Detection of pulmonary tuberculosis in patients with a normal chest radiograph.

OBJECTIVES: To describe the early symptoms of pulmonary tuberculosis (TB) when the chest radiograph (CXR) is normal. SETTING: Centralized, provincial TB control program. SUBJECTS: Twenty-five patients with culture-positive pulmonary TB and a normal CXR were identified from a review of 518 consecutive patients with culture-positive pulmonary TB in the province of Saskatchewan from January 1, 1988 to March 31, 1997. Patients with abnormal CXRs at the time of diagnosis were excluded from the analysis. RESULTS: Twenty-three of the 25 patients (92%) were symptomatic at the time of diagnosis, with cough/sputum (76%) being reported most commonly. Eleven patients were identified because of contact tracing from cases of infectious pulmonary TB, while the other 14 patients were identified because of an investigation of symptoms. Twenty-four patients (96%) exhibited one or more symptoms of cough for > 1 month, fever for > 1 week, or skin-test conversion after contact with infectious TB. The sputum smear of only one patient was positive. Two patients were pregnant at the time of diagnosis, one patient was HIV-positive, and one patient demonstrated isoniazid-resistant organisms on sensitivity testing. Five patients were diagnosed as having primary TB associated with Mantoux skin-test conversion. The incidence of culture-positive pulmonary TB with a normal chest radiograph was < 1% in the period from 1988 to 1989 and steadily increased to 10% in the period from 1996 to 1997. CONCLUSIONS: Culture-positive pulmonary TB with a normal CXR is not uncommon, and the incidence of this presentation is increasing. Patients with this presentation of TB are typically symptomatic and/or are detected by contact tracing to infectious cases of pulmonary TB. The results suggest that patients presenting with a cough for > 1 month, with a fever for > 1 week, or with documented skin-test conversion < 2 years after known exposure to infectious TB should have sputum submitted for a Mycobacterium tuberculosis smear and culture despite a normal CXR.

Bacterial and fungal flora of dust deposits in a pig building.

OBJECTIVE: The purpose of the study was to investigate the bacterial and fungal flora of dust deposits in a newly built pig grower finisher building. Viable bacterial counts and microbial species found in a barn which had never housed pigs were compared with those in a barn housing 144 pigs. METHODS: The quantitative streak plate method was used to measure viable bacterial counts on nutrient agar or sheep blood agar. Viable bacterial counts of the dust deposits were expressed as the number of colony forming units (CFUs)/mg of dust. Gram positive cocci and Gram negative bacilli were identified by an automated system. Identifications with a confidence interval > 90% were accepted at the species level. Fungi were identified to the genus level with slide culture preparations on cereal agar. RESULTS: The lowest viable bacterial count (4.8 x 10(4)/mg of dust) was found in the barn with no pigs. In the barn with pigs the highest viable bacterial count (2.1 x 10(6)/mg of dust) was in dust from the top of a partition close to pig activity. Six species of bacteria or fungi were found in dust from the room with no pigs, whereas 22 different microorganisms were detected in dust from the room with pigs. With the exception of Enterobacter agglomerans no other species of the family Enterobacteriaceae was found in dust deposits in this new pig building. Twelve species of Gram positive bacteria were found in the room housing pigs. CONCLUSIONS: The pig is not only a source but also a disperser of airborne bacteria in pig buildings. Speciation of the microbial flora in dust from the pig building suggests that many of the microorganisms were either of human or environmental origin. Nevertheless as some of these microorganisms are known opportunistic pathogens or allergens and because of the documented increased incidence of chronic respiratory symptoms in pig workers, precautions to reduce inhalation of microbial or dust particles by pig workers seem prudent.

Association of flagellum expression and intracellular growth of Legionella pneumophila.

We examined the role of the flagella of Legionella pneumophila in the infection of amoebae and human monocyte-like cells. Insertional mutants were constructed with mini-Tn10. Ten mutants (F-) which did not react with polyclonal L. pneumophila antiflagellar antisera were identified. Ten randomly selected mutants (F+) that did react with the polyclonal antiflagellar antiserum were also identified. The infectivity of these 20 mutants in Hartmannella vermiformis and human U937 cells was characterized. Seven of the 10 F- mutants were attenuated in their ability to multiply in the amoebae during the first 3 days of coincubation and failed to multiply in U937 cells. Three of the 10 F- mutants multiplied as well as the wild-type parent strain did in amoebae and to a limited degree in U937 cells. None of the 10 F+ mutants were attenuated in either the amoebae or U937 cells. While the flagellar structure is not essential for virulence, the ability of L. pneumophila to infect amoebae and human phagocytic cells appears to be linked to flagellar expression. We believe that the attenuated F- mutants contain insertions in genes critical to both flagellum expression and the infection process.

Pneumonia with pleural effusion due to Legionella pneumophila serogroup Lansing 3.

We describe a case of pneumonia with pleural effusion due to Legionella pneumophila serogroup Lansing 3 in a human immunodeficiency virus-infected person. The 55-year-old man had been treated with immunosuppressive agents for hypersensitivity pneumonitis.

Comparison of arbitrarily primed polymerase chain reaction, ribotyping, and monoclonal antibody analysis for subtyping Legionella pneumophila serogroup 1.

Arbitrarily primed polymerase chain reaction (AP-PCR) was used to characterize Legionella pneumophila serogroup 1. Cells from a single colony could be subtyped by AP-PCR within a few hours. The discrimination between strains of L. pneumophila serogroup 1 by AP-PCR was equivalent to that by monoclonal antibody analysis and ribotyping. Four strains representing the monoclonal antibody pattern most frequently associated with outbreaks all yielded unique amplicon patterns by AP-PCR.

Miliary Mycobacterium bovis induced by intravesical bacille Calmette-Guérin immunotherapy.

Intravesical instillation of bacille Calmette-Guérin (BCG), an attenuated strain of Mycobacterium bovis, is the treatment of choice for many patients with bladder cancer. In a small percentage, this therapy is associated with systemic side effects including pneumonitis. It is uncertain whether these systemic manifestations are due to dissemination of infection or due to hypersensitivity, an etiologic distinction that has important therapeutic implications. We report the first case in which miliary M. bovis was proven to be the responsible mechanism, by culture of M. bovis biovar BCG from a transbronchial lung biopsy and complete resolution on anti-tuberculous chemotherapy.

Characterization of an axenic strain of Hartmannella vermiformis obtained from an investigation of nosocomial legionellosis.

A free-living amoeba identified as Hartmannella vermiformis was isolated from a water sample obtained during an investigation of nosocomial legionellosis. Hartmannella vermiformis is known to support the intracellular multiplication of Legionella pneumophila. This strain of H. vermiformis, designated CDC-19, was cloned and established in axenic culture to develop a model for the study of the pathogenicity of legionellae. Isoenzyme patterns of axenically-cultivated strain CDC-19 were compared with two strains of H. vermiformis derived from the type strain, one axenic (ATCC 50236) and the other grown in the presence of bacteria (ATCC 30966). Enzyme patterns suggested that all three strains are assignable to the species H. vermiformis. Axenic H. vermiformis strain CDC-19 has been deposited with the American Type Culture Collection (ATCC 50237) and should prove useful in the study of protozoan-bacterial interaction.

Increased recovery of Legionella micdadei and Legionella bozemanii on buffered charcoal yeast extract agar supplemented with albumin.

The recovery of Legionella micdadei and L. bozemanii serogroups 1 and 2 from infected guinea pig spleens was evaluated by using two culture media: buffered charcoal yeast extract agar with 0.1% alpha-ketoglutarate (BCYE alpha) and the same medium supplemented with 1% bovine serum albumin (ABCYE alpha). At the lowest dilution of spleen tissue (10(-1)), recovery of all strains of L. micdadei and L. bozemanii was more efficient on ABCYE alpha than on BCYE alpha. L. micdadei strains had higher recovery rates on ABCYE alpha after another 10-fold dilution, but recoveries of L. bozemanii were similar on both media. Recovery rates for most test strains were comparable on BCYE alpha and ABCYE alpha at the highest dilution (10(-3)) of tissue tested. The presence of albumin in BCYE alpha increased the recovery rate of L. micdadei more than that of L. bozemanii. The use of ABCYE alpha medium in place of BCYE alpha may improve the recovery of L. micdadei and L. bozemanii from clinical specimens. Preliminary studies indicate that this medium also enhances recovery of certain Legionella spp. from environmental samples.

Effects of transport temperature and medium on recovery of Bordetella pertussis from nasopharyngeal swabs.

We compared relative recoveries of Bordetella pertussis from simulated nasopharyngeal (NP) specimens incubated in three separate transport media at different temperatures. Transport media included one-half-strength Regan-Lowe (RL.5), Regan-Lowe with one-half-strength agar (RL.5A), and buffered charcoal-yeast extract agar supplemented with alpha-ketoglutarate, lincomycin, and anisomycin (BCYE alpha LA). For each transport medium, recovery of B. pertussis was least efficient after storage at 25 degrees C. The highest recovery of B. pertussis from a mixed culture was achieved with RL.5 at 4 degrees C. Overall, RL.5 and RL.5A were comparable as transport media whether held at 4 or 25 degrees C, but fewer organisms were recovered from BCYE alpha LA. In addition, Regan-Lowe (RL), Bordet-Gengou, and cyclodextrin media were compared as primary isolation media for recovering B. pertussis from simulated NP swabs held at 4 and 35 degrees C in RL.5 medium. The highest recovery of B. pertussis was obtained on RL primary isolation medium. Bordet-Gengou medium recovered only 80% and cyclodextrin medium recovered less than 60% of the numbers recovered on RL medium. Based on these results, refrigeration (4 degrees C) of NP swabs shipped in RL.5 transport medium and using RL as the primary isolation medium are recommended for recovering B. pertussis from swab specimens.

Protocol for sampling environmental sites for legionellae.

A protocol for sampling environmental sites was developed and used to identify possible sources of Legionella species in support of epidemiologic investigations at two hospitals. In hospital A, legionellae were isolated from 43 of 106 (40%) different sites. Three separate Legionella pneumophila serotypes and a previously unrecognized species were present in different combinations in the positive samples. Two of five cooling towers contained the same L. pneumophila serogroup 1 monoclonal type (1,2,4,5) as was isolated from patients. The same monoclonal type was also isolated from make-up water for the two cooling towers, a hot water tank, water separators in four main air compressor systems for respiratory therapy, and cold and hot water faucets. In hospital B, 13 of 37 (38%) sample sites contained legionellae, all of which were L. pneumophila serogroup 1. The monoclonal type matching isolates from patients (1,2,4,5) was found at the highest concentration in a hot water tank, but it was also present at four other sample sites. Since legionellae not related to disease may be found in many of the sites sampled, an epidemiologic association with the probable source should be established before intervention methods, such as disinfection, are undertaken.

Isolation of protozoa from water associated with a legionellosis outbreak and demonstration of intracellular multiplication of Legionella pneumophila.

At the site of a legionellosis outbreak, amoebae and two ciliates, Tetrahymena sp. and Cyclidium sp., were isolated from cooling-tower water containing Legionella pneumophila. The Tetrahymena sp. and the amoebae repeatedly showed the ability to support intracellular multiplication of L. pneumophila. Both were isolated from cooling towers specifically implicated as the source for the spread of legionellosis. These protozoa may be reservoirs supporting the survival and multiplication of virulent legionellae in cooling-tower water.

Religiosity and United States suicide rates, 1972-1978.

Related annual variations in United States suicide rates between 1972 and 1978 to annual variations in church attendance of representative subpopulations of the United States. Variations in the suicide rates of white males, black males, white females, and black females were significantly, inversely correlated with variations in the attendance of the respective subpopulations. No significant differences were found between the correlations for white and black females and for white and black males nor between those for black females and males and for white females and males. The general hypothesis that religiosity deters suicide was supported.

Proliferation of Legionella pneumophila as an intracellular parasite of the ciliated protozoan Tetrahymena pyriformis.

In a series of experiments, we have determined that Legionella pneumophila will proliferate as an intracellular parasite of the ciliated holotrich Tetrahymena pyriformis in sterile tap water at 35 degrees C. After 7 days of incubation, serpentine chains of approximately 10(3) L. pneumophila cells were observed throughout the cytoplasm of the protozoan infected initially with 1 to 30 L. pneumophila cells. The overall L. pneumophila population increased from ca. 1.0 X 10(2) to ca. 5.0 X 10(4) cells per ml in the coculture within this time frame. The interactions between the protozoan and the bacterium appear to depend upon their concentrations as well as temperature of incubation. L. pneumophila did not multiply in sterile tap water alone, in suspensions of lysed T. pyriformis, or in cell-free filtrates of a T. pyriformis culture. In addition to establishing an ecological model, we found that addition of T. pyriformis to environmental specimens served as an enrichment method that improved isolation of legionella from the specimens.

Selective enrichment broth medium for isolation of Campylobacter jejuni.

A new selective Campylobacter enrichment broth for the isolation of Campylobacter jejuni has been tested with fecal specimens of human, poultry, and bovine origin. We compared the isolation rate with that from the simultaneous direct plating of a duplicate specimen. Of the 380 duplicate specimens examined comparatively, we obtained a 46.3% increase in isolation of C. jejuni by using the new Campylobacter enrichment broth medium.

Bottled beverages and typhoid fever: the Mexican epidemic of 1972-73.

A chloramphenicol resistant strain of S. typhi which caused a very large epidemic of typhoid fever in Mexico in 1972-73 survived in opened bottles of one carbonated drink with a pH of 4.6 for two weeks and in another such drink with a pH of 5.1 for six months. Bottled beverages are potential sources of large outbreaks of enteric disease, and deserve the same type of standards sand monitoring as comparable fluids such as milk.

Legionella gormanii sp. nov.

A new species of Legionella was isolated from soil collected from a creek bank. The name Legionella gormanii sp. nov. is proposed.

Shigellosis in the Marshall Islands: epidemiologic aspects of an outbreak.

An outbreak of diarrheal illness caused by Shigella flexneri 1b and associated with 11 deaths occurred in the Marshall Islands during June and July 1977. A house-to-house survey on Majuro indicated an attack rate of 6.2%. Neither the survey nor a case-control study uncovered a common source of exposure on Majuro, and it is believed that transmission was mainly person-to-person. Socioeconomic factors, type of water supply, distance to municipal water supply, and type of sanitary facility could not be related to the occurrence of illness, but a poor sanitary rating was associated with increased rate of household transmission. Absence of stool culturing for bacteria and false-positive identifications of amebae in stool specimens led to the outbreak's being attributed to Entamoeba histolytica. Subsequent parasitologic examinations and serologic studies indicated that E. histolytica played no role in the outbreak, and suggested that fecal leukocytes were being mistaken for amebae. Improved bacteriologic capabilities will be important in improving the approach to diarrheal illness in the Marshall Islands.

Epidemic salmonellosis from cheddar cheese: surveillance and prevention.

On August 3, 1976, ongoing Salmonella surveillance in Colorado first detected an epidemic of Salmonella heidelberg infections that eventually totaled 339 isolates. The majority of the cases occurred between July 23 and August 12 in two widely separated cities: Denver and Pueblo. Epidemiologic investigation successively incriminated 1) recent dining at Mexican-style restaurants (p less than 0.001), 2) eating foods containing cheese in these restaurants (p = 0.029), and 3) consumption of cheddar cheese from a single shipment of a single manufacturer (p less than 0.01). The prompt investigation enabled an embargo of 2087 kg (41%) of the contaminated cheese. S. heidelberg was isolated from seven production lots of the incriminated cheese. Surveillance and the epidemiologic investigation may have resulted in prevention of 25,000 diarrheal illnesses.

Isolation of the Legionnaires' disease bacterium from environmental samples.

We analyzed 24 environmental samples collected in or near the Indiana Memorial Union, where an epidemic of Legionnaires' disease occurred in early 1978. We conducted fluorescent antibody analyses and culture on F-G and charcoal yeast extract agars of each sample directly; splenic tissue of guinea pigs inoculated with the sample; and yolk sacs from embryonated eggs inoculated with splenic tissue of guinea pigs injected with the sample. Legionnaires' disease (LD) bacterium was isolated from seven of the 24 samples: one water sample from the air-conditioner cooling tower of the Union; three water samples from a stream near the Union; and three mud samples from the same stream. The LD bacterium strains were of three different serotypes. These findings indicate that LD bacteria may be widespread in nature.