Serologic detection of a rare case of Q fever in New York City having hepatic and unusual renal complications.

We describe the case of a 46-year-old resident of New York City with a one-year history of frequent urination and 3 weeks of undulating fevers. He also had liver and bone marrow abnormalities where a non-culturable Gram-negative rod was identified. Q fever was suspected and confirmed based on highly elevated phase I and II serum IgM/IgG antibodies against Coxiella burnetii.

[Knowledge and use of Pap-smear among HIV-positive women]. / Importanza della conoscenza del Pap-test e suo utilizzo tra le donne HIV-positive.

AIM: HIV-positive women are at increased risk for preneoplastic lesions and invasive cervical cancer (ICC). The occurrence of these lesions can be substantially reduced by appropriate cervico-vaginal screening protocols (i.e., Pap-test). The aim of study was to assess: 1) awareness of Pap-smear and 2) the association between awareness of Pap-smear and screening attitudes of HIV-positive women. METHODS: Three-hundred and ninety HIV-positive women who attended the HIV outpatient gynecological unit of the National Institute for Infectious Diseases, Rome, from January 2003 to April 2005 were included in this investigation. These 390 women were interviewed to assess whether they were aware that Pap-test was a preventive tool against cervical cancer. In addition, past history of Pap-test, socioeconomic condition, history of HIV infection, and sexual habits were investigated. Odds ratios (OR) and 95% confidence intervals (CI) were used to assess the association between knowledge of Pap-test and covariates. RESULTS: Of these 390 HIV-positive women, 54.6% were not aware that Pap-test could prevent ICC. Women with a low educational level (OR = 6.6) or women who originated from Africa (OR = 6.5) were more likely to be unaware of Pap-test. Lack of Pap-test awareness was strongly associated with negative history for lifetime Pap-test (OR = 4.7). CONCLUSIONS: We showed that a large proportion of HIV-infected women are not aware that ICC could be prevented through Pap-test screening, and that lack of Pap-test screening is strongly associated with lack of awareness. The need for Pap-test counseling targeted to HIV-infected women clearly emerges from our findings.

Large de novo deletion in chromosome 12 affecting the PAH, IGF1, ASCL1, and TRA1 genes.

Phenylketonuria is one of the most common genetic diseases in humans, affecting 1 in 10,000 whites. Deletions are generally uncommon in genes in which no long highly homologous segments are present, and in phenylalanine hydroxylase (PAH) deficiency they represent only 5% of cases. We present the case of a girl affected by classical phenylketonuria who has been screened for mutations in the PAH gene. During the molecular study a large de novo deletion has detected in 12qter, including PAH, and the genes for insulin-like growth factor 1 (IGF1), human achaete-scute homolog 1 (ASCL1), and tumor rejection antigen (TRA1). The patient showed phenylketonuria, short stature, and pathological electro-oculography results in both eyes, with high affectation of the relative electrogenesis of the photoreceptor-pigment epithelium complex. She had previously been misdiagnosed as homozygous for the IVS8nt-7A-G mutation, instead of heterozygous for a mutation and a de novo deletion. As a result incorrect genetic counseling had been given. The deletion of the PAH, IGF1, and ASCL1 genes could explain the patient's phenotype corresponding to a contiguous gene syndrome. We stress the relevance of polymorphic marker haplotype analysis and the importance of family study in genetic recessive diseases, such as phenylketonuria, to avoid incorrect diagnosis and genetic counseling.

Total homocysteine in patients with type 1 diabetes.

OBJECTIVE: Our aim was to study the presence of moderate hyperhomocysteinemia, a risk factor for premature cardiovascular disease, its modifying vitamin factors (folates, vitamins B12 and B6), and lipid risk factors in juvenile type 1 diabetes. RESEARCH DESIGN AND METHODS: A total of 91 patients with type 1 diabetes (46 girls and 45 boys) were studied, with ages ranging from 11 to 18 years, a duration of diabetes from 1 to 15 years, and in pubertal development (stages III, IV, V). In all patients, cholesterol, triglycerides, HDL and LDL cholesterol, lipoprotein(a), folates, cobalamin, vitamin B6, and total homocysteine were determined by specific assays. Microalbuminuria, defined as a ratio of albumin/creatinine >3 mg/mmol creatinine, was analyzed in the first morning specimen. RESULTS: Plasma total homocysteine (tHcy) concentrations were not different in the 91 diabetic children (median [range]) (11-15 years, 6.1 micromol/l [3.2-9.6]; 16-18 years, 7.3 micromol/l [3.9-12]) compared with the control group (11-15 years, 6.6 micromol/l [4.4-10.8]; 16-18 years, 8.1 micromol/l [4.6-11.3]). No significant differences were found in tHcy values in relation to the metabolic control of the disease as assessed by glycohemoglobin values, the duration of disease, alterations in fundus oculi, or presence of lymphocytic thyroiditis. A positive correlation was found between tHcy and plasma creatinine in type 1 diabetic patients that might be related with the increase in muscle mass. There was a negative correlation between tHcy and serum folate (P<0.001) and vitamin B12 (P<0.05), but not with vitamin B6 levels. No significant correlations were found between tHcy and the lipid parameters. CONCLUSIONS: Hyperhomocysteinemia was not detected in adolescents with type 1 diabetes.

Isolation of Borrelia burgdorferi from the blood of seven patients with Lyme disease.

PURPOSE: Borrelia burgdorferi, the etiologic agent of Lyme disease, has rarely been successfully cultured from blood. We report on seven patients from Westchester County, New York, with B. burgdorferi bacteremia diagnosed between April 1987 and August 1987. PATIENTS AND METHODS: One hundred thirty-two attempts to isolate spirochetes were made on blood specimens obtained from 104 patients. Twenty-two of these specimens were obtained from nine patients who had recently been bitten by Ixodes ticks but who were asymptomatic. Heparinized blood or serum specimens (0.2 to 0.4 mL) were inoculated onto 6 mL of modified Barbour-Stoenner-Kelly medium. Lyme serology was performed by enzyme-linked immunosorbent polyvalent, IgM, and IgG assays, fluorescent immunoassay, and microhemagglutination. RESULTS: Four of the seven patients had erythema migrans, two had facial nerve palsy, and one had a flu-like syndrome without rash. These patients represented 21% (four of 19) of all patients with the characteristic skin lesion who had blood cultures for B. burgdorferi, and 40% (two of five) of all those with facial nerve palsy. Serologic testing was frequently nonreactive; two patients had no detectable antibody on multiple sera by five different assays. All patients improved with antibiotic treatment, and had negative subsequent blood cultures, but five of seven had persistent complaints after completion of therapy. CONCLUSION: Culturing blood for B. burgdorferi may be useful in confirming the diagnosis of Lyme disease in selected patients. Use of spirochete blood cultures may facilitate a better understanding of the pathogenesis and natural history of Lyme disease.

Ontogeny of human T cells.

Current knowledge of human T cell ontogeny is reviewed in terms of appearance of T cells in central and peripheral lymphoid organs, maturation of T cell markers, and development of immune functions. Extrapolation of growth curves derived from cell counts from fetal thymus, spleen, and bone marrow indicates the appearance of lymphocytes at 3.5 weeks gestation. E-rosette-forming cells are present in thymus at 11 weeks and in peripheral organs 15 to 16 weeks gestation. beta-2-Microglobulin is associated with all lymphoid cells by 13 weeks gestation. Lymphocyte responses to the T cell mitogen phytohemagglutinin (PHA) are first detected in thymus at 10 weeks and in spleen and blood 3 to 4 weeks later. Allogeneic responses in mixed lymphocyte reactions develop at about 7.5 weeks in fetal liver and later in thymus and peripheral organs. Lymphocytotoxicity for xenogeneic cells is a property of bone marrow cells and not thymocytes. Several aspects of development of a suppressor T cell in human neonates is discussed and related to similar findings in the mouse. These studies indicate a relatively high degree of maturation of human T cells during fetal life.

Immunocompetence of murine placental lymphocytes. In-vitro response to mitogens and to allogeneic cells.

Murine lymphoid cells from late (16-20 day) gestational placentae were studied for their ability to respond to mitogens and adult allogeneic cells in the mixed lymphocyte reaction (MLR) and the cell-mediated lympholysis test. Placental lymphocytes from Balb/c mice expressed a weak to moderate proliferative response to concanavalin A (Con A), phytohemagglutinin (PHA), and pokeweed mitogen when compared to the mitogenic responses of adult spleen cells. The stimulatory effects of Con A and PHA were abrogated after depleting the T cells from the placental lymphocyte preparation. Lipopolysaccharide-induced reactivity was similar for both cell populations. In MLR Balb/c placental lymphocytes did not undergo significant DNA synthesis after in-vitro exposure to irradiated C75BL/6 spleen cells, nor were cytotoxic lymphocytes generated against H-2b alloantigens. Lack of an MLR response was not associated with the presence of a suppressor lymphoid-cell population in the placenta. In marked contrast, placental trophoblastic cells were refractory in their responsiveness when cultured with either mitogens or allogeneic cells. These data show that although there is a selective deficiency in the placenta of cells reactive toward alloantigens, limited differentiation of lymphoid cells does occur which may offer immunologic protection to the fetal allograft during embryogenesis.

Concurrent neuroborreliosis and Alzheimer's disease: analysis of the evidence.

Several recent reports have claimed a possible association between Borrelia burgdorferi infection and Alzheimer's disease (AD). Herein, we describe our search for additional evidence of neuroborreliosis in AD. Brain tissue from neuropathologically confirmed cases of AD was cultured for B burgdorferi using standard microbiologic methods. Material derived from culture was further examined using electron microscopy, direct immunofluorescence and acridine orange fluorescence. Previous studies have shown high titers of antiborrelia antibodies in CSF in all cases of confirmed neuroborreliosis; therefore, we tested CSF from neuropathologically confirmed cases of AD by indirect immunofluorescence and enzyme-linked immunoassay. In addition, imprint preparations from AD and control brain tissues were studied by direct immunofluorescence using a monoclonal antiborrelia antibody. Finally, a Western blot method was used to analyze protein extracts from cultures and AD brain tissue for the presence of borrelia antigen. Contrary to previous studies, our results do not support an association between infection with B burgdorferi and AD.

Suppression of murine allogeneic cell interactions by sex hormones.

Investigations have been carried out on the action of several steroid hormones on lymphocyte functions in inbred strains of mice. The recognitive, proliferative and effector phases of allogeneic cell interactions in vitro were assessed using a mixed lymphocyte reaction (MLR) and cell-mediated lympholysis (CML). In MLR containing Balb/c (responder) and C57bl/6 (stimulator) splenocytes DNA synthesis was markedly reduced in the presence of progesterone, cortisol or estradiol. In CML, progesterone and estradiol (1-5 microgram/ml) blocked in vitro generation of cytotoxic lymphocytes, while cultures with cortisol were partially inhibited. None of these hormones suppressed the cytotoxic activity of previously sensitized effector cells generated in vitro. Cultures containing testosterone expressed both normal DNA synthesis in MLR and cytotoxic activity in the CML test. These findings suggest a selective pattern of immunosuppression by sex hormones which may be important in preventing graft rejection or graft-versus-host interactions which may arise as a consequence of fetal engraftment during pregnancy.

Immunization and protection against malaria during murine pregnancy.

Normal and immune mice were evaluated for their ability to resist infection to the rodent malaria parasite, Plasmodium yoelii, during pregnancy. Parasitemia levels were slightly higher and time-to-death shorter in the nonimmunized pregnant group infected with virulent parasites relative to virgin controls. Subinoculation experiments revealed that numerous virulent organisms were present in the placentas of unprotected gravida but were absent from the fetal livers of their conceptuses. It was also found that mice preimmunized with irradiated P. yoelii survived a usually lethal challenge infection during mid-gestation and delivered healthy newborns. Associated with this protection against transplacental spread of parasites was the additional key finding that placental macrophages were as effective as peritoneal exudate cells in phagocytosing parasite derived material in vitro. This murine malaria-pregnancy model should provide new insights on the various factors (virulence, immunogenicity) of microbial infections affecting the fetal-maternal relationship, as well as on the expression of immune effector mechanisms and immunoregulation, during the reproductive process.

The use of metrizamide for isopyknic separation and enrichment of Plasmodium falciparum schizonts from continuous culture.

Plasmodium falciparum-parasitized erythrocytes obtained from continuous in vitro cultures were fractionated over metrizamide density gradients. Late developmental stage schizonts were isolated from uninfected erythrocytes and other intracellular blood stage forms (rings and trophozoites) by centrifugation through 15% metrizamide. Schizonts comprised, on the average, 85% of the total number of cells recovered from the top fraction of the gradient with the remaining cells being predominantly uninfected erythrocytes. The mean percentage of schizonts recovered was 27% relative to the estimated number of mature forms present before fractionation. The concentrated schizonts were viable based upon their ability to complete schizogony and undergo a new cycle of reinvasion and schizogony in vitro. In addition, in these short term synchronous cultures the newly infected cells were able to incorporate radiolabeled hypoxanthine. This function was inhibited by the addition of chloroquine to these 45- to 46-hour cultures. Metrizamide-purified schizonts should be useful for further study and characterization of the unique metabolic, biochemical, and immunological properties of the malaria parasite.

A murine IgG1 monoclonal antibody that binds specifically to outer surface protein A of Lyme disease spirochete Borrelia burgdorferi.

A murine monoclonal antibody, designated MA-2G9, directed against outer surface protein A (OspA) of the Lyme disease spirochete, Borrelia burgdorferi, has been produced. Antibody MA-2G9, IgG1 subclass, was purified by affinity chromatography on protein G Sepharose column and used for purification of OspA antigen from Borrelia burgdorferi cell lysate. Epitope specificity was studied by Western immunoblotting, using several strains of B. burgdorferi and non-Lyme disease bacteria such as Treponema pallidum and B. hermsii. The MA-2G9 monoclonal antibody reacted specifically with recombinant OspA as well as with native OspA in sonicated B. burgdorferi strains. No reaction was observed with T. pallidum, Escherichia coli, Staphylococcus aureus and B. hermsii lysates. The MA-2G9 antibody also recognized the denatured form of OspA indicating that it is directed against sequential epitope and not conformational epitope.

Antigens of Lyme disease of spirochaete Borrelia burgdorferi inhibits antigen or mitogen-induced lymphocyte proliferation.

Modulation of cellular immune responses by the spirochaete Borrelia burgdorferi, the bacteria that causes Lyme disease, was demonstrated. When cultured in the presence of sonicated Borrelia preparation (Bb), the mitogen- or antigen-stimulated proliferative responses of normal lymphocytes were consistently lowered. Bb caused the greatest reduction in Concanavalin A (ConA) or antigen-stimulated proliferation, where almost 100% reduction in proliferation could be achieved. Bb also reduced phytohemagglutinin-M (PHA) or pokeweed mitogen (PWM)-stimulated peripheral blood lymphocyte (PBL) proliferation, with the PWM proliferation being the least affected. This regulatory activity was not due to toxicity and was determined to be caused by Bb protein antigens. The degree of the proliferation reduction was directly proportional to both Bb quantity and length of exposure to lymphocytes. IL-2 production was significantly reduced from Bb-exposed lymphocytes. The entry of lymphocytes into the proliferating phases of the cell cycle was also shown to be blocked. These results have demonstrated an immune suppressive mechanism of B. burgdorferi. The magnitude of host immune responses may be dependent on the degree of suppression which is related to the spirochaete quantity and their length of presence in the host.

An indirect hemagglutination antibody test to detect antibodies to Borrelia burgdorferi in patients with Lyme disease.

An indirect hemagglutination antibody (IHA) test was evaluated for its ability to detect borrelial antibodies in serum samples from patients with Lyme disease. The key test reagent developed for this antibody detection system was tannic acid-treated and glutaraldehyde-fixed sheep red blood cells (SRBC) containing Borrelia burgdorferi (Bb) antigens attached to the outer surface of the SRBC. In order to establish suitable cut-off titers, initial specificity and sensitivity measurements were made using sera from 100 anonymous healthy volunteers and 30 additional pre-determined samples known to be non-reactive or reactive for Lyme disease or syphilis. These results were compared with those obtained using a commercially available ELISA. At titers >/=64, the IHA test had a combined 98% specificity and 100% sensitivity for these 130 serum samples, 30 of which were known positives or negatives, whereas the ELISA was less specific (93%) and much less sensitive (80%). Subsequent testing was performed on sera from 65 patients with the erythema migrans (EM) rash and 20 patients with early disseminated (cardiac/neurologic) symptoms or with Lyme arthritis. At initial presentation, 46-48% of the EM patients had IHA reactivity, with titers >/=128, while 42% were positive in the ELISA. Follow-up testing performed on these EM patients, 8-12 days after receiving antibiotic treatment, revealed that Bb antibodies were detected best by the IHA test (83-86% reactive) relative to the ELISA (81% reactive). Bb antibodies were readily detectable on all of the serum samples from the early disseminated and late stage Lyme disease cases in both assay systems. Based on these results and because of its technical and interpretive simplicity, the IHA test should be considered as a useful and convenient alternative for the serological analysis of Bb infections.

Failure in intrauterine contraception. Analysis of 137 cases of unfavourable outcome.

137 cases of unfavourable outcome in IUD insertion (i.e. early removal or expulsion because of complications) were investigated as regards age, parity, previous intrauterine contraception, previous induced abortion, type of device inserted, and type of complications observed. Moreover, this group was compared for each feature mentioned with a control group of 454 women who successfully concluded the prescribed period from the insertion. All the devices were inserted with a significantly higher rate of favourable outcome in pluriparous versus nulliparous patients; age probably didn't affect the outcome, but strongly conditioned the prevalence of particular complications such as PID and abnormal bleeding. Progesterone-loaded IUD didn't show a more favourable outcome than copper devices.

PIP: The factors associated with 137 cases of IUD expulsion or early removal due to complications were investigated in a case-control study conducted at an Italian family planning clinic. The 454 controls were women who did not experience adverse IUD outcomes. Complications in the study group included: bleeding (35%), expulsion (13%), pregnancy (13%), pelvic pain (15%), and pelvic inflammatory disease (24%). The majority of complications occurred 6-12 months after IUD insertion. Previous IUD use and the type of IUD inserted were unrelated to outcome. Most significant in terms of outcome was parity. There was a statistically significant (p .001) difference between the percentage of nulliparae in the study group (34%) compared with the control group (17%). Although most of the nulliparae in the study group were under 20 years of age, age did not have a significant correlation with IUD outcome. Pelvic inflammatory disease was significantly more prevalent in women under 30 years of age, while excessive bleeding was more common in cases above this age.

Diagnosis and follow-up of a case of peroxisomal disorder with peroxisomal mosaicism.

Peroxisomal disorder phenotypes are the result of mutations that cause defective peroxisomal assembly or alterations in the import mechanism of peroxisomal proteins that lead to multiple peroxisomal dysfunctions, or the result of a peroxisomal enzymatic deficiency with a single peroxisomal dysfunction. With complementation analysis, 16 groups have been found. Assignment of the genetic defect has been described for some of the complementation groups. We describe the clinical evolution and follow-up over 10 years of a patient who belongs to complementation group 4, although he showed a milder clinical course. It has been found in fibroblasts different peroxisome populations, normal processing and expression of beta-oxidation PTS1 and PTS2 proteins, abnormal ALD protein distribution and normal plasmalogen biosynthesis; abnormal beta-oxidation metabolites have also been detected in serum. Ultrastructural studies in liver showed peroxisomal mosaicism as in fibroblasts. It has been taken into account that peroxisomal mosaicism may lead to variability in peroxisomal diagnostic parameters, making difficult the final diagnosis in these patients.

Distribution of Trichinella spiralis larvae in muscles from a naturally infected horse.

Epidemiological investigations conducted during 10 trichinellosis outbreaks between 1975 and 1994 showed that horse-meat was the probable source of infection. Though hundreds of thousands of horses have been examined at abattoirs in America and Europe to detect Trichinella infection by artificial digestion or trichinelloscopy, an infected horse has never been detected during routine analysis, which consists of examining 1 g of tissue muscle from the diaphragm. In November 1996, a naturally infected horse imported from Romania was detected in Southern Italy. The parasite was identified as Trichinella spiralis by random amplified polymorphic DNA analysis. Artificial digestion of tissue samples from 60 different muscles from 13 different sites of the infected horse carcass showed that M. levator Labii maxillaris, M. hyoideus transversus, and M. buccinator were the 3 most infected muscles. Muscles from the tongue, the masseter, and the diaphragm, which have normally been considered the muscles of choice for diagnosis, were the 4th, 6th and 13th most infected muscles, respectively. When comparing body sites, muscle tissues from the head showed the highest level of infection, followed by muscles from the neck. This finding may explain the negative results that have been obtained in the past during routine examination of the diaphragm of horses.

Efficacy of low dose schedule pamidronate infusion in children with osteogenesis imperfecta.

BACKGROUND: Osteogenesis imperfecta (OI) is a rare condition in which bones are abnormally brittle with frequent fractures. A variety of therapeutic agents has been used with low efficacy. In this study, we present three patients treated for 4 years with i.v. pamidronate. PATIENTS AND METHODS: Three prepubertal patients, aged 9 (M), 9 (F) and 11 (F) years old, with OI, were treated with 30-60 mg i.v. pamidronate every 6 months over four years. Determinations were made of plasma 1,25-dihydroxycholecalciferol, 25-hydroxycholecalciferol, insulin-like growth factor-I (IGF-I) and its transport protein (IGFBP3), osteocalcin, total alkaline phosphatase and its osseous fraction, and parathormone (PTH) at baseline and after every pamidronate infusion, Densitometry and X-ray of the vertebral column were performed at the same intervals. RESULTS: Significant reductions of number of bone fractures and pain were observed in all patients, despite lack of any modification in biochemical parameters. Lumbar X-ray and densitometry showed a striking improvement by the end of the treatment period. CONCLUSION: Pamidronate seems to be useful in the treatment of patients with osteogenesis imperfecta.

Bisphosphonates, a new treatment for glucocorticoid-induced osteoporosis in children.

BACKGROUND: Long-term corticoids used as a treatment for rheumatic diseases are the most frequent cause of osteoporosis in the pediatric population. Bisphosphonates have been proved to be useful in treating osteoporosis. OBJECTIVE: To investigate the efficacy of pamidronate in corticoid-induced osteoporosis in children. PATIENTS AND METHODS: Ten children affected with rheumatic diseases and osteoporosis underwent biannual cycles of intravenous pamidronate (4 to 12 cycles). Complete clinical, radiological, biochemical and densitometric follow-up was performed at every treatment cycle. RESULTS: Good clinical and radiological evolution was observed in most of our patients; no new vertebral fractures were reported. Good densitometric evolution has been linked to the onset of puberty (rise in IGF-I levels) and low values for inflammatory activity markers (ESR and CRP). Self-limited hyperthermia and mild abdominal pain were observed during pamidronate infusion, but no other side effects were reported. CONCLUSIONS: Pamidronate is a safe and useful treatment for corticoid-induced osteoporosis in the pediatric population.

The efficacy of clarythromycin (A-56268, TE-031) in the treatment of genital chlamydial infection.

The authors report the preliminary results of an experience of treatment with clarythromycin in Chlamydia trachomatis endocervicitis/endourethritis; 100% of 51 outpatients treated had negative ELISA results 7-10 days after the end of treatment with clarythromycin 500 mg. b.i.d. for 7 days. Among 64 female outpatients with chlamydial cervicitis treated with erythromycin 1 g b.i.d. for 7 days, 88% were negative at ELISA at the same intervals after therapy. The authors conclude that the efficacy of clarythromycin in this experience makes it use worthy of other and more extensive studies.