Risk factors for idiopathic cerebellar ataxia of late onset.

In an attempt to identify risk factors for the development of idiopathic cerebellar ataxia (IDCA) we performed a case-control study of 59 IDCA patients. Hypertension and medicine intake were less frequent in IDCA than in neurological controls. Multiple logistic regression yielded an odds ratio (OR) for hypertension of 0.13 (95% confidence interval: 0.00-1.02, P=0.0527) and medicine intake of 0.10 (95% confidence interval: 0.00-0.72, P=0.0157). In contrast, we did not identify an association of IDCA with a number of medical diseases, head trauma, smoking, alcohol intake, rural living and well-water drinking. Some of these factors have been previously shown to be associated with other neurodegenerative diseases. In addition, serum antibody titers against neurotropic viruses were not elevated in IDCA.

Roe deer as sentinels for endemicity of tick-borne encephalitis virus.

The suitability of serological surveys of roe deer (Capreolus capreolus) in determining the spread of tick-borne encephalitis virus (TBEV) was tested in a south German area with a low risk of TBEV infection to humans. Sera obtained from 192 hunted roe were screened by an haemagglutination-inhibition test (HAI) and in an ELISA developed in our laboratory. Those found positive were tested in a neutralization test (NT). Fifty (26.0%) sera reacted positive by ELISA and 43 (86.0%) of these were confirmed by HAI or NT. Forty-seven (24.5%) samples were positive by HAI, 44 (93.6%) of which were also positive in NT or ELISA. Only insignificant increase of the antibody prevalence with age (P = 0.17 for HAI antibodies) suggests that most infections occur at an early age in scattered natural foci. The antibody prevalence in females was lower than in males (OR = 0.63; P = 0.02 for HAI antibodies). In determining the distribution of seropositive roe we increased the sample size to 235 sera. No antibodies were detected in 56 (23.8%) sera collected in the eastern third of the county. The areas of high antibody prevalence in roe match those in which humans have been infected. We conclude that serosurveys of roe deer are useful in marking out areas in which humans face the risk of infection, provided that an adequate number of sera, preferably from males, is available.

A H1 hemagglutinin of a human influenza A virus with a carbohydrate-modulated receptor binding site and an unusual cleavage site.

Two receptor binding variants of the influenza virus A/Tübingen/12/85 (H1N1) were separated by their different plaque formation in MDCK cells. Hemagglutination of variant I was restricted to red blood cells of guinea pigs, whereas variant II also hemagglutinated chicken cells. The variants differed also in their ability to bind to alpha 2,6-linked sialic acid. Evidence is presented that this difference is determined by a complex carbohydrate side chain at asparagine131 near the receptor binding site which is absent in variant II. With both variants, the arginine found at the cleavage site of all other human isolates analyzed so far was replaced by lysine.

Cerebellar encephalitis in adults.

We examined 11 adult patients with cerebellar encephalitis (CE) during the acute phase of the disease and at least 12 months later. Five patients were aged between 23 and 31 years, 3 patients between 43 and 44 years and 3 patients between 60 and 64 years. Serological tests gave evidence of Epstein-Barr virus infection in 4 of the 5 young patients. Two patients had serological evidence of varicella-zoster virus reactivation, whereas the serological findings were negative in all other cases. All patients in the younger and middle age groups recovered within 3-30 weeks after onset of CE. If at all, they had only minor cerebellar deficits at the follow-up examination. Magnetic resonance imaging (MRI) examination performed at the follow-up examination was normal in all of them. In contrast, 2 of 3 patients older than 60 years had persistent cerebellar ataxia following CE. In these patients, MRI revealed infratentorial atrophy. Our data show that the clinical spectrum of CE in adults is wider than assumed so far. In addition to typical cases of CE in young male patients with good recovery, CE may also occur in older patients and give rise to persistent cerebellar ataxia.

Stability of respiratory syncytial virus antigen due to buffer treatment for direct detection in nasopharyngeal specimens with enzyme immunoassay.

We developed an enzyme immunoassay (direct EIA; Enzygnost RSV[Ag]) for the direct detection of respiratory syncytial virus (RSV) antigen in nasopharyngeal specimens (NPS). The test procedure is the same as our recently described direct EIA for detection of influenza A and B virus antigens in NPS. For practical purposes it is of advantage to differentiate respiratory viruses on the same microtitration plate in the same run. The test shows no limitations by sample consistency, and results are obtained within 4 hr. In contrast to other test systems, sonification is not necessary. This is due to the sample buffer STD. We studied the influence of sample buffer STD on the stability of RSV (strain Long) antigen at different temperatures over a period of 7 days. PBS-BSA-buffer served as control. The treatment and storage of RSV (strain Long) with sample buffer STD at room temperature or at 4 degrees C showed no decrease of antigen detectability. The antigen is very stable in contrast to the storage of RSV (strain Long) in PBS-BSA buffer during the observation period of 7 days. Consequently, when NPS are stored in sample buffer STD, results of direct EIA are independent from the time of transport and temperature within 7 days. Thirty-eight NPS from infants with confirmed RSV infection were investigated. Confirmation was performed by virus isolation (n = 29) or with commercially available enzyme immunoassays or immunofluorescence test (n = 9). The direct EIA showed a specificity of 99.3% (n = 140) and a sensitivity of 95% (n = 38).

Spontaneous splenic rupture complicating acute Q fever.

Q fever is usually a self-limited febrile illness that involves the lungs and the liver. Acute complications are rare. We present the case of a 30-yr-old patient with spontaneous splenic rupture during the course of acute Q fever infection. He was admitted to the hospital with high temperature and the radiological signs of an atypical pneumonia. Forty-eight hours after admission, he developed shock. Because of free intraabdominal liquid, a laparatomy was performed that revealed a tear in the enlarged spleen. A splenectomy was performed. The diagnosis of Q fever was established by a significant titer increase in complement fixation test and IgM-ELISA. Serological investigations into the patient's surroundings revealed evidence of Q fever infection in 10 additional persons. Q fever should be taken into account as a possible differential diagnosis in patients with unexplained febrile illness and symptoms of pneumonia. The acute course of Q fever infection can be complicated by splenic rupture. The diagnosis of an acute infection with Coxiella burnetii often requires serologic testing of a second serum sample obtained at least 10 days after the onset of symptoms. Q fever should be ruled out in cases of unexplained splenic rupture particularly in Q fever endemic areas.

Direct detection of influenza virus antigen in nasopharyngeal specimens by direct enzyme immunoassay in comparison with quantitating virus shedding.

We developed a direct enzyme immunoassay [EIA; Enzygnost Influenza A(Ag) and Enzygnost Influenza B(Ag)] for the direct detection of influenza A and B virus antigens in nasopharyngeal secretion specimens (NPS). The test is performed without sonification of specimens, and results are obtained within 4 h. A direct comparison between direct EIA and quantitation of virus shedding for influenza A and B virus antigen detection was carried out. A total of 210 NPS and 98 nasopharyngeal wash specimens (NPW) were investigated. We isolated influenza A viruses from 79 (37.6%) of 210 NPS; of these 79 cell-culture-positive NPS, 70 (88.6%) were also positive by direct EIA. Of 29 (13.8%) NPS from which influenza B virus was isolated, 24 (82.8%) NPS were positive by direct EIA. Virus shedding was determined quantitatively in 48 NPS from patients with influenza A and in 24 NPS from patients with influenza B. Only a crude correlation between optical density values and virus concentrations was observed. Detection of influenza virus antigens in NPS by direct EIA showed sensitivities of 89.7% for influenza A virus and 87.9% for influenza B virus and specificities of 99.3% for influenza A virus and 100% for influenza B virus. With direct EIA, all NPW were negative for influenza A virus, although virus was isolated from 21 (21.4%) NPW. Of 15 NPW from which influenza B virus was isolated, 7 showed positive results in direct EIA. In addition, direct EIA is suitable for detecting influenza A and B viruses in cell cultures before the appearance of any cytopathic effects and can be used as a cell culture confirmation test.

[Toxic epidermal necrolysis (Lyell's syndrome) after rubella]. / Toxische epidermale Nekrolyse (Lyell-Syndrom) nach Röteln.

Rubella was confirmed clinically and serologically in a 14-year-old boy who had been admitted with mild general symptoms and an exanthematous rash presenting with medium size maculae. Within only three days the exanthema had faded. Five days later the boy again became ill with high fever (40 degrees C) and renewed erythema with at first irregular then rosette-like and widely confluent spots. On admission several nonspecific inflammatory signs were markedly elevated (erythrocyte sedimentation rate, C-reactive protein, alpha-globulin). There were mild abnormalities of left-ventricular repolarization at the electrocardiography. The skin changes were progressive and at first interpreted as erythema exudativum multiforme. Fever persisted, despite antibiotic treatment, and signs of epidermolysis appeared. After the diagnosis of non-staphylogenic Lyell's disease was made high-dosage prednisolone administration was begun (initially 3 mg/kg in 6 hours, then 2.5 mg/kg daily for 8 days). The patient's condition and the electrocardiographic findings returned to normal within 2 days. The epidermolysis was arrested within a few hours and the blisters dried out within 24 hours. There were no complications. Since no drugs were given before the second day of epidermolysis being noted, it is highly likely that rubella precipitated Lyell's disease.

[Croup and air pollutants: results of a two-year prospective longitudinal study]. / Krupp und Luftschadstoffe: Ergebnisse einer Zweijährigen prospektiven Längsschnittstudie.

The Reutlingen/Tübingen/Rottenburg region in Baden-Württemberg is characterized by medium and small sized towns and rural areas. In 1986/87 875 cases of croup were registered there by the treating physicians during a 24-months period. In consideration of meteorological and virological "disturbing variables" the influence of the measured air pollution by SO2, NO, NO2, CO, ozone and dust on croup frequency was computed by means of statistical regression methods. For the months September till March, the main manifestation period of croup, weak but statistically significant influences of the daily means of NO and NO2 were found, for the whole year influences of NO, NO2, and CO. During the winter months temperature correlates positively and velocity of wind negatively, both statistically with significance, to croup frequency. The essential conditions of croup are individual and familiar disposition on the one hand, virus infections on the other. Air pollution of a concentration like given in the investigated region was found to be a weak additional factor that favours the manifestation of croup.

[Rapid diagnosis of influenza virus infections from nasopharyngeal secretions]. / Schnelldiagnose von Influenzavirusinfektionen aus Nasen-Rachen-Sekreten.

Since virus isolation consumes a lot of work and time, and virus specific antibodies are not detectable before several days after the onset of illness we developed an enzyme immunoassay (ELISA) for the detection of influenza A and influenza B virus antigen in nasopharyngeal specimens (NPS). This test permits antigen detection within four hours. This ELISA was tested with 119 NPS from children, most of these between 1-12 years old. Virus isolation in MDCK-cells served as control. A total of 67 influenza A/H3N2-, 10 influenza A/H1N1, and 2 influenza B viruses were isolated from cell cultures. 68 (88.3%) of the NPS reacted positive in influenza A virus antigen ELISA, 2 in influenza B virus antigen ELISA, and 9 reacted falsely-negative. The failure to detect antigen could not be solely due to low antigen concentration in the NPS because in 5 materials high concentrations of infectious virus were shown in cell culture. The test allows the rapid diagnosis of influenza virus infections with high efficacy also for laboratories without the facility to perform tissue culture. For accelerating the diagnosis by isolation of viruses in cell cultures, ELISA is useful as cell culture confirmation test, because influenza virus antigen is detectable before a cytopathogenic effect appears.

[Prospective one-year epidemiologic longitudinal study of air pollutants and the incidence of croup]. / Prospektive epidemiologische Einjahreslängsschnittstudie über Luftschadstoffe und Krupp-Häufigkeit.

Among a population of 18,175 children below 7 years of age in medium sized towns and rural areas in south-western Germany 552 (3.03%) cases of croup were registered during a 12 months period in 1984-85 by their physicians. Distributions according to months, sex and age at the onset of the disease were the same as in other recent investigations: The level of the air-pollution measured (SO2, NOx, CO, CO2, ozone and dust) was low (highest monthly means in microgram/m3: SO2 88, NO2 73, NO 119, dust 41). There was no relevant influence of the degree of air pollution on croup-frequency. The rise of croup-frequency shortly after a period of several days of higher pollution was accompanied by an influenza epidemic as proved by virus isolations.

[The 1985 influenza epidemic in a pediatric practice]. / Influenza-Epidemie 1985 in einer Kinderarztpraxis.

Because it is not possible to distinguish clinically influenza from other respiratory infections, virological methods have to be used to establish the influenza etiology. Nasopharyngeal swabs from 202 children with respiratory symptoms were taken. Influenza A virus (H3N2) was isolated from 44 children, influenza A virus (H1N1) from 61 children and influenza B virus from 13 children. The maximal activity of the two influenza A virus subtypes was different. The following features permitted the classification of 3 groups; monophasic fever greater than or equal to 38.5 degrees C (81.35%), biphasic fever (14.41%), and pseudocroup (4.24%). 16.1% of the children with fever also had gastrointestinal symptoms. No relation between influenza type/subtype and type of manifestation could be established.

Subtype-specific identification of influenza virus in cell cultures with FITC labelled egg yolk antibodies.

We report on results obtained with a direct immunofluorescence test for subtype-specific identification of influenza virus in detached cells of MDCK cultures after inoculation of 281 clinical specimens from patients with influenza-like disease. Influenza virus antibodies were produced in eggs from immunized hens and labelled with FITC. In 157 cases CPE was found in MDCK cells. A total of 57 cases of influenza A (H3N2), 86 cases of influenza A (H1N1), and 14 cases of influenza B were identified. In 33 cases of influenza A (H1N1) infection with massive CPE guinea pig but not chicken erythrocytes were agglutinated by the cell culture supernatants. The single step immunofluorescence test described proved easy to perform and results were obtained within 1 h after CPE was observed in contrast to the conventional HIT which is very time-consuming.

Diagnostic significance of influenza subtype-specific IgG, IgA, and IgM antibodies.

Up to now, the complement fixation test (CFT) has been the basis for the serological diagnosis of influenza virus infection in routine laboratories. Generally, low CF titers (1:20 or 1:40) are difficult to interpret. This means that the differentiation between recent and remote influenza infections is not possible by CFTs on single sera. Nonetheless this is generally possible by the subtype- and immunoglobulin class-specific immunofluorescence test (IFT) reported in this paper. Sera from 76 patients with confirmed influenza infection were tested and we obtained the following results: only 27.6% contained antibodies of all immunoglobulin classes, 51% contained IgG and IgA antibodies (without IgM) and 3.9% responded only with the IgG isotype. The IFT-positive and CFT-negative were 5.2% and the IFT-negative and CFT-positive 4%. In 7.9% no antibody rises were detected by CFT or by IFT despite virus isolation. Results from IFT may permit the interpretation of low CF titers. In contrast to CFT, IFT makes possible the differentiation between vaccinated and unvaccinated persons because vaccinated persons regularly produce IgM antibodies against all strains of the vaccine.

Brucellosis: serological methods compared.

At least 12 persons contracted clinical, and 4 persons subclinical Brucella melitensis infection during a brucellosis epidemic in the spring and summer of 1983 in Southern Germany, a region which had been free of this disease for the past 20 years. All cases of illness were traced to one infected herd of sheep. The presence of antibodies against B. melitensis was examined in 72 sera of infected patients using the following tests: agglutination, Coomb's test, two complement fixation tests with different antigen preparations (CFT 1 and 2), IgG and IgM enzyme-linked immunosorbent assay (ELISA), and opsonophagocytosis; and the occurrence of cross-reacting antibodies against Yersinia enterocolitica O 9 was investigated in the agglutination and complement fixation tests. Sera from 100 blood donors and 112 other people with close contact with sheep were also examined. The results revealed the need to consider an intermediate range in the interpretation of ELISA results--due to elevated values of persons in groups at risk but without clinical signs of illness. In all other tests, however, such persons revealed the same cut-off levels as the general population. Results from all initial sera of infected persons revealed titres of optical densities above the baseline levels determined in the present study, with the exception of the Coomb's and CFT2 tests. The agglutination test, but not brucella CFT2, revealed complete cross-reactivity between Y. enterocolitica O 9 and B. melitensis. ELISA stood out as the only test which is suited to diagnosis of both recent and past infection, since ELISA IgM determination permits conclusions about the time of the onset of illness, and determination of IgG may still yield values above the cut-off level up to 623 days after the onset of illness. In 2 of the 16 infected persons, IgG ELISA was the only test revealing previous infection 424 and 528 days after the onset of illness. A procedural scheme is presented which may help to simplify the diagnosis of brucellosis.

Immunofluorescence test with antigen-loaded erythrocytes: detection of influenza virus specific IgG, IgA, and IgM antibodies.

An immunofluorescence test (IFT) for the detection of influenza virus antibodies was established to supplement the standard serological diagnostical complement fixation test (CFT). Current strains (A/Philippines/2/82, A/Brazil/11/78, B/Singapore/222/79) were loaded on formalinized chicken erythrocytes. In contrast to CFT, we can distinguish specific immunoglobulin classes against influenza virus. Unlike CFT, IFT is subtype-specific. A recent infection can be distinguished from a past infection by the differentiation of specific immunoglobulin classes. Anticomplementary factors and hemolytic sera do not influence the result of the IFT. IFT does not require cell cultures and is easy to read.

Early diagnosis of Q fever: detection of immunoglobulin M by radioimmunoassay and enzyme immunoassay.

The use of a radioimmunoassay and an enzyme immunoassay for early diagnosis of Q fever is described, both of which are based on the IgM antibody-capture principle. A commercially available phase II antigen and a labeled, purified anti-Q-IgG of human origin were employed. With these tests Q fever antibodies were detected earlier in the course of infection than with the complement fixation test.