Legionnaires' disease and hairy-cell leukemia. An unfortuitous association?

Four cases of legionnaires' disease were diagnosed by specific serologic tests in a group of 33 immunocompromised patients admitted to the same hematologic department for acute febrile pneumonitis. The underlying disease of these four patients was hairy-cell leukemia (HCL) in three cases and allogeneic bone marrow transplantation in the other. This article stresses the enhanced susceptibility of patients with HCL to Legionella pneumophila and discusses its possible causes, especially monocyte deficiency. We propose the use of erythromycin as part of the initial empiric antibiotic therapy in immunocompromised hosts with acute pneumonitis until the results of specific serologic tests or isolation of L pneumophila is obtained.

Isolation, purification and partial analysis of the lipopolysaccharide antigenic determinant recognized by a monoclonal antibody to Legionella pneumophila serogroup 1.

Monoclonal antibody II-6-18 recognizes a serogroup-1-specific Legionella pneumophila antigenic determinant which has been shown to be virulence-associated. We previously reported the physicochemical characterization by means of a quantitative fluorometric assay of monoclonal antibody II-6-18 binding to L. pneumophila, and its implications concerning the nature of the antigen. We describe here the isolation and the purification of the antigen by chemical and immunological methods, followed by its partial chemical analysis. The results demonstrate that the epitope--an immunodominant carbohydrate which includes a fucosamine-like residue--is part of the cell wall lipopolysaccharide (LPS). It is localized in the polysaccharide moiety of the LPS which contains KDO, rhamnose, mannose, glucosamine and an unidentified aminodideoxyhexose X1, but no heptose. The aminodideoxyhexose X1 could be fucosamine and is probably the immunodominant residue in the epitope, localized, at least partially, at the end of the polysaccharide chain.

Legionnaires' disease after bone marrow transplantation.

Four patients developed legionnaires' disease after bone marrow transplantation. Two cases occurred early after transplant and were considered as part of a hospital epidemic due to contamination of water supply. The other two cases were considered to be sporadic because they occurred 3-4 weeks after hospital discharge. The outcome was good in two patients. In the third patient, recurrent disease was probably due to acquired resistance to macrolides, and complete cure was achieved after treatment with pefloxacin and rifampicin. The fourth patient died of overwhelming infection despite early treatment with erythromycin and pefloxacin. During the same period we treated 14 patients with pefloxacin for prevention of bacterial infection, of whom none developed Legionella pneumophila infection, while three of the patients reported here were in a group of 11 patients who received only oral non-absorbable antibiotics for gut decontamination. The fourth patient in this report was receiving no antibiotics. Thus pefloxacin seems to be effective as prophylaxis against L. pneumophila infection. When the hospital water supply was heated to 60 degrees C and chlorinated, the nosocomial cases in the hospital completely disappeared.

Evaluation of sensitivity of two serological tests for diagnosing pneumonia caused by Legionella pneumophila serogroup 1.

The sensitivity of an indirect immunofluorescence antibody test (IFAT) and a rapid microagglutination test (RMAT) for the diagnosis of Legionnaires' disease caused by Legionella pneumophila serogroup 1 was evaluated using serum specimens from 119 patients with bacteriologically confirmed infections. The sensitivity of both assays was found to be about 80%. In addition, antibody titres suggestive of L pneumophila infection were found in 40% of patients in the first week after admission to hospital. These data show that both assays can be used with confidence in the early diagnosis of Legionnaires' disease.

[Severe jaundice in Legionnaires' disease: a case with early hepatic biopsy]. / Ictère intense au cours de la maladie des Légionnaires: un cas avec biopsie hépatique précoce.

Although liver tests are frequently disturbed in Legionnaires' disease, jaundice occurs rarely except as a terminal event. The authors report the case of a 68 year-old man with jaundice as a presenting feature of the disease. Jaundice deepened rapidly until death a few days later. Drugs and other causes of cholestasis could be ruled out. An early liver biopsy was performed. The liver was histologically normal except for mitochondrial margination in the hepatocytes. No Legionella could be demonstrated by direct fluorescent assay. These findings suggest that: jaundice in Legionnaires' disease is not related to direct bacterial insult, cholestasis is probably consecutive to endotoxinemia, the mitochondrial margination, a rare histologic finding, could result from Legionnaires' disease. This last point needs confirmation by further studies.

[The bacteriological and immunological diagnosis of Legionnaires' disease]. / Diagnostic bactériologique et immunologique de la maladie des légionnaires.

There has been very rapid progress in knowledge concerning Legionnaires' disease and the Legionella. Relatively simple and reliable diagnostic techniques are already available. Isolation of Legionella is now possible as a result of the development of sensitive and specific culture media. Detection of the organism in pathological material by direct immunofluorescence leads to emergency confirmation of the diagnosis in approximately 50% of cases. Finally, serology using a specific antigen often leads to a suspicion of Legionnaires' disease a few days after its clinical onset. It provides late confirmation in the immense majority of cases. These three techniques will no doubt be followed by others which will further facilitate the recognition of Legionnaires' disease, a not uncommon and grave illness.

[Tick bite meningoradiculitis and other neurological aspects of Lyme disease]. / La méningoradiculité à tique et autres aspects neurologiques de la maladie de Lyme.

In the majority of cases, meningoradiculitis consecutive to tick bite most probably belongs to Lyme disease caused by Borrelia burgdorferi. The disease may be limited to the primary, though inconstant, stage of cutaneous migratory erythema, or it may develop into cardiac and, mostly, neurological disorders. The nervous system involvement, which we observed in 7 patients, mainly consists of peripheral motor neuropathy of moderate severity and sometimes limited to the cranial nerves, associated with very severe radicular pain regularly heralding radicular deficit. Lyme disease predominates in a rural environment, and most patients live near wooded areas where ticks parasitize numerous mammals. The diagnosis, suggested by the socio-environmental context, the clinical features and the results of CSF examination, is confirmed by serology at a 1/256 dilution. Tetracyclines are effective in the initial stage, but intravenous penicillin is necessary in the secondary stage and to reduce the risk of arthritis and also perhaps neuropsychiatric disorders at a late stage.

[Neuropathologic study of 135 adult cases of acquired immunodeficiency syndrome (AIDS)]. / Etude neuropathologique de 135 cas adultes de syndrome d'immuno-déficience acquise (SIDA).

The central nervous system was examined in 135 adult AIDS patients who died between August 1982 and December 1990. Twenty two brains showed non-diagnostic changes including microglial nodules, discrete myelin pallor with reactive astrocytosis, mineralization of blood vessels and granular ependymitis. In 105 brains with specific changes, toxoplasmosis was the most frequent finding (55 cases) manifested by multifocal necrotic lesions or diffuse pseudo-encephalitic process. Other opportunists included cytomegalovirus (21 case), progressive multifocal leukoencephalopathy (1 cases), cryptococcosis (6 cases), mycobacterium avium intracellulaire (2 cases), varicella-zoster virus (2 cases), aspergillosis (1 case) and multiple bacterial microabscesses (1 case). Multinucleated giant cells were found in 52 cases. In 40 cases, they were widely disseminated throughout the brain and in 39 cases, they were associated with diffuse or multifocal white matter changes. Fifteen cases had a cerebral lymphoma, 9 hepatic encephalopathy, 1 centropontine myelinolysis and 1 focal pontine leukoencephalopathy. Three cases had a cerebral haemorrhage due to disseminated intravascular coagulation, antithrombin therapy and amyloid angiopathy. Spinal changes in 13 cases included vacuolar myelopathy (7 cases), HIV myelitis (1 case) and ganglio-radiculitis (1 cases), cytomegalovirus myelo-radiculitis (1 case) secondary spread from a lymphoma (1 case) and spinal infarcts due to disseminated intravascular coagulation (1 case). These lesions were frequently atypical and various combinations of all these pathologies were encountered in the same brain, sometimes in the same area and occasionally in the same cell. Chronological variations in the incidence of some complications could be related to changes in treatment.

[Survey of Legionella in the Parisian environment. Practical implications]. / Inventaire des Legionella dans l'environnement parisien. Implications pratiques.

A qualitative and quantitative survey of environmental Legionella in the Paris area was undertaken because of its epidemiological implications. Over a 2-year period, 322 water samples from the Paris area (unrelated to a legionnaires' disease outbreak) were examined for the presence of Legionella. No Legionella strain was isolated from the main water supplies of the municipality or from the distribution entry points of 36 buildings. Inside buildings, however, 84/190 (44.2%) tap water samples yielded one or several strains of Legionella (10(2) to 10(6) CFU/l). Contamination was significantly more frequent in hot tap water than in cold tap water. Legionella was isolated from 11 out of 14 air-conditioning systems investigated. Sixty-four of the 132 strains isolated were L. pneumophila serogroup 1. Other strains were L. pneumophila serogroups 2 to 6 (including a serogroup 4-5 variant), L. longbeachae serogroup 2 and 6 atypical Legionella.

[Borrelian meningoencephalomyelitis. A case]. / Méningonévraxite borrélienne. Un cas.

A 22-year old man had spastic paraparesis and cerebellar syndrome of 5 months duration. CSF showed lymphocytosis, elevated protein content, hypoglycorachia, hypochlorurachia and oligoclonal banding. CT scan and MRI were normal. Extensive laboratory procedures disclosed no bacterial, viral, fungic, parasitic or inflammatory disease. Anti-Borrelia burgdorferi antibodies were present in blood (1/4000) and in CSF (1/1024). With antibiotics (penicillin G 20 millions units per day for 10 days, followed by latamoxef 1.5 g per day for 3 months) and prednisone (50 mg per day for 2 months), the cerebellar signs disappeared, the paraparesis improved and the CSF abnormalities disappeared; blood and CSF anti-Borrelia antibody levels decreased. This case is an example of a severe form of CNS impairment by Borrelia burgdorferi. In Europe, most reports show progressive para- or tetraparesis with, sometimes, intellectual, cerebellar or cranial nerve impairment. In some cases, the signs are less diffuse or more acute. Lymphocytic meningitis is present with hyperalbuminorachia and oligoclonal banding; hypoglycorachia is mentioned in only one other report. Diagnosis is made by high blood and CSF antibody titers and demonstration of local synthesis. As in syphilis, borrelian meningoencephalomyelitis could be the third stage of the disease. Its treatment, often disappointing, consists of antibiotics (penicillin G or latamoxef) and in some cases corticosteroids.

[Negativity of Borrelia burgdorferi serology in scleroderma en plaques]. / Négativité de la sérologie pour Borrelia burgdorferi dans la sclérodermie en plaques.

The occurrence of morphea has been attributed to Borrelia, burgdorferi infection, but the relationship between localised scleroderma and borreliosis remains controverted. Antibodies directed against B. burgdorferi were looked for in 21 patients (18 female and 3 male, aged from 8 to 63 years) whose disease had been present for 6 weeks to 13 years. One patient had a single morphea, two had monomelic scleroderma and 18 had multiple localised morpheas. The search for antibodies was conducted in these 21 patients and in 200 blood donors from the Paris region by indirect immunofluorescence techniques, using the CDC method where only antibody titers of 1/256 or more are significant. Serology was lower than 1/256 in 20 cases and equal to 1/256 in one case. Among the 200 blood donors, five (2.5%) had antibody titers of 1/256 or more. None of the patients studied had been exposed to tick bite due to their occupation or place of residence. We therefore found no evidence of a link between B. burgdorferi infection and morphea in the Paris region.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tonsillitis today. Epidemiologic review. Clinical correlates. Therapeutic impact]. / Les angines actuellement. Enquête épidémiologique. Corrélations cliniques. Incidences thérapeutiques.

A prospective study was conducted in 216 patients with ulceration of throat and 100 controls. Bacteriology showed, in the low percentage of case with positive results, the classical distribution of germs generally identified from throat swabs, with predominance of haemolytic streptococci AB and associated fusospirilla. Haemophilus influenzae was very rarely isolated (1%) and immunofluorescence tests for Chlamydia trachomatis in the pharyngeal exudate were always negative, in both patients and controls. These findings confirm utility of Penicillin V as single therapeutic agent in ulcerated throat. Correlations between clinical findings and between these and bacteriology results demonstrated that clinical examination failed to provide data contributive to the establishment of an aetiological diagnosis and therefore to treatment, which, in the absence of complementary examinations, must remain empirical.

[Legionnaires' disease: 21 cases observed over 2.5 years in a Parisian respiratory intensive care unit]. / La maladie des légionnaires: 21 cas observés en 2 ans et demi dans une unité parisienne de soins intensifs respiratoires.

The incidence of Legionnaire's disease is probably underestimated in France. Its clinical presentation is very suggestive, especially after the failure of a 48 hour therapeutic trial of beta-lactams, when a pneumococcal infection is initially suspected. This one sign is sufficient to orient the diagnostic survey and constitutes an indication for a therapeutic trial of macrolides for at least 72 hours. In fact, the delay in the diagnosis appears to be the determinant factor in the fatal outcome of the disease.

[Lyme disease: biological diagnosis and treatment]. / Maladie de Lyme: diagnostic biologique et traitement.

In daily practice the diagnosis of Lyme disease is confirmed in the laboratory by serological tests the specificity and sensitivity of which are not fully satisfactory. There are false-positive results due to antibodies directed against antigens others than Borrelia burgdorferi, but the main problem is that most people living in endemic areas have specific antibodies while being, and remaining, asymptomatic. In addition, the sensitivity of the current tests is mediocre at the onset of the disease. A negative serology therefore should not exclude definitively a diagnosis of Lyme disease, just as a positive serology should not compulsorily lead to this diagnosis in patients with atypical clinical signs. The treatment of Lyme disease aims at eradicating the organisms, including those wHich infest the central nervous system. Beta-lactam antibiotics seem to be particularly suitable for this purpose: amoxycillin is used in ambulatory patients, and ceftriaxone is probably the most effective treatment of severe neurological manifestations of the disease.