduced health provider delay and tuberculosis mortality due to an improved hospital programme.

SETTING: A referral hospital in Kaohsiung, Taiwan. OBJECTIVE: To evaluate the impact of an in-hospital tuberculosis (TB) quality care programme initiated in May 2005 on health provider delay and outcome of newly diagnosed TB cases. DESIGN: Retrospective chart review of newly diagnosed TB cases presenting in 2002 and 2006. Health provider delay, clinical manifestations, management and outcome were recorded. RESULTS: Overall, 327 patients before (2002) and 262 patients after (2006) the programme began were enrolled. Patients were older men (mean age 65.9 years) and 23.4% (138/589) had diabetes; 84.4% had received anti-tuberculosis treatment. The programme shortened the time for doctors to order a chest X-ray (P < 0.01), and the reporting time for smear (P < 0.0001) and culture (P < 0.0001). On multivariable analysis, risk factors for attributable mortality included age >/=65 years (OR 4.4, 95%CI 1.8-10.9, P = 0.001) and liver cirrhosis (OR 4.3, 95%CI 1.1-16.6, P = 0.04). Treatment reduced mortality by 81% (OR 0.2, 95%CI 0.1-0.4, P < 0.001) and the programme halved overall mortality (OR 0.5, 95%CI 0.3-0.8, P = 0.01), and reduced attributable mortality by 62% (OR 0.4, 95%CI 0.2-0.8, P < 0.01). CONCLUSION: Intervention at the hospital level for quality control of TB care was instrumental in reducing health provider delay and led to a significant reduction in mortality.

Risk factors for extra-pulmonary tuberculosis compared to pulmonary tuberculosis.

BACKGROUND: Tuberculosis (TB) continues to be a major global health problem. Extra-pulmonary TB (EPTB) manifests with protean symptoms, and establishing a diagnosis is more difficult than pulmonary TB (PTB). SETTING: A university-affiliated hospital in southern Taiwan. OBJECTIVE: To analyse the risk factors for EPTB compared with PTB. DESIGN: This retrospective study compared patients with EPTB and PTB in southern Taiwan by analysing their demographic data and clinical underlying diseases. Risk factors for EPTB were further analysed. RESULTS: A total of 766 TB patients were enrolled in this study, with 102 (13.3%) EPTB and 664 (86.7%) PTB cases. Of the 766 patients, 3% of PTB patients had EPTB, while 19.6% of EPTB patients also had PTB. The most frequently involved EPTB site was the bone and joints (24.5%). The incidence of EPTB vs. PTB decreased significantly for each decade increase in patient age. Multivariate logistic regression analysis showed that being female, not being diabetic, having end-stage renal disease and not smoking were independent risk factors for EPTB. CONCLUSION: This study defines the risk factors for EPTB compared with PTB. Awareness of these factors is essential for physicians to have a high index of suspicion for accurate and timely diagnosis.

High prevalence of latent tuberculosis infection in patients in end-stage renal disease on hemodialysis: Comparison of QuantiFERON-TB GOLD, ELISPOT, and tuberculin skin test.

BACKGROUND: Individuals with end-stage renal disease (ESRD) are 10- to 25-fold more likely than immunocompetent people to develop active tuberculosis (TB) and are candidates for being treated for latent TB infection (LTBI). However, diagnosis using the tuberculin skin test (TST) is doubly difficult due to cutaneous anergy and cross-reactions with Bacille-Calmette-Guérin (BCG) vaccination. MATERIALS AND METHODS: This was a prospective, doublematched, cohort study in which 32 ESRD patients and 32 age-matched, healthy controls were enrolled. The TST and two new interferon-gamma blood tests, QuantiFERON-TB Gold (QFT-G) and T-SPOT.TB (ELISPOT), were performed. The subjects were followed up 2 years for active TB disease. ELISPOT was done in ESRD patients only. RESULTS: Compared to the healthy controls, a high prevalence of LTBI was found in the ESRD patients by TST (62.5%, 95% confidence interval [CI] 43.7-78.9), QFT-G (40.0%, 95% CI 22.7-59.4), and ELISPOT (46.9%, 95% CI 29.1-65.3). Agreement was moderate (kappa [kappa] = 0.53) for QFT-G and ELISPOT but only slight between TST and QFT-G (kappa = 0.25) and fair between TST and ELISPOT (kappa = 0.32). ESRD (p = 0.03) and diabetes mellitus (p = 0.04) were significant risk factors for QFT-G positivity on the multivariable analysis. The overall rate of active TB was 1.66 cases per 100 person-years (pys), with the rate higher in patients with ESRD (3.53 per 100 pys) and those with positive (3.40 per 100 pys) and indeterminate QFT results (30.16 per 100 pys), although the difference was not statistically significant. Sensitivity, specificity, and positive and negative predictive values of QFT-G for active TB was 100%, 62.1%, 8.3% and 100%. CONCLUSION: This pilot study is the first to compare QFT-G, ELISPOT, and TST in ESRD patients on hemodialysis and demonstrates a high prevalence of LTBI in this population. In our study, the QFT-G was the more accurate method for identifying those truly infected with Mycobacterium tuberculosis, even in BCG-vaccinated individuals.

Acute flaccid paralysis as an unusual presenting symptom of Japanese encephalitis: a case report and review of the literature.

Japanese encephalitis (JE) is an endemic disease in Taiwan. Acute JE virus infection characterized by acute flaccid paralysis in an adult has never been reported in Taiwan. We report a young adult man who received four doses of JEV (Nakayama strain) vaccination in childhood, but still developed acute JE virus infection, characterized with acute flaccid paralysis.He presented with fever, headache, progressive muscle weakness, and respiratory paralysis requiring mechanical ventilator. Deep tendon reflexes were decreased except for the Achilles reflex. After supportive care, he was weaned from the mechanical ventilator and at discharge 1 month later, his muscle power level and deep tendon reflexes recovered partially. The diagnosis of JE was based on the presence of anti-JE virus IgM in the CSF and seroconversion of IgM and IgG by the ELISA method. Electrophysiological findings were described. From the experience of this case, we caution that a history of vaccination for JE with the Nakayama strain may not provide a complete protection against natural infection in the community; and in Taiwan or any area where JE remains an endemic disease, Japanese virus encephalitis infection should be considered as a differential diagnosis in any adult presenting with acute flaccid paralysis.

The ethical implications of stratifying by race in pharmacogenomics.

Many predict that pharmacogenomics is poised to deliver on the promises of the genomic revolution in ushering an era of personalized medicine. However, questions have emerged over whether the field will deliver a truly individualized medicine or if population-based therapies that build on conventional notions of racial biology will prevail. At the heart of this issue is the challenge of knowing which axes of stratification are appropriate in identifying population differences and to what extent is race and/or ethnicity an appropriate method of comparison in studies of genetic variation. These questions make plain that in addition to the development of technical tools to identify salient gene variants associated with drug response, serious consideration over how best to characterize populations in human genetic variation research must be given in order to realize the putative benefits of tailored therapeutics.

Fever of unknown origin in Taiwan.

BACKGROUND: Fever of unknown origin (FUO) is a challenging problem worldwide. There was no prospective study of FUO in the past two decades in Taiwan. A prospective study was conducted. MATERIALS AND METHODS: The prospective study was undertaken from March 2001 to May 2002. All patients fulfilling the modified criteria for FUO, either admitted, referred or consulted in a medical center in southern Taiwan, were enrolled for analysis. RESULTS: A total of 94 cases met the criteria of FUO. The final diagnoses of FUO consisted of 54 infectious diseases (57.4%), 8 hematologic/neoplastic (8.5%), 7 noninfectious inflammatory (7.4%), 8 miscellaneous (8.5%) and 17 undiagnosed (18.1%) cases. The single most common cause of FUO was tuberculosis. Some infectious diseases, such as rickettsiosis and melioidosis, were rarely reported in western countries. Three patients with hemophagocytotic syndrome without ascertainable etiologies were present with FUO in this study. Between the patients with and those without a final diagnosis, the short-term survival (3 months) was compared by the Kaplan-Meier analysis, which revealed no difference. CONCLUSIONS: Mycobacteriosis is still the leading cause of FUO in Taiwan and it is important to identify this treatable disease from all causes of FUO. This study has showed geographical variation among the studies of FUO.

Residential water supply as a likely cause of community-acquired Legionnaires' disease in an immunocompromised host.

A 69-year-old man with Sweet's syndrome and myelodysplastic syndrome presented with pneumonia and respiratory distress. He had been taking corticosteroids and methotrexate. The diagnosis of Legionnaires' disease was established by the isolation of Legionella pneumophila serogroup 6 from sputum and a fourfold seroconversion of Legionella antibodies to 1:512. Legionella pneumophila serogroup 6 was isolated from faucets in two homes owned by the patient. Strains of Legionella pneumophila serogroup 6 isolated from the patient's sputum and from one home were demonstrated to be genetically identical by pulsed-field gel electrophoresis but different from strains found in the other home and in a hospital outpatient clinic that he visited. This case illustrates an emerging public health issue concerning acquisition of community-acquired Legionnaires' disease from the homes of immunocompromised hosts. This is the first such case reported in Asia.