Encephalitis

From 1958, seventy-five cases of encephalitis of varying predisposing causes have been admitted and treated in San Lazaro Hospital. Among the predispositions were infectious diseases, vaccinia, serum and toxins. Ascaron, the toxin elicited by Ascaris, has caused encephalitis from which the patients recovered after the expulsion of the parasites. (Summary)

Limulus lysate positivity and Herxheimer-like reactions in leptospirosis: a placebo-controlled study.

Jarisch-Herxheimer reactions are characteristic of some spirochetal diseases and have been reported in leptospirosis, but their pathogenesis and relationship to endotoxin remain unclear. Serial limulus amebocyte lysate assays (LAL) for endotoxin were performed on 40 patients with proven leptospirosis who were monitored for reactions after receiving either intravenous penicillin (24) or saline placebo (16). No Herxheimer-like reactions were observed, although 78% of patients had at least one positive LAL. Serum creatinine, serum bilirubin, and white blood cell counts were significantly higher (P less than .01) in simultaneously drawn LAL-positive specimens than in negative ones. Delayed hepatic clearance of endotoxin due to liver dysfunction may explain the high LAL positivity rate, since assay results correlated with severity of disease but not with the presence or absence of spirochetes. Fear of a Herxheimer-like reaction should not dissuade clinicians from administering antibiotics to patients with leptospirosis.

Skeletal and cardiac muscle involvement in severe, late leptospirosis.

Information is lacking on the prevalence and severity of cardiac and striated muscle injury in late leptospirosis, and it is unclear whether patients with one type of myositis are at increased risk of developing another. Therefore, 38 patients with severe, late Weil's disease were evaluated for heart and skeletal muscle involvement: 37% had myositis and 39% had abnormal electrocardiograms (ECGs). First-degree atrioventricular heart block and changes suggestive of acute pericarditis were the most common ECG findings. Two patients had transient pericardial friction rubs, but neither pericardial effusion, shock, nor congestive heart failure occurred. Cardiac involvement was not associated with skeletal muscle injury (P = .35), although both manifestations were correlated with severity of disease. Thus, ECG changes and myositis were prominent features of late Weil's disease but cardiac morbidity was not.

Comparison of Tensilon and antivenom for the treatment of cobra-bite paralysis.

We prospectively compared the ability of anti-venom and edrophonium (Tensilon) to improve paralytic symptoms in 8 patients envenomed by the Philippine cobra (Naja naja philippinensis). Twenty, 50 or 100 ml of Philippine cobra antivenom were administered in a double-blind fashion by constant intravenous infusion over 30 min. Even the largest dose of antivenom failed to produce marked improvement within 2 h, though enzyme-linked immunosorbent assays and neutralization tests demonstrated that it possessed high titres of anti-neurotoxin antibodies. Tensilon given at 2 h was significantly more effective than antivenom at increasing the duration of upward gaze (78 +/- 28 vs 43 +/- 26 sec, P less than 0.001), and either completely reversed or markedly decreased paralysis in every patient. The Tensilon test should be given to all patients with paralytic envenoming by cobras, and anticholinesterases administered to those with a positive response.

Placebo-controlled trial of intravenous penicillin for severe and late leptospirosis.

The effect of a 7-day course of intravenous penicillin (6 million units/day) on severe, advanced leptospirosis was examined in a randomised, placebo-controlled, double-blind trial involving 42 patients. Every measurable aspect of the disease was favourably affected by penicillin. Fever lasted more than twice as long in the placebo group (11.6 [SD 8.34] days vs 4.7 [4.19] days, p less than 0.005), and by the fourth day after starting penicillin more than half the treatment group, but only 1 of 19 in the placebo group, were afebrile (p less than 0.005). Creatinine rises persisted more than thrice as long in the patients receiving only placebo (8.3 [8.46] days vs 2.7 [1.90] days; p less than 0.01). Penicillin also shortened the hospital stay and prevented leptospiruria. Intravenous penicillin should be given to patients with severe leptospirosis, even if therapy can be begun only late in the course of their disease.

Prevalence of renal involvement in Schistosoma japonicum infection.

244 outpatients and 100 hospitalized patients with confirmed Schistosoma japonicum infection were prospectively surveyed for the presence of nephropathy. There was no association between schistosomiasis and renal disease in the outpatient group. Three hospitalized patients had evidence of significant nephropathy, but this number was not significantly higher than in a control group of 100 hospitalized age and sex-matched control patients without schistosomiasis. One schistosomiasis patient with severe nephrotic syndrome underwent percutaneous renal biopsy. Neither S. japonicum antigen nor antibody was found in the biopsy specimen. 64 of the 100 hospitalized patients had portal hypertension; in 28 patients there was hepatic decompensation. Only one of these hepatosplenic patients had evidence of renal disease. Thus renal involvement was uncommon in patients presenting various manifestations of chronic S. japonicum infection, including those with severe hepatosplenic disease. These results contrast markedly with S. mansoni infection, in which nephropathy associated with advanced liver disease is a distinct, well-recognized clinical entity.

Cardiopulmonary involvement rare in severe Schistosoma japonicum infection.

In a prospective study, 65 consecutive patients hospitalized with Schistosoma japonicum infection were evaluated for evidence of cardiopulmonary involvement. Thirty-two patients had evidence of severe liver dysfunction while 11 patients had portal hypertension only. Of these 43 patients with hepatosplenic disease, only one patient had pulmonary hypertension. Cardiopulmonary involvement is relatively uncommon in severe S. japonicum infections.