Usefulness of Nested PCR for Diagnosis of Scrub Typhus in Clinical Practice: Prospective study

BACKGROUND: Laboratory studies as diagnostic tools of scrub typhus have shown PCR to be sensitive and specific, but there have been few clinical studies. The aims of this study were to determine the diagnostic accuracy and clinical usefulness of the nested PCR through a prospective comparison of the nested PCR and indirect immunofluorescence assay (IFA). MATERIALS AND METHODS: We conducted a multicenter prospective study of patients with possible scrub typhus. Adult patients who have had fever together with eschar or a maculopapular skin rash and more or equal to two of the following symptoms: headache, malaise, myalgia, coughing, nausea, and abdominal discomfort were enrolled. Each patient was admitted between September, 2004 and December, 2004 to Chosun University Hospital and one of its three community branch hospitals (Haenam General Hospital, Jangheung Hospital, Muan Hospital), which are all located in the southwest of Korea. Whole blood samples were collected for PCR testing and sera were obtained for serology evaluation using the IFA and passive hemagglutination assay (PHA). RESULTS: We enrolled 135 possible scrub typhus patients, and 118 scrub typhus patients were confirmed on the basis of either a single indirect immunofluorescent specific IgM titer against O. tsutsugamushi of > or =1:10 or 4-fold or greater rise in IFA follow up titer. One hundred eighteen patients were confirmed as scrub typhus, 7 patients were undetermined and 10 patients were confirmed as the other diseases. The result of nested PCR assay demonstrated a sensitivity of 82.2% (95% confidence interval 0.74-0.88), a specificity of 100% (95% confidence interval 0.66-1), positive predictive value of 1 (95% confidence interval 0.95-1) and negative predictive value of 0.32 (95% confidence interval 0.17-0.51). 96 patients out of 118 patients were positive for IgM on the admission day. Of 22 patients with negative for IgM antibody at admission, 19 had positive results for nested PCR using buffy coat. CONCLUSION: The nested PCR assay of buffy coat is useful for rapid and reliable test for confirmation of the diagnosis of scrub typhus.

Usefulness of Nested PCR for Diagnosis of Scrub Typhus in Clinical Practice: Prospective study

BACKGROUND: Laboratory studies as diagnostic tools of scrub typhus have shown PCR to be sensitive and specific, but there have been few clinical studies. The aims of this study were to determine the diagnostic accuracy and clinical usefulness of the nested PCR through a prospective comparison of the nested PCR and indirect immunofluorescence assay (IFA). MATERIALS AND METHODS: We conducted a multicenter prospective study of patients with possible scrub typhus. Adult patients who have had fever together with eschar or a maculopapular skin rash and more or equal to two of the following symptoms: headache, malaise, myalgia, coughing, nausea, and abdominal discomfort were enrolled. Each patient was admitted between September, 2004 and December, 2004 to Chosun University Hospital and one of its three community branch hospitals (Haenam General Hospital, Jangheung Hospital, Muan Hospital), which are all located in the southwest of Korea. Whole blood samples were collected for PCR testing and sera were obtained for serology evaluation using the IFA and passive hemagglutination assay (PHA). RESULTS: We enrolled 135 possible scrub typhus patients, and 118 scrub typhus patients were confirmed on the basis of either a single indirect immunofluorescent specific IgM titer against O. tsutsugamushi of > or =1:10 or 4-fold or greater rise in IFA follow up titer. One hundred eighteen patients were confirmed as scrub typhus, 7 patients were undetermined and 10 patients were confirmed as the other diseases. The result of nested PCR assay demonstrated a sensitivity of 82.2% (95% confidence interval 0.74-0.88), a specificity of 100% (95% confidence interval 0.66-1), positive predictive value of 1 (95% confidence interval 0.95-1) and negative predictive value of 0.32 (95% confidence interval 0.17-0.51). 96 patients out of 118 patients were positive for IgM on the admission day. Of 22 patients with negative for IgM antibody at admission, 19 had positive results for nested PCR using buffy coat. CONCLUSION: The nested PCR assay of buffy coat is useful for rapid and reliable test for confirmation of the diagnosis of scrub typhus.

Deep Neck Infection due to Severe Neutropenia induced by Terbinafine in a Patient with Systemic Lupus Erythematosus / 대한류마티스학회지

Terbinafine, a fungicidal agent used for the treatment of onychomycosis, has been found to be safe and adverse effects are usually mild and transient. Neutropenia is a rare side effect of terbinafine. Terbinafine-induced neutropenia have been reported 7 cases worldwide and these patients had no predisposing factors that give rise to developing neutropenia. To date there has not been reported in Korea. We report a case of systemic lupus erythematosus of 47-yearold female patient who developed deep neck infection requiring intravenous antibiotics, tracheostomy, granulocyte colony-stimulating factor(G-CSF) to recover from terbinafine-induced neutropenia.

Two Cases of Chronic Tophaceous Gout in Systemic Lupus Erythematosus / 대한류마티스학회지

Gout and systemic lupus erythematosus(SLE)are relatively common diseases in rheumatism.But the case of coexistent gout and SLE is extremely rare.The rarity is that may be due to misdiagnosis and disparity of the epidemiology.It is suggested that immulonogic milieu in SLE and therapy for SLE may have a negative effect on the manifestations of gout.Especially,hyperuricemia that not caused by nephritis,renal failure,use of diuretics,alcohol drinking and other risk factors in premenopausal women is extremely rare.We experienced two cases of chronic tophaceous gout in female patients with SLE who did not have other hyperuricemic risk factors.

A Case of Sjogren's Syndrome with Interstitial Lung Disease and Multiple Cystic Lung Disease / 결핵

A 47-years-old woman presented with a 2-month history of a dry mouth and dry cough. The patient had been taking medication for Sjogren's syndrome for approximately 7 years. The chest radiography showed multiple cystic lesions and a hazy density in both lower lung fields. The HRCT showed a diffuse ground glass like appearance and multiple variable sized cystic lesions in both lung fields. After medication, the symptoms were aggravated. Bronchoscopy was preformed with a transbronchial lung biopsy. The biopsies showed an infiltration of lymphocytes, neutrophils, monocytes and histiocytes through the interstitial space of the alveola and a widening of the alveolar septa. However, the histological findings of the cysts were not obtained. Sjogren's syndrome is a slowly progressive inflammatory autoimmune disease, which is characterized by lymphocyte mediated destruction of the exocrine glands, with pulmonary involvement in approximately 19-65%, High-resolution CT is a sensitive technique for assessing the pulmonary involvement in patients with Sjogren's syndrome. Although a lung biopsy is not always necessary for establishing a diagnosis of an interstitial lung disease in Sjogren's syndrome. A lung biopsy may reveal a wide spectrum of changes ranging from a mild inflammatory response to end stage fibrosis with honeycombing. Because of the predominantly peribronchiolar inflammatory infiltration and inspissated secretions the cysts were suspected to have been formed by the ballvalve phenomenon. However, no definite evidence was obtained.