Fatal disseminated Acanthamoeba infection in a liver transplant recipient immunocompromised by combination therapies for graft-versus-host disease.

Immunosuppressed solid organ transplant recipients are at increased risk for acquisition of opportunistic pathogens, with potentially fatal consequences. With the introduction of novel immunosuppressive agents used to prevent organ rejection and to treat the sequelae of transplantation, severity and rates of infection with unusual opportunistic pathogens may increase. Various monoclonal antibodies are now being used in the treatment of severe, acute graft-versus-host disease (GVHD), including rituximab, daclizumab, and alemtuzumab. These therapies, particularly when used in combination and with other traditional forms of immunosuppression, may have profound effects on the immune system. Acanthamoeba species are ubiquitous, free-living protozoa that rarely cause disseminated disease in the immunocompromised host. We report a fatal case of disseminated Acanthamoeba infection with a dramatic cutaneous presentation in a liver transplant recipient severely immunocompromised by sequential standard and novel therapies used to successfully treat life-threatening acute GVHD. This case illustrates the current major limitation of these therapies, discusses the cutaneous findings in disseminated acanthamoebiasis, and highlights the need to maintain vigilance for the presence of unusual infection in patients receiving similar therapeutic regimens.

Integrating tuberculosis and HIV care in rural Rwanda.

SETTING: Rwanda has generalised human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics. The Rwandan Ministry of Health approved a policy on TB-HIV collaborative activities in 2005. The present study is a report on the results of the integrated TB and HIV activities at a rural health care site between July 2005 and June 2006. METHODS: Activities included provider-initiated HIV testing and counselling (PITC) of TB patients and the implementation of a standardised TB screening questionnaire for in-patients on medical wards and HIV-infected out-patients. RESULTS: Of a total 259 TB patients registered, 87% with unknown HIV status or who were HIV-negative accepted PITC. Overall, 48% (125/259) of TB patients were HIV-infected. The proportion of TB patients ever tested for HIV increased from 82% (138/169) in 2004-2005 to 93% (240/259) in 2005-2006 (P < 0.001). Of the 770 in-patients screened for TB, 162 (21%) tested positive, of whom 53 (33%) were diagnosed with TB; 39 (76%) of these were HIV co-infected. Three hundred out-patients with HIV were screened for TB; 80 (27%) tested positive, of whom 11 (14%) were diagnosed with TB. DISCUSSION: Activities integrating TB and HIV were feasible in a rural health care setting. PITC was successful in TB patients and unrecognised TB was common, particularly among HIV-infected in-patients.

Use of (99m)Tc-sulesomab for the diagnosis of prosthesis infection after total joint arthroplasty.

This study aimed to evaluate the diagnostic efficacy of antigranulocyte scintigraphy using the antibody fragment (99m)Tc-sulesomab (LeukoScan) for the diagnosis of prosthesis infection in patients with total hip or knee arthroplasty. The results from 19 patients with suspected total joint arthroplasty infection who had undergone a three-phase bone scan and a subsequent examination with (99m)Tc-sulesomab during a 1-year period were reviewed. Twelve patients were shown to have prosthesis infection on culture of aspirated synovial fluid or intra-operative samples. The overall sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy for (99m)Tc-sulesomab were 75%, 86%, 90%, 66% and 79%, respectively, compared with 54%, 83%, 88%, 45% and 63%, respectively, for the three-phase bone scan. This study showed that (99m)Tc-sulesomab had good diagnostic value for the detection of prosthesis infection. The combination of (99m)Tc-sulesomab with other laboratory or imaging examinations may improve diagnostic performance in prosthesis infection and should be investigated further.

Results of a tuberculosis-specific IFN-gamma assay in children at high risk for tuberculosis infection.

The specificity of the tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection (LTBI) is adversely affected by bacille Calmette-Guérin (BCG) vaccination and infection with non-tuberculous mycobacteria. Interferon-gamma release assays (IGRAs) using TB-specific antigens promise higher specificity. We compared a new IGRA and TST in 184 schoolchildren at high risk for LTBI. The IGRA and TST were positive in 33.2% and 43.5% of the children, respectively (P < 0.001). If studies confirm that this difference is due to higher specificity of this IGRA, it may have an important role to play in the diagnosis of LTBI and identification of children at true risk for TB.

Physician attitudes regarding latent tuberculosis infection: international vs. U.S. medical graduates.

Tuberculosis in the U.S. is increasingly noted among the foreign-born, with many individuals at risk being managed by international medical graduates (IMGs). We utilized anonymous surveys using hypothetical scenarios to assess and compare the attitudes of IMGs and U.S. medical graduates regarding the treatment of latent tuberculosis infection (LTBI) to identify how attitudes and intentions may influence physician behavior. IMGs were less likely to treat LTBI in almost all scenarios. Educational efforts should focus on IMGs to encourage attitudes more consistent with U.S. guidelines.

Multiple meningiomas.

A 57-year-old woman with hyperthyroid ophthalmopathy underwent somatostatin receptor scintigraphy with In-111 pentetreotide. She also reported migraine-type headaches over the previous 3 months, without any other obvious neurologic symptoms and signs. The study revealed an increased uptake of the radiopharmaceutical in both periorbital areas and the right lobe of the thyroid gland. Multiple foci of marked tracer uptake were also detected in the right half of the head. A brain MRI scan subsequently revealed multiple lesions consistent with meningiomas on the surface of the right cerebral hemisphere.

Linkage disequilibrium analysis of G-olf alpha (GNAL) in bipolar affective disorder.

This study examines G-olf alpha as a possible candidate gene for susceptibility to bipolar affective disorder (BPAD) using the Transmission Disequilibrium Test (TDT). G-olf alpha, which encodes a subunit of a G-protein involved in intracellular signaling, maps within a region of chromosome 18 that has been implicated by two different linkage studies as a potential site of BPAD susceptibility loci. The expression pattern of G-olf alpha in the brain, its coupling to dopamine receptors, and the effects of lithium salts on G-proteins all support G-olf alpha as a candidate gene for BPAD. Our study population consisted of 106 probands and sibs with bipolar I disorder, with a median age-at-onset of 21.5 years ascertained from the United States. There was no evidence of linkage disequilibrium between BPAD and any of the observed G-olf alpha alleles in our sample. Division of families based on sex of the transmitting parent did not significantly change the results. This sample had good power (78%) to detect linkage disequilibrium with alleles conferring a relative risk equal to that estimated for the putative 18p locus (2.58). Our results do not support a major role for G-olf alpha as a susceptibility locus for BPAD in a substantial portion of our sample. Other genes lying near G-olf alpha within the linked region on chromosome 18 cannot be excluded by our data. This study illustrates the use of the TDT in evaluating candidate genes within linked chromosome regions.

Reverse of the differential uptake intensity of Tc-99m MIBI and Tc-99m V-DMSA by multiple myeloma lesions in response to therapy.

PURPOSE: The objective of this study was to compare the uptake changes of Tc-99m 2-methoxy isobutyl isonitrile (MIBI) and Tc-99m pentavalent dimercaptosuccinic acid (V-DMSA) in multiple myeloma (MM) lesions in response to high-dose chemotherapy (HDC). MATERIALS AND METHODS: The authors compared Tc-99m MIBI and Tc-99m V-DMSA scans before and after HDC in a patient with focal MM lesions without amyloidosis who had received previous standard chemotherapy as well. RESULTS: HDC had the effect of eliminating all Tc-99m MIBI uptake in the lesions. Tc-99m V-DMSA uptake was increased in lesions presenting significant initial Tc-99m MIBI uptake. In 1 particular lesion that demonstrated this phenomenon, magnetic resonance showed necrosis of the area of MM. CONCLUSION: The authors consider that the effect of increasing Tc-99m V-DMSA uptake in the absence of an increase in viable plasma cells possibly reflects the treatment-generated inflammatory and fibrotic changes and not necessarily viable tumor tissue. Exclusive focal Tc-99m V-DMSA uptake in this clinical setting could be considered as a sign of effectively treated lesions and not a sign of deterioration.

Are the parasiticidal avermectins resistant to dissipation in the environment? The case of eprinomectin.

Eprinomectin (EPM) is a veterinary drug currently licensed in many countries for the treatment of endo- and ecto-parasites in cattle. Despite the notable evidence for its high toxicity to the terrestrial and aquatic environment ecosystems, its environmental behavior and fate are currently unknown. In the present research, the dissipation of EPM was studied in three soils and in cattle manure by using the OECD 307 guideline and the recently developed European Medicines Agency (EMA/CVMP/ERA/430327) guideline, respectively. The procedure presented by the FOrum for Co-ordination of pesticide models and their USe (FOCUS) was adopted for estimating the EPM degradation kinetics in soil and cattle manure. The EPM dissipation in soil was best described by the SFO (Simple First Order) and the HS (Hockey Stick) models, under aerobic and anaerobic conditions, respectively. The EPM dissipation in cattle manure was best described by the FOMC (First Order Multi Compartment) model. The Dissipation Time for the 50% of the initial EPM mass (DT50) range was 38-53days under aerobic and 691-1491days under anaerobic conditions. In addition, the DT50 for EPM in cattle manure was 333days. Therefore, EPM could be characterized as moderately to highly persistent to dissipation in soil, which depends on soil type, its oxygen content (aerobic or anaerobic conditions in soil) and the microbial activity. Moreover, the EPM resists dissipation in cattle manure, resulting to a high load in soil after manure application in agricultural land (or direct defecation in grassland). Consequently, the high possibility for EPM accumulation in soil and cattle manure should be considered when assessing the environmental risk of the drug.

Hepatobiliary scintigraphy and gamma-GT levels in the differential diagnosis of extrahepatic biliary atresia.

AIM: The aim of this paper is to identify extrahepatic biliary atresia (EHBA) as the cause of cholestasis in neonates with prolonged jaundice and thus accelerate the decision for surgical intervention, which is critical for prognosis. METHODS: We retrospectively studied 21 infants (13 girls, 8 boys) aged 2-16 weeks who have undergone( 99m)Tc-mebrofenin iminodiacetate ((99m)Tc-BrIDA) scintigraphy. They were referred because of direct hyperbilirubinemia and jaundice persisting beyond the 2nd postnatal week. They had received phenobarbitone premedication prior to scintigraphy. Dynamic images for 30 min and then static images (if required) at 1, 2 and 24 h postinjection were acquired. Images were evaluated visually and semiquantitatively, by calculating the liver-to-heart (L/H) ratio. Age, L/H ratios, and serum gamma glutamyl transpeptidase (gamma-GT) levels were compared (Mann-Whitney U test) between infants with EHBA (Group A) and infants without (Group B). The L/H ratios were correlated with age in each group and with gamma-GT in the entire population. RESULTS: A total of 7/21 infants were classified in Group A and 14/21 in Group B. The L/H ratios were significantly lower in Group A. The correlation between L/H ratio and age was negative in EHBA and positive in non-atretic infants. The gamma-GT levels were inversely correlated with the L/H ratios in the entire population, being significantly higher in Group A. CONCLUSION: In long-standing neonatal direct hyperbilirubinemia, (99m)Tc-BrIDA scintigraphy and the L/H ratio index seem to give useful information in the differential diagnosis of EHBA, especially when associated with markedly elevated serum gamma-GT levels.

Fertilizer management in watersheds of two Ramsar wetlands and effects on quality of inflowing water.

Two field experiments were carried out in the watersheds of two Ramsar wetland areas, Lakes Koronia and Volvi (area A) and Lakes Mikri and Megali Prespa (area B), to study the effect of application of N fertilizer on wheat yields, the quality of runoff water, and the quality of stream water. The treatments were a combination of two methods of fertilizer application (total amount in fall, and 2/3 in fall + 1/3 in spring) at three rates (0, 100, and 200 kg N/ha) with four replications. Concentrations of NH4+, NO3-, NO2-, P, and Cl- and pH were determined in all water samples. Runoff water quality was not influenced by fertilizer application in either area. Chemical parameters for water did not differ along the selected watercourses in area B, while in area A they were higher in the samples taken near Lake Koronia than in the samples taken upstream, indicating that the watercourses are polluted downstream by nonagricultural sources. The differences in wheat yields between the 100 and 200 kg N/ha application rates were not high. These results call for better fertilizer management in order to achieve better yields and to diminish the possibility to have negative effects to the environment.