DNA cleavage and religation by human topoisomerase II alpha at high temperature.

A common DNA religation assay for topoisomerase II takes advantage of the fact that the enzyme can rejoin cleaved nucleic acids but cannot mediate DNA scission at suboptimal temperatures (either high or low). Although temperature-induced DNA religation assays have provided valuable mechanistic information for several type II enzymes, high-temperature shifts have not been examined for human topoisomerase IIalpha. Therefore, the effects of temperature on the DNA cleavage/religation activity of the enzyme were characterized. Human topoisomerase IIalpha undergoes two distinct transitions at high temperatures. The first transition occurs between 45 and 55 degrees C and is accompanied by a 6-fold increase in the level of DNA cleavage at 60 degrees C. It also leads to a loss of DNA strand passage activity, due primarily to an inability of ATP to convert the enzyme to a protein clamp. The enzyme alterations that accompany the first transition appear to be stable and do not revert at lower temperature. The second transition in human topoisomerase IIalpha occurs between 65 and 70 degrees C and correlates with a precipitous drop in the level of DNA scission. At 75 degrees C, cleavage falls well below amounts seen at 37 degrees C. This loss of DNA scission appears to result from a decrease in the forward rate of DNA cleavage rather than an increase in the religation rate. Finally, similar high-temperature alterations were observed for yeast topoisomerase II and human topoisomerase IIbeta, suggesting that parallel heat-induced transitions may be widespread among type II topoisomerases.

Congenital syphilis and fluorescent treponemal antibody test reactivity after the age of 1 year.

BACKGROUND: Many believe that a persistently reactive fluorescent treponemal antibody absorption (FTA-ABS) is manifested with congenital syphilis after the age of 1 year, that it is useful in the retrospective diagnosis of children with congenital syphilis, and that it can be used to confirm other treponemal tests. GOAL: To determine whether a reactive FTA-ABS after the age of 12 months is indicative of congenital syphilis. STUDY DESIGN: Prospective outpatient follow-up evaluation until at least the age of 12 months was conducted for 194 babies born to mothers with reactive syphilis serology at delivery, and for two additional children with congenital syphilis diagnosed when they were younger than 1 year (total, 196 children). RESULTS: In the study group, 54 children had reactive FTA-ABS (reactors) until the age of at least 12 months or more, and 142 children had nonreactive FTA-ABS (nonreactors) at the age of 12 months or more. Of the 54 reactors, 17 (31%) had evidence of congenital syphilis at birth, whereas evidence of congenital syphilis was seen in 14 of the 142 (10%) nonreactors (P = 0.0002). At 15 months, nonreactive FTA-ABS developed in six reactors, and eventually in 15 of 44 reactors (34%) tested. CONCLUSIONS: A reactive FTA-ABS may be seen at 12 months in children with and without evidence of congenital syphilis at birth. Not all children with congenital syphilis will manifest reactive FTA-ABS at 12 months, and FTA-ABS reactivity wanes with time.

Risk factors for pelvic inflammatory disease in inner-city adolescents.

OBJECTIVE: To determine risk factors associated with pelvic inflammatory disease (PID) among inner-city adolescents. STUDY DESIGN: A case-control study was performed from 1994 to 1997 in an inner-city hospital. METHODS: Seventy-one adolescent girls diagnosed with PID and 52 sexually active adolescents girls without PID participated in a confidential face-to-face interview using a questionnaire about risk behaviors. Established criteria were used for the diagnosis of PID. Data were analyzed using t tests, chi-square tests, and stepwise logistic regression. RESULTS: Persons with PID were significantly more likely to show younger age at first intercourse, older sex partners, involvement with a child protection agency, prior suicide attempt(s), consumption of alcohol before last sex, and a current Chlamydia trachomatis infection. There were no significant differences between the two groups regarding number of lifetime sex partners, condom use, rape, syphilis, prior PID, hepatitis B, hepatitis C, or HIV infection. CONCLUSIONS: Not previously noted in the literature are the association of PID with older sex partners, prior involvement in a child protection agency, and a prior suicide attempt. Confirming prior studies are the association of PID with earlier age at first sex, alcohol use, and C trachomatis infection.

Pediatric imported malaria in New York: delayed diagnosis.

The records of 20 children with imported malaria admitted to Kings County Hospital between October 1987 and May 1995 were reviewed. All had a history of recent travel or immigration from a malaria endemic area (West-Africa [16], Central-America [three], and the Caribbean [one]). None of the 10 children with a travel history received appropriate malaria chemoprophylaxis. The most common symptoms and signs were daily fever, chills, and hepatomegaly. Diagnosis was delayed in seven children who were initially felt to have pharyngitis or viral syndrome. Common laboratory findings were anemia and thrombocytopenia. P. falciparum was identified in 70% of the patients. Other species were P. malariae and P. vivax. Complications occurred in six children, hyponatremia in five, seizures in three, and cerebral malaria in one patient. The high incidence of chloroquine-resistant malaria makes chemoprophylaxis difficult in children. The clinical presentation of malaria is nonspecific, and diagnostic delays occur, so a high index of suspicion is needed in children with a travel history.

Obturator internus muscle abscess in children: report of seven cases and review.

Obturator internus muscle (OIM) abscess is an uncommon entity often mistaken for septic arthritis of the hip. We describe seven children with OIM abscess and review seven previously reported cases. The most common presenting symptoms were hip or thigh pain (14 patients), fever (13), and limp (13). The hip was flexed, abducted, and externally rotated in 11 patients. Magnetic resonance imaging and computed tomography (CT) were diagnostic for OIM abscess in the 14 patients. Associated abscesses were located in the obturator externus muscle (5 patients), psoas muscle (2), and iliac muscle (1). The etiologic agents were Staphylococcus aureus (8 patients), Streptococcus pyogenes (2), Neisseria gonorrhoeae (2), and Enterococcus faecalis (1). Three patients underwent CT-guided percutaneous drainage, and three had surgical drainage. Three patients had ischial osteomyelitis in addition to OIM abscess. The 11 children with uncomplicated OIM abscess were treated for a median of 28 days. All patients had an uneventful recovery.

Congenital syphilis: detection of Treponema pallidum in stillborns.

Paraffin-embedded tissue from all 17 autopsies performed following 56 stillbirths associated with maternal syphilis during a 3-year period (1987-1989) was reexamined to compare immunofluorescent antigen (IFA) testing with silver staining for the detection of Treponema pallidum. Congenital syphilis (CS) originally was diagnosed in 9 of the 17 cases of stillbirth, on the basis of positive silver stains (7 cases) or morphological findings alone (2). Upon review, silver staining revealed T. pallidum in 10 of 17 cases and IFA testing revealed the pathogen in 15 of 17 cases, enabling diagnosis of CS in 16 of 17 cases of stillbirth associated with a reactive maternal rapid plasma reagin (RPR) card test. Most stillbirths associated with a reactive maternal RPR test during this time period involved CS, and IFA testing for T. pallidum is superior to silver staining for the identification of treponemes.

Maternal immunity to measles and infant immunity at less than twelve months of age relative to maternal place of birth.

Sera from infants aged 5 to 11 months and from their mothers were used to investigate the level and duration of transplacentally derived measles antibody. The infants of foreign-born, inner-city mothers were more likely to have measles antibody and were less likely to get measles. Infants of foreign-born mothers, because they are less likely to respond to measles vaccine, may require different vaccine strategies than infants of mothers born in the United States.

Diagnosis of congenital syphilis by combining Treponema pallidum-specific IgM detection with immunofluorescent antigen detection for T. pallidum.

Most infants at risk for congenital syphilis can be identified easily by a positive maternal serologic test for syphilis. However, a diagnosis of congenital syphilis can be difficult to make in an individual infant. Seven infants with delayed-onset congenital syphilis and 101 newborns at risk for congenital syphilis were evaluated for characteristic physical findings and laboratory-detectable abnormalities of congenital syphilis. By using a combination of Western blot for T. pallidum-specific IgM detection and immunofluorescent antigen detection for the identification of T. pallidum, a diagnosis of congenital syphilis was made in all 7 infants with delayed-onset congenital syphilis and 24 of the 101 newborns at risk for congenital syphilis. However, T. pallidum-specific IgM was negative in 6 of the 24 newborns with congenital syphilis. T. pallidum-specific IgM detection alone is inadequate for the diagnosis of congenital syphilis.

Maternal and congenital syphilis in Brooklyn, NY. Epidemiology, transmission, and diagnosis.

OBJECTIVE: To define the epidemiology, to determine factors associated with transmission, and to describe the clinical and laboratory features of congenital syphilis. DESIGN: Retrospective chart review and prospective analysis. SETTING: Kings County Hospital Center, Brooklyn, NY. PATIENTS: A total of 403 pregnancies during a 23-month period associated with positive syphilis serological findings. RESULTS: Seventy-three pregnancies (18%) resulted in congenital syphilis (35 live-born and 40 stillborn neonates). Pregnancies associated with congenital syphilis were significantly associated with lack of prenatal care, lack of maternal therapy for syphilis, and a higher rapid plasma reagin titer, but not with a reported history of "crack" or cocaine use, although detection of cocaine in urine samples was more likely with positive syphilis serology. CONCLUSION: Most live-born infants with congenital syphilis (23 of 35) lacked rash, hepatosplenomegaly, or adenopathy but were identified by laboratory tests (roentgenograms, cerebrospinal fluid VDRL test, conjugated bilirubin determination, or aspartate aminotransferase levels in serum samples). Half of the infants with congenital syphilis were stillborn.

Evaluation of prophylaxis against hepatitis B in a large municipal hospital.

BACKGROUND: Perinatal transmission of hepatitis B can be interrupted by the administration of hepatitis B vaccine and hepatitis B globulin to the infants of carrier mothers. Universal screening of pregnant women makes this strategy possible. METHODS: To evaluate the implementation of universal hepatitis B surface antigen screening of women giving birth at Kings County Hospital Center during 1988, we reviewed laboratory records to find all women with a positive test result who might give birth. We also randomly reviewed records of women who gave birth to live infants to determine the percentage of screening in the population. Infants' charts were reviewed for documentation of maternal hepatitis B surface antigen status and administration of hepatitis B immune globulin and vaccine. RESULTS: Sixty infants who lived long enough to receive antihepatitis B prophylaxis were distinguished out of a total of 5146 births. Screening was done for from 66.8% to 80.4% (95% confidence interval) of the mothers of these infants. Although 44 of 60 infants received hepatitis B immune globulin and 39 of 60 infants received vaccine, only 27 of 60 received vaccine within 12 hours in combination with immune globulin (Centers for Disease Control-recommended therapy). CONCLUSIONS: Documentation of hepatitis B surface antigen in the infant's delivery room record was present in 23 of 60 infants. Those infants all received hepatitis B immune globulin and vaccine; 21 received hepatitis B immune globulin within 12 hours. Hepatitis B immune globulin was given within 12 hours to 8 of 37 infants who lacked documentation of hepatitis B surface antigen status on the delivery room record. These differences were highly significant (p less than 0.001) even when only the 40 patients who had documented prenatal screening at Kings County Hospital Center (21/23 vs 4/17). Prenatal care did not have any effect on outcome.

Gastric syphilis: five recent cases and a review of the literature.

OBJECTIVE: To describe five cases of early syphilis with gastric involvement and to review the literature pertaining to this disorder. DATA IDENTIFICATION: Five patients were diagnosed with gastric syphilis at Kings County Hospital and the Brooklyn Veterans Affairs Hospital between 1987 and 1990. English-language articles pertaining to gastric syphilis were identified by searching MEDLINE and by manually reviewing bibliographies of retrieved articles. STUDY SELECTION: Sources containing information pertinent to the clinical manifestations and diagnosis of gastric syphilis were selected. DATA SYNTHESIS: The most common clinical manifestations of gastric syphilis are abdominal pain, vomiting, and weight loss. Endoscopic findings in the stomach range from minimal nodularity and erythema to deep ulceration. Complications of gastric syphilis include hemorrhage, gastric outlet obstruction, and perforation. The diagnosis can be confirmed by serologic testing and by demonstration of spirochetes on silver and immunofluorescent stains of gastric mucosal biopsy specimens. Response to treatment is usually prompt and complete. CONCLUSIONS: The current syphilis epidemic will likely result in an increased incidence of gastric syphilis. Unless syphilis is considered as a cause of gastric mucosal inflammation and ulceration, misdiagnosis may delay appropriate treatment, and serious complications can occur.

Detection of Bordetella pertussis associated with the alveolar macrophages of children with human immunodeficiency virus infection.

In humans, infection with Bordetella pertussis is considered to be localized to an epithelial surface. However, an intracellular state in cultured cells and in the macrophages of infected animals has been shown. By using indirect immunofluorescence with a monoclonal antibody, it was found that 3 of 20 bronchoalveolar lavage specimens from children with human immunodeficiency virus infection had B. pertussis associated with pulmonary alveolar macrophages. None of the cultures from the patients grew B. pertussis. The B. pertussis appeared to be intracellular.

Comparison of maternal and newborn serologic tests for syphilis.

OBJECTIVE: To compare the cord blood, newborn serum, and maternal serum for the diagnosis of congenital syphilis. DESIGN: Retrospective chart review. SETTING: Kings County Hospital Center, Brooklyn, NY. PATIENTS: Three hundred forty-eight mother-newborn pairs with positive syphilis serology. MEASUREMENTS AND RESULTS: One hundred fifteen newborns (33%) had rapid plasma reagin tests of cord blood that were nonreactive. Their mothers had positive serologic findings. There were 10% false-positive cord blood samples (cord blood rapid plasma reagin tests reactive, newborn serum rapid plasma reagin tests nonreactive) and 5% false-negative cord blood samples (cord rapid plasma reagin tests nonreactive, newborn serum rapid plasma reagin tests reactive). Thirty-three newborns had congenital syphilis. Seven newborns had cord titers fourfold higher than their mothers'; only four of these newborns had congenital syphilis. Maternal serology is superior to cord blood analysis for identifying newborns at risk of congenital syphilis.

Early use of indirect immunofluorescence for the detection of respiratory syncytial virus in HEp-2 cell culture.

Respiratory syncytial virus is detected in cell culture by the presence of cytopathic effect. To detect RSV before cytopathic effect is usually seen, slides were evaluated retrospectively from 482 HEp-2 cell cultures on days 2-4 after inoculation. Indirect immunofluorescent staining detected RSV in 57 of 94 cultures that eventually were found positive by cytopathic effect. In an additional 19 cases that ultimately showed no cytopathic effect, RSV also was detected. In 15 of the latter cases, the presence of RSV was confirmed in the original specimen. Use of indirect immunofluorescence can be used to augment the sensitivity of cell culture for the detection of RSV because cytopathic effect may not always be evident.

Failure of recommended maternal therapy to prevent congenital syphilis.

A pregnant women with secondary syphilis received appropriate therapy with penicillin in the last trimester of pregnancy. At delivery, her titre had fallen fourfold, and the baby had a non-reactive cord blood titre at birth. However, the treatment failed to prevent infection in the infant, and the baby had developed signs of congenital syphilis at 10 weeks of age. The definition of "adequate therapy" of pregnant women is unclear, and recent guidelines are contradictory. Therefore, literature that pertains to penicillin therapy in pregnancy is reviewed, and new guidelines for therapy proposed.

Pneumococcal C and type polysaccharide detection in the concentrated urine of patients with bacteremia.

The C polysaccharide of Streptococcus pneumoniae was detected in the concentrated urine of 23 of 33 patients with pneumococcal bacteremia using latex agglutination. Type-specific polysaccharides were detected in the urine of 17 of these 33 patients including 4 patients lacking C polysaccharide in their urine. These 4 with the 23 detected above gave a total sensitivity of 82% (27/33). The concentrated urine from an additional 11 patients with other bacteremias were tested by C polysaccharide and type-specific reagents and were negative. C polysaccharide detection in the concentrated urine of patients may be helpful in the diagnosis of pneumococcal infections.

Rapid diagnosis of pneumonia in children.

Antigen detection techniques are available for the identification of bacterial polysaccharides, viruses, and chlamydia. Viruses and chlamydia are detected by direct immunofluorescence (DFA) or enzyme immunoassay (EIA). Bacterial polysaccharides are detected by latex agglutination or staphylococcal coagglutination of serum or concentrated urine. Most studies have not compared these techniques to the gold standard of lung puncture, so the role of dual infections with bacteria and viruses cannot be adequately determined. The sensitivity of any of these techniques is dependent on the quality of the antisera used. Monoclonal sera are now available for the detection of most viruses and seem to be as sensitive as polyclonal sera. DFA or EIA may offer equal sensitivity but their advantages and disadvantages must be considered by the local diagnostic laboratories. Most DFA and EIA systems have a sensitivity of 90% when compared with viral cultural for the identification of the organism. Agglutination reagents are available commercially for the detection of pneumococcal and Hemophilus influenzae type b polysaccharides. The sensitivity and specificity of each brand should be determined on serum or urine from patients known to have positive blood cultures and those free of disease. The brand chosen should be the one that has reasonable sensitivity and specificity. Rapid diagnostic techniques are helpful if they are used within a clinical context and they are positive. Negative tests do not rule out infection.