Validation of the Dri-Dot Latex agglutination and IgM lateral flow assays for the diagnosis of typhoid fever in an Egyptian population.

Laboratory confirmation of typhoid fever is essential for appropriate medical treatment. Blood culture is a standard test for diagnosis of typhoid fever, but well-equipped diagnostic facilities to perform culture are seldom available in endemic areas. We retrospectively compared 2 diagnostic field tests, a latex agglutination Dri-Dot assay and an IgM Lateral Flow assay, to blood culture, in patients with clinically diagnosed typhoid fever. Sensitivity of the Dri-Dot was 71.4%, and specificity was 86.3% for samples collected at time of first diagnosis. Sensitivity and specificity of IgM Lateral Flow were 80% and 71.4%, respectively. A major limitation of these serologic tests is the limited sensitivity at the early stage of the disease. Performing both tests in parallel increased sensitivity to 84.3%, but decreased specificity to 70.5%. There was a trend towards improved diagnostic performance using either assay over a longer duration of illness. These rapid, point-of-care assays for typhoid fever provide easy-to-interpret results in typhoid-endemic countries and may be most useful in patients presenting 1 week after symptom onset.

Injection drug use is a risk factor for HCV infection in urban Egypt.

OBJECTIVE: To identify current risk factors for hepatitis C virus (HCV) transmission in Greater Cairo. DESIGN AND SETTING: A 1:1 matched case-control study was conducted comparing incident acute symptomatic hepatitis C patients in two "fever" hospitals of Greater Cairo with two control groups: household members of the cases and acute hepatitis A patients diagnosed at the same hospitals. Controls were matched on the same age and sex to cases and were all anti-HCV antibody negative. Iatrogenic, community and household exposures to HCV in the one to six months before symptoms onset for cases, and date of interview for controls, were exhaustively assessed. RESULTS: From 2002 to 2007, 94 definite acute symptomatic HCV cases and 188 controls were enrolled in the study. In multivariate analysis, intravenous injections (OR = 5.0; 95% CI = 1.2-20.2), medical stitches (OR = 4.2; 95% CI = 1.6-11.3), injection drug use (IDU) (OR = 7.9; 95% CI = 1.4-43.5), recent marriage (OR = 3.3; 95% CI = 1.1-9.9) and illiteracy (OR = 3.9; 95% CI = 1.8-8.5) were independently associated with an increased HCV risk. CONCLUSION: In urban Cairo, invasive health care procedures remain a source of HCV transmission and IDU is an emerging risk factor. Strict application of standard precautions during health care is a priority. Implementation of comprehensive infection prevention programs for IDU should be considered.

Isolation of cryptococcus, Candida, Aspergillus, Rhodotorula and nocardia from meningitis patients in egypt.

Meningitis occurs throughout Egypt and is largely attributed to bacterial pathogens, but there is little information on fungal etiologies of meningitis. We, therefore, investigated fungal infections among Egyptian patients with acute and subacute meningitis who tested negative for bacterial and viral agents. A total of 1000 cerebrospinal fluid (CSF) samples collected from nine governorates of Egypt during 1998-2002 were initially stained with Gram's, India ink, and lacto-phenol cotton-blue stains, and examined under light microscope to detect fungal elements. All CSF samples were cultured on brain heart infusion, Wickerham and Staib agar media for fungus isolation. CSF with suspected Cryptococcus neoformans infections were also tested by latex agglutination test for antigen detection. Species identification of selected isolates was carried out at the Mycotic Diseases Branch, CDC, Atlanta, Georgia, USA. Fungal agents were detected microscopically and by culture in 17 of 1000 (1.7%) CSF samples tested. Ten of 17 were identified as C. neoformans var grubii (serotype A), 4 as Candida albicans, and one each of Aspergillus candidus, Rhodotorula mucilaginosa (rubra) and Nocardia spp (actinomycetes). Out of the 17 cases with fungal CSF infection, 8 died (Cryptococcus-3, Candida-2, Aspergillus, Rhodotorula and Nocardia) and 2 suffered neurological sequelae. Of the 10 cryptococcal meningitis patients, 4 were HIV positive and one was diagnosed with lymphoma. To our knowledge, this is the first study on isolation of fungi other than Cryptococcus from CSF of Egyptian patients with acute/subacute meningitis. Consideration must now be given to cryptococcosis and candidiasis as potential etiologies of meningitis in Egypt.

Community transmission of hepatitis B virus in Egypt: results from a case-control study in Greater Cairo.

BACKGROUND: To identify current risk factors for hepatitis B virus (HBV) transmission in Greater Cairo. METHODS: A 1:1 matched case-control study was conducted in two 'fever' hospitals in Cairo. Acute hepatitis B cases were patients with acute hepatitis, positive HBs antigen, and high anti-HBc IgM titres. Control subjects were acute hepatitis A patients (positive anti-HAV IgM) or relatives of patients diagnosed with acute hepatitis C, identified at the same hospitals, with no past HBV infection (negative anti-HBc) and matched to cases on the same age and sex. Conditional logistic regression was used to identify factors associated with acute hepatitis B. RESULTS: Between April 2002 and June 2006, 233 cases and 233 controls were recruited to the study. In multivariate analysis, factors associated with an increased HBV risk in males were illiteracy [odds ratio (OR) = 6.1, 95% confidence interval (CI) = 2.8-13.1], shaving at barbers (OR = 2.1, 95% CI = 1.1-3.9) and injecting drug use (IDU) (OR = 3.4, 95% CI = 1.0-11.4). In females, factors associated with an increased HBV risk were illiteracy (OR = 2.2, 95% CI = 1.0-5.0), recent (<1 year) marriage (OR = 42.0, 95% CI = 3.8-463.9 compared with single women) and giving birth (OR = 3.7, 95% CI = 1.0-13.9). CONCLUSION: In this study, HBV transmission took place primarily in the community, whether as a result of recent marriage (presumably first sexual intercourse), shaving at barbershops or IDU, and was more common among illiterates. Health promotion campaigns should be carried out to increase awareness about community transmission of HBV. In addition to routine immunization for infants and other populations, premarital screening might be useful to identify at-risk spouses in order to propose targeted immunization.

Surveillance of acute hepatitis C in Cairo, Egypt.

Surveillance of acute hepatitis has been set up in two fever hospitals in Cairo to diagnose acute hepatitis C. Patients were categorized as definite acute hepatitis C with positive hepatitis C virus (HCV) RNA and without anti-HCV antibody, or probable acute hepatitis C with positive HCV RNA, positive anti-HCV antibody, alanine aminotransferase >/=4 times the upper limit of normal (ULN), and high risk parenteral exposure in the 1--3 months prior to the beginning of symptoms. From May to November 2002, 315 patients were recruited in the study. Of these, 115 (36.5%) had acute hepatitis A, 89 (28.3%) had acute hepatitis B, and 111 (35.2%) had non-A non-B acute hepatitis. Of the total with complete data (n=309), 12 (3.9%, 95% CI=2.0%-6.7%) had definite acute hepatitis C, and 11 (3.6%, 95% CI=1.8%-6.3%) had probable acute hepatitis C. In patients with definite acute hepatitis C, dental exposure (n=5) and intravenous drug use (n=2), were the only high risk procedures found in the 6 months prior to diagnosis. Five patients had no identifiable parenteral exposure. In conclusion, results from this study suggest that acute hepatitis C can be diagnosed by surveillance of acute hepatitis in hospital settings in Cairo and that minor community exposures contribute substantially to local HCV transmission.

The changing epidemiology of meningococcal meningitis after introduction of bivalent A/C polysaccharide vaccine into school-based vaccination programs in Egypt.

BACKGROUND: The strategy recommended by the World Health Organization (WHO) to curtail outbreaks of meningococcus in Africa is enhanced surveillance with administration of oily chloramphenicol as well as vaccination when incidence thresholds are exceeded. The role of capsular polysaccharide meningococcal vaccine in outbreak prevention has been the subject of considerable debate. The Egyptian Ministry of Health and Population initiated a school-based vaccination program with bivalent A/C capsular polysaccharide vaccine in 1992. This investigation reviews data on meningococcal meningitis in Egypt comparing years before and after introduction of the vaccine. METHODS: This is a retrospective review of several sources to examine the rates and serogroups of meningococcal meningitis before and after the introduction of the meningococcal A/C vaccine in Egypt. FINDINGS: Between 1967 and 1991, outbreaks of meningococcal disease were documented with a periodicity of 8 years in Egypt. However, there has not been an outbreak since 1991 and over the same period, there has also been a progressive decline in the baseline incidence of meningococcus. Also, a shift from a serogroup A to serogroup B predominance in meningococcal disease was noted during the study period. These data suggest that there has been an alteration in the epidemiology of meningococcal disease in Egypt that coincided with the implementation of the school-based vaccination program. INTERPRETATION: Routine use of the bivalent A/C meningococcal vaccine may be an alternative for the control and prevention of meningococcal disease in high-risk areas including the "meningitis belt".

Relationship between intracranial granulomas and cerebrospinal fluid levels of gamma interferon and interleukin-10 in patients with tuberculous meningitis.

Cerebrospinal fluid gamma interferon (IFN-gamma) and interleukin-10 levels in 39 patients with tuberculous meningitis were serially measured. Cytokine levels did not predict intracranial granuloma (IG) development, but IFN-gamma levels in the top quartile after 1 month of therapy were highly associated (odds ratio = 18) with detection of an IG by computed tomography scanning.

Short-course azithromycin for the treatment of uncomplicated typhoid fever in children and adolescents.

We studied 149 children and adolescents 3-17 years of age with clinical typhoid fever who were treated with either oral azithromycin (20 mg/kg per day; maximum dose, 1000 mg/day) or intravenous ceftriaxone (75 mg/day; maximum dose, 2.5 g/day) daily for 5 days. Blood and stool specimens were obtained for culture before the initiation of therapy and were repeated on days 4 and 8 of treatment. Isolation of Salmonella enterica serovar Typhi or S. enterica serovar Paratyphi from the initial culture was required for inclusion in the final analysis. S. Typhi was isolated from 68 patients, 32 of whom were receiving azithromycin. Cure was achieved in 30 (94%) of 32 patients in the azithromycin group and in 35 (97%) of 36 patients in the ceftriaxone group (P=NS). Mean time to clearance of bacteremia was longer in the azithromycin group than in the ceftriaxone group. No patient who received azithromycin had a relapse, compared with 6 patients who received ceftriaxone. A 5-day course of azithromycin was found to be an effective treatment for uncomplicated typhoid fever in children and adolescents.

Rapid diagnosis of typhoid fever by enzyme-linked immunosorbent assay detection of Salmonella serotype typhi antigens in urine.

We developed and evaluated an enzyme-linked immunosorbent assay (ELISA) using monoclonal antibodies to capture somatic antigen 9 (O9), flagellar antigen d (Hd), and the Vi capsular polysaccharide antigen (Vi) from the urine of persons with and without typhoid fever. Sequential urine samples were collected from 44 patients with blood culture-confirmed typhoid fever and from two control groups. The first control group included patients with brucellosis (n = 12) and those with clinically diagnosed, non-typhoid, acute, febrile illness (n = 27). The second control group was a sample of healthy volunteer laboratory workers (n = 11). When assessed relative to date of fever onset, sensitivity was highest during the first week for all three antigens: Vi was detected in the urine of nine (100%) patients, O9 in 4 (44%) patients, and Hd in 4 (44%) patients. Sequential testing of two urine samples from the same patient improved test sensitivity. Combined testing for Vi with O9 and Hd produced a trend towards increased sensitivity without compromising specificity. The specificity for Vi exceeded 90% when assessed among both febrile and healthy control subjects, but was only 25% when assessed among patients with brucellosis. Detection of urinary Vi antigen with this ELISA shows promise for the diagnosis of typhoid fever, particularly when used within the first week after fever onset. However, positive reactions for Vi antigen in patients with brucellosis must be understood before urinary Vi antigen detection can be developed further as a useful rapid diagnostic test.

Fluconazole for the treatment of Cryptococcus neoformans meningitis in an immunocompetent host.

We present a case of a 23-year-old immunocompetent male who presented with chronic meningitis and was diagnosed as cryptococcal meningitis by positive cryptococcal antigen titer. The cerebrospinal fluid culture was positive for Cryptococcus neoformans. He was treated initially with amphotericin B but was later changed to fluconazole due to toxicity. This case highlights the use of fluconazole to successfully treat chronic meningitis in an immunocompetent host.