Molecular epidemiology of tuberculosis in Cambodian children.

SUMMARY We analysed Mycobacterium tuberculosis strains from children, hospitalized from January 2004 to July 2008 in the largest paediatric hospital complex in Cambodia. Specimens were tested for drug susceptibility and genotypes. From the 260 children, 161 strains were available. The East African-Indian genotype family was the most common (59.0%), increasing in frequency with distance from the Phnom Penh area, while the frequency of the Beijing genotype family strains decreased. The drug resistance pattern showed a similar geographical gradient: lowest in the northwest (4.6%), intermediate in the central (17.1%), and highest in the southeastern (30.8%) parts of the country. Three children (1.9%) had multidrug-resistant tuberculosis. The Beijing genotype and streptomycin resistance were significantly associated (P < 0.001). As tuberculosis in children reflects recent transmission patterns in the community, multidrug resistance levels inform about the current quality of the tuberculosis programme.

Position-dependent accommodative shift of retropupillary fixated iris-claw lenses.

PURPOSE: After implantation of retropupillary fixated iris-claw lenses, changes of the objective refraction can occur depending on the patients' position. The purpose of this study was to evaluate and quantify these changes as well as the influencing factors. METHODS: Within a retrospective study, postoperative refraction visual, acuity and anterior chamber depth after implantation of a retropupillary fixated iris-claw lens (Artisan® / Verisyse®) were measured in 51 eyes (49 patients) depending on their head position. These parameters were determined with the assistance of a mobile auto-refractometer, acoustic biometry, IOL-Master, chart projector and accommodometer in primary position, as well as in forward- and backward-tilted head position. RESULTS: The data analysis indicated a position-dependent change of the anterior chamber depth, which was largest in the backward-tilted head position (median: 4.25 mm/min.: 3.39 mm/max.: 5.37 mm). In comparison to the primary position (4.15 mm), it decreased in a forward-tilted position of the head (4.08 mm). A significant difference in anterior chamber depth was verified for backward- and forward-tilted heads (median: 0.155 mm). Refraction showed a significant difference (0.37 D) between forward- and backward-tilted head position. In comparison to the back-tilted head position (mean: -0.065 D), a smaller spherical equivalent could be demonstrated by bending the head forward (mean: -0.438 D). In addition, no correlation was found between lens movement and other continuous attributes. CONCLUSIONS: Significant changes in anterior chamber depth and refraction due to the iris-claw lens shift were found, depending on head position. The phenomenon of pseudophakic accommodation is explained by pseudo-myopia and pseudo-hyperopia. A considerable influence on visual acuity depending on patients´ head position could not be verified.

[Lysosomal storage diseases - update and new therapeutic options]. / Lysosomale Speichererkrankungen - Update und neue therapeutische Optionen.

Lysosomal storage diseases represent a group of about 50 genetic disorders. The deficiencies of lysosomal and non-lysosomal proteins cause an accumulation of compounds which are normally degraded within the lysosome. There are currently no therapeutic options to cure patients suffering from a lysosomal storage disease. Due to their progressive nature there is considerable morbidity and mortality. Thus, an early treatment to maintain major systemic functions is of utmost importance. While so far only symptomatic therapies are in use, the newly available enzyme replacement therapies offer a real causal approach for selected storage diseases. Many of these disorders are characterised by pathognomonic eye findings. Therefore, the ophthalmological examination provides the opportunity for an early and non-invasive diagnosis and a chance to initiate early treatment. This review is intended to give a survey of the most common lysosomal storage diseases, particularly with regard to ophthalmological changes as well as illustrate new therapeutic options.

Seasonality of tuberculosis in an Eastern-Asian country with an extreme continental climate.

Aggregate monthly notifications of incident sputum smear-positive tuberculosis (TB) in Mongolia, stratified by sex and age groups, were analysed separately for Ulaanbaatar, Mongolia, and the rest of the country for the 9-yr period from 1998 to 2006. TB notifications were compared with ambient surface temperature. More than twice as many TB cases were notified in the peak month (April) compared with the trough months (October-December), paralleling the temperature curve. The fluctuations recurred consistently over the entire observation period, were identical in the capital compared with the rest of the country, and were independent of age and sex. TB notifications parallel the temperature amplitudes and have a magnitude not reported elsewhere. We hypothesise that the influence of temperature on life either indoors or outdoors is consistent with the transmission probability of Mycobacterium tuberculosis and the subsequent delay to disease recognition and notification with the incubation period, possibly co-determined by other factors, rather than accessibility to services.

Development of real-time PCR for the differential detection and quantification of Ureaplasma urealyticum and Ureaplasma parvum.

Ureaplasma parvum and Ureaplasma urealyticum are recently recognized species of the genus Ureaplasma. In humans, Ureaplasma spp. can be found on mucosal surfaces, primarily in the respiratory and urogenital tracts. They have been implicated in various human diseases such as nongonococcal urethritis, intrauterine infections in association with adverse pregnancy outcome and fetal morbidity, and pneumonitis in immunocompromised hosts. We have developed two quantitative real-time PCR assays to differentially detect U. parvum and U. urealyticum. Based upon the sequence information of the urease gene (ureB), we designed two TaqMan primer and probe combinations specific for U. parvum and U. urealyticum, respectively. The assays did not react with nucleic acid preparations from 16 bacterial species commonly encountered in relevant clinical specimens, including seven urease-producing species. Each assay had a detection limit of approximately five copies per reaction of the respective gene target. The results suggest that these assays are both sensitive and specific for U. parvum and U. urealyticum. Further investigation of both assays using clinical specimens is appropriate.

Paediatric, invasive pneumococcal disease in Switzerland, 1985-1994. Swiss Pneumococcal Study Group.

BACKGROUND: Cost effective use of new vaccines against pneumococcal disease in children requires detailed information about the local epidemiology of pneumococcal infections. METHODS: Data on 393 culture-confirmed cases of invasive pneumococcal infection in children (<17 years) hospitalized in Swiss paediatric clinics were collected retrospectively for the years 1985-1994. RESULTS: Meningitis (42%) was most frequent, followed by pneumonia (28%) and bacteraemia (26%). The overall annual incidence was 2.7 cases per 100000 children <17 years old and 11 cases per 100000 children <2 years old. Annual incidence rates were stable over the study period. Lethality was high for meningitis (8.6%) and bacteraemia (8.9%). A history of basal skull fracture was reported in 3.3% of children with pneumococcal meningitis. Residence in a rural region was associated with an increased risk of pneumococcal infection (relative risk = 1.45, 95% confidence interval: 1.01-2.00). CONCLUSIONS: Paediatric, invasive pneumococcal disease seems to be less frequent in Switzerland than in other European and non-European countries. This may be due to differences in diagnostic strategies and lower frequency of risk factors such as the use of day care. Children with a history of basal skull fracture are at increased risk for pneumococcal meningitis. Further investigation of the association of invasive pneumococcal infection with rural residence and the use of antibiotics for upper respiratory tract infections might give new insight into the dynamics of Streptococcus pneumoniae infection and the development of antibiotic resistance.

Risk factors for invasive Haemophilus influenzae disease among children 2-16 years of age in the vaccine era, Switzerland 1991-1993. The Swiss H. Influenzae Study Group.

BACKGROUND: Continued surveillance, and detailed investigation of direct and indirect effects of conjugated vaccines and risk factors for invasive H.influenzae serotype B (Hib) disease in the vaccine era are important. METHODS: 143 cases with invasive disease between 1991 and 1993 aged 2-16 years were selected retrospectively from a large incidence trend study. Controls (n = 336) were recruited from local vital registries and matched to cases for age, gender, and residence. Hib vaccination histories among study subjects and their siblings and other sociodemographic variables were obtained by questionnaires completed by the parents of these children. Adjusted odds ratio (OR) estimates were calculated by conditional logistic regression analysis. RESULTS: Most vaccinated subjects had received the Polysaccharide-Diphtheria Toxoid vaccine and estimated vaccine efficacy was high (95%; 95% confidence interval [CI] 60-99%). Also, the results suggested that protection afforded by vaccination against Hib extended to the family members of vaccinated children. School attendance was found to be protective against invasive Hib disease (OR:0.33; CI:1.2-14.4). Cases more often than controls reported suffering from asthma and allergies (OR:4.8; CI:1.2-19.4). CONCLUSIONS: Post-licensure vaccine efficacy is high among children > or = 2 years of age. The observed association between asthma and epiglottitis is novel and deserves further investigation.

The immune response to S. aureus in atopic dermatitis.

The skin of patients with atopic dermatitis is heavily colonized with S. aureus, and their immune response to S. aureus shows some particular features: (1) A selective hyporesponsiveness to purified S. aureus cell walls in delayed type hypersensitivity skin reactions. (2) The presence of IgE to cell walls and soluble antigens of S. aureus in patients with high serum IgE levels. (3) Elevated cell wall IgE do not correlate with positive immediate skin reactions to whole S. aureus and their cell walls. (4) Regional lymphadenopathy but not impetiginization is associated with high total IgE and S. aureus cell wall IgE. We suggest that these changes in the immune response to S. aureus are related to the chronic S. aureus colonization of the skin.

Laboratory diagnosis of tuberculosis in a large pediatric hospital in Cambodia.

SETTING: Tuberculosis laboratory in the Jayavarman VII Children's Hospital in Siem Reap, part of the Kantha Bopha Hospitals, the largest pediatric hospital complex in Cambodia. OBJECTIVE: To determine the efficiency of on-site microscopy and rRNA amplification in children with a clinical diagnosis of tuberculosis (TB) and specimen sampling for culture. RESULTS: From 1 July 2005 to 31 March 2006, 52,400 children were admitted to the hospital. Among these, 405 children had tuberculosis, including 91 (22.5%) laboratory-confirmed cases, or respectively 7.7 and 1.7 per 1000 admissions. Among cases confirmed by microscopy or rRNA assay, rRNA identified 91.2%. Among all culture-confirmed cases, rRNA identified 90.5%. Culture alone contributed 7.1% to all laboratory confirmed cases. The yield of culture from preserved specimens was not affected by shipment delay. For 97.4% of the children, the maximum turnaround time for the on-site laboratory result was 48 h. CONCLUSION: Implementation of a mycobacteriology service in a referral hospital is feasible, as the molecular technique is highly efficient. Storage of specimen aliquots allows subsequent culture without loss of viability due to shipment delay.

[Pseudomelanomas of the choroid]. / Pseudomelanome der Aderhaut.

BACKGROUND: The aim of this study was to evaluate what are the most frequent ocular diseases that were suspected for choroidal melanoma ("pseudo melanoma"). PATIENTS AND METHODS: The data of all patients who were seen in the University Hospital of Mainz under the suspicion of choroidal melanoma between 1.1.1994 and 1.1.2004 and underwent ultrasound examination, fluorescein angiography or fundus photography, were analysed retrospectively. Among 458 examined eyes a choroidal melanoma was diagnosed in 212 cases. In 246 cases the diagnosis was "pseudomelanoma". RESULTS: The most frequent ocular diseases suspected for choroidal melanoma were "suspicious nevi" in 31 % of the cases and "disciforme macula degeneration" in 34 %. Less frequently we found hyperplasty of pigment epithelium (5 %), melanocytoma (10 %), choroidal haemangioma (6 %), choroidal detachment (7 %) and retinal macroaneurysma with epi-/subretinal haemorrhages (3 %). Rare diagnoses were orbital tumour, scleritis posterior and a combined hamartoma of retina and pigment epithelium (4 % at all). In 58 eyes without a fundus view, ultrasound revealed an intraocular tumour. In these cases vitrectomy/cataract extraction was performed and we found a choroidal melanoma in 5 eyes, a disciforme macula degeneration in 48 eyes and in 5 eyes a retinal macroaneurysma. CONCLUSIONS: Age-related macula degeneration (AMD) is the cause for one third of all pseudomelanomas. Because of its increasing incidence in the future, more attention must be paid to AMD in the differential diagnosis of chorioretinal lesions suspicious of melanoma.

[Listeria in food]. / Listerien in Nahrungsmitteln.

Since some outbreaks of listeriosis have been traced to various foods, the contamination rate of the foodstuffs is of great interest. Out of 1708 samples of milk and milk products, 105 samples (6.1%) proved to contain Listeria spp. L. monocytogenes was isolated from 54 specimens (3.0%). The isolation rate among 496 samples of meat and raw meat products was 38.9%. L. monocytogenes was found in 14.1% of these samples. Salads and vegetables proved to be contaminated by Listeria spp. in 6.4%; 2.1% of the strains were identified as L. monocytogenes. 57.4% of food samples contained less than 10 Listeria spp. per gram, while in the other samples the Listeria count ranged between 10 and 10(3)/g. In only one sample of cheese was more than 10(3) Listeria/g found. In contrast to cheese, where the contamination normally occurs during the ripening process and must be considered a hygiene problem, meat is already contaminated during slaughtering and processing. Beside these findings, there are further differences in the listerial microbiology of cheese and raw meat products. Additional studies are needed to determine the bearing of these factors on the epidemiology of human listeriosis.

[Tuberculosis: quo vadis? Spotlight on history and current aspects]. / Tuberkulose: Quo vadis? Streiflichter aus der Geschichte und Aktualitäten.

In short review some milestones of the history of tuberculosis research are outlined. Perspectives on the past, present and the future of tuberculosis research are linked to these historical facts. Within this context the contribution of members of the Medical Faculty at the University of Berne such as L. Lichtheim, Th. Langhans and E. A. E. Klebs receive particular consideration in connection with the 125th anniversary issue of the "Schweizerische Medizinische Wochenschrift" which was founded in 1871 by Klebs.

[Ludwig Lichtheim and Robert Koch. How the discovery of the tubercle bacillus in Switzerland was made known (1882/1883)]. / Ludwig Lichtheim und Robert Koch. Wie die Entdeckung des Tuberkelbazillus in der Schweiz bekannt wurde (1882/1883).

The discovery of the tubercle bacillus by Robert Koch in March 1882 was immediately reported by the medical press, including that of Switzerland. Among the clinicians most active in introducing the new views and techniques to Swiss medical practitioners was Ludwig Lichtheim (1845-1928), professor of internal medicine in Berne (1879-1888), who had been acquainted with Koch since their time in Breslau. Lichtheim's successful efforts are illustrated by quotations from his (unpublished) memoirs.

Simultaneous detection of DNA and RNA by differential polymerase chain reaction (DIFF-PCR).

A new technique, the differential polymerase chain reaction (DIFF-PCR), allows the simultaneous amplification of DNA and homologous RNA in a single assay by the combination of DNA-PCR and RNA-PCR on the same target. DNA-PCR amplifies a selected segment of dsDNA, whereas RNA-PCR amplifies a complementary DNA (cDNA), produced by reverse transcription of RNA. In a mixture of target DNA and RNA, DNA is amplified using a combination of sense and antisense primers under high-stringency conditions giving a D-amplicon. RNA is first reverse-transcribed with a primer carrying a nontarget 5' end into a tagged cDNA at low stringency. Tagged cDNA is subsequently amplified, providing an R-amplicon smaller in size than the D-amplicon. By quantifying the relative amounts of amplified RNA and homologous DNA, a sensitive measure for the transcription rate of a defined DNA segment is obtained. Thus, DIFF-PCR may serve as a useful tool for monitoring gene expression as well as for studying gene regulation and gene function.

Congenital cytomegalovirus infection in newborn infants of mothers infected before pregnancy.

The rate of congenital cytomegalovirus (CMV) infection was studied in newborn infants in an African population in which all adults had experienced primary CMV infection during childhood. Viruria within the first 12 hours after delivery was taken as evidence of prenatal CMV infection. 28 of 2032 newborn infants examined had viruria, giving a rate of 1.4% congenital CMV infection. The presence of meternal serum antibody therefore appears not to protect the fetus from intrauterine infection. Either reactivation of latent maternal CMV infection or recurrence of infection during pregnancy despite the presence of serum antibodies may explain these findings. Whether the long-term effects of CMV infection acquired in utero differ in cases of primary maternal infection from those due to reactivated or recurrent infection in seropositive mothers, remains undecided. Thus, the value of a live CMV vaccine to prevent prenatal CMV infection may be questioned.

Neutrophil function in children with kwashiorkor.

Peripheral blood polymorphonuclear neutrophil (PMN) function has been investigated for 46 children with kwashiorkor (without overt infection) in the Ivory Coast, West Africa. In vitro chemotactic response, candidacidal activity, and kinetic studies of metabolism during phagocytosis have been performed. Postphagocytic morphological events were evaluated by electron microscopy. The reduction of nitroblue tetrazolium (NBT), measurement of enzyme activities, activity of glycolysis, and hexose monophosphate shunt (HMS) activity were assessed. The extent of iodide incorporation into trichloracetic acid (TCA)-precipitable protein by phagocytizing PMN'S and thyroid hormone degradation were measured. Chemotactic response was reduced at early time intervals (30, 60, and 120 minutes) and reached control values after 180 minutes. Whereas PMN's of controls killed 32.13 +/- 11.10 per cent of Candida albicans after 60 minutes, PMN's from kwashiorkor patients killed 18.55 +/- 7.74 per cent (p less than 0.01). HMS activity for resting PMN's of kwashiorkor children was higher than for controls, and during particle ingestion the extent of stimulation was comparable to controls. Electron microscopic assessment of phagocytic vacuole formation and degranulation showed no difference between PMN's from kwashiorkor and and control subjects. Incorporation of 131 I into TCA-precipitable proteins by phagocytizing PMN's from kwashiorkor children was reduced in compraison to controls, with either viable or heat-killed lactobacilli. No impairment in thyroxine (T4) degradation was observed for PMN's from kwashiorkor cases. PMS's from kwashiorkor patients show toxic granules, Dohle bodies, evidence of high baseline NBT reduction, and glucose decarboxylation. Functional studies indicate impaired kinetics of chemotaxis, diminished candidacidal activity, and reduced iodination. Enzymatic activities of resting cells are normal. Lactate production, HMS activity during phagocytosis, and morphological events are not impaired. Thus, impaired in vitro microbicidal activity, increased resting metabolism, and decreases iodination by PMN's may be related to the high incidence of infection in kwashiorkor.

[Chronic, septic granulomatosis (author's transl)]. / Zur chronischen septischen Granulomatose.

A case report is presented on an 18-month-old boy who suffered from recurrent infections from early infancy. He was hospitalised for osteomyelitis in the left elbow; differential diagnosis also raised the possibility of a Ewing sarcoma. We were, however, able to eliminate this possibility on the basis of clinical data. Together with the immunologist, we discovered a malfunction of the granulocytes, consisting essentially in the fact that certain bacteria, although phagocytised, cannot be killed off within the cells. This has therapeutic consequences, which are discussed in this paper together with questions of prognosis.