Iatrogenic botulism. / Iatrogen botulisme.

This case study describes severe iatrogenic botulism following treatment with a botulinum toxin injection at a private clinic abroad.

[Brucellosis with acute arthritis and positive blood culture] / Brucellose med akutt artritt og positiv blodkultur.

BACKGROUND: Brucellosis is transmitted from infected animals to humans mainly by unpasteurised dairy products. Typical symptoms include undulant fever and arthralgia, but the disease can affect all organ systems and cause chronic debilitating and disabling illness. The condition is likely severely underdiagnosed, especially in impoverished populations. CASE PRESENTATION: A young girl presented with a one-day history of ankle pain and low-grade fever. She was born in a refugee camp in the Middle East, but lived with a Norwegian foster family and was considered to be healthy before the symptoms emerged. Blood culture surprisingly revealed growth of Brucella melitensis. She was successfully treated with a combination of trimethoprim-sulfamethoxazole and rifampicin. INTERPRETATION: This girl was likely infected with Brucella through ingestion of goat's milk, which she was given in the refugee camp. The disease presented with arthritis nearly two years after exposure.

Increased household transmission and immune escape of the SARS-CoV-2 Omicron compared to Delta variants.

Understanding the epidemic growth of the novel SARS-CoV-2 Omicron variant is critical for public health. We compared the ten-day secondary attack rate (SAR) of the Omicron and Delta variants in households using Norwegian contact tracing data, December 2021 - January 2022. Omicron SAR was higher than Delta, with a relative risk (RR) of 1.41 (95% CI 1.27-1.56). We observed increased susceptibility to Omicron infection in household contacts compared to Delta, independent of contacts' vaccination status. Among three-dose vaccinated contacts, the mean SAR was lower for both variants. We found increased Omicron transmissibility from primary cases to contacts in all vaccination groups, except 1-dose vaccinated, compared to Delta. Omicron SAR of three-dose vaccinated primary cases was high, 46% vs 11 % for Delta. In conclusion, three-dose vaccinated primary cases with Omicron infection can efficiently spread in households, while three-dose vaccinated contacts have a lower risk of being infected by Delta and Omicron.

Adaptation of Brucella melitensis Antimicrobial Susceptibility Testing to the ISO 20776 Standard and Validation of the Method.

Brucellosis, mainly caused by Brucella (B.) melitensis, is associated with a risk of chronification and relapses. Antimicrobial susceptibility testing (AST) standards for B. melitensis are not available, and the agent is not yet listed in the EUCAST breakpoint tables. CLSI recommendations for B. melitensis exist, but they do not fulfill the requirements of the ISO 20776 standard regarding the culture medium and the incubation conditions. Under the third EU Health Programme, laboratories specializing in the diagnostics of highly pathogenic bacteria in their respective countries formed a working group within a Joint Action aiming to develop a suitable method for the AST of B. melitensis. Under the supervision of EUCAST representatives, this working group adapted the CLSI M45 document to the ISO 20776 standard after testing and validation. These adaptations included the comparison of various culture media, culture conditions and AST methods. A Standard Operation Procedure was derived and an interlaboratory validation was performed in order to evaluate the method. The results showed pros and cons for both of the two methods but also indicate that it is not necessary to abandon Mueller-Hinton without additives for the AST of B. melitensis.

Whole-genome sequencing and antimicrobial resistance in Brucella melitensis from a Norwegian perspective.

Brucellosis is a rarely encountered infection in Norway. The aim of this study was to explore all Brucella melitensis isolates collected in Norway from 1999 to 2016 in relation to origin of infection and antimicrobial resistance patterns. A total of 23 isolates were analysed by whole-genome sequencing and compared with selected sequences of B. melitensis available from NCBI. Additionally, SNP analysis in antibiotic resistance determining genes was performed. The majority belonged to the East Mediterranean clade (genotype II), while the remaining isolates belonged to the African clade (genotype III). These results indicate that human brucellosis in Norway is related to travels or migration from the Middle East, Asia or Africa, in accordance with results from Germany, Denmark and Sweden. Antibiotic susceptibility patterns were determined by broth microdilution method and/or gradient strip method. All isolates were susceptible for all tested antibiotics, except for rifampicin where phenotypical results indicated resistance or intermediate resistance in all isolates based on broth microdilution method, and in four isolates based on gradient strip testing. In contrast, screening of the rpoB gene did not reveal any mutations in the previously described rpoB "hot spot" regions related to rifampicin resistance, indicating overestimation of resistance based on phenotypical results.

Soluble markers of the Toll-like receptor 4 pathway differentiate between active and latent tuberculosis and are associated with treatment responses.

BACKGROUND: Biomarkers to differentiate between active tuberculosis (TB) and latent TB infection (LTBI) and to monitor treatment responses are requested to complement TB diagnostics and control, particularly in patients with multi-drug resistant TB. We have studied soluble markers of the Toll-like-receptor 4 (TLR-4) pathway in various stages of TB disease and during anti-TB treatment. METHODS: Plasma samples from patients with culture confirmed drug-sensitive TB (n = 19) were collected before and after 2, 8 and 24 weeks of efficient anti-TB treatment and in a LTBI group (n = 6). Soluble (s) CD14 and myeloid differentiation-2 (MD-2) were analyzed by the Enzyme-linked immunosorbent assay (ELISA). Lipopolysaccharide (LPS) was analyzed by the Limulus Amebocyte Lysate colorimetric assay. Nonparametric statistics were applied. RESULTS: Plasma levels of sCD14 (p<0.001), MD-2 (p = 0.036) and LPS (p = 0.069) were elevated at baseline in patients with untreated active TB compared to the LTBI group. MD-2 concentrations decreased after 2 weeks of treatment (p = 0.011), while LPS levels decreased after 8 weeks (p = 0.005). In contrast, sCD14 levels increased after 2 weeks (p = 0.047) with a subsequent modest decrease throughout the treatment period. There was no significant difference in concentrations of any of these markers between patients with pulmonary and extrapulmonary TB or between patients with or without symptoms. CONCLUSION: Our data suggest that plasma levels of LPS, MD-2 and sCD14 can discriminate between active TB and LTBI. A decline in LPS and MD-2 concentrations was associated with response to anti-TB treatment. The clinical potential of these soluble TLR-4 pathway proteins needs to be further explored.

[Severe falciparum malaria treated with exchange transfusion]. / Alvorlig falciparummalaria behandlet med utskiftingstransfusjon.

BACKGROUND: Acute severe malaria can be seen at any Norwegian hospital. The prognosis of this serious disease depends on rapid and effective treatment. MATERIAL AND METHODS: Two case reports of patients treated with exchange transfusions are presented. RESULTS: Two young Norwegian women travelled without adequate prophylaxis against malaria in South-East Asia and Central and Southern Africa respectively. A few days after leaving the endemic areas they got high fever, joint and muscular pain, and headache. In one of the patients the symptoms were interpreted as flu symptoms; one week later the patient was admitted to hospital suffering from severe malaria. The other patient was admitted to hospital on the day she returned to Norway, six days after getting febrile. Thin blood films showed Plasmodium falciparum, with 30% and 40-50% parasitaemia respectively. Both patients were icteric with thrombocytopenia and increased creatinine. The first patient had severe renal failure and signs of cerebral affection. She was treated with haemodialysis and exchange transfusions. The other patient was treated with exchange transfusions because of her high parasitaemia. Both patients made a complete recovery and were discharged after three and two weeks. INTERPRETATION: Severe falciparum malaria is a condition with high case-fatality if diagnostics and treatment is not optimal. In especially severe cases, exchange transfusion may be lifesaving.