Molecular epidemiology and clinical manifestations of human cryptosporidiosis in Sweden.

This study describes the epidemiology and symptoms in 271 cryptosporidiosis patients in Stockholm County, Sweden. Species/genotypes were determined by polymerase chain reaction-restriction fragment-length polymorphism (PCR-RFLP) of the Cryptosporidium oocyst wall protein (COWP) and 18S rRNA genes. Species were C. parvum (n=111), C. hominis (n=65), C. meleagridis (n=11), C. felis (n=2), Cryptosporidium chipmunk genotype 1 (n=2), and a recently described species, C. viatorum (n=2). Analysis of the Gp60 gene revealed five C. hominis allele families (Ia, Ib, Id, Ie, If), and four C. parvum allele families (IIa, IIc, IId, IIe). Most C. parvum cases (51%) were infected in Sweden, as opposed to C. hominis cases (26%). Clinical manifestations differed slightly by species. Diarrhoea lasted longer in C. parvum cases compared to C. hominis and C. meleagridis cases. At follow-up 25-36 months after disease onset, 15% of the patients still reported intermittent diarrhoea. In four outbreaks and 13 family clusters, a single subtype was identified, indicating a common infection source, which emphasizes the value of genotyping for epidemiological investigations.

A foodborne norovirus outbreak at a manufacturing company.

Over 400 office workers from the same unit of a manufacturing company in Stockholm County, Sweden, fell ill with gastroenteritis. A retrospective cohort study of office workers in the affected unit demonstrated that canteen visitors on one day had an increased risk of illness [risk ratio (RR) 27.1, 95% confidence interval (CI) 15.7-46.8] compared to non-visitors. A second study, investigating canteen visitors' consumption of particular food items, showed that both tomatoes from the salad buffet (RR 5.6, 95% CI 3.2-9.6) and hamburgers (RR 4.9, 95% CI 2.4-9.8) were the most likely vehicles of infection. Norovirus GI.3 (Desert Shield) was identified in stool samples from three office workers and from a food handler who prepared the tomatoes for the salad buffet and hamburger ingredients before vomiting at the workplace on 12 November. The outbreak could have been prevented if the food items prepared by the food handler some hours before vomiting had not been served.

A food-borne outbreak of cryptosporidiosis among guests and staff at a hotel restaurant in Stockholm county, Sweden, September 2008.

In September 2008, 21 cases of cryptosporidiosis occurred among guests and staff at a wedding reception in a hotel restaurant in Stockholm county, Sweden. The most probable source of the outbreak was bearnaise sauce containing chopped fresh parsley.

Outbreak of salmonellosis in a restaurant in Stockholm, Sweden, September - October 2006.

The largest outbreak of salmonellosis in 25 years in Stockholm County occurred during September - October 2006. A total of 115 persons who had a meal at a restaurant in Stockholm were notified as cases of salmonellosis through the Swedish surveillance system. The probable vehicle of the outbreak was mung beans, soaked in lukewarm water for 24 hours before being served at the restaurant. These mung beans had been included in all dishes served in the restaurant and the outbreak was terminated when they were excluded from the menu. Either Salmonella Bareilly or Salmonella Virchow were isolated from affected persons. No person was found to have an infection with both serotypes. The majority of affected persons were females with a median age of 34 years. This and similar outbreaks associated with consumption of vegetables and fruits highlight the increasing importance of fresh produce as vehicle for foodborne outbreaks in Europe.

Comparison of intravenous penicillin G and oral doxycycline for treatment of Lyme neuroborreliosis.

To compare the efficacy of oral doxycycline and IV penicillin G for the treatment of neuroborreliosis, we randomized consecutive patients with Lyme neuroborreliosis to receive either IV penicillin G (3 g q 6 h) or oral deoxycycline (200 mg q 24 h) for 14 days. All patients had antibodies against Borrelia burgdorferi in serum, CSF, or both, or had a positive CSF culture. Twenty-three patients randomized to penicillin G and 31 patients to doxycycline were included in the study. All patients improved during treatment, and there were no significant differences between the two treatment groups in patient scoring, CSF analysis, or serologic and clinical follow-up during 1 year. There were no treatment failures, although one patient in each treatment group was re-treated because of residual symptoms. In conclusion, oral doxycycline is an adequate and cost-effective alternative to IV penicillin for the treatment of Lyme neuroborreliosis.

Clinical manifestations and diagnosis of neuroborreliosis.

Lyme borreliosis has in a few years turned out to be a health problem not only in the United States, but also in many European countries. When it affects the nervous system, Lyme borreliosis acts as the great disease imitator. Because of this characteristic it is often difficult to diagnose on clinical grounds. Patients with neuroborreliosis might appear within all medical disciplines. Clinical markers, such as preceding tick bite and/or ECM, are important clues to the diagnosis. Mononuclear pleocytosis and elevated CSF protein are present in most patients with neuroborreliosis. Final evidence for the diagnosis is the demonstration of specific antibodies in serum and/or CSF. Measurement of antibody titers should be carried out in both serum and CSF, since these methods are complementary when trying to obtain a serological diagnosis of neuroborreliosis.

Treatment of Lyme borreliosis with emphasis on neurological disease.

We have studied 113 patients with neurologic Lyme borreliosis and meningitis who were treated with intravenous high-dose antibiotics (penicillin G, 12 g, mostly for 14 days in 47 patients; penicillin G, 9 g, mostly for 10 days in 58 patients; doxycycline, 200 mg, in 5 patients; and cefuroxime, 4.5-9 g, in 3 patients). Seventy percent of the patients had peripheral nerve symptoms and 13% had central nervous symptoms. Almost half of the patients were treated more than 4 weeks after the onset of symptoms and 15% of the patients had persisting or progressive symptoms between 4 and 11 months. There seemed to be clinical benefit as well as a decrease of spinal fluid pleocytosis and spinal proteins. No significant symptoms of Herxheimer reaction were demonstrated.

Clostridium difficile cytotoxin B in adults with diarrhea: a comparison of patients treated or not treated with antibiotics prior to infection.

OBJECTIVE: To study the detection rate of Clostridium difficile cytotoxin B in stool specimens from adults with diarrhea as related to previous antimicrobial treatment. METHODS: Stool specimens from 802 adult patients with diarrhea and 203 healthy controls were tested for C. difficile cytotoxin B using a cell cytotoxicity assay. Antibiotic susceptibility testing of C. difficile was performed with the E test. RESULTS: Of 173 patients treated with antimicrobial medication within 5 weeks of onset of diarrhea, 60 (35%) were positive for C. difficile cytotoxin B (group A) compared to only 41 (7%) of 629 untreated patients (group B) and two of the 203 (1%) healthy controls. Compared to patients in group A, patients in group B possessed characteristics not usually connected with C. difficile disease. They were generally younger (median age 40 years vs. 73 years), had been hospitalized less frequently (10% vs. 67%), had more often travelled abroad within the previous 2 weeks (46% vs. 1%), and more often had multiple enteropathogens (41% vs. 3%). Minimal inhibitory concentrations for vancomycin, metronidazole and fucidic acid to C. difficile isolates ranged from 0.5 to 4 mg/L, from 0.125 to 256 mg/L and 0.25 to 4 mg/L, respectively. CONCLUSIONS: The detection rate of C. difficile cytotoxin B in patients with diarrhea, not associated with antibiotic treatment, is comparable to that in healthy control subjects. It probably merely reflects a carrier state without clinical significance.

Suppurative epididymo-orchitis due to Salmonella enteritidis.

A 50-year-old man developed suppurative epididymo-orchitis 3 weeks after an episode of gastroenteritis. Culture of the removed testis yielded Salmonella enteritidis. The importance of remembering salmonella in the differential diagnosis of epididymo-orchitis is stressed.

Reactive arthritis.

Reactive arthritis (ReA) develops after an infection elsewhere in the body, generally in the genitourinary or intestinal tract. Chlamydia trachomatis, Yersinia enterocolitica, salmonella, shigella, and campylobacter are frequent triggering agents. Between 60% and 90% of patients are positive for HLA-B27. The arthritis occurs within 4 weeks of the primary infection and is oligoarticular and asymmetric. Extra-articular manifestations include mucocutaneous symptoms, ocular inflammation, and urethritis. The average duration of arthritis is 4 to 5 months but two-thirds of patients have symptoms for more than a year. Bacterial antigens have been found in synovial specimens from patients with ReA, but cultures are sterile. The treatment of ReA comprises non-steroidal anti-inflammatory drugs, intra-articular steroid injections, and physical treatment. Short-term antibiotic treatment has no effect in manifest ReA, whereas a tendency to improvement has been seen with treatment over months, at least after chlamydia infection.

Effect of perorally administered pivmecillinam on the normal oropharyngeal, intestinal and skin microflora.

To study the ecological effects of pivmecillinam on the human oropharyngeal, intestinal and skin microflora, 15 healthy volunteers were given pivmecillinam tablets 400 mg twice daily for 7 days. Saliva, stool and skin specimens were taken before (days -3 and 0) and on the 2nd, 4th and 7th days during the administration period and 14 and 21 days after the start of administration. Mecillinam caused no major changes in the aerobic or anaerobic oropharyngeal microflora. In the aerobic intestinal microflora there was a decrease in the numbers of Escherichia coli while no changes occurred in the anaerobic microflora. In the skin microflora there was a transient decrease in the numbers of Propionibacterium spp. underneath the wing of the nose. The major effect of pivmecillinam was seen on E. coli and to some extent on Propionibacterium spp. No further ecological disturbances were noticed in the oropharyngeal, intestinal or skin microflora.

Early antibiotic treatment of reactive arthritis associated with enteric infections: clinical and serological study.

OBJECTIVE: To find out whether a 10-14 days' course of antibiotics early in the course of reactive arthritis associated with enteric infections could reduce the severity and duration of the disease and whether the antibody response in patients with reactive arthritis associated with yersinia infection differed between those treated and those not treated with the antibiotics. DESIGN: Prospective multicentre trial in which patients were randomised to treatment or no treatment with antibiotics. Patients were seen at three and six weeks and three, six, nine, 12, and 18 months after their first visit. SETTING: Departments of infectious diseases in three hospitals in Linköping, Malmö, and Stockholm, Sweden. PATIENTS: 40 Consecutive patients who had had symptoms of reactive arthritis associated with enteric infection for less than four weeks. INTERVENTIONS: 20 Patients were allocated to treatment with antibiotics and 20 patients did not receive antibiotics. All patients received non-steroidal anti-inflammatory drugs, and four also received intra-articular steroid injections after at least six weeks' observation. MAIN OUTCOME MEASURES: Arthritic symptoms assessed clinically and by using Ritchies' index; blood measurements reflecting inflammatory activity; serum IgG, IgM, and IgA antibody titres; HLA tissue type. RESULTS: No difference was observed concerning duration of arthritis, grade of inflammation, and number of joints affected between patients treated and those not treated with antibiotics. Furthermore, there was no significant difference between the two groups in erythrocyte sedimentation rate and haptoglobin, IgG, and IgA concentrations. All values had returned to normal within three months. No patient developed chronic arthritis, but sustained slight arthralgia occurred in three patients. The HLA-B27 antigen was found in 23 (58%) of the patients, and its presence did not affect clinical outcome. The IgG, IgM, and IgA antibody responses were similar in patients treated with antibiotics and those not treated. CONCLUSION: Short term antibiotic treatment has no beneficial effect on the clinical outcome of reactive arthritis associated with enteric infection.