Reduced susceptibility to penicillin of viridans group streptococci in the oral cavity of patients with haematological disease.

The occurrence of oral penicillin-resistant viridans group streptococci (VGS) was studied in 50 patients with either newly diagnosed acute leukaemia or autologous peripheral stem cell transplants. One patient was excluded because of Staphylococcus aureus growth in the stem cell harvest. VGS were isolated from the oral cavity of 48 of the remaining 49 patients. Of these 48 patients, 12 (25%) yielded VGS resistant (MIC > 2 mg/L) to penicillin. These 12 patients had a higher frequency of septicaemia (p 0.04) and more days of treatment with trimethoprim-sulphamethoxazole (p 0.04) than patients who harboured susceptible or intermediately resistant VGS (MIC 2 mg/L). There were no other statistically significant differences between the two groups. It is important to be aware of the high level of penicillin resistance in oral VGS in patients with haematological disease, and this parameter should be considered when selecting antibiotic therapy for cases of septicaemia caused by VGS in immunocompromised patients.

Polymerase chain reaction for diagnosis of cerebral toxoplasmosis in cerebrospinal fluid in HIV-positive patients.

It is important but sometimes difficult to establish a diagnosis of toxoplasma encephalitis (TE) in an HIV-positive immunodeficient patient. The most promising non-invasive method is polymerase chain reaction (PCR) for Toxoplasma gondii in cerebrospinal fluid (CSF). In a retrospective study PCR was used to analyse CSF for the presence of T. gondii DNA in 5 HIV-infected patients with a clinical suspicion of TE (group 1), 8 patients with other HIV-associated symptoms (group 2) and 7 other patients with neurological disorders (group 3). PCR was positive in 2/4 patients with a final diagnosis of TE and negative in all remaining patients in all 3 groups. The 2 patients with positive PCR had a fulminant course and experienced treatment failure. The albumin index was elevated in 4/5 patients in group 1, of whom 3/4 had a final diagnosis of TE, with suspected TE in 1. This small study confirms earlier data indicating that the PCR test has a low sensitivity but a high specificity.

Prospective study of prognostic factors in community-acquired bacteremic pneumococcal disease in 5 countries.

To define the influence of prognostic factors in patients with community-acquired pneumococcal bacteremia, a 2-year prospective study was performed in 5 centers in Canada, the United States, the United Kingdom, Spain, and Sweden. By multivariate analysis, the independent predictors of death among the 460 patients were age >65 years (odds ratio [OR], 2.2), living in a nursing home (OR, 2.8), presence of chronic pulmonary disease (OR, 2.5), high acute physiology score (OR for scores 9-14, 7.6; for scores 15-17, 22; and for scores >17, 41), and need for mechanical ventilation (OR, 4.4). Of patients with meningitis, 26% died. Of patients with pneumonia without meningitis, 19% of those with >/=2 lobes and 7% of those with only 1 lobe involved (P=.0016) died. The case-fatality rate differed significantly among the centers: 20% in the United States and Spain, 13% in the United Kingdom, 8% in Sweden, and 6% in Canada. Differences of disease severity and of frequencies and impact of underlying chronic conditions were factors of probable importance for different outcomes.

Endocarditis: clinical outcome and benefit of trans-oesophageal echocardiography.

The improved prognosis for infective endocarditis (IE) seen in the last decade is due partly to more active surgical treatment and partly to improved diagnosis by echocardiography. To evaluate the clinical value of repeated trans-oesophageal echocardiography (TEE) 34 patients with 35 episodes of suspected IE were included in a prospective part of the study (group A). TEE was carried out for diagnosis, at discharge and about 5 months after hospitalization. Endocarditis was classified using Duke's criteria. In a retrospective part of the study 32 other patients with 34 episodes of IE were included (group B). Both groups were analysed regarding mortality, frequency of surgery and classification according to Duke. The diagnosis was regarded as definite in 49 and possible in 20 episodes. Vegetation-size decreased significantly (p < 0.001) during treatment. In contrast, no significant changes in valvular insufficiency were found. In episodes diagnosed as definite, the mortality was 2/49 (4.1%). The low mortality might be explained by the high frequency of surgery (22%), the inclusion of patients with right-sided IE, and 'early diagnosis'. The first TEE was important for correct diagnosis in patients with small vegetations and for those needing surgery. The clinical value of the additional investigations was low in native valve endocarditis.

[Tuberculosis a threat again. Multiresistance in the Baltic States and in Russia; Nordic countries initiate cooperation to prevent transmission]. / Tuberkulos åter ett hot. Multiresistens i Baltikum och Ryssland; nordiskt samarbete inlett för att hejda spridning.

The incidence of tuberculosis (TB) has more than doubled in the Baltic States during the last decade and is now 10-15 times higher than in Sweden. It is also a serious problem in Russia. Strains resistant to one or several of the anti-tuberculous drugs are common as is multi-drug resistance (MDR), i.e. strains resistant to the two most effective drugs rifampicin and isoniazid. MDR-TB is very difficult to treat; the mortality rate is high. Initiatives have been taken in the Nordic countries in order to help to control and improve the situation by way of supportive measures.

[Shortages in Swedish tuberculosis care. Good results only in 71 percent of cases after 12-month treatment as shown in a current study]. / Det finns brister inom den svenska tuberkulosvården. Fullgott resultat efter tolv månader hos endast 71 procent visar aktuell studie.

During the period August 1994-December 1995 783 cases of active tuberculos (TB) were notified to the health authorities in Sweden. By means of questionnaires sent to the consulting physicians (92 per cent response rate) the treatment outcome was studied twelve months after the diagnosis. Out of 676 patients only 71 per cent were reported to have completed the treatment and be cured of TB. This indicates that there is room for improvement as regards monitoring patients, if necessary by Directly Observed Therapy (DOT), in order to make sure that prescribed treatment is adhered to.

[Extrapulmonary tuberculosis--an infection of concern in most clinical settings]. / Extrapulmonell tuberkulos--en infektionssjukdom som berör de flesta kliniker.

In a retrospective study at the Department for Infectious Diseases at Huddinge Hospital, 57 patients with extrapulmonary tuberculosis were identified from 1992 to 1997. Two categories of patients were found: young persons born abroad (the largest group) and elderly persons born in Sweden. Most patients showed a positive PPD, and the diagnosis was verified through bacteriological culture in 42/51 (82 per cent). Patients had sought help in a number of different clinical settings. Only four patients were shown to have resistant strains. This study demonstrates the difficulties inherent in the diagnostic process, with a long interval between appearance of symptoms to start of treatment: median 8 weeks but with a wide range. For one quarter of the patients, data sufficient to warrant conclusions regarding completed treatments are lacking. Efforts to increase knowledge on the part of medical personnel, compliance on the part of patients, and improvements in follow-up are essential in order to halt the spread of tuberculosis, to reduce morbidity and to prevent the development of resistance.

Salivary sIgA response in HIV-1 infection.

Local and systemic production of total and HIV-1 specific IgA was determined in whole saliva and serum from 45 HIV-1-infected individuals and 15 healthy controls. The antigenic domains important for sIgA and IgG binding, respectively, was investigated with epitope mapping using synthetic peptides of HIV-1 proteins. Decreased levels of total sIgA in saliva were found among patients with low CD4+ cell counts in advanced stages of acquired immunodeficiency. HIV-1 specific IgA response, predominantly directed to the envelope proteins, was found in saliva and serum also at later stages of disease. Analyses using peptide enzyme-linked immunosorbent assays (ELISA) showed that the sIgA antibody response in saliva was mainly directed to the V4 region (aa 385-409) and a more C-terminal part of the V3-region (aa 325-344) compared with the IgG response, which predominantly was directed to a more central part of the V3 loop (aa 308-325). A similar picture was seen for immunoglobulins of the two isotypes derived from serum. We have in this study shown IgA epitope-specific immune response within HIV-1 gp160, indicating that antibodies of IgA isotype may recognize somewhat different antigenic domains compared to IgG antibodies.

Shedding of cytomegalovirus and herpesviruses 6, 7, and 8 in saliva of human immunodeficiency virus type 1-infected patients and healthy controls.

We used the polymerase chain reaction to study the presence of DNA from cytomegalovirus (CMV) and human herpesvirus (HHV)-6, HHV-7, and HHV-8 in saliva from 44 human immunodeficiency virus (HIV) type 1-infected patients at different stages of disease and in 15 healthy HIV-seronegative controls. CMV DNA, HHV-6 DNA, and HHV-7 DNA were found in all groups, but HHV-8 DNA was found only in symptomatic HIV-1-infected patients (5 [17%] of 29). One of the patients with HHV-8 DNA in saliva had oral Kaposi's sarcoma at the time of sampling, and another later developed the tumor. CMV DNA was found most often in the patients with AIDS. HHV-6 shedding tended to be less frequent among HIV-1-infected patients than among healthy controls. HHV-7 DNA was detected least frequently in the group of patients with AIDS. The presence of viral DNA was not correlated either with antiherpesvirus drug therapy or with oral symptoms, apart from Kaposi's sarcoma.

Virulence factors of Staphylococcus aureus in the pathogenesis of endocarditis. A comparative study of clinical isolates.

It is now generally accepted that adherence of microorganisms to various components of cardiac valve surfaces or vegetation lodging on the heart valves is an important early event in the pathogenesis of infective endocarditis. 120 clinical isolates of S. aureus obtained from patients with endocarditis and wound infections and from nasopharyngeal carriers were quantitatively analysed in vitro for their ability to bind to fibronectin and to produce protein A and alpha-toxin. Both cell-bound and extracellular protein A were measured and alpha-toxin was determined as antigen and as haemolytic activity. The highest fibronectin binding ability was found in carrier strains while no significant differences between strains were observed regarding the production of protein A. Strains isolated from patients with endocarditis produced significantly lower amounts of alpha-toxin than did strains from the other two groups. An inverse relationship between the production of protein A and of alpha-toxin was noticed in the material. Animal passage of five strains in an experimental endocarditis model showed a good reproducibility of the test systems and one strain was upregulated in its fibronectin binding ability and in alpha-toxin production. These in vitro results indicate that the fibronectin binding ability is not the decisive adherence factor and question the role of alpha-toxin as a virulence factor in endocarditis.

[Policy program to minimize spread of infection. Prolonged cough may be a sign of tuberculosis]. / Policyprogram för minskad smittspridning. Långdragen hosta kan vara tuberkulos.

In a worldwide epidemiological perspective, Sweden is well favoured with an annual tuberculosis incidence of approximately six cases per 100,000 of the population. Neither the impact of the HIV pandemic nor the occurrence of multiresistant strains of Mycobacterium tuberculosis has yet become a major problem in the care of tuberculosis patients in Sweden. Only a few per cent of HIV patients have developed tuberculosis, and during the period, 1991-94, only one per cent of M. tuberculosis isolates in Sweden were resistant to such antimycobacterials as isoniazid and rifampicin. However, the epidemiological situation in the neighbouring Baltic states is a matter for concern. Bovine tuberculosis has been eradicated in Sweden, the last case having been diagnosed in 1978. Although the reported efficacy of BCG (bacillus Calmette-Guérin) tuberculosis vaccine varies according to the population studied, protective rates of 70-85 per cent have been reported for Sweden and other west European countries. Re-vaccination of tuberculin-negative individuals has not been shown to yield added protection. The aim of a national programme for protection against tuberculosis is to preserve our favourable epidemiological situation by early detection of new cases, effective contact tracing, and BCG vaccination of children in population groups at risk. The primary means of achieving this is the education of health care personnel to retain tuberculosis as a differential diagnosis. Moreover, national guidelines for contact tracing must be duly observed, and immigrants from high prevalence areas need to be screened for tuberculosis. Registration of all cases of tuberculosis should be maintained at regional and national levels, and follow-up must be meticulous until a successful outcome of treatment is accomplished. Recommendations for dealing with tuberculosis should be made available and duly implemented at all hospitals caring for tuberculosis patients, in order to avoid nosocomial transmission. Although BCG vaccination at birth was formerly general in Sweden, since 1975 only children considered to be at risk have been vaccinated. Thus, non-vaccinated young adults are now entering the health care sector as students or employees, and should be offered BCG vaccination. Moreover, the epidemiological situation both in Sweden and in neighbouring countries needs to be monitored carefully in order that recommendations concerning BCG vaccination and other preventive measures can be modified if necessary.

Prevalence and risk factors for HTLV-II infection in 913 injecting drug users in Stockholm, 1994.

The prevalence and risk factors for acquisition of human T-cell lymphotropic virus type I and II (HTLV-I and II) were investigated in a prospective study of 913 injecting drug users (IDUs) in Stockholm in 1994. Epidemiologic data were recorded, and blood samples were tested for antibodies against HTLV-I and HTLV-II; human immunodeficiency virus (HIV) types 1 and 2; and hepatitis A (HAV), B (HBV), C (HCV), and D (HDV). Positive serologic results for HTLV were confirmed by Western blot (WB) and polymerase chain reaction (PCR). Of the 905 participants with conclusive HTLV-II status, 29 (3.2%) were HTLV-II positive, and all but three were of Nordic descent. None was HTLV-I infected. One person was infected as early as 1981, before HIV had reached the IDU population in Sweden. The prevalence of HTLV-II infection was 12% among HIV-1-seropositive and 1.8% among HIV-1-seronegative participants. The overall seroprevalences were 14% for HIV-1, 0% for HIV-2, 41% for HAV, 75% for HBV, 92% for HCV, and 8% for HDV. Although amphetamine has been the main injecting drug in Sweden for several decades, heroin abuse combined with a debut of injecting drugs before 1975 was identified as the most important risk factor associated with HTLV-II infection. HAV and HIV seropositivity were also independent risk factors.

Penicillium marneffei infection in a Swedish HIV-infected immunodeficient narcotic addict.

We report a case of Penicillium marneffei infection, acquired in Thailand, in a Swedish HIV-infected immunodeficient heroin addict. This is the first case of penicilliosis marneffei diagnosed in Sweden. The patient had fever without focal symptoms. Cultures from bronchoalveolar lavage fluid and a mediastinal lymph node yielded the dimorphic fungus Penicillium marneffei. Treatment with amphotericin B followed by itraconazole was successful. Penicillium marneffei infection should be considered in HIV patients with fever who have visited Southeast Asia, especially northern Thailand and southern China.

Acyclovir and prednisolone treatment of acute infectious mononucleosis: a multicenter, double-blind, placebo-controlled study.

Ninety-four patients with infectious mononucleosis and symptoms < or = 7 days were randomized to treatment with oral acyclovir (800 mg 5 times/day) and prednisolone (0.7 mg/kg for the first 4 days, which was reduced by 0.1 mg/kg on consecutive days for another 6 days; n = 48), or placebo (n = 46) for 10 days. Oropharyngeal Epstein-Barr virus (EBV) shedding was significantly inhibited during the treatment period (P = .02, Mann-Whitney rank test). No significant effect was observed for duration of general illness, sore throat, weight loss, or absence from school or work. The frequency of latent EBV-infected B lymphocytes in peripheral blood and the HLA-restricted EBV-specific cellular immunity, measured 6 months after onset of disease, was not affected by treatment. Thus, acyclovir combined with prednisolone inhibited oropharyngeal EBV replication without affecting duration of clinical symptoms or development of EBV-specific cellular immunity.

Multiple serovars of Mycobacterium avium complex in patients with AIDS.

Mycobacterium avium complex (MAC) was isolated and serotyped from 127 samples from 43 HIV-infected patients with disseminated disease in Sweden. Thirteen different serovars were observed. Serovar 6 was the most common, followed by 4, 9 and 11. Serovar 8 was rare. In 22 of the patients the same serovar was found in blood and at other sites. Clinical symptoms and outcome were compared in patients with different serovars. Analysis of patient records revealed no association between clinical picture and any specific serovar. The median survival time after MAC infection was 7 months. Somewhat shorter survival was observed in patients with serovar 4 than in those with serovar 6.

Classification of infective endocarditis by Duke's criteria and transesophageal echocardiography: a 1-year retrospective analysis.

A sensitive, specific, and rapid diagnosis of infective endocarditis (IE) is important for prognosis, and to exclude IE and thus avoid prolonged treatment with antibiotics. The diagnostic system for IE according to Duke's university includes echocardiographic results and classifies patients in 3 categories--'definite', 'possible', and 'rejected'--by combining pathologic, echocardiographic, clinical, and blood culture findings. Transesophageal echocardiography (TEE) has better diagnostic sensitivity compared to transthoracic echocardiography. Duke's criteria were used on 83 patients examined by TEE in a retrospective study. Of 83 patients with suspected IE, 49 episodes in 48 patients were classified as 'rejected' and were not treated. The remaining 37 patients (15 of whom were intravenous drug users) were treated and classified as follows: 'definite', 26 episodes in 24 patients, 'possible', 11 episodes in 11 patients; and 'rejected', 2 episodes in 2 patients. In this retrospective analysis Duke's criteria were easy to apply. A negative TEE made IE unlikely and a positive TEE made IE probable when other signs of infection were present.

HTLV infections among Swedish intravenous drug users in 1992.

Serum samples collected in 1992 from 1158 intravenous drug users (IVDUs) in Stockholm, Sweden, were tested retrospectively for antibodies to human T-lymphotropic virus type I and II (HTLV-I and II). The overall prevalence rate of HTLV infections was 2.4% (28/1158). A majority of the HTLV infections were caused by HTLV-II (27/28). A significant association between HTLV-II and HIV-1 seropositivity was found, the prevalence of HTLV-II infection being 11.4% (11/96) in HIV-seropositive individuals compared with 1.5% (16/1062) in HIV-seronegative persons (p < 0.001). All the HTLV-infected individuals were of Scandinavian origin. No significant differences in age and sex distribution were observed in HTLV-infected persons compared to seronegative individuals. This study confirms that HTLV-II infection is present in the Swedish IVDU population and the findings provide baseline information for future epidemiological studies.