A cluster of Legionnaires' disease in a community hospital--a clue to a larger epidemic.

Four patients with atypical pneumonias admitted within a 1-week period to a community hospital were suspected and confirmed to have Legionnaires' disease. The patients had a common travel history. This cluster of cases uncovered a larger epidemic associated with cruise travel.

Outbreak of Legionnaires' disease among cruise ship passengers exposed to a contaminated whirlpool spa.

BACKGROUND: Outbreaks of travel-related Legionnaires' disease present a public-health challenge since rapid, sensitive, and specific diagnostic tests are not widely used and because detection of clusters of disease among travellers is difficult. We report an outbreak of Legionnaires' disease among cruise ship passengers that occurred in April, 1994, but that went unrecognised until July, 1994. METHODS: After rapid diagnosis of Legionnaires' disease in three passengers by urine antigen testing, we searched for additional cases of either confirmed (laboratory evidence of infection) or probable Legionnaires' disease (pneumonia of undetermined cause). A case-control study was conducted to compare exposures and activities on the ship and in ports of call between each case-passenger and two or three matched control-passengers. Water samples from the ship, from sites on Bermuda, and from the ship's water source in New York City were cultured for legionellae and examined with PCR. FINDINGS: 50 passengers with Legionnaires' disease (16 confirmed, 34 probable) were identified from nine cruises embarking between April 30 and July 9, 1994. Exposure to whirlpool spas was strongly associated with disease (odds ratio 16.2, 95% Cl 2.8-351:7); risk of acquiring Legionnaires' disease increased by 64% (95% Cl 12-140) for every hour spent in the spa water. Passengers spending time around the whirlpool spas, but not in the water, were also significantly more likely to have acquired infection. Legionella pneumophila serogroup 1 was isolated only from the sand filter in the ship's whirlpool spa. This isolate matched a clinical isolate from the respiratory secretions of a case-passenger as judged by monoclonal antibody subtyping and by arbitrarily primed PCR. INTERPRETATION: This investigation shows the benefit of obtaining a recent travel history, the usefulness or urine antigen testing for rapid diagnosis of legionella infection, and the need for improved surveillance for travel-related Legionnaires' disease. New strategies for whirlpool spa maintenance and decontamination may help to minimise transmission of legionellae from these aerosol-producing devices.

Unexplained immunodeficiency in children. A surveillance report.

From Oct 1, 1982, to Oct 1, 1983, the Centers for Disease Control (CDC) received reports of 35 children whose illness met the CDC definition of acquired immune deficiency syndrome (AIDS). All of the children had serious opportunistic infections without a known underlying illness to explain susceptibility to the infections. The 35 children were residents of ten different states; cases clustered in five major metropolitan areas. Three of the children had a parent with AIDS, and one child who had been previously reported had received a blood transfusion from a person in whom AIDS later developed. Most of the children had at least one parent in a population group in which adult AIDS cases have occurred. Many of the children had histories of prodromal symptoms, including pneumonitis, lymphadenopathy, hepatomegaly, and oral thrush. The mean age at onset of illness was 5 months, and the mean age at diagnosis was 12 months. To determine whether opportunistic infection in children without underlying immunodeficiency was truly a new phenomenon, a review of requests to the CDC for the drug pentamidine isethionate was undertaken. This revealed an apparent increase from 1979 to 1983 in Pneumocystis carinii pneumonia in children without known underlying immunodeficiency.

Transfusion malaria in the United States, 1972-1981.

Twenty-six cases of transfusion-induced malaria were reported in the United States from 1972 through 1981. In nine patients malaria was due to Plasmodium malariae; eight, P. falciparum; eight, P. vivax; and one, P. ovale. Four patients died. The estimated rate of transfusion malaria for this period was 0.25 cases per million donor units collected. Of the 18 cases in which a specific infective blood donor could be identified, at least nine of the donors should have been rejected for blood donation because of recent residence or travel to a malarious area. Among 17 patients for whom the national origin of the implicated blood donor was reported, 12 were born in malarious countries. We propose minor changes in donor procedures and standards, including stricter criteria for donors born in malarious countries. Potential donors should be deferred for 3 years after an unexplained febrile illness occurring 1 year after exposure to malaria.

A survey of malaria in Indochinese refugees arriving in the United States, 1980.

During the months April-June and October-November 1980, a survey was conducted among Indochinese refugees arriving in California to assess the prevalence of malaria. During the two study periods, 3,433 refugees were met and 3,289 (95.8%) of the arriving refugees were screened for malaria by examining thick blood smears and by indirect fluorescent malaria antibody tests of blood absorbed on filter paper. Examination of the blood smears showed that the overall patency rates were 1.7% and 0.6% for the first and second surveys, respectively. The Cambodian Refugees and refugees from camps in Thailand had the highest patency rate in the first survey. In the second survey, the Cambodian refugees and refugees from camps in Indonesia had the highest patency rate. The average malaria seropositivity rate was 15% in the first and 13.6% in the second survey. The Laotian refugees had the highest rate of malaria seropositivity in both surveys. Plasmodium vivax was the most commonly identified species in blood examination, while a higher rate of seropositivity to P. falciparum was found in both surveys. This study indicates that the malaria infection rate was at least 1.7% based on blood smear examination but might be as high as 45% based on serologic examinations. The results of this study when combined with malaria surveillance indicate that the likelihood of introduced malaria in the United States from the Indochinese refugees is low.

Studies of the plasma factor which induces augmented granulocyte adherence during hemodialysis.

Transient granulocytopenia develops during the first few minutes of hemodialysis, and is associated with a marked increase in granulocyte adherence as the cells marginate in the pulmonary circulation. The increased adherence is mediated by factors present in the plasma, thought to be complement components activated by the dialysis coil. In the present study, an assay of plasma for adherence-augmenting activity shows that it is maximal at 15 min after starting dialysis, and undetectable at 40 min. The factor is not affected by heating to 56 degrees C for 30 min, or by incubation at 37 degrees C for 7 days, nor does dialysis for 24 h against physiologic saline diminish its activity. However, exposure to pH 6.0 reduces the activity to 58.4% of control, and pH 5.0 reduces it to 40.1%. Finally, pretreatment of patients with prednisone before hemodialysis does not prevent granulocytopenia or increased adherence. These findings are discussed in relation to the known properties of various biologically active fragments of complement.

Comparative penetration of various cephalosporins into inflammatory exudate.

A rabbit sterile peritonitis model was used to determine the relative penetration of four cephalosporin antibiotics into exudate fluid. Male New Zealand white rabbits were given 120 ml of sterile saline intraperitoneally, and peritonitis developed over the following 8 h, with exudate fluid containing a mean of 17,188 granulocytes per mm(3) at 8 h. Each antibiotic was administered intramuscularly at a dose of 30 mg/kg 3 h after peritonitis was initiated, and serum and peritoneal concentrations were measured 0.5, 1, 2, and 4 h later. Cefamandole gave the highest mean peak serum level (26.8 mug/ml), and cephalothin, cephacetrile, and cephradine all gave peak serum levels between 13 and 15 mug/ml. When peak peritoneal exudate concentration was expressed as a percentage of peak serum concentration, cephradine developed 28.5% of the peak serum level, cephacetrile 27.7%, cephalothin 14.0%, and cefamandole 12.5%. These percentages of exudate penetration were inversely proportional to the degree of serum protein binding: cephradine 26.6%, cephacetrile 36.3%, cephalothin 50%, and cefamandole 88%.

Anaerobic spinal epidural abscess. Case report.

An acute spinal epidural abscess is reported from which a pure growth of the anaerobe Fusobacterium necrophorum was isolated. The mode of infection and pathogen makes it unique. The literature concerning the bacteriology of epidural abscess and the implications of anaerobic epidural infection are discussed.