Diagnostic challenge of Strongyloides stercoralis hyperinfection syndrome: a case report.

Strongyloides stercoralis causes chronic, mostly asymptomatic infections but hyperinfection syndrome may occur in immunosuppressed patients, especially in those receiving corticosteroids. We report a case of S. stercoralis hyperinfection syndrome in a solid organ transplant recipient that occurred approximately 2.5 months after heart transplantation. The patient presented to the intensive care unit with acute respiratory distress, bacteremia, and petechial rash on abdomen and toe. Microbiology testing of respiratory samples excluded infection with Pneumocystis jirovecii, respiratory viruses, pathogenic bacteria and fungi. No eosinophilia was found. Histopathological examination of the skin biopsy of the petechial rash provided the first indication of the diagnosis, revealing the presence of isolated filariform S. stercoralis larvae in the dermis. Subsequent microbiology testing confirmed the diagnosis. This case highlights the role of histopathological examination of a skin rash in diagnosing patients with atypical clinical presentation of Strongyloides hyperinfection syndrome.

Characterization of Tularemia Cases in Slovenia with Multiple-Locus Variable-Number Tandem Repeat Analysis.

Francisella tularensis is the etiologic agent of tularemia, a bacterial zoonotic disease. The genome of F. tularensis shows a recent evolutionary change, especially in reservoirs. Variable number of tandem repeats (VNTR) is described as a high-speed molecular clock and can thus be used as a high-resolution typing system. The main objective of our study was to investigate the molecular diversity of F. tularensis strains and reveal possible sources of infection. Using real-time PCR targeting the ISFtu2 region, we successfully amplified targeted DNA in 13/31 Slovenian patients with a clinical diagnosis of tularemia, and with PCR targeting the fopA gene, we obtained 11/13 PCR products. Sequencing revealed that all samples were identified as F. tularensis subsp. holarctica. We successfully obtained one F. tularensis isolate from a lymph node aspirate by culture on chocolate agar. Our isolate was clustered into major clade B12 (subclade B43). We optimized VNTR typing to be used directly on clinical samples. Multiple-locus VNTR analysis (MLVA) revealed five unique MLVA types; 45.5% samples had the same MLVA type, another 27.3% shared a different MLVA type, and each of the remaining had a unique MLVA type. Most samples differed at only two VNTR markers (Ft-M03 and Ft-M06). Additionally, we investigated samples from small mammals (n = 532) and Ixodes ricinus ticks (n = 232) captured in the same geographical area in which patients with tularemia were found. No F. tularensis DNA was detected in samples of small mammals or I. ricinus ticks. The diversity of MLVA types in Slovenia was high, despite the small region, but most of the samples from the same region shared the same MLVA type. Our results suggest that MLVA is a useful tool for quick molecular characterization of F. tularensis directly from patient samples, especially when investigating geographically localized outbreaks.

Detection of herpes simplex and varicella-zoster virus from skin lesions: comparison of RT-PCR and isothermal amplification for rapid identification.

We compared 2 molecular tests for detection of herpes simplex viruses 1 and 2 (HSV-1, HSV-2) and varicella-zoster virus (VZV): real-time polymerase chain reaction (RT-PCR) (Argene, BioMerieux, France) performed on an LC480 platform (Roche Applied Science, Mannheim, Germany) and isothermal amplification using a Solana HSV1 + 2/VZV assay (Quidel Corporation Worldwide Headquarters, San Diego, CA) with helicase-dependent amplification performed by a Solana® instrument. With both methods, HSV-1 was detected in 68/291 (23.4%), HSV-2 in 23/291 (7.9%), and VZV in 48/291 (16.5%) skin lesions. Both methods agreed completely only in detection of HSV-2 (kappa = 1). Concordance between Solana HSV1 + 2/VZV and RT-PCR was 98.3% (kappa = 0.95) for HSV-1 and 99.3% (kappa = 0.98) for VZV. Rapid detection of HSV-1, HSV-2, and VZV using the Solana platform is a useful method for routine diagnostics and for urgent swab samples requiring a short turnaround time.

The prevalence of Coxiella burnetii in ticks and animals in Slovenia.

BACKGROUND: The obligate intracellular bacterium Coxiella burnetii causes globally distributed zoonotic Q fever. Ruminant livestock are common reservoirs of C. burnetii. Coxiella burnetii are shed in large numbers in the waste of infected animals and are transmitted by inhalation of contaminated aerosols. This study was conducted to evaluate the prevalence of C. burnetii infection in domestic animals and ticks in areas of Slovenia associated with a history of Q fever outbreaks. RESULTS: A total of 701 ticks were collected and identified from vegetation, domestic animals and wild animals. C. burnetii DNA was detected in 17 out of 701 (2.4%) ticks. No C. burnetii DNA was found in male ticks. Ticks that tested positive in the PCR-based assay were most commonly sampled from wild deer (5.09%), followed by ticks collected from domestic animals (1.16%) and ticks collected by flagging vegetation (0.79%). Additionally, 150 animal blood samples were investigated for the presence of C. burnetii-specific antibodies and pathogen DNA. The presence of pathogen DNA was confirmed in 14 out of 150 (9.3%) blood samples, while specific antibodies were detected in sera from 60 out of 150 (40.4%) animals. CONCLUSIONS: Our results indicate that ticks, although not the primary source of the bacteria, are infected with C. burnetii and may represent a potential source of infection for humans and animals. Ticks collected from animals were most likely found to harbor C. burnetii DNA, and the infection was not lost during molting. The persistence and distribution of pathogens in cattle and sheep indicates that C. burnetii is constantly present in Slovenia.

Borrelia burgdorferi sensu lato infection in patients with peripheral facial palsy.

The aims of the study were to determine the frequency of borrelial infection in patients with peripheral facial palsy (PFP) and to compare clinical and laboratory characteristics of patients with borrelial PFP and patients with PFP of unknown etiology. Adult patients with PFP who presented at our department between January 2006 and December 2013 qualified for the study if they had undergone lumbar puncture and also been tested for the presence of borrelial IgM and IgG antibodies in serum and cerebrospinal fluid (CSF) in indirect chemiluminescence immunoassay. Patients with PFP who had obvious signs/symptoms indicating a disease other than Lyme borreliosis (LB) were excluded. Patients who qualified for the study were classified into three groups according to the clinical and microbiological criteria: those having confirmed LB, those with possible LB, and those with PFP of unknown etiology. Of 589 patients diagnosed with PFP during the eight-year period, 436 patients (240 males, 196 females) with median age 42.5 years (15-87 years) qualified for the study. Among these patients, 64 (14.7%) fulfilled criteria for confirmed LB, 120 (27.5%) had a diagnosis of possible LB, and in 252 (57.8%) the cause of their PFP remained unknown. When compared with patients with unknown cause of PFP, the patients with confirmed LB were older, more often presented in summer, more often reported tick bites, more frequently had LB in the past, more often complained of constitutional symptoms and radicular pain, and more often had bilateral palsy and CSF pleocytosis. Among the patients with possible LB and patients with unknown cause of PFP there were no differences in frequency of constitutional symptoms, radicular pain, bilateral palsy or CSF pleocytosis. Presentation in summer, tick bites, constitutional symptoms and radicular pain, bilateral palsy, and CSF pleocytosis strongly suggest borrelial etiology of PFP.

Laboratory diagnosis and epidemiology of herpes simplex 1 and 2 genital infections.

Herpes simplex virus types 1 and 2 are the main cause of genital ulcers worldwide. Although herpes simplex virus type 2 is the major cause of genital lesions, herpes simplex virus type 1 accounts for half of new cases in developed countries. Herpes simplex virus type 2 seroprevalence rises with sexual activity from adolescence through adulthood. Slovenian data in a high-risk population shows 16% seroprevalence of HSV-2. HSV-1 and HSV-2 DNA in genital swabs was detected in 19% and 20.7%, respectively. In most cases, genital herpes is asymptomatic. Primary genital infection with herpes simplex virus types 1 and 2 can be manifested by a severe clinical picture, involving the vesicular skin and mucosal changes and ulcerative lesions of the vulva, vagina, and cervix in women and in the genital region in men. Direct methods of viral genome detection are recommended in the acute stage of primary and recurrent infections when manifest ulcers or lesions are evident. Serological testing is recommended as an aid in diagnosing genital herpes in patients with reinfection in atypical or already healed lesions. When herpes lesions are present, all sexual activities should be avoided to prevent transmission of infection. Antiviral drugs can reduce viral shedding and thus reduce the risk of sexual transmission of the virus.