Review of brucellosis cases from laboratory exposures in the United States in 2008 to 2011 and improved strategies for disease prevention.

Five laboratory-acquired brucellosis (LAB) cases that occurred in the United States between 2008 and 2011 are presented. The Centers for Disease Control and Prevention (CDC) reviewed the recommendations published in 2008 and the published literature to identify strategies to further prevent LAB. The improved prevention strategies are described.

Fatal case of brucellosis misdiagnosed in early stages of Brucella suis infection in a 46-year-old patient with Marfan syndrome.

We report a fatal case of Brucella suis endocarditis initially misdiagnosed by automated identification systems as Ochrobactrum anthropi infection in a patient with a history of Marfan syndrome and recreational feral swine hunting. This report emphasizes the need to consider brucellosis as a part of the differential diagnosis of acute febrile illness, particularly in patients with known risk of exposure.

Occult HBV infection among anti-HBc positive HIV-infected patients in apex referral centre, Eastern India.

BACKGROUND: The prevalence of occult HBV, defined by the presence of HBV DNA in individuals with antibodies to HBV core antigen and with absence of HBV surface antigen, but its clinical significance and virological features in HIV-infected patients is still unclear. AIM: To investigate the prevalence, clinical significance and molecular characterization of occult hepatitis B virus infection in ART-Naive HIV-positive individuals. MATERIAL AND METHODS: Among the 1077 HIV-infected patients with different risk factors for HIV infection, 297 were HBsAg-ve ART-naive, of them 112 was randomly selected for the study. HBV DNA was tested by in-house PCR and quantified by qPCR. Molecular characterization was performed by sequencing the envelope and overlapping polymerase genes. RESULTS: We found the prevalence of occult HBV to be 10.7% among a randomly selected group of HBsAg-ve/antiHBc+ve HIV-infected patients. Overall 33.9% (38 of 112) of the patients were antiHBc positive indicating exposure to HBV infection. HBV DNA was detected in 12/38 (31.5%) antiHBc positive samples and 50% of them had CD4 T cell count < 200 cells/mm(3). HCV coinfection was low (2.7%). No surrogate marker for OBI could be identified. Presence of antiHBs antibodies did not rule out OBI. Liver biopsy in six cases showed varying stages of chronic hepatitis. Several mutations were detected but not the common immune escape mutant G145R. CONCLUSION: In conclusion the prevalence of OBI was significantly high among HIV coinfected patients, which highlights the importance of HBV DNA testing in these patients and indicates need for further prospective studies in larger cohorts to assess its clinical significance.

Subgenotypes of hepatitis B virus genotype D (D1, D2, D3 and D5) in India: differential pattern of mutations, liver injury and occult HBV infection.

Hepatitis B genotype D (HBV/D) is the most widespread genotype and exists as at least five subgenotypes (HBV/D1-D5). However, little is known about the association of virological characteristics with clinical differences among HBV/D subgenotypes. To investigate the virological characteristics of these subgenotypes and their clinical implications, we selected a cohort of 109 genotype D infected individuals from the state of West Bengal, India, including 68 HBsAg positive patients and 41 with occult HBV infection. Among the HBsAg positive subjects 28 had chronic hepatitis B virus infection, 40 were asymptomatic carriers based on clinical examination, liver function test and ultrasonograph results. Overall, HBV/D1 was found in 17%, HBV/D2 in 29%, HBV/D3 in 34% and HBV/D5 in 20% of the cases. HBV/D1 was significantly associated with chronic liver disease (P = 0.01), and in this subgenotype A1896 (PreC mutations) were most common. Although BCP mutations (A/C1753 and T1762/A1764) were found to be frequently associated with HBV/D2 (33% and 33%) and D5 (47% and 59%), no apparent clinical correlation was observed. On the other hand, occult HBV infection was significantly associated with HBV/D3 infection, along with low level of BCP and PreC mutations and several non-synonymous substitutions in the catalytic reverse transcriptase (RT) domain of polymerase gene. Similar nucleotide substitutions in the surface (S) gene region were observed from both northern and eastern Indian HBV/D3 isolates. In conclusion, HBV/D subgenotypes differ in their mutational patterns in the S, polymerase and the BCP/PreC regions that may influence their clinical outcomes.

Detection of human immunodeficiency virus (HIV) and human lymphotropic virus (HTLV) type I or II dual infections by polymerase chain reaction.

To type the specific human T-lymphotropic virus (HTLV) coinfection in acquired immunodeficiency syndrome (AIDS) patients, we have utilized the polymerase chain reaction technique. The primer pairs employed for HTLV-I and HTLV-II are derived from pol and env regions and gag region for human immunodeficiency virus (HIV). The data indicate that the selected primer pairs are specific for each virus and are able to detect HTLV-I and -II coinfection in lymphoid cells established from AIDS patients.

The role of calcium ions in the permeability changes produced by external ATP in transformed 3T3 cells.

External ATP causes a rapid increase in passive permeability to nucleotides and phosphate esters in transformed cell lines, such as 3T6 mouse fibroblasts. However, untransformed lines, such as 3T3, do not show a similar sensitivity to external ATP. Ca2+ inhibits permeabilization, but only at concentrations approaching those of external ATP. In contrast, La3+ and Tb3+ inhibit ATP-dependent permeabilization at one-fifth the concentration of external ATP. Considering reports that lanthanides can substitute for calcium ion in many enzymatic reactions, often with a higher affinity, it would appear that Ca2+ plays a specific role in the maintenance of a passive membrane permeability barrier and in opposing the effects of external ATP. Other data suggest a regulatory role for the Ca2+-calmodulin complex in the permeabilization process. Trifluoperazine, chlorpromazine and W-7, compounds which inhibit cellular functions dependent on the Ca2+-calmodulin complex, are able to enhance the effect of external ATP. Thus, a dramatic stimulation of nucleotide permeability occurs with concentrations of external ATP and inhibitor that are ineffective when added alone. Calmodulin antagonists and low concentrations of external ATP increased membrane permeability to Na+ and K+ as was previously shown for permeabilization with ATP alone. Earlier studies have shown that energy inhibitors which reduce intracellular ATP levels greatly increase the sensitivity of transformed cells to external ATP. However, the Ca2+-calmodulin antagonists used in the present study exert their effects at concentrations which do not alter intracellular ATP levels.

Human Brucella canis Infection and Subsequent Laboratory Exposures Associated with a Puppy, New York City, 2012.

Human Brucella canis infection incidence is unknown. Most identified cases are associated with pet dogs. Laboratory-acquired infections can occur following contact with Brucella spp. We identified a paediatric B. canis case, the source and other exposed persons. A 3-year-old New York City child with fever and dyspnoea was hospitalized for 48 h for bronchiolitis. After her admission, blood culture grew B. canis, she was prescribed anti-microbials and recovered. B. canis was also isolated from blood of the child's pet dog; these isolates were genetically similar. The dog originated from an Iowa breeding facility which was quarantined after identification of the dog's infection. Additionally, 31 laboratory workers were exposed and subsequently monitored for symptoms; 15 completed post-exposure prophylaxis. To our knowledge, this is the first report strongly suggesting B. canis zoonotic transmission to a child in the United States, and highlights the need for coordinated control policies to minimize human illness.

Comparison of inactivated, live and recombinant DNA vaccines against influenza virus in a mouse model.

The protective efficacy of influenza hemagglutinin expressed from recombinant vaccinia virus was compared with that induced by inactivated or infectious influenza vaccines. Intraperitoneal and intranasal routes of vaccination were compared. All the vaccines except the intranasally administered, inactivated vaccine induced detectable levels of neutralizing and hemagglutination-inhibiting antibodies in the serum of mice at 28 days postvaccination. Immunization with any of the intranasally administered vaccines reduced the amount of influenza virus nucleoprotein antigen in lungs after challenge with a homologous, mouse-adapted strain of influenza virus. Intraperitoneally administered vaccines failed to provide such protection. These results indicated that the route of vaccine administration may be the most critical factor for inducing protective immunity. The results also showed that in this mouse model a recombinant DNA-based vaccine could provide protection equivalent to that provided by conventional attenuated and inactivated influenza vaccines.

Arsenic levels in drinking water and the prevalence of skin lesions in West Bengal, India.

BACKGROUND: A cross-sectional survey was conducted between April 1995 and March 1996 to investigate arsenic-associated skin lesions of keratosis and hyperpigmentation in West Bengal, India, and to determine their relationship to arsenic water levels. METHODS: In all, 7683 participants were examined and interviewed, and the arsenic levels in their drinking water measured. RESULTS: Although water concentrations ranged up to 3400 microg/l of arsenic, over 80% of participants were consuming water containing <500 microg/l. The age-adjusted prevalence of keratosis was strongly related to water arsenic levels, rising from zero in the lowest exposure level (<50 microg/l) to 8.3 per 100 for females drinking water containing >800 microg/l, and increasing from 0.2 per 100 in the lowest exposure category to 10.7 per 100 for males in the highest exposure level (> or =800 microg/l). However, 12 cases with keratosis (2 females and 10 males) were drinking water containing <100 microg/l of arsenic. Findings were similar for hyperpigmentation, with strong dose-response relationships. Among those with hyperpigmentation, 29 cases were exposed to drinking water containing <100 microg/l. Calculation by dose per body weight showed that men had roughly two to three times the prevalence of both keratosis and hyperpigmentation compared to women apparently ingesting the same dose of arsenic from drinking water. Subjects who were below 80% of the standard body weight for their age and sex had a 1.6 fold increase in the prevalence of keratoses, suggesting that malnutrition may play a small role in increasing susceptibility. CONCLUSION: The surprising finding of cases who had arsenic-associated skin lesions with apparently low exposure to arsenic in drinking water needs to be confirmed in studies with more detailed exposure assessment. Further research is also needed concerning susceptibility factors which might be present in the exposed population.

Arsenic in drinking water and the prevalence of respiratory effects in West Bengal, India.

BACKGROUND: A large population in West Bengal, India has been exposed to naturally occurring inorganic arsenic through their drinking water. A cross-sectional survey involving 7683 participants of all ages was conducted in an arsenic-affected region between April 1995 and March 1996. The main focus of the study was skin keratoses and pigmentation alterations, two characteristic signs of ingested inorganic arsenic. Strong exposure-response gradients were found for these skin lesions. The study also collected limited information concerning respiratory system signs and symptoms, which we report here because increasing evidence suggests that arsenic ingestion also causes pulmonary effects. METHODS: Participants were clinically examined and interviewed, and the arsenic content in their current primary drinking water source was measured. There were few smokers and analyses were confined to non-smokers (N = 6864 participants). RESULTS: Among both males and females, the prevalence of cough, shortness of breath, and chest sounds (crepitations and/or rhonchi) in the lungs rose with increasing arsenic concentrations in drinking water. These respiratory effects were most pronounced in individuals with high arsenic water concentrations who also had skin lesions. Prevalence odds ratio (POR) estimates were markedly increased for participants with arsenic-induced skin lesions who also had high levels of arsenic in their current drinking water source (> or = 500 microg/l) compared with individuals who had normal skin and were exposed to low levels of arsenic (<50 microg/l). In participants with skin lesions, the age-adjusted POR estimates for cough were 7.8 for females (95% CI : 3.1-19.5) and 5.0 for males (95% CI : 2.6-9.9); for chest sounds POR for females was 9.6 (95% CI : 4.0-22.9) and for males 6.9 (95% CI : 3.1-15.0). The POR for shortness of breath in females was 23.2 (95% CI : 5.8-92.8) and in males 3.7 (95% CI : 1.3-10.6). CONCLUSION: These results add to evidence that long-term ingestion of inorganic arsenic can cause respiratory effects.

Rapid and sensitive genotyping of Epstein-Barr virus using single-strand conformation polymorphism analysis of polymerase chain reaction products.

Two distinct wild-type Epstein-Barr virus (EBV) strains (A and B) that have significantly diverged at the two small RNA-encoding region (EBER) have been identified (Arrand et al., 1989). In order to test whether single-strand conformation polymorphism analysis (SSCP) would correlate with these sequence variations, we designed primer pairs specific for EBER-encoding regions for amplification of divergent sequences by polymerase chain reaction (PCR). The PCR-amplified products from six EBV-positive cell lines were analyzed by SSCP method, and the results were compared with the prototype strains B95-8 (type A) and AG876 (type B). Type-specific point mutations were detected as demonstrated by shifts in mobility due to conformational changes of DNA sequences. The locations of point mutations were identified by direct sequencing of the PCR amplified DNA. Of the three primer pairs designed, the pair that amplified a 190 bp fragment spanning six type-specific point mutations gave the best resolution in SSCP analysis. This pair is now preferred for initial genotyping of EBV-infected tumor biopsies. Thus, SSCP is a simple, fast and efficient technique for genotyping of EBV-associated diseases.

Evaluation of mycobacillin and versicolin as agricultural fungicides. III. Growth pattern and antibiotic production in soil by Aspergillus versicolor.

Soil supports the growth of a jute pathogen Colletotrichum gloeosporioides but only to a limited extent that of its antagonist Aspergillus versicolor. The growth of the sensitive pathogen is considerably checked by the antagonist in mixed soil culture although versicolin production could not be demonstrated within the limits of assay. Both the sensitive and the antagonistic organisms grow well in soil-compost medium and versicolin production by the latter is also enhanced. The antagonistic effect of Aspergillus versicolor on Colletotrichum gloeosporioides is expectedly more marked in soil-compost medium than in soil medium.

Nutritional studies of 3,5-dimethyoxy salicylic acid (antithiamine) on rat as well as on the growth of S. aureus.

1. The growth of rats treated with 3,5-dimethyoxy salicylic acid was retarded in comparison to that of normal rats. 2. The free cholesterol level of plasma of rats treated with 3,5-dimethoxy salicylic acid diminished while the pyruvate level of erythrocyte under the same condition increased in comparison with their normal levels; but on administration of thiamine both the cholesterol and pyruvate levels became normal. 3. The growth of a thiamine dependent strain of S. aureus was retarded when the organism was incubated in the medium containing 3,5-dimethoxy salicylic acid and this growth can be restored with the supplementation of thiamine in the medium.

Portal hypertensive gastropathy and gastric varices before esophageal variceal sclerotherapy and after obliteration.

OBJECTIVES: To evaluate the frequency and clinical importance of portal hypertensive gastropathy (PHG) and gastric varices (GV) before endoscopic sclerotherapy (EST) and after esophageal variceal obliteration. METHODS: Patients with portal hypertension (PHT) with variceal bleed were prospectively evaluated for PHG and GV before EST with intravariceal injection of absolute alcohol and after esophageal variceal obliteration. Gastric varices and PHG were characterized and graded according to previously established criteria. Patients were followed up for 12-48 (mean 37) months after variceal obliteration. RESULTS: Of 70 patients with PHT 26 had PHG before (severe in two) [18/37 in cirrhosis, 6/20 in non-cirrhotic portal fibrosis (NCPF), and 2/13 in extrahepatic portal vein obstruction (EHPVO)] and 50 had PHG after variceal obliteration (severe in 22) (27/37 in cirrhosis, p = 0.03 before versus after esophageal variceal obliteration; 16/20 in NCPF, p < 0.01; and 7/13 in EHPVO, p = ns). Type I GV (continuation of esophageal varix into the stomach) was found in 25/70 before and 5/70 after esophageal variceal obliteration (p < 0.001); in contrast, other types of GV were seen in 14/70 before and 29/70 after (p < 0.01). Overt bleeding from GV and PHG during follow-up after variceal obliteration occurred in 6 and 4 patients, respectively. CONCLUSIONS: Esophageal variceal obliteration by EST increases the frequency of PHG and GV (except type I GV which get obliterated); both PHG and GV have potential to cause rebleeding.

Hepatic manifestations in chronic arsenic toxicity.

OBJECTIVE: The hepatotoxic action of arsenic, when used as a therapeutic agent, has long been recognized. Data on liver involvement following chronic exposure to arsenic-contaminated water are scanty. We report the nature and degree of liver involvement on the basis of hospital-based and cohort follow-up studies in patients who consumed arsenic-contaminated drinking water for 1 to 15 years. METHODS: 248 patients with evidence of chronic arsenic toxicity underwent clinical and laboratory examinations including liver function tests and HBsAg status. Liver biopsy was done in 69 cases; in 29 patients, liver arsenic content was estimated by neutron activation analysis. A cohort follow up of 23 patients who took arsenic-free water for 2-12 years was also carried out. RESULTS: Hepatomegaly was present in 190 of 248 patients (76.6%). Noncirrhotic portal fibrosis (91.3%) was the predominant lesion in liver histology. The maximum arsenic content in liver was 6 mg/Kg (mean 1.46 [0.42], control value 0.16 [0.04]; p < 0.001); it was undetected in 6 of 29 samples studied. Cohort follow-up studies showed elevation of globulin in four cases and development of esophageal varices in one case. CONCLUSION: We report the largest number of patients with liver disease due to chronic arsenicosis from drinking arsenic-contaminated water. Noncirrhotic portal fibrosis is the predominant lesion in this population.

Primary pulmonary hypertension in cirrhosis of liver.

BACKGROUND: Primary pulmonary hypertension (PPH) is a grave association of portal hypertension, and is potentially fatal in liver transplant candidates. AIM: To investigate the prevalence of PPH among cirrhotics with portal hypertension. METHODS: 43 cirrhotics with portal hypertension (Child B 22, C 14), after screening for cardiopulmonary diseases, were evaluated by hemodynamic study. RESULTS: PPH was detected in 2 cases (4.7%), both in Child B, hepatitis B and C viruses being the etiologies. Neither had portal axis thrombosis. Two other cases also had pulmonary hypertension, but with high pulmonary capillary wedge pressure (PCWP). The 41 cases without and 2 cases with PPH had, respectively, mean pulmonary artery pressure (MPAP) 16.3 (5.9) mmHg, 26 mmHg and 33 mmHg; PCWP 11.5 (6.7) mmHg, 12 mmHg and 11 mmHg; transpulmonary pressure gradient 4.8 (2.6) mmHg (n = 27), 14 mmHg and 22 mmHg; and pulmonary vascular resistance 80.2 (55.8) dyne.sec.cm-5 (n = 27), 155.6 dyne.sec.cm-5 and 366.7 dyne.sec.cm-5. No correlation of MPAP was found with either Child-Pugh scoring (r2 = 0.0347) or with hepatic venous pressure gradient (r2 = 0.0021). CONCLUSION: PPH has a prevalence of 4.7% among cirrhotics with portal hypertension; it bears no relation with severity of liver disease.

Management of the Budd-Chiari syndrome by balloon cavoplasty.

BACKGROUND: Obstruction of the suprahepatic inferior vena cava (IVC) by a membrane or stricture is the commonest cause of Budd-Chiari syndrome in the eastern hemisphere. We present our experience with the outcome of balloon cavoplasty in such cases. METHODS: We followed up 40 consecutive cases of Budd-Chiari syndrome over seven years. Doppler study of hepatic venous outflow tract (in all cases), liver biopsy (30 cases) and necropsy (two cases) were performed. Balloon cavoplasty was done in selected cases. RESULTS: Of 40 patients with BCS (mean age 35.2 [SD 8.7] years; 26 men) 5, 5 and 30 had fulminant, acute and chronic presentation, respectively. Inferior vena cavography was performed in 32 cases, and showed membranous obstruction of the IVC in 12, segmental occlusion of the IVC in 11 cases, and block in both the IVC and the main hepatic veins in the rest. Successful balloon cavoplasty was done in 18 cases with obstruction of the IVC (membrane or stricture); 15 of them are well over a mean follow up of 56 (14.6) months. Three patients developed restenosis; two of them, treated with redilatation, are doing well, and one died of septicemia and hepatic failure following a surgical bypass. Pressure gradient between the IVC and right atrium decreased significantly after cavoplasty (15.4 [2.8] vs 6.6 [2.0] mmHg; p< 0.001). CONCLUSION: Balloon cavoplasty gave encouraging results in the management of Budd-Chiari syndrome due to membranous obstruction or stricture of the IVC.

Primary pulmonary hypertension in non-cirrhotic portal fibrosis.

BACKGROUND: Primary pulmonary hypertension (PPH) has been reported in association with cirrhosis and extrahepatic portal venous obstruction; reports of PPH in noncirrhotic portal fibrosis (NCPF) are few. AIM: To evaluate pulmonary arterial pressure in patients with NCPF. METHODS: Twenty two patients with NCPF underwent hemodynamic studies for pulmonary arterial pressure after excluding secondary causes of pulmonary hypertension. Hemodynamic studies were carried out through the femoral route using 7F Swan-Ganz catheter. Splenoportal venography was done by percutaneous splenic puncture. RESULTS: The mean pulmonary arterial pressure was 12.9 +/- 3.1 mmHg with pulmonary capillary wedge pressure of 8.3 +/- 2.1 mmHg in 20 of 22 cases; in the remaining two cases, the corresponding pressures were 30 mmHg and 28 mmHg and 13 mmHg and 12 mmHg, respectively. CONCLUSION: Two of 22 patients with NCPF had PPH. PPH can thus develop without hepatocellular failure or recurrent embolization from portal axis thrombosis as has been described in cirrhosis.

Pulmonary involvement in chronic arsenic poisoning from drinking contaminated ground-water.

OBJECTIVES: Chronic arsenic poisoning, due to ingestion of contaminated ground-water, is a major public health problem in West Bengal. It causes multiorgan damage. The present study attempts to objectively investigate the pulmonary involvement by examining the lung function. The nature of lung changes was also evaluated. MATERIAL AND METHODS: One hundred and seven subjects with (cases) and 52 subjects without (controls) chronic arsenic poisoning were examined by spirometry. Forced expiratory volume-I second (FEVI), forced vital capacity (FVC) and peak expiratory flow rate (PEFR) were measured. Bronchoalveolar lavage (BAL) was performed in five cases with and five cases without pulmonary involvement. RESULTS: Thirty three (30.8%) cases and four (7.6%) controls (p<0.01) had respiratory involvement. The pattern of involvement in cases was: obstructive- 20(68.9%) (including three (10%) with bronchiectasis), restrictive- 1(3.5%), mixed- 8(27.6%), malignancy- 4(12.1%) (adenocarcinoma-I, squamous cell- 2, undifferentiated- I). FEVI (69.7+/-25.9 [n=105] vs 83.7+/-15.19 [n=51], p=0.0005), FVC (77.4+/-22.7 [n=105] vs 85.6+/-18.23 [n=51], p=0.025), FEVI/FVC (73.6+/-13.38 [n=105] vs 79.1+/-18.65 [n=52], p=0.007) and PEFR (53.9+/-21.52 [n= 103] vs 67.3+/-18.36 [n=51], p=0.0002) (percent of predicted) were all reduced more in cases compared to controls. Worsening of these parameters correlated with increasing degree of arsenic toxicity. Markers of inflammation (macrophage, lactate dehydrogenase, nitric oxide) were apparently more in the BAL fluid of those with lung involvement than in those without, though the arsenic content did not differ significantly. CONCLUSION: Chronic arsenic poisoning causes pulmonary involvement, predominantly obstructive, the degree of which worsens with increasing degree of arsenic toxicity. Inflammation, rather than direct toxicity, appears to be the underlying mechanism.

Disseminated tuberculosis presenting as hemobilia, successfully treated by arterial embolization.

Tuberculosis, specially disseminated tuberculosis, involves the liver frequently. Focal hepatic tuberculosis with local hemorrhage has been reported. We report on a twenty-one year female with disseminated tuberculosis presenting with initially non-localisable massive upper gastrointestinal bleeding, subsequently found to have pancreatitis, right sided pleural effusion and hemobilia which was treated successfully.