Elevated cerebrospinal fluid kynurenic acid levels in patients with tick-borne encephalitis.

BACKGROUND: Kynurenic acid (KYNA) is a neuroactive metabolite of tryptophan that is thought to regulate cognitive functions. Previous studies have shown that levels of KYNA increase during virus infection and that this metabolite interacts with the immune system. OBJECTIVE: The aim of the study was to investigate whether patients with tick-borne encephalitis (TBE), a viral infectious disease associated with long-term cognitive impairment, have increased levels of KYNA in the cerebrospinal fluid (CSF). METHODS: CSF KYNA was analysed using high-performance liquid chromatography in 108 patients with TBE and 52 age-matched controls. Patients were classified according to the severity of TBE: mild (47%), moderate (44%) or severe (9%). RESULTS: Concentrations of CSF KYNA were considerably higher in patients with TBE (5.3 nmol L(-1) ) than in control subjects (0.99 nmol L(-1) ). KYNA concentration in the CSF varied greatly amongst individuals with TBE and increased (P < 0.05) with the severity of disease. CONCLUSIONS: This is the first study to demonstrate increased levels of CSF KYNA in patients with TBE. The importance of brain KYNA in both immune modulation and neurotransmission raises the possibility that abnormal levels of the compound in TBE might play a part in the pathophysiology of the disease. A detailed knowledge of endogenous brain KYNA during the course of CNS infection might yield further insights into the neuroimmunological role of the compound and may also provide new pharmacological approaches for the treatment of cognitive symptoms.

High plasma efavirenz level and CYP2B6*6 are associated with efavirenz-based HAART-induced liver injury in the treatment of naïve HIV patients from Ethiopia: a prospective cohort study.

The objective of this study was to assess the incidence, timing and identify pharmacogenetic, efavirenz (EFV) pharmacokinetic and biochemical predictors of EFV-based antiretroviral therapy (ART) drug-induced liver injury (DILI). ART-naïve HIV patients (n = 285) were prospectively enrolled. Pretreatment laboratory evaluations included hepatitis B surface antigen and C antibody, CD4 count and viral load. Liver tests were done at baseline, 1st, 2nd, 4th, 8th, 12th, 24th and 48th weeks during ART. Plasma EFV and 8-hydroxyefvairenz concentration was determined at week 4 using liquid chromatography-mass spectrometry. CYP2B6, CYP3A5, ABCB1 3435C/T and UGT2B7*2 genotyping was done using Taqman genotyping assay. Data were analyzed using survival analysis and Cox proportional hazards model. The incidence of DILI was 15.7% or 27.9 per 100 person-years and that of severe injury was 3.4% or 6.13 per 100 person-years. The median time for the development of DILI and severe injury was 2 and 4 weeks after initiation of ART, respectively. There was significant association of DILI with lower baseline platelet, albumin, log plasma viral load and CD4 count (P = 0.031, 0.037, 0.06 and 0.019, respectively). Elevated baseline alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, plasma EFV level and CYP2B6*6 were good predictors for the development of DILI (P = 0.03, 0.01, 0.016, 0.017 and 0.04, respectively). We report for the first time CYP2B6*6 as a putative genetic marker and high plasma EFV concentration as intermediate biomarker for vulnerability to EFV-induced liver injury in HIV patients. CYP2B6 genotyping and/or regular monitoring of EFV and lever enzymes level during early therapy is advised for early diagnosis and management of DILI.

Severe chickenpox disease and seroprevalence in Sweden - implications for general vaccination.

OBJECTIVES: To describe the current panorama of severe chickenpox disease and seroprevalence in Sweden, as a basis for the approaching decision on universal vaccination. METHODS: Patients discharged with an International Classification of Diseases 10th revision-code for chickenpox (B01-B01.9) in eight pediatric and infectious diseases departments in Stockholm and Gothenburg in 2012-2014 were included in the study and their medical charts were reviewed. Further, residual serum samples collected from 11 laboratories across Sweden were analyzed for varicella zoster IgG-antibodies to investigate age-specific seroprevalence. RESULTS: A total of 218 children and 46 adults were included in this hospital-based study; 87.2% of children and 63.0% of adults had complications. An underlying condition was not associated with an increased risk of complication. Dehydration (31.7%), bacterial skin infections (29.8%) and neurological involvement (20.6%) were the most frequent complications in children. Among adult cases, 63% were born abroad. The seroepidemiological analysis included 957 patient samples. Seroprevalence was 66.7% at 5 years and 91.5% at 12 years. Infants and adolescents/adults were overrepresented among admitted patients compared to seroprevalence data. CONCLUSIONS: Half of all complications in hospitalized chickenpox cases were seen in previously healthy children, which supports universal childhood vaccination. Adult migrants was a risk group for chickenpox hospitalization. Age-specific seroprevalence was similar to neighboring countries.

Inhibition of leukocyte rolling with polysaccharide fucoidin prevents pleocytosis in experimental meningitis in the rabbit.

Inflammatory recruitment of leukocytes into the cerebrospinal fluid (CSF) during bacterial meningitis has been shown to contribute significantly to the neurological damage commonly associated with this serious disease. In this study we tested whether or not inhibition of leukocyte rolling, a precondition for firm leukocyte adhesion to vascular endothelium in vivo, may reduce CSF leukocyte recruitment and associated inflammatory changes in rabbits with experimental meningitis. As documented by intravital microscopy of small venules in the rabbit mesentery and tenuissimus muscle, leukocyte rolling was rapidly and profoundly reduced by intravenous treatment with the polysaccharide fucoidin, a homopolymer of sulfated L-fucose known to block the function of the leukocytic "rolling receptor" L-selectin. Moreover, fucoidin treatment dramatically reduced the accumulation of both leukocytes and plasma protein in the CSF of rabbits challenged intrathecally with pneumococcal antigen. These main findings thus illustrate that inhibition of leukocyte rolling, an early and obligatory step in the process of leukocyte extravasation, may be an effective therapeutic approach to attenuate leukocyte-dependent central nervous system damage in bacterial meningitis.

Prevention of chemotherapy-induced ulcerative mucositis by transforming growth factor beta 3.

Mucositis is a common, dose-limiting complication in patients receiving cancer chemotherapy, which appears to be a consequence of the rate of epithelial proliferation. The beta transforming growth factors have been shown to be negative regulators of epithelial cell proliferation. Here we show that transforming growth factor beta 3 administration reduced proliferation of oral epithelium in vitro and in vivo. Topical application of transforming growth factor beta 3 to the oral mucosa of the Syrian golden hamster prior to chemotherapy significantly reduced the incidence, severity, and duration of oral mucositis, reduced chemotherapy-associated weight loss, and increased survival.

Polymorphic diffuse B-cell hyperplasias and lymphomas in renal transplant recipients.

The lymphoproliferative processes that developed in five renal transplant recipients were studied in an attempt to characterize and classify them morphologically. Nine surgical specimens, hematological material on all patients, and autopsy specimens from three patients were available. Studies performed included: conventional histopathology; evaluation of cell markers (immunoglobulins and sheep erythrocyte, complement, and Fc receptors) and cytoplasmic immunoglobulins (peroxidase-antiperoxidase technique); ultrastructural examination; and karyotype analysis. The lymphoid lesions in our patients shared marked cytological polymorphism (small and large cells, of both follicular center and "medullary" type) and polyclonal B-cell features, which indicated a common reactive nonneoplastic origin. However, other features, such as morphological atypia of the immunoblasts, extensive necrosis, chromosomal aberrations, and an incipient monoclonal component suggested the development of lymphoma in some of these lesions. In contradistinction, the abundance of typical immunoblasts was a feature that seemed to correlate with the clinical activity of the disease rather than with the biological malignancy. The multiplicity of B-cell types and the presence of a follicular center cell component with diffuse distribution, as well as the extensive necrosis in the malignant forms, seem to differentiate morphologically the lymphoproliferative processes arising in transplant recipients from both the hyperplasias and the lymphomas developing in immunologically normal hosts. For the former, we propose the terms of "polymorphic diffuse B-cell hyperplasias" and "polymorphic B-cell lymphomas."

Chromosomal abnormalities in acute lymphoblastic leukemia.

Chromosome abnormalities in acute lymphoblastic leukemia (ALL) and their possible clinical significance are briefly reviewed based upon the literature and 60 cases studied at the University of Minnesota. Almost all cases of ALL appear to demonstrate clonal abnormalities; the major abnormal clone is usually hyperdiploid or pseudodiploid. Among cases of non-T, non-B ALL, at least four translocations appear to be present with an increased frequency: t(9;22); t(4;11); t(11;14); and t(1;3). Patients with these translocations appear to have unique clinical and laboratory findings. Although the presence of abnormal clones does not seem to influence remission duration, the nature of the abnormality does. Patients whose leukemias demonstrate predominantly a pseudodiploid abnormal clone or a translocation have significantly shorter first remissions. Most importantly, among patients with non-T, non-B ALL, the presence or absence of translocations may separate poor responders from good responders.

A novel mechanism for cytokine regulation: screening, selection, and characterization of anticytokine monoclonal and polyclonal autoantibodies.

We have recently described an immunoregulatory mechanism involving release of neutralizing autoantibodies (Aab) to cytokines during bacterial infections. Intraperitoneal inoculation of Haemophilus influenzae type b (Hib) into Sprague-Dawley rats resulted in high levels of inflammatory mediators early after infection. Increased titers of cytokine Aab were observed, with a peak at day 7. We cloned Aab-producing B cells. Screening of the clones with five different cytokines resulted in detection of Aab-producing clones reactive with each cytokine. After repeated subcloning, monoclonal Aab (mAab) were selected and characterized for their specificity, isotypes, and affinities. To elucidate regulatory importance, mAab to interferon-gamma (IFN-gamma) and tumor necrosis factor-alpha (TNF-alpha) dose-dependently inhibited IFN-gamma-induced MHC expression by peritoneal macrophages and TNF-alpha-induced thymocyte proliferation, respectively. Fab fragments exhibited binding and neutralizing effects, confirming specificities. Cross-reactivity with other rat cytokines was excluded. Pools of clones containing several mAab to each cytokine were obtained and served as polyclonal Aab. The relative affinity of the Aab was determined and found to be of high index. The characterized Aab were tested in methodologic assays for cytokine detection, revealing that some Aab were useful in a cell release capturing (CRC) ELISA.

Comparison of intravenous penicillin G and oral doxycycline for treatment of Lyme neuroborreliosis.

To compare the efficacy of oral doxycycline and IV penicillin G for the treatment of neuroborreliosis, we randomized consecutive patients with Lyme neuroborreliosis to receive either IV penicillin G (3 g q 6 h) or oral deoxycycline (200 mg q 24 h) for 14 days. All patients had antibodies against Borrelia burgdorferi in serum, CSF, or both, or had a positive CSF culture. Twenty-three patients randomized to penicillin G and 31 patients to doxycycline were included in the study. All patients improved during treatment, and there were no significant differences between the two treatment groups in patient scoring, CSF analysis, or serologic and clinical follow-up during 1 year. There were no treatment failures, although one patient in each treatment group was re-treated because of residual symptoms. In conclusion, oral doxycycline is an adequate and cost-effective alternative to IV penicillin for the treatment of Lyme neuroborreliosis.

Chronic fatigue syndrome differs from fibromyalgia. No evidence for elevated substance P levels in cerebrospinal fluid of patients with chronic fatigue syndrome.

Levels of substance P were determined in the cerebrospinal fluid (CSF) in 15 patients with chronic fatigue syndrome (CFS). All values were within normal range. This is in contrast to fibromyalgia (FM). The majority of patients with FM have increased substance P values in the CSF. The results support the notion that FM and CFS are different disorders in spite of overlapping symptomatology.

Quantitation of C-reactive protein in cerebrospinal fluid and serum by zone immunoelectrophoresis assay (ZIA).

The zone immunoelectrophoresis assay (ZIA) for C-reactive protein (CRP) determinations is easy to perform and requires only small amount of antiserum, e.g., 25-100 and 0.5-1.0 microliter anti-CRP antibody/20 serum and CSF samples, respectively. For quantitating CSF-CRP the immunoprecipitates formed were stained using alkaline phosphatase-conjugated secondary antibodies and the lowest standard concentration used was 30 micrograms/l. The immunoprecipitates formed when measuring CRP in serum were stained by Coomasie brilliant blue R250 with a detection limit of about 300 micrograms/l. CRP was determined in cerebrospinal fluid in 27 patients with bacterial meningitis (range less than 0.03-23.0 mg/l) and in 25 patients with viral meningitis (range less than 0.03-0.23 mg/l). CRP was quantitated in 52 sera by both the CRP ZIA method (y) and by electroimmunoassay (x). The correlation coefficient was r = 0.992 with the regression line y = 1.024 x + 0.855.

Regional cerebral blood flow scintigraphy in tick-borne encephalitis and other aseptic meningoencephalitis.

UNLABELLED: In a prospective study, regional cerebral blood flow (rCBF) was studied in patients with aseptic meningoencephalitis at 6 wk and 1 yr after onset of disease. METHODS: Patients with tick-borne encephalitis ([TBE] n = 73) and meningoencephalitis of other etiology ([non-TBE] n = 56) were investigated with rCBF-scintigraphy (SPECT). SPECT images in the acute phase of disease and at long-term follow-up were analyzed for blood-flow disturbances and their localization in the central nervous system and were correlated to clinical course and outcome. RESULTS: Decreased rCBF was seen in 50% of patients after 6 wk (TBE 49%, non-TBE 50%) and in 46% (TBE 47%, non-TBE 46%) after 1 yr. The decrease in rCBF was moderate in 18% and 11% at 6 wk and in 8% and 9% at the 1-yr follow-up of TBE and non-TBE patients, respectively. Reduced rCBF was significantly more common among patients with encephalitis than among those with meningitis, and more common in males. The distribution of cerebral flow changes was predominantly patchy or multifocal. At long-term follow-up, improvement in rCBF was seen in 28 of 109 patients (26%), but worsening of decreased rCBF was demonstrated in 19 of 109 (17%). In TBE patients, remaining neurological symptoms at 6 wk of disease were associated with worsening of decreased rCBF at the 1-yr follow-up. CONCLUSION: With SPECT, rCBF changes, mostly slight and patchy or multifocal, were detected in patients with aseptic meningoencephalitis. Decreased rCBF was more frequent in patients with moderate-to-severe encephalitis, although the clinical use in predicting long-term outcomes in aseptic meningoencephalitis (e.g., TBE) seems limited.

A new DIG-PCR-EIA method for the detection of Chlamydia pneumoniae DNA in clinical samples.

Chlamydia pneumoniae, a common respiratory pathogen, may also play a role in the pathogenesis of other chronic conditions. For accurate detection of infected persons and verification of results obtained by other PCR methods, a DIG-PCR-EIA method was evaluated. In the DIG-PCR-EIA, a 437 bp DNA sequence was amplified and hybridized with a newly synthesized 229 bp biotin-labeled probe. The end product was detected by an enzyme immunoassay. The sensitivity of DIG-PCR-EIA was compared with Southern blot hybridization and one-step HR/HL PCR, which was the routine method used. DNA was detected to the level of 20 elementary bodies of DIG-EIA-PCR compared to less than 2 by Southern blot, and 200 by HR/HL PCR. Thus a 100-fold increase in sensitivity could be expected by DIG-EIA-PCR compared to the routine method. Throat swabs and adenoid tissue from 22 children with otitis and middle ear secretions from 29 children, as well as throat swabs from 179 blood donors, were analyzed with DIG-EIA-PCR, HL/HR PCR and nested touchdown PCR. 32% of the ear secretions were positive by DIG-EIA-PCR as compared to 5% by the other two methods. Three adenoid tissue samples were positive by all methods applied. Among the child and adult throat samples, 18% and 32%, respectively, were positive by DIG-EIA-PCR and 5% and 10% by HR/HLPCR. The results indicate the suitability of DIG-PCR-EIA for verification of results of HR/HL PCR. DIG-PCR-EIA has a potential for increased sensitivity and adaptation for automation. It should be further evaluated using various types of tissue specimens and DNA extraction methods.

15;17 Translocation in acute promyelocytic leukemia.

Acute promyelocytic leukemia (APL) is a relatively rare subtype of leukemia that has been reported to be associated with a specific chromosome abnormality, t(15;17). It has been suggested that this translocation may have a geographical distribution and its presence may signify a poorer prognosis. In this present series of 14 patients with APL, 9 patients (64%) had the t(15;17) and 5 did not; however, no significant differences in clinical features or outcome could be found between those who did and those who did not express the translocation. When ethnic backgrounds were explored, no differences were found. More cases of the t(15;17) were found in recent years (7 of 8 patients studied since 1978 compared to 2 of 6 before 1978). This corresponded to changes made in our cytogenetic techniques suggesting that the finding of the t(15;17) may be a function of technique, rather than a real difference in disease entities, and all patients with APL may have the t(15;17) when appropriately studied.

Short-course aminoglycoside therapy in patients with spinal cord injury. Standard dose versus low dose.

Twenty-nine patients with spinal cord injury and asymptomatic urinary tract infection were treated with standard or reduced doses of tobramycin and amikacin. The patients received five days of intramuscular antibiotics. Most of the patients in the tobramycin groups had Pseudomonas aeruginosa infection and most of those in the amikacin group had either Proteus rettgeri or Providencia stuartii infections. Only 1 patient had a positive urine antibody coating test. High antibiotic concentrations were demonstrated in the urine of all patients during therapy. Urine cultures were obtained two and seven days after completion of therapy. Forty-eight per cent of the patients were cured, while 31 per cent showed persistence or relapse, and 21 per cent had reinfection with other bacteria. No significant differences in results were observed between the standard-dose and low-dose regimens and between the amikacin and tobramycin groups. The low success rate of the regimens used may indicate the need to evaluate alternative therapeutic regimens to treat urinary tract infections in this special group of patients.

Tick-bone encephalitis in Sweden in relation to aseptic meningo-encephalitis of other etiology: a prospective study of clinical course and outcome.

A total of 149 patients with clinical symptoms of acute viral meningo-encephalitis were enrolled in this study from June 1991 to December 1993. Tick-borne encephalitis (TBE) was diagnosed in 85 of the 149 patients (males 54%, median age 42 years (range 15-78)). The initial clinical appearance of TBE was classified as mild (mainly meningeal; (n = 47), moderate (n = 31) or severe (n = 7), more or less encephalitic. The most common acute symptoms of encephalitis were ataxia (26%), altered consciousness (20%), decreased concentration or memory (9%), irritable response to light and sound (28%), tremor (9%) and dysphasia (9%). Spinal nerve paralysis (11%) occurred in all three clinical stages and did not correlate with the severity or duration of encephalitis. The duration of hospitalisation, the time on the sick-list and the time to recovery were significantly longer in TBE patients. All patients survived, but many patients with TBE suffered an extended period of neurological dysfunction. Of patients with TBE 80% (68/85) showed persisting symptoms of CNS dysfunction on follow-up at week 6, compared with 55% (35/64) of the patients with aseptic meningitis of other aetiology. The corresponding figures after 1 year were 40% (33/83) and 20% (13/64). One year after TBE 13 (28%) patients with initially mild, meningeal symptoms had decreased memory and decreased concentration capacity, dysphasia or ataxia. Spinal nerve paralysis persisted after 1 year in 5 of 9 patients with TBE. In conclusion, TBE in Sweden is associated with a significant morbidity and a post-TBE syndrome existed after 1 year in more than one third of the patients.

Association between marginal bone loss around osseointegrated mandibular implants and smoking habits: a 10-year follow-up study.

While many factors are conceivable, occlusal loading and plaque-induced inflammation are frequently stated as the most important ones negatively affecting the prognosis of oral implants. Currently, little is known about the relative importance of such factors. The aim of this study was to analyze the influence of smoking and other possibly relevant factors on bone loss around mandibular implants. The participants were 45 edentulous patients, 21 smokers and 24 non-smokers, who were followed for 10-year period after treatment with a fixed implant-supported prosthesis in the mandible. The peri-implant bone level was measured on intraoral radiographs, information about smoking habits was based on a careful interview, and oral hygiene was evaluated from clinical registration of plaque accumulation. Besides standard statistical methods, multiple linear regression models were constructed for estimation of the relative influence of some factors on peri-implant bone loss. The long-term results of the implant treatment were good, and only three implants (1%) were lost. The mean marginal bone loss around the mandibular implants was very small, about 1 mm for the entire 10-year period. It was greater in smokers than in non-smokers and correlated to the amount of cigarette consumption. Smokers with poor oral hygiene showed greater marginal bone loss around the mandibular implants than those with good oral hygiene. Oral hygiene did not significantly affect bone loss in non-smokers. Multivariate analyses showed that smoking was the most important factor among those analyzed for association with peri-implant bone loss. The separate models for smokers and non-smokers revealed that oral hygiene had a greater impact on peri-implant bone loss among smokers than among non-smokers. This study showed that smoking was the most important factor affecting the rate of peri-implant bone loss, and that oral hygiene also had an influence, especially in smokers, while other factors, e.g., those associated with occlusal loading, were of minor importance. These results indicate that smoking habits should be included in analyses of implant survival and peri-implant bone loss.

Sputum concentration improves diagnosis of tuberculosis in a setting with a high prevalence of HIV.

Sputum microscopy for acid-fast bacilli (AFB), although relatively insensitive, is still the cornerstone of tuberculosis (TB) diagnosis in the developing world. Its diagnostic value has been eroded owing to the increasing number of HIV-related smear-negative pulmonary TB cases. Concentration of sputum by centrifugation after liquefaction with sodium hypochlorite is a possible means of increasing the sensitivity of direct microscopy. This procedure has been studied recently in developing countries although with conflicting results. The aim of our study, performed in 1996 in Addis Ababa, Ethiopia, was to evaluate the sensitivity of the concentration method in a large cohort of consecutive patients with suspected pulmonary TB. We show that the overall sensitivity increased from 54.2% using conventional direct microscopy to 63.1% after concentration (P < 0x0015). In HIV-positive patients, sensitivity increased from 38.5% before to 50.0% after concentration (P < 0x0034). The significant increase in yield of AFB in HIV-positive patients suggests that this method has a place in routine diagnosis of pulmonary TB in countries with a high prevalence of HIV.

Virucidal treatment of blood protein products with UVC radiation.

The virus safety of blood derivatives continues to be of concern, especially with respect to nonenveloped and/or heat-stable viruses. Previously, we demonstrated that treatment of whole plasma, AHF concentrate or fibrinogen with short wavelength ultraviolet light (UVC) results in the inactivation of > or = 10(6) infectious doses (ID) of encephalomyocarditis virus (EMCV), hepatitis A virus (HAV) and porcine parvovirus (PPV), each of which is nonenveloped. Protein recovery was enhanced greatly by inclusion of the flavonoid, rutin, added prior to UVC exposure to quench reactive oxygen species. We now report on the treatment of albumin and intravenous immune globulin (IVIG) isolated by a previously described, integrated chromatographic method. Albumin was treated with either 0.1 or 0.2 J/cm2 UVC in the presence of 0.8 or 1.6 mM rutin; IVIG was treated with either 0.05 or 0.1 J/cm2 UVC in the presence of 0.5 or 1.0 mM rutin. Our results show that > or = 10(6.9) ID of EMCV and PPV were inactivated under each of the conditions studied except the treatment of albumin with 0.1 J/cm2 UVC in the presence of 1.6 mM rutin where 10(4.3) ID of EMCV and > or = 10(6.9) ID of PPV were killed. It appears that the sensitivity of PPV to UVC exceeds that of EMCV and that virus kill with UVC is higher in IVIG than in albumin. In the absence of rutin, UVC increased the extent of aggregation of both albumin and IVIG by two- to three-fold. With rutin present, the increase in albumin aggregation was reduced, and it was virtually eliminated by subsequent processing on Sephacryl S-200, a step in the existing procedure designed to remove aggregates. The increase in aggregation of IVIG appeared to be eliminated on inclusion of either 0.5 mM or 1 mM rutin. We conclude that both albumin and IVIG can be treated with UVC to inactivate > or = 10(6) ID of nonenveloped viruses. The inclusion of rutin during treatment helps protect against protein aggregation.

Case report. Failure of metronidazole in amebic liver abscess.

A 51-year-old man was treated with open surgical drainage and metronidazole for an amebic liver abscess. During therapy and while the original abscess was resolving, a second, noncontiguous amebic liver abscess developed. This second abscess eventually responded to emetine, chloroquine, and diodohydroxyquin therapy without surgical drainage. This unique case serves to document that new abscess may develop in the course of metronidazole therapy and illustrates the value of serial hepatoscanning in such patients.