Cough and fear of sleep: early clinical signs of Bordetella pertussis in an adult

Pertussis is increasing in frequency among adults, but early diagnosis requires special attention to details in the medical history. We describe a 64 year-old male with classic signs and symptoms of pertussis and documented Bordetella pertussis infection that were overlooked because he presented with a chief complaint of cough and fear of falling asleep. Coughing paroxysms and a feeling of suffocation (30-60 seconds) only occurred at night after short periods of deep sleep (30-45 minutes). The physicians did not observe these episodes during daytime examinations, and the basis of the patient's fear of sleep was not explored. We recommend reassessment of how adults describe symptoms of pertussis, including fear of sleep, and we suggest the use of PCR technology to allow early diagnosis and prompt treatment.

Vaccine adjuvants: A new hope for effective immunization

Two important issue regarding the use of immunization to control infections and malignancies in the futureare: 1) the need to render poorly immunogenic, often highly purified, antigens more effective; and 2) the desire to direct the immune response in specific ways to achieve the most relevant response for each disease. The first issue can be solved by a broad range of vaccine adjuvants. The second requires careful selection among the adjuvants to allow directing of the immune response in the most appropriate manner. For exemple, in different settings expansion of a B cell response, cytotoxic T cell response, or enhancement of either a Th1 or Th2 subset response may be desired. These goals are accomplished by the use of several newly developed non-cytokine adjuvants, or by direct injection of the relevant cytokines. Some non-cytokine molecular adjuvants and cytokines used as adjuvants have already been proven effective in animal models and/or in clinical trials. Here, we review the present state of art in the use of vaccine adjuvants for control of various infections diseases.

A Role for granulocyte-macrophage colony-stimulating factor (GM-CSF) in the treatment of neutropenic patients with pneumonia

Pneumonia is a serious, difficult to manage, and often fatal infection in neutropenic patients. The availability of hematopoietic growth factors has made it possible to evaluate the role of reversing the neutropenic state. Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been used in an investigator-initiated, open-label clinical trial in approximately 1200 patients. Data colleted on each patient was reviewed to identify all patients who had the combination of neutropenia and pneumonia. Sixty-eight patients (5 percent of the patients for whom GM-CSF was requested) met the criteria for having neutropenic peneumonia. In this patient population there were 45 males and 20females (gender was not indicated in 3). Ages ranged from 3 to 83 years (mean 39 ñ 18 years). The underlying diseases included: 7 patients who were receiving chemotherapy for solid malignant tumors, 14 for lymphoma, and 22 for leukemia; 15 post bone marrow transplantation primarily for hematologic malignancy; 3 idiosyncratic drug-induced neutropenia; and 7 with other causes of neutropenia. The type of pneumonia was predominantly fungal in 21 patients, bacterial in 23, viral in 2, protozoal in 1, and uncertain in 21 (presumed to be bacterial in 19 and viral in 2). Patients received a mean of 5µg/kg GM-CSF (range 1.3-12.5µg/kg) daily for a mean of 13 ñ 10 (range 2-57) days. The mean leukocyte count at start of treatment was 600 ñ 500 cells/mmü, and at the end of treatment was 5600 ñ 9200 cells/mmü (P=0.001). The time between start of GM-CSF and a leukocyte level in excess of 1500/mmü was a median of 13 days. Hematopoietic recovery was showm in 46/62 (74 percent), 40/64 (63 percent) showed good clinical and/or radiologic improvement, and 41/68 (60 percent) survived. Four illustrative case reports are provided. By comparing the hematologic responders to non-responders, it is clear that persistent neutropenia contributed significantly to poor clinical outcome and mortality. Only 3/22 (13 percent) of non-responders survived, whereas 38/46 (83 percent) of responders survived. There were 7 adverse events (rash 1, fever/chills 2, malaise 1, myalgia/bone pain 2, increased myeloblasts 1) which were considered to be related to use of the cytokine. Aggravation of the pulmonary inflammation or sepis syndrome was not observed. Tolerability was good or very good in 89 percent of patients. Based on this open-label study, the use of GM-CSF in combination with appropiate antibiotics ...

Aedes aegypti surveillance and correlation with the occurrence of dengue fever in Bahia, Brazil

Due to the high frequency of dengue fever cases and the presumed association of such an epidemic with an increase in the population of the mosquito vector, Aedes aegypti, we examined the records of the Ministry of Health in the state of Bahia, Brazil, regarding the monitoring of domestic mosquito larvae in municipalities throughout the state. The "House Index" number for larvae in domestic water reservoirs was determined for each municipality based on annual surveys from 1990 to 1994, and in 1996. In 1996, 69 percent of the municipalities surveyed in Bahia were positive, and 30 percent had indices above 5 percent. During 1990 and 1991, the level of larvae identified was low and stable; however, during November and December, 1992, a dramatic increase was recorded. The increase continued until 1996, when over 100-fold increases in house indices were recorded in Feira de Santana and Ilhéus, and 60-fold in Salvador. The dengue fever epidemic was documented in the region beginning in 1994. A strong correlation has been demonstrated between an increase in the mosquito larvae population and the emergence of dengue fever.