A massive intestinal vaso-occlusive crisis or "girdle syndrome" in a 6-year-old boy observed as a first manifestation of sickle cell disease.

UNLABELLED: Sickle cell disease is a chronic hematologic disease with variable but often severe systemic symptoms. In this report, we describe a 6-year-old boy presenting with acute bowel pseudo-obstruction. During this episode, previously undiagnosed sickle cell disease was discovered upon peripheral blood smear analysis. The condition was therefore interpreted as a massive intestinal vaso-occlusive crisis or "girdle syndrome". Conservative treatment with hydration therapy, analgesia and a manual partial exchange transfusion was initiated. The patient fully recovered within 5 days. CONCLUSION: Girdle syndrome is a rare but severe adverse event associated with sickle cell disease that must be considered as differential diagnosis in patients with sickle cell disease.

Reactogenicity and immunogenicity of a new live attenuated combined measles, mumps and rubella vaccine in healthy children.

OBJECTIVE: To compare the reactogenicity and immunogenicity of a novel live attenuated measles-mumps-rubella vaccine, SB MMR (Priorix; SmithKline Beecham Biologicals), with a widely used MMR vaccine, Merck MMR (M-M-R II; Merck & Co. Inc). METHODS: A total of 4702 healthy children, ages 9 to 24 months, were enrolled in 8 single blind, randomized, controlled trials. Reactogenicity (local and general solicited symptoms and all unsolicited symptoms) was assessed for up to 42 days postvaccination. Immunogenicity [seroconversion rates and geometric mean titers (GMT)] was assessed at 42 or 60 days postvaccination in 1912 subjects in 7 studies. In two studies the persistence of the antibodies at Month 12 postvaccination was assessed in 201 subjects. RESULTS: Local symptoms (pain on or immediately after injection; pain, redness and swelling within 4 days of injection) were reported less frequently after SB MMR than Merck MMR (P < 0.0001). General symptoms and all other events were similar between the two groups. Fever >39.5 degrees C was reported after 9.5 and 11.9% of the SB MMR and Merck MMR doses, respectively. At Days 42 to 60 postvaccination seroconversion rates for antimeasles antibodies were higher with SB MMR than with Merck MMR (98.7% vs. 96.9%, P < 0.031) but similar in both groups for anti-mumps and anti-rubella antibodies, GMTs being approximately 10% higher (P < 0.05) with Merck MMR than with SB MMR. At the Month 12 assessment the seropositivity rates and GMTs were similar in both groups. CONCLUSION: When administered as primary vaccination in children in the second year of life, the new SB MMR vaccine has been shown to be superior to a comparator vaccine in terms of local reactogenicity, with equivalent immunogenicity.

Early responses to nonconjugated polyribosylribitol phosphate challenge as evidence of immune memory after combined diphtheria-tetanus-pertussis-polio-Haemophilus influenzae type b primary vaccination.

OBJECTIVES: A high risk of invasive Haemophilus influenzae type b (Hib) disease exists in the first few years of life. A reduction in anti-polyribosylribitol phosphate (PRP) antibody concentrations follows the administration of certain diphtheria-tetanus-acellular pertussis (DTPa)-based Hib conjugate combined vaccines. However, these combined vaccines prime the immune memory, which is an important factor in protection. As yet there is no direct evidence of the time scale involved in the development of the immune memory post-primary vaccination. In this report we investigated the presence of immune memory at 10 and 12 months of age, 4 and 6 months after primary vaccination of young infants with a pentavalent combination of DTPa, inactivated poliovirus vaccine (IPV) and Hib (DTPa-IPV/Hib) vaccine. METHODS: In two trials (A and B) infants received DTPa-IPV combined with Hib-tetanus conjugate (PRP-T) vaccine at 2, 4 and 6 months of age. The presence of immune memory was assessed by measuring anti-PRP concentrations 7 to 10 days after a nonconjugated PRP challenge given at 10 months in Trial A and at 12 months in Trial B. RESULTS: Administration of a nonconjugated PRP challenge 4 and 6 months after primary vaccination in Trials A and B, respectively, elicited an increase in anti-PRP geometric mean concentrations (4.5 and 5.8 microg/ml, respectively) within 7 to 10 days. These concentrations exceed those reported in the literature involving unprimed children who had received a single dose of nonconjugated PRP at the same age. CONCLUSION: The results demonstrate the development of anti-PRP immune memory at an early age, 4 and 6 months after completion of a three dose primary vaccination course of combined DTPa-IPV/Hib vaccine. The ability of primed infants to mount a rapid response is an important observation given the high risk of Hib infection at this critical age.

Safety and immunogenicity of a combined pentavalent diphtheria, tetanus, acellular pertussis, inactivated poliovirus and Haemophilus influenzae type b-tetanus conjugate vaccine in infants, compared with a whole cell pertussis pentavalent vaccine.

BACKGROUND: We compared the safety and immunogenicity of two combined diphtheria-tetanus-pertussis-inactivated poliovirus vaccines containing either acellular (Pa, SmithKline Beecham Biologicals) or whole cell (Pw, Pasteur Merieux Connaught) pertussis components, mixed with a Haemophilus influenzae type b polysaccharide polyribosylribitol phosphate-tetanus conjugate vaccine in an open, randomized study in healthy infants. DESIGN: The combined vaccines were given at 2, 4, 6 and 12 months of age, and serum samples were obtained at ages 2, 6, 7, 12 and 13 months. Adverse events were obtained by diary cards. RESULTS: The Pa group (n = 101) had a clearly lower incidence of both local and systemic adverse events than the Pw group (n = 100). Immunogenicity was comparable for the diphtheria and tetanus components, but significantly superior for pertussis toxin, filamentous hemagglutinin, pertactin and polioviruses 1, 2 and 3 in the Pa group. Both groups had an appropriate response with regard to H. influenzae type b polysaccharide polyribosylribitol phosphate, but the dynamics of the response were significantly different: geometric mean concentrations (micrograms per ml) after the second, third and booster doses were 1.27, 5.06 and 23.12 in the Pa group and 2.72, 6.66 and 13.59 in the Pw group, respectively (P = 0.0002 after second dose; P = 0.0005 after booster). CONCLUSION: The presently studied diphtheria, tetanus, acellular pertussis-H. influenzae b vaccine conjugated to tetanus toxoid combination was at least as immunogenic as the diphtheria, tetanus, whole cell pertussis-H. influenzae b vaccine conjugated to tetanus toxoid combination, with a significantly better safety profile. This is of obvious importance in countries where inactivated poliovirus vaccine is part of the routine infant immunization programs.

The microbiologic aspects, including diagnosis, of beta-hemolytic streptococcal and enterococcal infections.

Basic principles concerning the collection, transport, and processing of clinical specimens for the detection of Streptococcaceae are given. Identification of beta-hemolytic streptococci (S. pyogenes, S. agalactiae, Lancefield group C and G streptococci, S. anginosus) and enterococci is based on the careful observation of colony morphology and hemolytic pattern on sheep blood agar plates; subsequent genus or species confirmation is achieved by rather simple biochemical or enzymatic tests and by detection of streptococcal cell wall carbohydrate antigens (Lancefield grouping). Rapid antigen tests for the detection of group A and B streptococci directly from pharyngeal and vaginal swabs, respectively, are highly specific, thus allowing an immediate antibiotic therapy in patients with a positive test result. The reported sensitivities of these nonculture tests are too low to exclude streptococcal colonization or infection, however. The elucidation of the genetics of some major virulence factors of group A and B streptococci has contributed to knowledge of their association with disease, and molecular techniques have supplemented the traditional (mostly culture and serologic) methods for an improved understanding of the epidemiology and pathogenesis of streptococcal infections. Recently employed examples include the M protein gene typing of group A streptococci by oligonucleotide probes and the use of PCR assays for the detection of the genes encoding for the pyrogenic exotoxins. Restriction enzyme endonuclease digestions of bacterial DNA in association with DNA fragment separation by conventional or PFGE have been applied successfully to several species of Streptococcaceae (e.g., S. pyogenes, S. agalactiae). Enterococci are important pathogens in the hospital setting, exhibiting high morbidity and mortality rates in bacteremic patients with severe underlying disease. Molecular typing methods have clearly confirmed their potential to be nosocomially transmitted. E. faecalis and E. faecium still account for the majority of human infections, but some of the newer enterococcal species (at present 19 species are recognized) have been encountered as well. The definitive species identification of enterococci requires the performance of an array of biochemical tests. The increasing antimicrobial resistance of enterococci, including high-level resistance to penicillins and aminoglycosides and occasionally also to glycopeptides, has hampered standard therapeutic regimens. All enterococci isolated from serious infections should be tested for high-level gentamicin and streptomycin resistance by one of several methods evaluated; beta-lactamase production (primarily found in E. faecalis) is reliably detected by the nitrocefin test.(ABSTRACT TRUNCATED AT 400 WORDS)

Rapid typing of group A streptococci by the use of DNA amplification and non-radioactive allele-specific oligonucleotide probes.

Because of the allelic variations within the M protein gene (emm gene) of group A streptococci, reliable typing of this important human pathogen can be accomplished by the use of emm gene-specific oligonucleotide probes. Two technical modifications (a reverse dot blot and a reverse line blot hybridization assay) of a novel approach for the type-specific identification of emm genes have been developed. Both procedures involved amplification of an emm gene by polymerase chain reaction. The non-radioactively labeled amplicon was subsequently hybridized to a membrane carrying an array of immobilized emm gene-specific oligonucleotide probes, thus allowing the simultaneous analysis of the gene polymorphism in a single hybridization reaction. The feasibility of these rapid and easy to perform methods was shown for the unequivocal identification of reference strains and clinical isolates belonging to 16 different M serotypes.

Flavimonas oryzihabitans septicaemia in a T-cell leukaemic child: a case report and review of the literature.

We describe the first case of septicaemia with Flavimonas oryzihabitans reported from Germany and possibly associated with colonisation of a venous port system. The patient, an 8-year-old T-cell leukaemic girl, was receiving a third course of chemotherapy before bone marrow transplantation. The cardinal symptom, fever, subsided when the venous port system for administration of drugs was no more used. The organism was tested extensively for characteristic biochemical features and antimicrobial susceptibility. We discuss the relevant literature and suggest the means of making a definitive microbiological diagnosis.

Contiguous inflammation of the skin.

Contiguous inflammation of the skin (CIS) is a condition comprising localized inflammatory skin reactions which are secondary to a source of infection originating in deeper anatomical structures (bacterial or sterile abscesses, neoplasm-associated inflammations, foreign bodies, osteomyelitis, sinusitis, etc.). The main clinical symptom of contiguous inflammation of the skin is an asymmetrical, localized and painful erythema in combination with different case-specific symptoms. Four patients are presented below, who developed CIS caused by an ethmoidal carcinoma with superinfection, a postoperative mediastinal abscess, an odontogenic staphylococcal abscess and a purulent sinusitis maxillaris. The purpose of this paper is to bring attention to this condition and to offer guidelines for a rapid diagnosis of its underlying, potentially life-threatening, causal inflammatory focus.

[Current data on the antibiotic sensitivity of Streptococcus pneumoniae (Pneumococcus). The significance of penicillin resistant isolates]. / Aktuelle Daten zur Antibiotikaempfindlichkeit von Streptococcus pneumoniae (Pneumokokken). Die Bedeutung von penicillinresistenten Isolaten.

Antibiotic-resistant pneumococci, including strains resistant to penicillin, are being isolated with increasing frequency also in Europe. Therefore, we studied the antibiotic sensitivity to penicillin, erythromycin, chloramphenicol, tetracycline, ofloxacin, and ciprofloxacin in 131 strains of Streptococcus pneumoniae; most of them were isolated from patients with systemic infections. A reduced susceptibility to penicillin was found in 7.6% (n = 10) of the Streptococcus pneumoniae strains. For the first time in Germany, in the present investigation two pneumococcal strains highly resistant to penicillin were isolated (minimal inhibitory concentration [MIC] values > or = 2 mg/l). These strains exhibited high MIC values against various cephalosporins as well. 10.7% of all pneumococci were resistant to tetracycline, resistance to erythromycin was found in 3.8% of the isolates. The emergence of pneumococci in Germany with reduced susceptibility to penicillin underscores the importance to include alternative drugs in sensitivity testing of pneumococci involved in systemic infections. Depending on the localization of the infection, parenteral third generation cephalosporins, glycopeptides and quinolone derivatives are primarily adequate in the treatment of infections caused by penicillin-resistant pneumococci.

Randomized evaluation of benzathine penicillin V twice daily versus potassium penicillin V three times daily in the treatment of group A streptococcal pharyngitis. Pharyngitis Study Group.

In a randomized, prospective, multicenter study the clinical and bacteriological efficacies of three dosage schedules with two different salts of oral penicillin V suspensions (regimen 1: potassium salt of penicillin V, 50,000 U/kg of body weight per day in three divided doses; regimen 2: benzathine salt of penicillin V, 50,000 U/kg of body weight per day in two divided doses; and regimen 3: benzathine salt of penicillin V, 100,000 U/kg of body weight in two divided doses) for the treatment of streptococcal pharyngitis were evaluated. Children with clinical signs of acute pharyngitis and a positive throat culture for group A beta-hemolytic streptococci (GABHS) were eligible. There was no difference between the treatment groups with respect to the overall clinical success rate. Eradication of the original serotype of GABHS from throat cultures was achieved in 87.1% (regimen 1), 85.5% (regimen 2) and 87.7% (regimen 3) of patients. The incidence of potential drug-related adverse events was significantly higher in patients treated with regimen 3. The results of this and earlier studies strongly suggest that oral penicillin given twice daily should be the recommended treatment for the initial treatment of pharyngitis due to GABHS. Doubling the total daily dose is not beneficial in the usual clinical setting. Because of its favorable pharmacokinetics, the benzathine salt of penicillin V appears to be well suited for a twice-a-day dosage schedule.

Chromosomally mediated high-level gentamicin resistance in Streptococcus mitis.

Four blood culture isolates of Streptococcus mitis were found to be resistant to penicillin (MIC, 16 to 32 micrograms/ml) and gentamicin (MIC, 128 or 1,000 micrograms/ml), and the two antibiotics demonstrated a lack of in vitro synergy. As shown by polymerase chain reaction assays, the structural gene known to encode high-level gentamicin resistance in Enterococcus faecalis, Enterococcus faecium, and Streptococcus agalactiae was also present in all four S. mitis strains. Attempts to isolate plasmids were unsuccessful, but an oligonucleotide probe derived from the gentamicin resistance gene hybridized to distinct restriction fragments of genomic DNA, suggesting that the resistance genes in these strains are integrated into the bacterial chromosome.

Isolation of Enterococcus mundtii from normally sterile body sites in two patients.

Enterococcus mundtii, a recently described nonmotile, yellow-pigmented enterococcal species, was isolated from a chronic thigh abscess and from operatively obtained sinus mucosa. It is emphasized that this species may be encountered in clinical specimens and that the correct species identification may be missed when commercially available identification systems are relied on.

Species identification and antibiotic susceptibility of enterococci isolated from clinical specimens of hospitalized patients.

Over a 4-month period, a total of 315 enterococci were isolated from various clinical specimens of hospitalized patients. By applying an array of biochemical tests, all strains were accurately identified to the species level, and their susceptibilities to clinically relevant antibiotics were determined by a standardized agar dilution technique. E. faecalis and E. faecium accounted for 87.3% and 9.2% of isolates, respectively. E. avium (1%), E. gallinarum (1%), E. durans (0.6%), E. hirae (0.6%), and E. casseliflavus (0.3%) isolates were also identified. Eleven strains of E. faecium and 1 E. hirae isolate were resistant to ampicillin, but none of the isolates produced beta-lactamase. Twenty-three E. faecium and 3 E. faecalis strains as well as 1 E. hirae isolate revealed imipenem resistance. A total of 25.4% enterococci (60 E. faecalis and 19 E. faecium isolates, 1 E. hirae strain) were erythromycin-resistant. Twelve strains (11 E. faecium and 1 E. avium) exhibited ciprofloxacin resistance. High-level resistance to streptomycin was found in 58 (21.1%) E. faecalis, 9 (31%) E. faecium, and both E. hirae strains, whereas high-level gentamicin resistance (HLGR) was exclusively seen in the species E. faecalis (11.6% of isolates belonging to this species). A simple agar screening test containing 500 micrograms of gentamicin per ml proved to be highly reliable for detection of HLGR. The structural gene coding for HLGR was specifically amplified by the polymerase chain reaction in all isolates showing this resistance trait. Moreover, the gene was specifically detected by a nonradioactively labelled oligonucleotide probe in colony blot hybridization assays, indicating the potential application of these molecular approaches as a diagnostic tool.

Molecular investigation of clinical Enterococcus faecium isolates highly resistant to gentamicin.

Over a 10-month period, 22 beta-lactamase negative E. faecium strains resistant to ampicillin were isolated from severely compromised hospitalized patients. Most isolates were clinically significant. Twenty of these strains were also resistant to extraordinarily high levels of gentamicin, a finding described rarely in E. faecium. By whole-cell DNA restriction endonuclease digestion, the 20 strains with both ampicillin and high-level gentamicin resistance segregated into only 3 different groups, suggesting introduction of limited clones into this population of patients. Plasmid DNA profiles and plasmid DNA restriction enzyme analysis supported this grouping for 18 of these 20 strains, the two remaining isolates had slightly different profiles. Both strains lacking high-level gentamicin resistance had clearly different molecular profiles. The results of hybridization experiments strongly suggested the presence of a similar genetic determinant of high-level gentamicin resistance in E. faecalis and E. faecium. High-level gentamicin resistance in E. faecium was shown to be transferable on conjugative plasmids, so that further dissemination of this resistance trait may be anticipated. Our data indicate that the use of a nucleic acid probe is a promising diagnostic tool for screening both E. faecium and E. faecalis for high-level gentamicin resistance.

[Serotypes and antibiotic sensitivity of Streptococcus pneumoniae (pneumococci) in the cologne area (1980-1982)]. / Serotypen und Antibiotikaempfindlichkeit von Streptococcus pneumoniae (Pneumokokken) im Raum Köln (1980-1982).

The commercial availability of a 14-valent pneumococcal polysaccharide vaccine justifies repeated investigations of the prevalent pneumococcal serotypes to estimate the probable efficacy of vaccination for patients at high risk of pneumococcal infection. Immunoprophylaxis of infection with S. pneumoniae appears to gain importance since more and more isolates with reduced sensitivity to antibiotics including penicillin are reported. Our investigation of 324 pneumococcal strains, isolated between October 1980 and December 1982 from various clinical sources at the Institute of Hygiene, Cologne, showed that the distribution of predominant serotypes did not differ substantially from that of 1970 to 1972. This distribution resembled closely to those reported from other European countries. However, a lower percentage of the Cologne isolates belonged to the serotypes of the 14-valent vaccine. The potential coverage of the vaccine in our area would probably be in the range of about 60% or less. Determination of the antibiotic sensitivity of the isolates demonstrated resistances against tetracycline, chloramphenicol, and macrolides. Moreover, 1.7% of the strains were "relatively resistant" to penicillin G (MIC 0.125 to 0.25 mg/l). Some isolates were multiply resistant.

Genetic variability of the emm-related gene of the large vir regulon of group A streptococci: potential intra- and intergenomic recombination events.

One of the most prevalent genetic lineages of group A streptococci (GAS) harbors a genomic locus termed the large vir regulon, which contains an emm gene encoding the antiphagocytic M protein, and structurally related fcrA and enn (emm-related) genes encoding immunoglobulin-binding proteins. In the present study more than 100 large vir regulons from 42 different GAS serotypes were analyzed by PCR and partial DNA sequencing. On comparing these data to published sequences, sites of mutational and putative recombinational events were identified and ordered with respect to their intra/intergenic or intra/intergenomic nature. The emm-related genes were found to display small intragenic deletions or insertions, were completely deleted from, or newly inserted into the genome, or were fused to adjacent genes. Intergenomic exchanges of complete emm-related genes, or segments thereof, between different vir regulons were detected. Most of these processes seem to involve short flanking direct repeats. Occasionally, the structural changes could be correlated with changes in the functions of the encoded proteins.