Deep, respiratory tract and ear infections caused by Pseudallescheria (Scedosporium) and Microascus (Scopulariopsis) in Finland. A 10-year retrospective multi-center study.

Deep, respiratory tract and ear infections due to Microascaceae (Pseudallescheria, Scedosporium, Microascus or Scopulariopsis) were studied nationwide in Finland during 1993-2002. The data were based on 52,000 fungal cultures that represented about 50% of all such specimens in Finland and included all Finnish cases of profound immunosuppression. There were 39 cases that were re-evaluated as clinically significant, i.e., three pneumonias, two deep pedal infections and five wound infections, 11 sinusitis and 18 ear infections. The pedal infections and most pneumonias occurred in immunocompromised patients. Most cases, except the ear infections, were due to Pseudallescheria boydii. Two patients had lethal P. boydii pneumonia and a deep P. boydii infection of the foot contributed to a third lethal case. Two of the patients with lethal outcomes had received an allogeneic haematopoietic stem cell transplantation (AHSCT). Two patients with haematological malignancies were cured of deep site infections by a prolonged course of itraconazole. Wound, sinus and ear infections were cured or improved by local surgery or topical therapy. There were 0.8-1.7 cases of any type of infection per million inhabitants per year (MY) and 3.4 cases/1000 AHSCT. Mortality associated with Microascaceae in any type of patient was 0.06-0.12 MY.

Relationships of Scopulariopsis based on LSU rDNA sequences.

Relationships between Scopulariopsis species and allied fungi were studied by sequencing a 350 bp gene region of the large subunit ribosomal RNA gene (LSU rDNA). In addition, a limited morphological dataset of nine characters was included in the cladistic analysis. Nineteen mitosporic strains (nine Scopulariopsis, five Wardomyces, three Doratomyces, one Trichurus and one Scedosporium species) and 21 meiosporic strains (14 Microascus, 4 Kernia and 3 Pithoascus species) were studied. The data were analysed using parsimony methods. Based on the analyses, the studied microascaceous fungi are divided to 12 molecular lineages. Most of the opportunistic human pathogenic Scopulariopsis species are placed in one clade ('Microascus manginii Clade'). Most synnematous anamorphs with Scopulariopsis-like conidia (Doratomyces and Trichurus) are placed in another clade ('Microascus albonigrescens Clade'), together with Wardomyces. Microascus sensu lato can be divided into seven clades which also incorporate all studied Pithoascus, Scopulariopsis, Wardomyces and Trichurus species and most of the Doratomyces species. Most of the Kernia teleomorphs and one Doratomyces species are placed in a different main clade, together with Pseudallescheria and Petriella. Future alternatives in the taxonomy of Microascus include splitting the genus or redefining it to include deviating taxa. More molecular data need to be obtained and considered in either case.

Summer spores of birch rust fungus in Papanicolaou smears from healthy mass screening participants.

OBJECTIVE: To evaluate the origin and identification of mysterious particles in Papanicolaou smears from healthy, asymptomatic women participating in a local mass screening program. STUDY DESIGN: The material consisted of 16,000 cerricovaginal smears studied at the cytology laboratory of Pathology Laboratory of South-Western Finland Ltd. Unidentified particles were found in four apparently independent smears. All the slides were rescreened, but no further positive cases were found. RESULTS: Several swab samples were collected from the investigation room, but all were negative. Attempts at identification included numerous consultations. A telepathology consultation with the Cellular Division, Armed Forces Institute of Pathology, Washington, D.C., U.S.A., was conducted. Another teleconsultation with the reference laboratoryfor intestinal parasites in Iceland was conducted. Finally, the Aerobiology Unit, University of Turku, was consulted. The aerobiologist suggested that the particles were most probably summer spores of birch rust fungus (Melampsoridium betulinum). To confirm this we obtained a reference specimen of the fungus from the herbarium at the University of Turku. The morphology of the spore particles was identical to that in the cervicovaginal smears, proving that the smears were contaminated with birch rust fungus spores. CONCLUSION: Birch rust is ubiqutitous in Finland. Outside the hospital window there is a wide lawn behind which, at a distance of 70 m, there is a forest of birch trees. It is most likely that the rust spores flew in through the open window, to settle down on the surface of material that was used in sample taking. Airborne dust may cause misleading and surprising artefacts. Protection of specimens and instruments against dust should minimize the problem.

Fungal colonization of haematological patients receiving cytotoxic chemotherapy: emergence of azole-resistant Saccharomyces cerevisiae.

Fungal colonization during cytotoxic chemotherapy was studied in 42 patients with a recent diagnosis of a haematological malignancy. In total, 2759 surveillance cultures were taken from the nostrils, throat, urine, stool and perineal region. Seven hundred and ninety-six positive surveillance cultures (28.9%) yielded 968 fungal isolates. The rate of fungal colonization did not differ between patients with acute leukaemia, patients with other haematological malignancies and control patients in the same ward at admission (71% vs. 67% vs. 80%). Patients with acute leukaemia were colonized at a significantly lower rate in samples from the throat (32%), urine (10%), stool (45%) and perineum (29%) taken during hospitalization when compared with other haematological patients (respective values 58%, 21%, 67% and 45%; P-values 0.001). This could be attributed to differences in the use of antifungal drugs. Although 21/42 (50%) of our patients had multiple-site fungal colonization at the end of follow-up, only one systemic Candida infection was diagnosed. Extensive use of antifungal treatment may have influenced the low incidence of systemic fungal infections during the follow-up. In addition to Candida species, Malassezia furfur, Geotrichum candidum and Saccharomyces cerevisiae were frequently isolated. The rate of S. cerevisiae isolation increased significantly over time after admission (1%, vs. 18% of isolates, P<0.001), suggesting hospital-acquired transmission. These isolates were highly resistant to azole antifungals (MIC90 128 microg/mL for fluconazole and 16 microg/ml, for itraconazole), and caused persistent multiple site colonization in 12 patients. Extensive use of antifungal agents in a haematological ward may keep the incidence of invasive fungal infections low in spite of heavy fungal colonization. However, there may be a risk of emergence of resistant fungal strains.

Screening for connexin 32 mutations in Charcot-Marie-Tooth disease families with possible X-linked inheritance.

The X-linked dominant form of Charcot-Marie-Tooth disease (CMTX) is associated with mutations in a gene coding for the gap-junction protein connexin 32 (Cx32). We screened 32 CMT families with a pedigree pattern suggestive of X-linked inheritance for the presence of mutations in the coding region of Cx32 by direct sequencing. Five of the families had a CMT1 diagnosis, 24 had a CMT2 diagnosis and 3 patients had an unspecified CMT. Eight families with a Cx32 point mutation were detected. Five different mutations (four of them published previously) were found in six CMT2 families and one mutation was found in a sporadic CMT1 male patient. One of the mutations, Met194Val, is among the first described in the fourth transmembrane domain of Cx32. Two CMT2 families and the sporadic CMT1 patient had the same mutation, Arg22Gln. An additional, previously unpublished mutation, Arg75Trp, was found in a male patient with unspecified CMT, who subsequently was verified to have a variant Klinefelter syndrome with 48,XXYY karyotype. Our findings show the difficulty in distinguishing CMTX patients from CMT1 and CMT2 patients, and they emphasize the need for Cx32 mutation screening in families previously diagnosed with CMT2.

Zonal distribution of transcripts of four hepatic transcription factors in the mature rat liver.

Within the liver acinus the majority of genes are expressed in an ascending or descending gradient from the portal to the central vein. The regulatory factors involved in this spatial pattern of gene expression are still poorly understood. Many liver genes are regulated by liver-enriched transcription factors. Here we report on mRNA distribution of four transcription factors in cell lysates obtained from either the periportal or the perivenous region after zone-specific digitonin infusion and by in-situ hybridization. Northern blot analysis revealed that there were slightly more transcripts of C/EBP, HNF1 beta (n.s.) and HNF4 (p < 0.05), but fewer of HNF3 gamma (n.s.), in perivenous than in periportal lysates. A somewhat stronger staining in the perivenous region of HNF4 was also seen by in-situ hybridization. The moderate acinar zonation of the mRNAs of these transcription factors suggests that at best they could modulate but not govern the zonated expression of liver genes in the mature liver.

Pulmonary adiaspiromycosis in a two year old girl.

A case of disseminated bilateral pulmonary adiaspiromycosis is reported in a two year old Finnish girl. She recovered from this rare infection after treatment with amphotericin B. She is the first human case of adiaspiromycosis in Scandinavia and she is the youngest child with this disease reported so far. Electron microscopy showed that the three layers of the spore wall were not typical; rather, there seemed to be a gradual transition between the main wall zones, which may be split into an indefinite number of thin layers. Varying numbers and thicknesses were seen with different staining methods, and in different spores. Diagnosis relies on recognition of the fungus in a pulmonary biopsy specimen, because there are no reliable serological tests and culture of the fungus is time consuming and not always successful. It was thought that this patient had become infected as a result of contact with soil dust containing the spores in the yard surrounding her home, and as a result of her mother's work in a large garden shop.

Relatedness of Pseudallescheria, Scedosporium and Graphium pro parte based on SSU rDNA sequences.

Genetic relatedness of 10 strains of opportunistic human pathogenic fungi in the genera Pseudallescheria and Scedosporium and related fungi including Petriella setifera, Graphium tectonae and Ceratocystis fimbriata, were tested by sequencing the entire SSU rDNA. From these molecular data, the imperfect genus Scedosporium can be divided in two, S. prolificans being separable from the S. apiospermum complex. Nearest sexual relatives of S. prolificans seem to be in the microascalean genus Petriella. Strains of Ps. boydii and S. apiospermum, although differing by their previously known DNA/DNA reassociation values, were not separable from each other once a 380 nucleotide long insertion had been removed from the sequence of the two S. apiospermum strains tested. The SSU rDNA of Ps. ellipsoidea is identical to that of Ps. boydii. Fungi which have been known to have Graphium anamorphs can be divided in at least three groups, one of which is related to Petriella and includes Graphium tectonae.

Value of clinical symptoms, intrathecal specific antibody production and PCR in CSF in the diagnosis of childhood Lyme neuroborreliosis.

Due to the wide spectrum of clinical manifestations of Lyme neuroborreliosis laboratory investigations are necessary to confirm the diagnosis. Serum and CSF antibodies against Borrelia burgdorferi (Bb) as well as mononuclear CSF pleocytosis are usually present in patients with suspected neuroborreliosis. In some cases, however, the results may be conflicting, causing difficulty for the clinician in making a therapeutic decision. We therefore analysed the value of clinical symptoms, the presence of intrathecal antibody production against Bb with a modified IFA and a capture ELISA test, and the presence of Bb in the CSF with PCR testing in eleven children with suspected neuroborreliosis. In six of eight children with probable neuroborreliosis we could demonstrate intrathecal antibody production against Bb. In only one of these cases could Bb be detected in the CSF with the PCR assay. In two children the clinical manifestations consisting of erythema chronicum migrans and facial palsy, the presence of mononuclear CSF pleocytosis, and the presence of Bb specific antibodies in serum supported the diagnosis of neuroborreliosis, despite the absence of intrathecal specific antibodies. Three additional children with possible neuroborreliosis based on the occurrence of nonspecific clinical symptoms along with high serum antibody titers to Bb were included in the study. Intrathecal antibodies against Bb could not be detected and the PCR result was negative; therefore the diagnosis of neuroborreliosis was not substantiated in these three patients. We conclude that in addition to clinical symptoms, serological evidence and CSF findings suggestive of neuroborreliosis, the demonstration of intrathecal specific antibody synthesis against Bb may be helpful in establishing a definitive diagnosis of neuroborreliosis. The absence of CSF antibodies, however, does not necessarily indicate a lack of CNS involvement, especially if the examination is performed early in the course of disease. PCR testing in CSF is not suitable for routine application in the diagnosis of Lyme neuroborreliosis.

[Brain tumors in infants]. / Hirntumoren im Säuglingsalter.

1975-87 there were 15 infants in the Childrens University Hospital of Zürich, cared for a brain tumor. In 3 cases the first symptoms were already present by birth. In our cases epileptic convulsions were the most common first manifestation of the tumor (40%). In most cases neither clinical symptoms nor EEG changes helped to localize the tumor. In one third of the cases the tumor was manifested with symptoms of increased intracranial pressure. In 11 children (73%) the tumor was localized supratentorially, in 3 cases in the cerebellum, in one case in the brainstem. 13 children were operated, without perioperative mortality. In 10 cases the tumor was radically extirpated, in 3 cases only a subtotal excision of the tumor was possible.

[Carbamyl phosphate synthase deficiency: clinical symptoms, diagnosis and dietary-medicamentous treatment in the neonatal period and infancy]. / Carbamyl-Phosphat-Synthetase-Mangel: klinische Symptomatik, Diagnostik und diätetisch-medikamentöse Behandlung im Neugeborenen- und Säuglingsalter.

Carbamyl phosphate synthetase (CPS) catalyses the synthesis of carbamyl-phosphate from ammonia and bicarbonate and is the first step in ureagenesis. The infant described in this report suffered from deficiency of this enzyme. The symptoms started on the 2nd day of life with tachycardia, apathy, irritability and metabolic alcalosis, on the 4th day coma and fits occurred due to hyperammonia (ammonia in the blood max 496 mumol/l, normally up to 150 in newborns). In hepatic tissue no activity of carbamyl phosphate synthetase could be measured (normal range 0.66-2.1 mumol/h/mg protein). Peritoneal dialysis was instituted, but the metabolic crisis could only be overcome by the following therapeutic measures: restriction of protein intake to 1.5 g/kg/d in part as a special aminoacid mixture, in part as breast milk; sufficient caloric supply (600-500 kJ/kg/d); sodium benzoate 350 mg/kg/d: arginine 2 mmol/kg/d respectively citrulline 350 mg/kg/d, and carnitine 150 mg/kg/d. By these procedures the exogenous and endogenous load of ammonia could be minimized. Electroencephalogram and mental development were normal. Acute metabolic crises with hyperammonia during catabolic states (infections) could be treated several times. At the age of 8 months, however, the patient died during such a crisis. This case shows that it is possible to achieve a normal psychomotor development in complete CPS-deficiency by adequate therapy. Catabolic states are difficult to manage.

Magnetic resonance imaging of the brain in congenital cytomegalovirus infection.

Ten children (age 2 months to 8 years) with a congenital cytomegalovirus (CMV) infection were studied by magnetic resonance imaging (MRI) using a 2.35 Tesla magnet. CMV infection was confirmed by serological investigations and virus culture in the neonatal period. Nine children had severe mental retardation and cerebral palsy, 1 patient suffered from microcephaly, ataxia and deafness. The cranial MRI examination showed the following abnormalities (N): dilated lateral ventricles (10) and subarachnoid space (8), oligo/pachygyria (8), delayed/pathological myelination (7), paraventricular cysts (6), intracerebral calcification (1). This lack of sensitivity for calcification is explainable by the basic principles of MRI. The paraventricular cystic lesions were adjacent to the occipital horns of the lateral ventricles and separated only by a thin membrane. This finding might represent a "new sign" for congenital CMV infection in MRI examinations, being characteristic but nevertheless nonspecific, like calcification in CT.

Bioavailability of sodium valproate suppositories during repeated administration at steady state in epileptic children.

Oral administration of antiepileptic drugs can temporarily be impossible under certain conditions, such as altered states of consciousness, spike-wave stupour, gastro-intestinal disturbances with nausea and vomiting, prior to or during surgery or certain diagnostic procedures, and because of drug refusal in patients with mental retardation or psychiatric problems. Although rectal administration of sodium valproate (NaVPA) has been shown to be a possible alternative route, little is known about the bioavailability and local effects during repeated administration of NaVPA suppositories. These aspects were investigated in 13 epileptic children and adolescents on chronic NaVPA therapy. Eight patients were treated with the oral solution (Group A; mean age 10.6 years) and five patients with enteric coated tablets (Group B, mean age 16.4 years). In every patient five serum levels of VPA over a 24 h period were measured under steady-state conditions. Thereafter, suppositories were administered for 2-7 days and serum levels were again determined (identical dosing and sampling times). Bioavailability of NaVPA was calculated on the basis of the area under the concentration vs. time curve over 24 h. The average bioavailability for suppositories compared with the oral form was 112.4% in Group A and 99.5% in Group B. Fluctuations of serum VPA levels were very similar with suppositories and oral solution, and more pronounced than with the enteric coated tablets. Stool frequency was not increased by repeated administration of suppositories, except for a three-fold increase in one patient. There was no objective or subjective evidence of local irritation from the suppositories. In conclusion, NaVPA suppositories have the same bioavailability under steady-state conditions as oral preparations and they are well tolerated.(ABSTRACT TRUNCATED AT 250 WORDS)

Electroencephalogram during and after an acute attack of asthma in children.

EEGs were recorded in 12 children who were admitted to hospital because of an asthmatic attack. One EEG was recorded during the attack, one immediately after, and a third EEG several weeks later. The severity of the attack was classified as moderate in eight children, severe in three and very severe in one child. There was a corresponding change in the blood gases, but other laboratory values (electrolytes, glucose, etc.) were normal. Contrary to previous findings, no change was seen in the three successive EEG recordings which had been related to the attacks. It is therefore concluded that an asthmatic attack as such does not give rise to changes in the EEG, and a complicating factor should be suspected if such changes are seen.