Deep, respiratory tract and ear infections caused by Pseudallescheria (Scedosporium) and Microascus (Scopulariopsis) in Finland. A 10-year retrospective multi-center study.

Deep, respiratory tract and ear infections due to Microascaceae (Pseudallescheria, Scedosporium, Microascus or Scopulariopsis) were studied nationwide in Finland during 1993-2002. The data were based on 52,000 fungal cultures that represented about 50% of all such specimens in Finland and included all Finnish cases of profound immunosuppression. There were 39 cases that were re-evaluated as clinically significant, i.e., three pneumonias, two deep pedal infections and five wound infections, 11 sinusitis and 18 ear infections. The pedal infections and most pneumonias occurred in immunocompromised patients. Most cases, except the ear infections, were due to Pseudallescheria boydii. Two patients had lethal P. boydii pneumonia and a deep P. boydii infection of the foot contributed to a third lethal case. Two of the patients with lethal outcomes had received an allogeneic haematopoietic stem cell transplantation (AHSCT). Two patients with haematological malignancies were cured of deep site infections by a prolonged course of itraconazole. Wound, sinus and ear infections were cured or improved by local surgery or topical therapy. There were 0.8-1.7 cases of any type of infection per million inhabitants per year (MY) and 3.4 cases/1000 AHSCT. Mortality associated with Microascaceae in any type of patient was 0.06-0.12 MY.

Bronchoalveolar lavage in immunocompromised patients with haematological malignancy--value of new microbiological methods.

PURPOSE: To assess the usefulness of new culture-independent microbiological methods to analyse bronchoalveolar lavage (BAL) fluid from haematological patients with clinical pneumonia. PATIENTS AND METHODS: Results of 135 BALs from 122 disease episodes in 99 patients treated between 1996 and 2002 were retrospectively analysed. Forty-three patients had undergone haematopoietic stem cell transplantation and 56 patients had been treated with conventional chemotherapy for haematological malignancy. In addition to conventional microbiological methods, polymerase chain reaction (PCR) tests for Pneumocystis carinii, cytomegalovirus (CMV), Legionella sp., mycobacterium, Mycoplasma pneumoniae, and Chlamydia pneumoniae and the Aspergillus antigen test were performed. RESULTS: Three (2.2%) quantitative and four (3.0%) special bacterial cultures gave an aetiological diagnosis. A respiratory virus was isolated in 10 episodes (8.2%). The diagnostic yield increased to 35.6% (48 of 135) by other methods. The P. carinii PCR test was positive in 21 of 24 patients with P. carinii pneumonia, being the only microbiological indication of P. carinii in four cases. The CMV PCR test was positive in 18 patients, but in 14 patients the clinical significance of the finding remained unproven. The Aspergillus antigen test was positive in seven of nine patients with aspergillosis, being the only microbiological indication of Aspergillus in three cases. The result of BAL indicated commencement of specific antimicrobial treatment in 27 episodes (22.1%). CONCLUSION: The contribution of new culture-independent methods to the total diagnostic yield was of note. Among these methods, the P. carinii PCR and Aspergillus antigen tests proved the most valuable, while the CMV PCR test was not clinically useful.

Aetiological diagnosis of brain abscesses and spinal infections: application of broad range bacterial polymerase chain reaction analysis.

OBJECTIVE: To evaluate the usefulness of the broad range bacterial rDNA polymerase chain reaction (PCR) method combined with DNA sequencing in the aetiological diagnosis of intracranial or spinal infections in neurosurgical patients. METHODS: In addition to conventional methods, the broad range bacterial PCR approach was applied to examine pus or tissue specimens from cerebral or spinal lesions in patients treated in a neurosurgical unit for a clinical or neuroradiological suspicion of bacterial brain abscess or spondylitis. RESULTS: Among the 44 patients with intracranial or spinal lesions, the final diagnosis suggested bacterial disease in 25 patients, among whom the aetiological agent was identified in 17. A causative bacterial species was identified only by the rDNA PCR method in six cases, by both the PCR methodology and bacterial culture in six cases, and by bacterial culture alone in five. All samples in which a bacterial aetiology was identified only by the PCR approach were taken during antimicrobial treatment, and in three patients the method yielded the diagnosis even after >/= 12 days of parenteral treatment. One case also identified by the PCR approach alone involved a brain abscess caused by Mycoplasma hominis, which is not readily cultured by routine methods. CONCLUSIONS: In patients with brain abscesses and spinal infections, the broad range bacterial rDNA PCR approach may be the only method to provide an aetiological diagnosis when the patient is receiving antimicrobial treatment, or when the causative agent is fastidious.

The reliability of diagnosis of infection during revision arthroplasties.

BACKGROUND: Follow up studies have shown that 0.5 to 4% of the total joint arthroplasties will be complicated by infection. Distinction between aseptic loosening and infection is important for prediction of the final outcome after revision arhtroplasty but also for the choice of operative treatment. However, diagnosis of low grade chronic infection is extremely demanding. MATERIALS AND METHODS: 68 hip and knee revision arthroplasties were reviewed retrospectively in order to evaluate the reliability of pre- and perioperative analysis of infection during total joint revision arthroplasties. The sensitivity and specificity for clinical signs, blood white-cell count, C-reactive protein level, radiographic analysis, bone and leukocyte scans, joint aspirations, and gram staining were determined. Tissue sample were harvested and cultured in all cases. Positive cultures were regarded as a true infection. RESULTS: We were not able to characterize the infection by clinical signs. Also no single test was able to show the presence of infection in all cases. The best results were obtained from pre- and perioperative joint aspirations. Joint aspiration showed 1.0 specificity and 0.75 sensitivity. CONCLUSION: It is clear from this study that no single test is able to show the presence of infection in every case. Classical clinical signs, laboratory tests, special imaging studies and joint aspirations have all yielded a notable rate of false negative results. Therefore, we recommend that, if arthroplasty patients have pain in prosthetic joint without clear radiological evidence of loosening, bone scans and preoperative joint aspirations should be undertaken. Also, if radiological evidence of loosening is accompanied with one or more of following criteria; C-reactive protein level elevated, radiologic evidence of infection, loosening within the first five years after implantation. In case of infection a delayed two-stage reconstruction should be managed.

Diagnosis of Mycoplasma pneumoniae pneumonia in children.

We evaluated a commercial immunoglobulin M (IgM)-capture immunoassay for the detection of Mycoplasma pneumoniae infections in 278 pediatric patients with community-acquired, radiographically defined pneumonia. Acute- and convalescent-phase serum samples were collected from all patients and were tested for M. pneumoniae-specific IgM and IgG antibodies by Platelia enzyme immunoassays (Sanofi Diagnostica Pasteur, Marnes la Coquette, France). Nasopharyngeal aspirates (NPAs) were collected at the time of admission to the hospital. A total of 227 NPAs were subjected to the detection of M. pneumoniae DNA by PCR, and 191 NPAs were cultured by using the Pneumofast kit (International Mycoplasma, Signeswere, France). Southern hybridization of PCR products and the IgM test with solid-phase antigen (Serion Immunodiagnostica, Würzburg, Germany) were used for additional confirmation of a positive result, which required agreement of at least two different methods. A total of 24 (9%) confirmed diagnoses of mycoplasma infection were made, 5 (21%) of which were in children <5 years of age. Of the positive children, 24 of 24 (sensitivity, 100%) were positive by the IgM-capture test with convalescent-phase serum, 19 of 24 (79%) were positive by the IgM-capture test with acute-phase serum, 19 of 24 (79%) were positive by IgG serology, 10 of 20 (50%) were positive by PCR, and 8 of 17 (47%) were positive by culture. An additional 5 (of 254) children were positive by the Platelia IgM test alone (specificity, 98%). When the PCR with Southern hybridization result was combined with the IgM-capture test result with the acute-phase sera, the sensitivity of rapid laboratory diagnosis increased to 95%. In conclusion, the IgM serology test was the single most valuable tool for the diagnosis of M. pneumoniae pneumonia in children of any age.

Coinfection is common in measles-associated pneumonia.

BACKGROUND: Measles continues to be a significant health problem in developing countries. OBJECTIVES: To describe the clinical features of measles-associated pneumonia (MAP) and to identify other pathogens involved. METHODS: Measles diagnosis was ascertained either by the typical symptom complex or by a sensitive enzyme immunoassay for antibody among children < 5 years of age admitted to the hospital with pneumonia. Other pathogens were identified by blood culture, virus isolation or antigen detection from nasopharyngeal aspirate and antibody determination from serum. RESULTS: Of 182 MAP cases 162 (89%) had clinically typical measles. Twenty patients had a diagnostic antibody finding with an atypical clinical presentation. Thirteen percent were younger than 9 months of age. The case fatality rate was 17%, with a significantly increased odds ratio (OR) for those with cyanosis [OR 4.6, 95% confidence interval (CI) 1.7 to 13], respiratory rate > or = 60/min (OR 3, 95% CI 1.3 to 7) or fulfilling criteria for very severe pneumonia (OR 5.3, 95% CI 2.3 to 12). Mixed infection was found in 53% of patients. Blood culture was positive in 10 patients, Streptococcus pneumoniae (N = 5) being the most common finding. Adenovirus (19%) and parainfluenza (25%) viruses were the most frequent other viruses. A dense infiltrate was seen significantly more often among measles patients with bacterial coinfection (87.5%) than those with other viruses (36%, P = 0.007) or no evidence of other infection (33%, P = 0.004). CONCLUSION: In MAP, coinfection with other microbes is common. Cyanosis and a respiratory rate of > or = 60/min predict a greater risk of dying.

Bone bank service in Finland. Experience of bacteriologic, serologic and clinical results of the Turku Bone Bank 1972-1995.

560 bones were harvested by The Turku Bone Bank between 1972-1995. It was started with massive allografts for bone tumor surgery, but today most are femoral heads for hip revision surgery. The increase in harvested bones nearly trebled from 1984-1989 to 1990-1995. Only 1 positive hepatitis C test was found. There were no hepatitis B or HIV positive donors. The incidence of discarding after screening was 24%, with positive bacterial growth (8%, usually Staphylococcus epidermidis) as the commonest reason. 2 massive grafts with negative cultures when harvesting were positive after thawing and resulted in deep infection. 369 allografts were transplanted. The infection rate of massive allografts for bone tumor surgery was 5/63 in 1973-1995, and 2/52 in 1985-1995. The infection rate for hip revision surgery was 3.4%. The clinical functional results correspond to those reported in larger international series.

Longitudinal analysis of human salivary immunoglobulins, nonimmune antimicrobial agents, and microflora after tonsillectomy.

In order to study the role of tonsils in the host defense in the oral region one pre- and two postoperative (1 and 6 months) whole saliva samples were collected from 25 young adults referred for tonsillectomy. Saliva samples were analyzed for selected host defense factors, representing both immune (total IgA, IgG, IgM, anti-Streptococcus mutans, anti-EBV, anti-CMV, and anti-adenovirus IgA and IgG) and nonimmunoglobulin (lysozyme, lactoferrin, salivary peroxidases, thiocyanate, hypothiocyanite, and agglutinins) mediators. Following tonsillectomy, a significant (P < 0.04) reduction was observed in specific IgG antibodies, suggesting that tonsils participate in local IgG response to oral antigens. Total IgM levels also decreased (P< 0.006), which may to some extent reflect reduced antigenic stimuli compared to preoperative status with frequent tonsillitis. Saliva-derived nonimmunoglobulin host defense factors, except lactoferrin, which declined significantly, remained normal throughout the study period. Our study indicates that tonsils play a role in local oral IgG-mediated immune response but tonsillectomy does not seem to lead to any significant long-term impairment of salivary defense capacity.

Virus-specific, antibody-secreting cells during upper respiratory infections.

The humoral immune response of 18 army recruits with febrile upper respiratory infection (URI) was studied by enumerating virus-specific, antibody-secreting cells in the peripheral blood. Diagnosis was based on viral antigen detection in nasopharyngeal specimens, virus isolation from throat swabs, or on antibody measurement from paired serum samples. At the time of the sample collection, three viruses, including adenovirus, influenza A, and influenza B, were found mainly to cause URIs among the recruits, and ELISPOT assay for enumeration of the specific antibody-secreting cells was selected for these viruses. Of the 36 patients with febrile URI studied, viral diagnosis was made in 18 cases, which included 11 patients with adenovirus infection, three with influenza A, and four with influenza B. The first blood sample was collected at the first signs of URI and the second and third samples at 2-week intervals. The adenovirus-positive patients developed a strong IgG class antibody-secreting cell response against the homologous virus, which peaked at the first sample and decreased steeply by the second and third samples. In the influenza A and B patients, the response was similar kinetically to that seen in adenovirus-positive patients. In those cases where also IgA and IgM class antibody-secreting cells were determined, the IgG response dominated. The ELISPOT method has potential also as a diagnostic tool for respiratory infections.

Molecular and biological characteristics of echovirus 22, a representative of a new picornavirus group.

Recent sequence analysis revealed that the human pathogen echovirus 22 (EV22) is genetically distant from all the other picornaviruses studied to date (T. Hyypiä, C. Horsnell, M. Maaronen, M. Khan, N. Kalkkinen, P. Auvinen, L. Kinnunen, and G. Stanway, Proc. Natl. Acad. Sci. USA 89:8847-8851, 1992). We have further characterized the biological properties of the virus and show here that the virion has properties similar to those of other picornaviruses. However, the protein composition is unique, in that most copies of one of the three major capsid proteins, VP0, do not undergo the further processing to VP2 and VP4 observed during the maturation of the virus in previously studied picornaviruses. Alignment of the capsid protein sequences with those of other picornaviruses revealed, furthermore, that the VP3 polypeptide contains an apparent insertion of approximately 25 amino acids at its amino terminus. An arginine-glycine-aspartic acid (RGD) motif is found in VP1, and by using synthetic peptides, it was shown that this sequence plays a role in cell surface receptor recognition. Finally, EV23 was shown to share remarkable identity with EV22 in certain parts of the genome and also belongs to this previously unrecognized picornavirus group.

Performance of two new enzyme immunoassays for the detection of IgM and IgG antibodies to rubella.

Two new enzyme immunoassays for detection of rubella-specific IgM and IgG antibodies, Rubaset EIA-M and Rubaset EIA-G, were evaluated. Serum samples from 350 patients with or without rubella symptoms were tested. Rubaset EIA-M had a sensitivity of 98.0%, a specificity of 95.2% and an overall agreement of 96.8% compared with Rubazyme-M. Sera from patients with autoimmune diseases showed no false-positive reactivity. The corresponding values for Rubaset EIA-G were 98.5%, 94.8% and 96.9% respectively, compared with Rubazyme. Sera yielding discordant results were mainly acute-phase specimens from patients with confirmed rubella infection.

Clinical scoring system in the evaluation of adult pharyngitis.

OBJECTIVE: To compare results of a clinical scoring system for diagnosis of group A streptococcal pharyngitis with microbiologic results, when several different pharyngeal pathogens were tested simultaneously. DESIGN: Evaluation of clinical manifestations of 106 adult patients with pharyngitis of different microbial origin. SETTING: General private practice; Health Center Pulssi, Turku, Finland. PATIENTS: Adult patients whose chief complaints were sore throats. MAIN OUTCOME MEASURE: A symptom score that was assigned to each patient according to the total number of certain signs and symptoms that are postulated to increase the probability of group A streptococcal pharyngitis and blood measurements for infection. RESULTS: The highest symptom scores, 3 and 4, were found in 21 patients. These patients had pharyngitis due to group A streptococcus (four patients), group C streptococcus (four patients), group G streptococcus (two patients), group F streptococcus, Mycoplasma pneumoniae, Chlamydia pneumoniae, influenza A virus, influenza B virus, herpes simplex type 1 virus (two patients), and coxsackie B4 virus. No pathogen could be identified from three of the 21 patients. The C-reactive protein values and the leukocyte counts were raised significantly more often in streptococcal infections than in infections of other origin; the P values were .00016 and .028, respectively. CONCLUSION: Use of a clinical scoring system alone for diagnosis of pharyngitis may lead to improper use of anti-microbial agents. There is a need for accurate microbiologic diagnostic procedures in general practice to determine proper treatment of pharyngitis as well as to test the effect of antibacterial and, in the future, antiviral treatment in respiratory tract infections.

Preceding respiratory infection predisposing for primary and secondary invasive Haemophilus influenzae type b disease.

Cases (117) with invasive Haemophilus influenzae type b (Hib) disease and their family members reported symptoms of respiratory infection during the 4-week period before the onset of Hib disease significantly more often than age-, sex- and residence-matched controls (225) and their family members during the same time period. Viral (adenovirus; influenza A and B; parainfluenza types 1, 2 and 3; and respiratory syncytial virus) and Mycoplasma pneumoniae serology was performed in 84 paired sera from cases and 112 paired sera from controls, who were healthy children matched to the cases by age, year and season. Viral or M. pneumoniae infection was diagnosed equally often among cases and controls (18% for both groups). However, patients who were associated cases of Hib disease (i.e. either the primary or secondary case of a case pair) had a diagnostic viral serology more often (50%) than did sporadic cases (13%) (odds ratio, 7.0; 95% confidence interval, 1.6 to 33; P = 0.006). These results suggest that some infectious agent(s) caused symptoms among the patients and circulated among the patients' closest contacts immediately before their development of Hib disease and possibly predisposed for invasive Hib disease. For the development of associated Hib disease among close contacts of an index case, adenovirus, influenza A, respiratory syncytial virus or para-influenza type 1, 2 and 3 infections may be important.

Salivary antimicrobial proteins and mutans streptococci in tonsillectomized children.

Whole saliva from 53 children who had been tonsillectomized when they were younger than 4 years old was analyzed for selected antimicrobial proteins and oral mutans streptococci 3-4 years after the operation. The results were compared with those from age- and gender-matched control children with no history of tonsillectomy. The salivary analyses comprised both immune (total IgA, IgG and IgM) and selected nonimmune (lactoferrin, myeloperoxidase, salivary peroxidase) antimicrobial proteins. Specific IgA and IgG antibodies against viral antigens (adeno-, cytomegalo-, respiratory syncytial- and Epstein-Barr-viruses) and against Streptococcus mutans cells were quantitated in both groups. The tonsillectomized children had statistically significantly higher concentrations of all immunoglobulin isotypes (P 0.001) as well as of lactoferrin (P less than 0.005), and myeloperoxidase (P less than 0.001) in saliva. However, no differences were found in the numbers of cariogenic mutans streptococci or in the total oral aerobic flora. In line with the streptococcal counts, no differences existed in anti-S. mutans IgA or IgG titers between the groups. Most antibodies against viruses, especially of IgG isotype, were significantly (P less than 0.001) higher in saliva of tonsillectomized children than in that of the controls. The results suggest that, within a long run, the humoral immune status of human saliva is not weakened by tonsillectomy. Also, mainly serum-derived antimicrobial proteins (myeloperoxidase, lactoferrin, IgG) exist in high concentrations in whole saliva after tonsillectomy.

Prokaryotic expression of a VP1 polypeptide antigen for diagnosis by a human parvovirus B19 antibody enzyme immunoassay.

To produce parvovirus B19 antigen for diagnostic purposes, partially overlapping segments covering the genes encoding the viral structural proteins VP1 and VP2 were cloned into expression vectors. The constructs were induced in Escherichia coli, resulting in the expression of beta-galactosidase fusion proteins. In immunoblotting experiments with sera from patients with erythema infectiosum, immunoglobulin G (IgG) and IgM antibodies bound to a single polypeptide of 235 amino acids at the N terminus of VP1. The DNA fragment encoding this polypeptide was amplified by the polymerase chain reaction and cloned into an expression vector. The viral capsid antigen expressed in E. coli was purified by preparative agarose gel electrophoresis and used in IgG and IgM solid-phase enzyme immunoassays. Comparison with reference gamma- and mu-capture radioimmunoassays using whole virus antigen showed that these antibody tests are suitable for the serodiagnosis of human infections caused by parvovirus B19.

Viral lower respiratory tract infections in Filipino children.

Viral causes of acute lower respiratory tract infection were studied prospectively between 15 June and 31 October 1984 in 312 Filipino children less than 5 years old living in periurban slums and middle-class housing. The cause was based on viral antigen detection, virus isolation, and antibody assays. There were 131 children (41.2%) who were admitted to the hospital, and 150 (47%) had an infiltrate on chest radiograph. A total of 198 viral infections were confirmed in 162 patients (51.9%), 42.3% with single viral infection and 9.6% with mixed (two or more) infection. The infections were measles (21.4%), influenza A (15.9%), parainfluenza types 1, 2, and 3 (8.8%), respiratory syncytial virus (7.1%), influenza B (5.8%), enteroviruses (5.1%), adenoviruses (3.9%), herpes simplex virus (1.6%), and cytomegalovirus (1.3%). Viral infections other than measles were seen in 39.7% of the cases. The presence of viral infection correlated with better nutritional status. Influenza A or B diagnosis was associated with mild forms of acute respiratory tract infection, measles and a preceding rash with severe disease.

Acute otitis media and respiratory virus infections.

We studied the association of acute otitis media with different respiratory virus infections in a pediatric department on the basis of epidemics between 1980 and 1985. Altogether 4524 cases of acute otitis media were diagnosed. The diagnosis was confirmed by tympanocentesis in 3332 ears. Respiratory virus infection was diagnosed during the same period in 989 patients by detecting viral antigen in nasopharyngeal mucus. There was a significant correlation between acute otitis media and respiratory virus epidemics, especially respiratory syncytial virus epidemics. There was no significant correlation between outbreaks of other respiratory viruses and acute otitis media. Acute otitis media was diagnosed in 57% of respiratory syncytial virus, 35% of influenza A virus, 33% of parainfluenza type 3 virus, 30% of adenovirus, 28% of parainfluenza type 1 virus, 18% of influenza B virus and 10% of parainfluenza type 2 virus infections. These observations show a clear association of respiratory virus infections with acute otitis media. In this study on hospitalized children Haemophilus influenzae strains were the most common bacteriologic pathogens in middle ear fluid, occurring in 19% of cases. Streptococcus pneumoniae was present in 16% and Branhamella catarrhalis in 7% of cases. There was no association between specific viruses and bacteria observed in this study.

Enzyme immunoassays for detection of IgG and IgM antibodies to parainfluenza types 1, 2 and 3.

Quantitative enzyme immunoassays for parainfluenza type 1, 2 and 3 IgG antibodies were developed. Serum specimens were tested at a single dilution of 1:1000 and results expressed in units by the use of a standard curve. The unit values correlated well with titres obtained by testing the same specimens in serial dilutions. All serum pairs with significant titre rises also showed significant rises in unit values. Parainfluenza IgG and IgM serology was evaluated in 66 patients with a proven parainfluenza infection. Diagnostic IgG antibody increases were detected in 70, 69 and 87% of parainfluenza type 1, 2 and 3 infections, respectively. Heterologous titre rises between parainfluenza types 1 and 3 were common. IgM antibodies were detected in 42% of the patients, most commonly in those below two years of age and rarely in adults.

Adenovirus infection in families.

Eighteen families were followed up for four to six weeks after one member of each family was diagnosed as having an adenovirus infection. In 17 of 18 index cases the diagnosis was based on the rapid detection of adenovirus hexon antigen in the nasopharyngeal mucus specimens and in one case (the only adult index case) on isolation of the virus. All index cases had high temperatures associated most commonly with tonsillitis, acute otitis media, gastroenteritis, or febrile convulsions. In 14 of the 16 families with symptomatic contacts the index case was the first symptomatic case, or one of the first symptomatic cases, in that family. Fifteen (94%) of the siblings and 20 (56%) of the parents had signs and symptoms of acute infection during the follow up period. In 10 (63%) and eight (20%) of these cases, respectively, adenovirus was confirmed. The mean (SD) incubation period of confirmed adenovirus infections was 10 (3) days. The observations show that adenovirus infection spreads actively to other siblings in the family. Rapid diagnosis permits parents to be informed prospectively about the expected spread and clinical picture of the illness in the family.