Shigellosis - a re-emerging sexually transmitted infection: outbreak in men having sex with men in Berlin.

In December 2001, the Robert Koch-Institut (RKI) was informed about a cluster of 10 Shigella sonnei infections in men who have sex with men (MSM), diagnosed in Berlin since September 2001. A retrospective investigation on sexual risk factors for infection in all shigella cases from Berlin from 2001 was initiated by sending a questionnaire to all patients without known travel history. Simultaneously laboratories were asked to send new shigella isolates from patients to the National Reference Centre at the RKI. Out of 29 responders, 24 self-identified as MSM. Seventeen of these reported sexual contacts as the most likely potential risk of infection. Almost all MSM reported direct or indirect oral-anal sexual contacts in the week before they fell ill. Fifteen of 27 shigella isolates collected during the prospective sampling period showed identical plasmid profiles, PFGE- and resistance patterns and can therefore be regarded as clonally identical. Asymptomatic and/or prolonged shedding in the reconvalescent phase may contribute to the transmission risk of shigella infection during oral-anal sexual practices. Awareness among practitioners and among MSM about the risk of sexual transmission of orally transmitted agents needs to be raised.

Sensitivity and specificity of indirect immunofluorescence and Grocott-technique in comparison with immunocytology (alkaline phosphatase anti alkaline phosphatase = APAAP) for the diagnosis of Pneumocystis carinii in broncho-alveolar lavage (BAL).

The purpose of the study was to compare the sensitivity and specificity of the indirect method of immunofluorescence with the immunocytological technique of alkaline phosphatase anti alkaline phosphatase complex (APAAP) for the detection of Pneumocystis carinii by bronchoalveolar lavage (BAL) in HIV-1 positive patients. - 83 HIV-1 positive patients with clinical presentations suggestive of Pneumocystis carinii pneumonia (PcP) were included in the study. 28 samples were found Pc-positive by immunofluorescence (IFT), 26 by Grocott and 29 by APAAP. In comparison to the lab results 33 patients were diagnosed as PcP according to the clinical course (i.e. therapeutic outcome, drugs used, and therapy changes). Compared to the clinical diagnoses, the following lab tests proved to be false positive and false negative: false positive: IF = 1, Grocott = 0, APAAP = 4 (3F6). false negative: IF = 5, Grocott = 7, APAAP = 4 (3F6). - Grocott stain shows insufficient correlation to the clinical diagnoses (p = 0.0156, McNemar-Test, two-tailed). - The two different detection methods (IFT and APAAP) showed no significant statistical difference with regard to their sensitivity (p = 0.3438, McNemar-Test, two tailed) and specificity. Considering cost and time the immunofluorescence technique seems to be the most suitable for the diagnosis of PcP in HIV-1 positive patients.

HIV-related nontuberculous mycobacterial infection: incidence, survival analysis and associated risk factors.

To evaluate the incidence and survival time for AIDS-patients affected by different stages of nontuberculous mycobacterial (NTM) infection we performed a retrospective study. Data of 1540 hospitalised AIDS-patients was analyzed with respect to survival time and incidence rates. The overall incidence rate of NTM following AIDS was 16.6/100 person-years (PY), with an increase from 12.1/100PY (1987-1990) to 18.9/100PY (1991-1994). Antiretroviral therapy (ART) and toxoplasmosis prophylaxis reduced the risk of NTM disease whereas CD4 cells <40/ microl at time of the first AIDS defining illness led to a 2.5 fold higher risk. Pneumocystis carinii pneumonia (PCP), wasting syndrome and PCP prophylaxis increased the risk of progression from colonization to dissemination. Cryptococcus neoformans infection, wasting syndrome, PCP prophylaxis and CD4 cells <40/ microl were linked to immediate NTM dissemination. Though the incidence of NTM dissemination increased by the factor 1.56 in 1991-1994, survival did not differ between patients with and without NTM infection.

[Disseminated cryptococcosis with extensive cutaneous involvement in AIDS]. / Disseminierte Kryptokokkose mit ausgeprägtem Hautbefall bei AIDS.

BACKGROUND: Diagnosis of an ulceratively decaying indolent papule in the skin of an AIDS patient. CASE REPORT: In a 36-year-old HIV-positive man with a CD4 lymphocyte count of 60/microliters, a diagnosis of disseminated cryptococcosis was established based on a biopsy of an ulceratively decaying indolent papule in the skin of the left side gluteal region. In additional papulopustular skin lesions of neck, upper arm, upper thigh, and rima ani, Cryptococcus neoformans var. neoformans was detected by specific culture. The Cryptococcus neoformans antigen titre in serum was 1:160. The extensive cryptococcal skin involvement was accompanied by symptoms of meningeal cryptococcosis like hearing at an abnormal sound volume, a sensation of high pressure in the head and a change of behaviour, but absence of cephalgia and stiff neck. Attention is drawn to the importance of biopsy for the differential diagnosis of the skin lesions and to the significance of a specific cultural detection of Cryptococcus neoformans in view of the therapy and epidemiology of this mycosis. Under a combination therapy, consisting of amphotericin B, flucytosine and fluconazole, a healing of the skin lesions and disappearance of the neurological symptoms followed by negative cultural and serological tests were seen. Specific comments on the epidemiology of cryptococcosis in AIDS are made. CONCLUSION: In case of doubt, papulopustular skin lesions of HIV-positive patients should be biopsied. Cryptococcosis should also be considered.

[The solid-phase hemadsorption (SPHA) test in syphilis reinfection]. / Der Solid-Phase-Hämadsorptions(SPHA)-Test bei Syphilis-Reinfektionen.

In patients with re- and multiple syphilitic infections the titres of VDRL-, FTA- and SPHA-tests were compared. Among reinfections in which the VDRL gave no or initially no hint for a new infection, the SPHA is significantly reactive. The increase of IgG in the FTA-test confirmed the specificity of a new infection.

[Method and initial results of percutaneous ultrasound-controlled sclerotherapy of parathyroid adenoma in secondary or tertiary hyperparathyroidism]. / Methodik und erste Ergebnisse der perkutanen ultraschallgezielten Verödung von Nebenschilddrüsenadenomen bei sekundärem oder tertiärem Hyperparathyreoidismus.

In 16 of 96 patients with clinical, roentgenological and biochemical signs of hyperparathyroidism due to chronic renal failure the parathyroid adenomas were detected ultrasonographically. Verification of the adenoma was done using fine-needle biopsy and cytological evaluation. In 8 patients an ultrasonographic-guided sclerotherapy using absolute ethanole was performed. The efficacy of this method was evaluated by control of the biochemical parameters. In all cases a reduction of the serum calcium level and of the parathormone was observed. This method may represent an adjuvant therapy in the treatment of renal hyperparathyroidism.

Efficacy of different methods for detection of low Cryptosporidium parvum oocyst numbers or antigen concentrations in stool specimens.

The detection of Cryptosporidium parvum oocysts in stool specimens by acid-fast (AF) stains or immunofluorescence assays (IFA) requires the presence of large numbers of oocysts. To determine whether new commercially available enzyme immunoassays (EIAs) are more sensitive alternatives, three EIAs, a direct IFA, and the modified cold Kinyoun AF stain were compared, particularly with respect to detection of low oocyst numbers or antigen concentrations. Thirty-one negative and 31 calf stool-enriched human stool specimens were tested. One EIA method detected only nine positive specimens, demonstrating a sensitivity significantly less (p < 0.0001) than that of the IFA, the AF stain, and the other two EIAs. No differences could be found with respect to specificity. In addition, serial dilutions of 28 patients' stool samples containing cryptosporidian oocysts were prepared and examined using two EIAs, IFA, and the AF stain. One EIA yielded significantly inferior results (p < 0.0001), whereas the other one and the two microscopic methods did not differ significantly in either part of the study. The results indicate that the new EIAs do not exhibit higher sensitivities for detection of Cryptosporidium parvum than the two routinely used microscopic methods. Thus, for most laboratories, the IFA or AF stain may still represent the preferred method for the diagnosis of cryptosporidiosis.

Co-infection by Cryptococcus neoformans and Mycobacterium avium intracellulare in AIDS.

In the observation of various opportunistic pathogens in HIV-positive persons, co-infection by Cryptococcus neoformans together with Mycobacterium avium intracellulare was found if there was a CD4 lymphocyte count as low as 3-20 microl. In 1540 HIV-positive patients under treatment at a Berlin hospital (Auguste-Viktoria-Krankenhaus) during 1985-1994, all AIDS-relevant diseases were examined in a multivariate analysis as variables of influence on the manifestation of a systemic Mycobacterium avium complex (MAC) infection. The analysis involved data on 36 cases of cryptococcosis and 202 cases with a typical clinical course in whom MAC had been detected at sterile body sites. As significant and independent factors of influence, the following were identified: C. neoformans infection, wasting syndrome, lower age, low CD4 lymphocyte count and preceding Pneumocystis carinii pneumonia (PcP) prophylaxis. Cryptococcosis ranged first with an odds ratio of 2.75. The concomitant manifestation of cryptococcosis and systemic MAC infection in six patients is shown. Because both opportunists, C. neoformans and avian mycobacteria, may have their common habitat in droppings of defined species of pet birds, a common source of infection deserves further clinical and epidemiological attention.

Cryptococcosis in HIV infection of man: an epidemiological and immunological indicator?

Cryptococcosis is an epidemiological and immunological indicator due to the absence of Cryptococcus neoformans as a saprophyte in immunocompetent humans and the advantage of specific C. neoformans culture. On this basis, a report is presented on the CD4 lymphocyte count of 36 AIDS patients suffering from cryptococcosis and other concomitant or missing opportunistic AIDS-defining infections. In 26 out of 36 patients, i.e. 72%, a CD4 lymphocyte count of < or = 50/microL (mean value 39.5%) was found. Cryptococcosis as the sole opportunistic infection was diagnosed in 5 cases (13.9%). In 31 cases, various combinations of AIDS-associated diseases were found: Pneumocystis carinii pneumonia (PCP) (n = 19), cytomegalovirus infection (CMV) (n = 10), Kaposi's sarcoma (n = 6), Mycobacterium avium intracellulare infection (MAI) (n = 5), pneumonia (n = 2), toxoplasmosis (n = 2), Candida esophagitis (n = 1), tuberculosis (n = 1), lambliasis (n = 1), salmonellosis (n = 1) and wasting syndrome (n = 5). The conspicuous simultaneous occurrence or succession of pneumocystosis and cryptococcosis and the contrasting absence of aspergillosis and mucormycosis (zygomycosis) are commented. Based on the present observations in HIV-infected persons in Berlin, a CD4 lymphocyte count of < 150/microL may be used as a parameter indicating a predisposition for cryptococcosis as an airborne AIDS-defining infection. Attention is drawn to bird droppings as the sole habitat of C. neoformans and accidental niche of various other microorganisms.

CD4 lymphocyte count in HIV-positive persons exposed to Cryptococcus neoformans.

A report is presented on four HIV-positive homosexual men examined after several months of exposure during cleaning of a flat from masses of pigeon droppings heavily colonized by Cryptococcus neoformans. Only one out of the four persons, with a CD4 lymphocyte count of 50/microL, fell sick from systemic cryptococcosis, but not the others, with CD4 lymphocyte counts of 180, 250, and 630/microL, respectively; they remained clinically and mycologically inconspicuous and free from C. neoformans. Open questions in view of the epidemiology of opportunistic pathogens in AIDS are discussed with regard to the CD4 cell count as a parameter indicating a predisposition for cryptococcosis as an airborne AIDS-defining opportunistic infection. This has been confirmed by specific cultural diagnosis of the agent in both the environment and the patient. Already in 1987/88, the probable source of infection had been the subject of epidemiological studies on C. neoformans in Berlin.

Co-infection by Cryptococcus neoformans and Mycobacterium avium intracellulare in AIDS. Clinical and epidemiological aspects.

In the observation of various opportunistic pathogens in HIV-positive persons, co-infection by Cryptococcus neoformans together with Mycobacterium avium intracellulare was found if there was a CD4 lymphocyte count as low as 3-20/microliters. In 1540 HIV-positive patients under treatment at a Berlin hospital (Auguste-Viktoria-Krankenhaus) during 1985-1994, all AIDS-relevant diseases were examined in a multivariate analysis as variables of influence on the manifestation of a systemic Mycobacterium avium complex (MAC) infection. The analysis involved data on 36 cases of cryptococcosis and 202 cases with a typical clinical course in whom MAC had been detected at sterile body sites. As significant and independent factors of influence, the following were identified: C. neoformans infection, wasting syndrome, lower age, low CD4 lymphocyte count and preceding Pneumocystis carinii pneumonia (PcP) prophylaxis. Cryptococcosis ranged first with an ods ratio of 2.75. The concomitant manifestation of cryptococcosis and systemic MAC infection in six patients is shown. Because both opportunists, C. neoformans and avian mycobacteria, may have their common habitat in droppings of defined species of pet birds, a common source of infection deserves further clinical and epidemiological attention.

Evaluation of IS1245-based PCR for detection of mycobacterium avium bacteraemia in AIDS patients.

A PCR method based on the repetitive IS1245 sequence was evaluated for the detection of Mycobacterium avium bacteraemia in AIDS patients. Two blood preparation methods were applied: lysis of erythrocytes using a hypotonic buffer and Ficoll density centrifugation. Results were compared with culture and PCR amplification of the non-repetitive pMav22 sequence. Fifty-one of 251 tested samples grew M. avium. Bacterial densities lower than 10 cfu/ml blood were frequent, they occurred in 59% of blood samples from patients with mycobacteraemia. Inhibitory substances were detected more frequently with the lysis method (36%) than the Ficoll processed samples (19%). While specificity of PCR was high, sensitivities varied according to the methods used and the load of infection in the bloodstream. False-negative PCR results were attributable to low level bacteraemia and inhibition of PCR. Moreover, 1 of 186 and 9 of 51 M. avium strains investigated lacked the IS1245 and the pMav22 sequence, respectively. Sensitivities of culture, IS1245- and pMav22-based PCR were 88, 64 and 58%, within the lysis processed samples and 95, 86 and 50% using Ficoll prepared samples, respectively. Thus, we conclude that IS1245-based PCR is a rapid and specific method for diagnosing M. avium bacteraemia and shows a higher sensitivity than single copy gene targets, but that the sensitivity is inferior to culture.

A new acid-fast trichrome stain for simultaneous detection of Cryptosporidium parvum and microsporidial species in stool specimens.

The detection in stool specimens of Cryptosporidium parvum and microsporidia, the most frequent parasitic pathogens causing diarrhea in AIDS patients, until now has depended on two different staining methods. However, since double infections occur and minimization of laboratory costs is mandatory, development of a method for simultaneous detection of these parasites appeared desirable. We report on a new, inexpensive, and easy-to-perform staining procedure to demonstrate both acid-fast oocysts of C. parvum and other coccidia, as well as microsporidial spores. This acid-fast trichrome stain yields results comparable to those obtained by the Kinyoun and modified trichrome methods and considerably reduces the time necessary for microscopic examination.

Comparative evaluation of modified trichrome and Uvitex 2B stains for detection of low numbers of microsporidial spores in stool specimens.

At present, the laboratory diagnosis of intestinal infections caused by microsporidia depends on the detection of the typical spores either with a modified trichrome stain (MTS) or by staining with fluorochromes. The purpose of the present study was (i) to compare staining with MTS (MTS method) and the staining with the fluorochrome Uvitex 2B (U2B method) with respect to their sensitivities and specificities, particularly in the presence of low numbers of spores, and (ii) to evaluate their reliabilities under routine laboratory conditions. First, 30 negative human stool specimens as well as 30 specimens enriched with a low concentration of microsporidial spores were examined. The U2B and MTS methods detected 27 and 30, of the positive samples, respectively (95% confidence intervals for sensitivity, 0.73 to 0.98 for the U2B method and 0.88 to 1.00 for the MTS method) without yielding false-positive results (95% confidence intervals for specificity, 0.88 to 1.00 for the MTS and U2B methods). In addition, analysis of serial dilutions of 17 stool specimens from AIDS patients containing microsporidia revealed comparable detection thresholds (P = 0.52) for both methods. Finally, 40 slides prepared from one stool specimen containing very few microsporidia and 40 negative slides were included in the routine diagnostic program during 1 month in order to monitor laboratory handling and run-to-run variations. Again, both methods exhibited comparable sensitivities (95% confidence intervals, 0.83 to 0.99 for the MTS method and 0.91 to 1.00 for the U2B method) and specificities (95% confidence intervals, 0.91 to 1.00 for the MTS and U2B methods). In conclusion, MTS and U2B methods are equally useful in the diagnosis of microsporidiosis. However, since detection thresholds for both methods differed considerably in all diluted stool specimens, performance of a combination of both methods may be more sensitive than the performance of only one procedure in the event of very low numbers of microsporidial spores.

Blinded, externally controlled multicenter evaluation of light microscopy and PCR for detection of microsporidia in stool specimens. The Diagnostic Multicenter Study Group on Microsporidia.

The quality parameters for the detection of microsporidia in identical sets of 50 stool samples were determined for six laboratories where technicians used light microscopy and for six laboratories where technicians used PCR. The average overall sensitivities were 67% (89% for patient samples only) for the PCR laboratories and 54% (80% for patient samples only) for the light microscopy laboratories. Specificities were 98 and 95%, respectively. Differences in results were most apparent between the individual laboratories rather than between the two major methods used.