Case report: Fatal Legionella infection diagnosed via by metagenomic next-generation sequencing in a patient with chronic myeloid leukemia.

Legionella is an aerobic, gram-negative, intracellular pathogen and is an important cause of community-acquired pneumonia. Legionella pneumophila is the most common causative agent of Legionella pneumonia. Clinical diagnosis of Legionella pneumonia is challenging due to the lack of specific clinical manifestations and the low positive rates of conventional pathogen detection methods. In this study, we report a case of a patient with chronic myeloid leukemia who developed rigors and high fever after chemotherapy and immunotherapy. Chest computed tomography revealed consolidation in the left lower lobe of the lung and ground-glass opacities in both lower lobes. Multiple blood cultures showed Escherichia coli, Staphylococcus aureus, Bacillus licheniformis, and positive results in the ß-D-glucan test (G test). The patient was treated with various sensitive antimicrobial agents, including meropenem plus fluconazole, meropenem plus carpofungin, and vancomycin. Unfortunately, the patient's condition gradually worsened and eventually resulted in death. On the following day of death, metagenomic next-generation sequencing (mNGS) of 1whole blood revealed L. pneumophila pneumonia with concurrent bloodstream infection (blood mNGS reads 114,302). These findings suggest that when conventional empirical antimicrobial therapy proves ineffective for critically ill patients with pneumonia, the possibility of combined Legionella infection must be considered, and mNGS can provide a diagnostic tool in such cases.

The diagnosis and treatment of attention deficit-hyperactivity disorder in children and adolescents with cystic fibrosis: a retrospective study.

BACKGROUND: There has been minimal study of the impact of attention deficit-hyperactivity disorder (ADHD) in cystic fibrosis (CF) or other chronic illness. OBJECTIVE: To examine patterns of ADHD diagnosis and treatment in CF. METHOD: Retrospective chart review of all pediatric patients in the Massachusetts General Hospital (MGH) CF Program referred from 8/05-12/08 for outpatient child psychiatric consultation and diagnosed with ADHD. The medication trial resulting in the best improvement in ADHD symptoms with the most tolerable side effects was designated the Best Regimen for each patient. RESULTS: Of the 188 patients aged 5-18 followed in the MGH CF Program during this time, 18 (9.6%) were referred to the liaison psychiatrist and diagnosed with ADHD. Eleven (61%) had CF treatment non-adherence as a presenting problem. Psychopharmacologic treatment of ADHD was attempted in 13 of the 18 cases. In eight cases the Best Regimen achieved a Clinical Global Impression improvement rating of much or very much improved. In three cases, the Best Regimen consisted of stimulant monotherapy; two consisted of nonstimulant monotherapy; two used a combination of two nonstimulants; and one used a combination of a stimulant and a nonstimulant. CONCLUSION: ADHD is common and treatable in pediatric patients with CF. Stimulants, nonstimulants, and combination therapies are viable treatment options. The presence of ADHD or other psychiatric disorders should be considered when behavior is interfering with adherence to medical care. Further research is needed into the prevalence and treatment of ADHD in CF and its impact on medical adherence and outcomes.

[The diagnostic value of polymerase chain reaction for the detection of Pneumocystis carinii DNA from induced sputum samples].

OBJECTIVES: To evaluate the diagnostic value of PCR for detection of Pneumocystis carinii DNA from induced sputum samples. METHODS: P. carinii cysts or trophozoites were detected in induced sputa by Giemsa stain or Gomori Methenamine silver (GMS) stain. A fragment of the Pneumocystis carinii mitochondrial large-subunit rRNA gene was amplified from sputum samples using a one-step PCR method with mt-rRNA primers. RESULTS: In this study, sputum samples from 16 patients with a clinical diagnosis of Pneumocystis carinii pneumonia (PCP) and 20 patients with other respiratory infections were first tested by cytochemical staining. Pneumocystis carinii was detected in 8 and 0 sputum samples from the two groups, respectively. The sensitivity and specificity of cytochemical stain were 50% and 100%. With the one-step mt-rRNA-PCR method, Pneumocystis carinii DNA was detected in 14 and 0 sputum samples from 16 PCP patients and 20 non-PCP patients. The sensitivity and specificity of mt-rRNA-PCR was 88% and 100%, respectively. CONCLUSIONS: The specificity of both Giemsa and GMS staining of induced sputum samples is high and the methods are simple, but the sensitivity is low. The sensitivity of PCR for P. carinii DNA from induced sputum samples is significantly higher than cytochemical stains, and the method is highly specific when used in the clinical diagnosis of PCP.

Modulation of astrocyte inducible nitric oxide synthase and cytokine expression by interferon beta is associated with induction and inhibition of interferon gamma-activated sequence binding activity.

Although interferon (IFN)-beta is firmly established as a therapeutic agent for multiple sclerosis, information regarding its role in astrocyte cytokine production is limited. In primary cultures of human astrocytes, we determined the effects of IFN-beta on astrocyte cytokine [tumor necrosis factor-alpha (TNF-alpha) and interleukin (IL)-6] and inducible nitric oxide synthase (iNOS) expression by ribonuclease protection assay and ELISA. We found that IFN-beta inhibited astrocyte cytokine/iNOS induced by IL-1 plus IFN-gamma, but in the absence of IFN-gamma, IFN-beta enhanced IL-1-induced cytokine/iNOS expression. Electrophoretic mobility shift analysis (EMSA) demonstrated that IFN-gamma induced sustained IFN-gamma-activated sequence (GAS) binding, while IFN-beta induced transient GAS binding. When used together, IFN-beta inhibited IFN-gamma-induced GAS binding activity. Nuclear factor-kappa B (NF-kappaB) activation was not altered by either IFNs, whereas IFN stimulated response element (ISRE) was only activated by IFN-beta and not IFN-gamma. These results suggest that IFN-beta can both mimic and antagonize the effect of IFN-gamma by modulating induction of nuclear GAS binding activity. Our results demonstrating differential regulation of astrocyte cytokine/iNOS induction by IFN-beta are novel and have implications for inflammatory diseases of the human CNS.

Role of mitogen-activated protein kinases in inducible nitric oxide synthase and TNFalpha expression in human fetal astrocytes.

Astrocytes are important sources of proinflammatory mediators such as iNOS and TNFalpha in the diseased central nervous system. In previous studies, we showed that the cytokine IL-1 plays a critical role in the activation of human astrocytes to express TNFalpha and the inducible form of nitric oxide synthase (iNOS). In the present study, we have addressed the role of the MAP-kinase pathway in the signaling events leading to the induction of these genes. Treatment with SB203580, a specific inhibitor of p38 mitogen-activated protein kinases (MAPK), potently inhibited IL-1-mediated induction of iNOS and TNFalpha in cultures of human fetal astrocytes. In contrast, PD98059, an upstream inhibitor of the extracellular regulated kinase (ERK)1/2 pathway, had little or no effect. Interestingly, SB203580 reduced the mRNA expression for iNOS, TNFalpha, and IL-6, indicating inhibition prior to translation. Transfection of astrocytes with a dominant-negative Jun-NH(2)-terminal kinase (JNK) construct also reduced iNOS expression. Western blot analysis showed phosphorylated p38 and JNK in IL-1-activated astrocytes, and phosphorylated ERK in both resting and activated cells. Electrophoretic mobility shift assay (EMSA) showed that IL-1 induced NF-kappaB and AP-1 DNA complex formation in astrocytes, and that SB203580 inhibited AP-1 complex formation. Taken together, these results demonstrate the differential roles played by the three MAP kinases in human astrocyte inflammatory gene activation and point to a crucial function of p38 and JNK MAP kinases in IL-1-mediated astrocyte activation.