Rapid identification of Streptococcus pneumoniae serotypes by cpsB gene-based sequetyping combined with multiplex PCR.

BACKGROUND/PURPOSE: Streptococcus pneumoniae is an important human pathogen that causes invasive infections in adults and children. Accurate serotyping is important to study its epidemiological distribution and to assess vaccine efficacy. METHODS: Invasive S. pneumoniae isolates (n = 300) from 27 teaching hospitals in China were studied. The Quellung reaction was used as the gold standard to identify the S. pneumoniae serotypes. Subsequently, multiplex PCR and cpsB gene-based sequetyping methods were used to identify the serotypes. RESULTS: Based on the Quellung reaction, 299 S. pneumoniae isolates were accurately identified to the serotype level and 40 different serotypes were detected. Only one strain was non-typeable, and five most common serotypes were identified: 23F (43, 14.3%), 19A (41, 13.7%), 19F (41, 13.7%), 3 (31, 10.3%), and 14 (27, 9.0%). Overall, the multiplex PCR method identified 73.3 and 20.7% of the isolates to the serotype and cluster levels, respectively, with 1.7% of the isolates misidentified. In contrast, the cpsB sequetyping method identified 59.0 and 30.3% of the isolates to the serotype and cluster levels, respectively, and 7% were misidentified. CONCLUSIONS: The cpsB gene sequetyping method combined with multiplex PCR, can greatly improve the accuracy and efficiency of serotyping, besides reducing the associated costs.

Progressive liver injury and increased mortality risk in COVID-19 patients: A retrospective cohort study in China.

BACKGROUND: Liver injury is common and also can be fatal, particularly in severe or critical patients with coronavirus disease 2019 (COVID-19). AIM: To conduct an in-depth investigation into the risk factors for liver injury and into the effective measures to prevent subsequent mortality risk. METHODS: A retrospective cohort study was performed on 440 consecutive patients with relatively severe COVID-19 between January 28 and March 9, 2020 at Tongji Hospital, Wuhan, China. Data on clinical features, laboratory parameters, medications, and prognosis were collected. RESULTS: COVID-19-associated liver injury more frequently occurred in patients aged ≥ 65 years, female patients, or those with other comorbidities, decreased lymphocyte count, or elevated D-dimer or serum ferritin (P < 0.05). The disease severity of COVID-19 was an independent risk factor for liver injury (severe patients: Odds ratio [OR] = 2.86, 95% confidence interval [CI]: 1.78-4.59; critical patients: OR = 13.44, 95%CI: 7.21-25.97). The elevated levels of on-admission aspartate aminotransferase and total bilirubin indicated an increased mortality risk (P < 0.001). Using intravenous nutrition or antibiotics increased the risk of COVID-19-associated liver injury. Hepatoprotective drugs tended to be of assistance to treat the liver injury and improve the prognosis of patients with COVID-19-associated liver injury. CONCLUSION: More intensive monitoring of aspartate aminotransferase or total bilirubin is recommended for COVID-19 patients, especially patients aged ≥ 65 years, female patients, or those with other comorbidities. Drug hepatotoxicity of antibiotics and intravenous nutrition should be alert for COVID-19 patients.

NFKB2 mutation in common variable immunodeficiency and isolated adrenocorticotropic hormone deficiency: A case report and review of literature.

BACKGROUND: Common variable immunodeficiency (CVID) with central adrenal insufficiency is a recently defined clinical syndrome caused by mutations in the nuclear factor kappa-B subunit 2 (NFKB2) gene. We present the first case of NFKB2 mutation in Asian population. METHODS AND RESULTS: An 18-year-old Chinese female with adrenocorticotropic hormone (ACTH) deficiency was admitted due to adrenal crisis and pneumonia. She had a history of recurrent respiratory infections since childhood and ectodermal abnormalities were noted during physical examination. Immunologic tests revealed panhypogammaglobulinemia and deficient natural killer (NK)-cell function. DNA sequencing of NFKB2 identified a heterozygous nonsense mutation (c.2563 A>T, p.855: Lys>*) in the patient but not her parents. CONCLUSION: Clinicians should be alert to comorbidities of adrenal insufficiency and ectodermal dysplasia in CVID patients as these might suggest a rare hereditary syndrome caused by NFKB2 mutation.

Low-dose adefovir dipivoxil may induce Fanconi syndrome: clinical characteristics and long-term follow-up for Chinese patients.

BACKGROUND: Adefovir dipivoxil (ADV) nephrotoxicity is well known at a dose of 60 mg day(-1) or 120 mg day(-1). However, renal toxicity at a low-dose of 10 mg ADV for HBV-infected patients is not fully described. Our objective was to analyse the clinical features and outcomes of ADV-related Fanconi's syndrome in the Chinese population. METHODS: This was a retrospective study. A total of 35 patients with ADV-related Fanconi's syndrome were studied. Clinical manifestations and biochemical parameters were analysed. 19 patients were from Peking Union Medical College Hospital (PUMCH) included from August 2010 to December 2012. A total of 16 patients were eligible from case reports in the Chinese population retrieved in PUBMED, WANFANG and CNKI database. Bone mineral density and biochemical parameters including serum phosphate, calcium, creatinine, alkaline phosphatase (ALP) were measured before and after ADV cessation and during the follow-up. RESULTS: All recruited patients had hypophosphataemia, increased urinary phosphate excretion and elevated alkaline phosphatase. Serum phosphate levels rapidly increased especially within the 4 weeks after ADV cessation. Serum creatinine remained high or at the upper limit of normal range even after ADV cessation for 1 year. ALP increased in the first three months of ADV cessation and decreased at the 24th week. Bone mineral density was significantly improved after 6 months cessation of ADV. CONCLUSIONS: ADV can be nephrotoxic at prolonged low doses of 10 mg. For those who take ADV long term, regular monitoring of serum phosphate, creatinine levels and urine routine tests are required.

Serum HBV DNA level at week 12 is superior to viral response at week 24 in predicting long-term treatment outcome of telbivudine for chronic hepatitis B patients.

BACKGROUND: Telbivudine, one of the five nucleos(t)ide antiviral drugs, was reported to be superior to lamivudine in a better biochemical, virological, and histological response for treatment-naive patients in the GLOBE trial. The aim of this study was to determine the antiviral potency, viral resistance, and the signifcance of early response for long-term telbivudine treatment. METHODS: We recruited 161 patients of chronic hepatitis B (CHB) on telbivudine between January 2009 and September 2011 in Macau, China. The serum hepatitis B virus DNA levels, hepatitis B e antigen (HBeAg) seroconversion, alanine aminotransferase (ALT) normalization, and viral resistance were analyzed. RESULTS: The median age and follow-up duration were 48 years and 16.9 months. All patients were followed up for at least 6 months, while data were collected for 132, 120, 95, and 53 patients at 12, 24, 48, and 96 weeks respectively. The cumulative HBeAg seroconversion rate was 20.8% and only three patients (1.9%) presented with telbivudine low level resistance. The ALT normalization rates were 76.9% at 48 weeks and 77.6% at 96 weeks. Undetectable HBV DNA was achieved by 1.8%, 31.6%, 60%, and 74.1% in HBeAg positive patients and 29.3%, 60.3%, 84%, and 84.6% in HBeAg negative patients at each time point. Week 12 HBV DNA level < 1000 copies/ml (< 200 IU/ml) was a better predictor of viral suppression at 2-year follow-up (P = 0.001, OR = 27.00) than undetectable HBV DNA level at week 24 (P = 0.120, OR = 4.81). CONCLUSIONS: Two-year telbivudine treatment yielded high rates of viral suppression and ALT normalization. Serum HBV DNA level at week 12 is a superior predictor for long-term viral suppression.

Steady-state pharmacokinetics of zidovudine in Chinese HIV-infected patients.

BACKGROUND: The pharmacokinetics of zidovudine (AZT) are possibly influenced by weight, age, sex, liver and renal functions, severity of disease, and ethnicity. Currently, little information is available on the steady-state pharmacokinetics of AZT in Chinese HIV-infected patients. The current study aimed to characterize the steady-state pharmacokinetics of AZT in a Chinese set-up. METHODS: Eleven Chinese HIV-infected patients were involved in the steady-state pharmacokinetic study. In total, 300 mg of AZT, as a part of combination therapy, was given to patients, and serial blood samples were collected for 12 hours. The samples were measured by a high-performance liquid chromatography (HPLC) assay, and the results were analyzed by both the non-compartment model and the one-compartment model. RESULTS: The C(max) of AZT in Chinese patients was higher than that in non-Asian patients. The half-life of AZT, analyzed by the non-compartment model (P = 0.02), in male patients ((1.02 ± 0.22) hours) was shorter than that of AZT in female patients ((1.55 ± 0.29) hours). The AZT clearance, analyzed by the one-compartment model (P = 0.045), in male patients ((262.60 ± 28.13) L/h) was higher than that in female patients ((195.85 ± 60.51) L/h). CONCLUSION: The present study provides valuable information for the clinical practice of AZT-based highly active antiretroviral therapy in a Chinese set-up.

[The microbiological and clinical analysis of bloodstream infections with identifiable sources].

OBJECTIVE: To evaluate the microbial spectrum and clinical characteristics of microbiological diagnosed bloodstream infections (BSI) with identified infective sources. METHODS: The hospitalized patients microbiologically diagnosed as BSI with identified infective sources were included in this study from January 2008 to December 2009. Data were collected retrospectively and analyzed by software SPSS 17.0. RESULTS: In this 2-year study, 301 strains of microbes were isolated from 249 patients. There were 205 (82.33%) patients with monomicrobial BSI, while the other 44 (17.67%) patients with polymicrobial BSI. The most common identified source of bloodstream infections was lower respiratory tract infection (125, 41.5%), followed by intraabdominal infection (55, 18.3%) and intravascular devices related infection (54, 17.9%). The four most common isolated pathogens were Acinetobacter species (60, 19.9%), Escherichia coli (50, 16.6%), Pseudomonas species (35, 11.6%) and Staphylococcus Aureus (34, 11.3%). Eighty-eight (35.3%) patients died during hospitalization due to all causes, out of which 62 (24.9%) patients died owing to BSI. The patients with BSI originated from lower respiratory tract had a higher crude in-hospital case-fatality ratio than those with BSI originated from other resources (OR = 2.186; 95%CI 1.260 - 3.792; χ(2) = 7.879, P = 0.005). In the multivariate regression, age ≥ 65, invasive mechanical ventilation, reservation of central line and polymicrobial BSI during hospitalization were independent risk factors of death due to all causes. CONCLUSIONS: Lower respiratory tract is the most common originated source of BSI with microbiological identified sources. Gram-negative bacillus taking advantage, the microbial spectrum of BSI with identified sources in our study is different from those reported before both in primary and secondary BSI. The patients with BSI originated from respiratory tract have a higher crude in-hospital case-fatality ratio.

[Clinical analysis of adult primary bloodstream infection].

OBJECTIVE: Evaluate the microbiological and epidemiological characteristics of primary bloodstream infections as well as the associated patients' clinical features at Peking Union Medical College Hospital. METHOD: Microbiological and clinical data of the adult patients with primary bloodstream infections during January 1, 2008 and December 31, 2009 were retrospectively collected and evaluated. Pearson χ(2) test was used to compare the difference between proportions and Logistic regression was used in multivariate analysis. RESULT: Five hundred and eighty-six strains of microbes were isolated from 494 adult patients with primary bloodstream infections. There were 80 patients with polymicrobial primary bloodstream infection of the 586 isolates, coagulase-negative staphylococci (175, 29.9%) was the most common, followed by Escherichia coli (93, 15.9%), Enterococcus species (60, 10.2%), Streptococcus species (41, 7.0%), and Staphylococcus Aureus (39, 6.7%). Central-line was the leading suspected infective source among the suspected infective source involving 108 (18.4%) isolates. Excluded the 108 isolates with suspected sources, 77 (45.3%) out of 167 patients with the primary bloodstream infections caused by coagulase-negative staphylococci or Staphylococcus Aureus had a central-line, with a higher proportion of the patients with a central-line than the patients with bloodstream infection caused by other pathogens (χ(2) = 10.419, P = 0.001). One hundred and fourteen patients died during hospitalization, with the crude mortality rate 23.0%. Fifty-nine patients (11.9%) died due to primary bloodstream infection. The patients with polymicrobial bloodstream infection were with a higher attributable mortality (OR = 2.159;95%CI 1.165 - 4.002; χ(2) = 6.194, P = 0.013). In the multivariate analysis, the independent risk factors of crude mortality rate to primary bloodstream infections were elderly patients, central neurological disorder, mechanical ventilation, and reservation a central-line. CONCLUSION: The most common microbe causing primary bloodstream infections was G+ cocci. Polymicrobial primary bloodstream infection added risk to attributable in-hospital fatality ratio. Elderly patients, neurological disorder, reservation of central-line, and mechanical ventilation were the independent risk factors of crude in-hospital fatality ratio.

[The clinical characteristics of 70 cases of fungemia].

OBJECTIVE: To evaluate the etiological and clinical characteristics of fungemia in Peking Union Medical College Hospital. METHODS: Microbial and clinical information of patients with fungemia consulted in Peking Union Medical College Hospital during 2008 to 2010 were retrospectively analyzed. RESULTS: A total of 70 patients were diagnosed with fungemia, and 100% of them had underlying diseases or potential risk factors. Of them, 40 (57.1%) patients were monomicrobial fungemia, and the other 30 (42.9%) patients with positive blood cultures were caused by at least two different microbes during hospitalization. Among 122 strains of microbes isolated from blood cultures, 72 were fungi and 50 were bacteria. Among the isolated fungi, 61 (84.7%) were Candida species, 31 (50.8%) were Candida albicans and 30 (49.2%) were non-albicans. According to the colonization or infected sites other than blood of the isolated fungi, 35 cases (50.0%) were primary fungemia; 18 (25.7%) were colonizing at lower respiratory tract simultaneously; 10 (14.3%) caused central-line related fungemia; 3(4.3%) were secondary to intra-abdominal fungal infection; and another 4 (5.7%) isolates had multiple colonization sites. During hospitalization, 37 cases died with a crude mortality rate of 52.9%, and 22 (32.9%) died of fungemia itself. In single factor analysis, ICU hospitalization (χ(2) = 15.136, P < 0.001), operation history within 30 days (χ(2) = 3.540, P = 0.060) and invasive mechanical ventilation (χ(2) = 4.450, P = 0.035) were related to crude mortality. Bacteremia during hospitalization (χ(2) = 5.657, P = 0.017), circulatory underlying diseases (χ(2) = 3.399, P = 0.065) and ICU treatment (χ(2) = 4.955, P = 0.026) increased attributable mortality. In the multivariate analysis, ICU history increased mortality during hospitalization, however, the operation history within 30 days was independently irrelevant to crude mortality during hospitalization. ICU history and bacteremia during hospitalization were independently correlated to attribution mortality of the patients with fungemia. CONCLUSIONS: Fungemia, usually accompanied with bacteremia, occurs often in the patients with underlying diseases. Patients with fungemia have poor prognosis and more than 50% patients die. ICU history increases the risk both to crude and attributable mortality. The patients with fungemia who had polymicrobial bloodstream infection have a higher attribution mortality. Operation history within 30 days is independently negatively correlated to attributable mortality.

[A report of eight cases of Behcet's disease with intracardiac thrombus and literatures review].

OBJECTIVE: To analyze the clinical characteristics of Behcet's disease with intracardiac thrombus. METHODS: The data of 8 patients diagnosed as Behcet's disease with intracardiac thrombus in Peking Union Medical College Hospital from January, 1990 to January, 2011 were studied retrospectively. RESULTS: Behcet's disease with intracardiac thrombus was found in 8 patients (5 men and 3 women) with a median age of 28.5 years. Most of them were young men. Thrombus was mostly found in the right side of the heart. Most of the patients had pulmonary thromboembolism with negative anticardiolipid antibody and basically normal C-reactive protein and erythrocyte sedimentation rate. CONCLUSION: Intracardiac thrombus associated with Behcet's disease most commonly occurs in young men and usually involves the right side of the heart.

[A clinical analysis of 25 cases of prosthetic valve endocarditis].

OBJECTIVE: To report the clinical characteristics of prosthetic valve endocarditis (PVE). METHODS: All 25 cases of definite PVE (Duke criteria) diagnosed at our hospital between January 1992 to December 2008 were retrospectively analyzed. Among them, 7 cases were pathologically confirmed and the others were clinically confirmed with either 2 major criteria or 1 major and ≥ 3 minor criteria. Their clinical characteristics, underlying heart diseases, previous heart operations, presenting manifestations, causative microbes, echocardiographic findings and prognosis, were studied. RESULTS: (1) Although most cases underwent valve transplantations for underlying heart diseases of rheumatic heart diseases and congenital heart diseases, 10 patients were complicated with infectious endocarditis (IE) prior to the operations, 4 of them were PVE. (2) Eleven of them developed PVE within 2 months postoperatively. Fever (100%), major vessel embolism (48%), and anemia (36%) were the most frequently manifestations. Fourteen cases (56%) had positive culture results with 15 causative pathogens, including 5 coagulase-negative Staphylococcus (CNS, 3 were methicillin-resistant coagulase-negative Staphylococcus, MRSCoN), 4 fungi, 2 Enterococcus faecalis, 2 Burkholderia cepacia, 1 Stenotrophomonas maltophilia, and 1 Streptococcus. (3) Prosthetic valve vegetations, periannular leakage, regurgitation, were the main echocardiographic findings. Transesophageal echocardiography (TEE) revealed 13 PVE who had no positive findings on previous transthoracic echocardiography (TTE). (4) Eighteen PVE (72%) developed peri-annular complications (12 leakage, 3 dehiscence, 2 abscesses, 1 fistula), major vessel embolism, congestive heart failure (16%) were frequently observed, 9 of the 17 patients died in hospital, in spite of intensive managements. CONCLUSIONS: PVE has a high mortality and is a severe complication for patients who underwent heart surgery. Its causative pathogen spectrum is quite different from that of native valve endocarditis. TTE is not sensitive for some PVE cases.

[Clinical significance of positive sputum culture for filamentous fungi].

OBJECTIVE: To investigate the clinical significance of positive sputum culture for filamentous fungi. METHODS: The medical data of 140 patients positive for filamentous fungi in sputum culture at Peking Union Medical College Hospital were reviewed retrospectively. Based on the diagnostic criteria by European Organization for Research and Treatment of Cancer/Mycoses Study Group, invasive pulmonary fungal infection (IPFI) was diagnosed. The clinical characteristics of cases with and without IPFI were analyzed respectively. RESULTS: Among all 140 cases positive for filamentous fungi in sputum culture, only 22 cases could be diagnosed as IPFI. Two of 22 IPFI cases were confirmed by post-operative pathology, 1 case was confirmed by positive blood culture for filamentous fungi and the remaining 19 cases were diagnosed clinically according to the nature of hosts, characteristics of pulmonary infections and microbiological evidence (positive sputum culture for filamentous fungi, 2 - 5 times for each case). Most of etiological fungi in IPFI patients belonged to Aspergillus. And the identity of isolated fungal strain was mostly one strain for each patient. In IPFI group, patients who had been treated with broad-spectrum antibiotics (100%), steroids (13, 59.1%) or immunosuppressant (7, 31.8%) or who had pulmonary X-ray imaging changes (100%), primary diseases (21, 95.5%), hypoalbuminemia (18, 81.8%) or hemoptysis (10, 45.5%), were significantly more than those in non-IPFI group (66.9%, 34.7%, 18.6%, 79.7%, 72.0%, 45.8% and 4.2% respectively; P < 0.05 for each item). In IPFI group, itraconazole, amphotericin B and/or voriconazole were administrated, 8 patients (36.4%) were cured and 14 patients (63.6%) passed away. In non-IPFI group, the patients were treated with antibiotics, fluconazole, anti-tuberculosis, steroids or combined with immunosuppressant, chemotherapy or bronchoalveolar lavage; 96 cases (81.4%) were cured or showed improvement, and 22 cases (18.6%) died or gave up further treatment. CONCLUSIONS: The clinical significance of positive sputum culture for filamentous fungi are associated with the times of positive culture, the number and species of isolated fungal strains. Meanwhile it is important to determine whether there is IPFI according to the nature and clinical characteristics of patients.

[Clinical analysis of 120 cases of infective endocarditis].

OBJECTIVE: To improve the diagnosis and treatment of infective endocarditis (IE) by exploring its causes, pathogenic microorganism and clinical characteristics. METHODS: The clinical data of 120 IE patients treated in Peking Union Medical College Hospital from October 1997 to September 2007 were analyzed retrospectively. RESULTS: Of the 120 consecutive cases diagnosed as IE according to the Duke's new criteria, 79 were male and 41 female with a average age of (43.2 +/- 16.7) years old. Twelve cases were prosthetic valve endocarditis (PVE) and 108 cases native valve endocarditis (NVE) and there were no previously known heart diseases in 29 of the cases. Seventy-nine of the 108 (73.1%) NVE patients had basic cardiac abnormalities before IE diagnosis, such as congenital cardiovascular disease (30 cases), idiopathic mitral valve prolapse (23 cases) and rheumatic heart disease (11 cases). Fever (100.0%), anemia (54.2%) and embolism (48.3%) were the most common clinical manifestations in the IE development. Of the 83 patients who had a positive blood culture result, Streptococcus viridans (51.8%) was the most common isolated microorganism. CONCLUSIONS: Congenital cardiovascular diseases and idiopathic mitral valve prolapse are the two most commonly heart diseases in IE. Blood culture and echocardiogram should always be done to exclude IE, especially presenting with fever of unknown reasons.

Impact of baseline CD4(+) T cell counts on the efficacy of nevirapine-based highly active antiretroviral therapy in Chinese HIV/AIDS patients: a prospective, multicentric study.

BACKGROUND: CD4(+) T cell counts have been used as the indicator of human immunodeficiency virus type 1 (HIV-1) disease progression and thereby to determine when to start highly active antiretroviral therapy (HAART). Whether and how the baseline CD4(+) T cell count affects the immunological and viral responses or adverse reactions to nevirapine (NVP)-containing HAART in Chinese HIV-1 infected adults remain to be characterized. METHODS: One hundred and ninety-eight HIV-seropositive antiretroviral therapy (ART)-naive subjects were enrolled into a prospective study from 2005 to 2007. Data were analyzed by groups based on baseline CD4(+) T cell counts either between 100 - 200 cells/microl or 201 - 350 cells/microl. Viral responses, immunologic responses and adverse events were monitored at baseline and at weeks 4, 12, 24, 36, 52, 68, 84, 100. RESULTS: Eighty-six and 112 subjects ranged their CD4(+) T cell counts 100 - 200 cells/microl and 201 - 350 cells/microl, respectively. The pre-HAART viral load in CD4 201 - 350 cells/microl group was significantly lower than that in CD4 100 - 200 cells/microl group (P = 0.000). After treatment, no significant differences were observed between these two groups either in the plasma viral load (pVL) or in the viral response rate calculated as the percentage of pVL less than 50 copies/ml or less than 400 copies/ml. The CD4(+) T cell counts were statistically higher in the 201 - 350 group during the entire follow-ups (P < 0.01) though CD4(+) T cell count increases were similar in these two groups. After 100-week treatment, the median of CD4(+) T cell counts were increased to 331 cells/microl for CD4 100 - 200 cells/microl group and to 462 cells/microl for CD4 201 - 350 cells/microl group. Only a slightly higher incidence of nausea was observed in CD4 201 - 350 cells/microl group (P = 0.05) among all adverse reactions, including rash and liver function abnormality. CONCLUSIONS: The pVLs and viral response rates are unlikely to be associated with the baseline CD4(+) T cell counts. Initiating HAART in Chinese HIV-1 infected patients with higher baseline CD4(+) T cell counts could result in higher total CD4(+) T cell counts thereby achieve a better immune recovery. These results support current guidelines to start HAART at a threshold of 350 cells/microl.

[Common variable immunodeficiency: report of 12 cases and review of literature].

OBJECTIVE: To study the clinical features of a heterogeneous immunodeficiency disease, common variable immunodeficiency (CVID), and to enhance the understanding of it. METHODS: 12 cases of CVID treated in Peking Union Medical College Hospital from January 1990 to March 2007 were analyzed retrospectively, including the clinical characteristics, laboratory results, treatment and prognosis. RESULTS: Among the 12 patients, the ratio of male to female was 2:1, the average onset age (26 +/- 9) years old and the median time from onset to diagnosis 18 months. The main symptoms were fever (with a percentage of 67.0%), recurrent cough and expectoration (58.3%) and diarrhea(41.6%). Anemia and leukocytopenia were the common laboratory changes. All the cases were diagnosed due to the presence of hypoimmunoglobulinemia. The tests available for subtypes of lymphocytes in 9 patients showed that B cells and CD. T cells decreased obviously, with an inverse ratio of CD4/CD8, indicating T cell dysfunction. Clinical improvement was demonstrated after treatment with intravenously administered immunoglobulin (IVIG) in 10 cases. CONCLUSIONS: CVID is a heterogeneous group of immunologic disorders of unknown etiology, characterized by impaired antibody responses and recurrent airway and/or gastrointestinal infection and accompanied with autoimmune diseases or cancer. Hypo-immunoglobulinemia is the main evidence of its diagnosis. IVIG as a replacement therapy is an effective way of management.

[Clinical analysis of otogenic intracranial complications].

OBJECTIVE: To analyze the clinical features and treatment protocols of otogenic intracranial complications in Peking Union Medical College Hospital. METHODS: Retrospective study of 14 patients (10 males and 4 females, aged between 12 - 62 years, mean age 32.1 years) hospitalized from 1982 - 2006. Twelve cases were otitis media (OM) with cholesteatoma, the other 2 cases were non-cholesteatomatous OM. All the otogenic intracranial complications located at the same sides as otologic disorders. Brain abscess was the most common type of otogenic complications and Proteus was the most common microorganism detected. Suppurative ear discharge, headache, high fever and nausea with vomiting were the most common clinical manifestations with very high incidences. All the patients received combined protocols of mastoid surgeries and antibiotics treatment. RESULTS: All the 14 patients recovered clinically. For patients discharged before 1987, there were 4 patients followed up for 22.5 - 24.4 years with a mean time of 23.8 without recurrence, 1 patient died of cardiovascular disease 19.2 years later after discharge, 4 patients lost follow-up. For the 5 patients discharged after 1997, brain abscess recurred in one patient with pseudo-recovery after 24 days and he fully recovered after re-hospitalization and treatment. All the five patients were followed up for 1.5 years to 10.6 years with a mean time of 6.5 years without recurrence. CONCLUSIONS: Youngsters and males seemed to be more vulnerable. Brain abscess was the most common intracranial complication and Proteus was the most common pyogenic microorganism. Combination of mastoid surgery and antibiotics were essential for effectively controlling the intracranial complications and improving the recovery. CT and MRI were essential for correct diagnosis bedtimes and MRI seemed to have a better performance.

[A clinical analysis of 9 cases of actinomycosis].

OBJECTIVE: To study the clinical features of actinomycosis and to increase the understanding of it. METHODS: To review the clinical data of 9 cases of actinomycosis retrospectively in Peking Union Medical College Hospital from January 1990 to June 2006. RESULTS: (1) Nine patients including 7 female and 2 male, with age ranging from 30 to 50 years (mean age 39.8 years) were studied and they suffered from the disease for a mean period of 13.1 months (2 - 36 months). (2) Three of the 9 patients had cervicofacial actinomycosis, 2 pelvic actinomycosis, 2 thoracic actinomycosis, 1 breast and 1 intestinal actinomycosis. In 3 cases the lesion spread to many other organs from the primary site. (3) The diagnosis was made with biopsy in 6 cases, sputum or sulphur granules in 2 and clinical as well as laboratory examination in one. (4) All the 9 patients accepted appropriate therapy of antibiotics and the treatment was effective in 8. The one failed to respond to antibiotics died. CONCLUSION: Actinomycosis is infrequent clinically. It usually presents as chronic abscess and may be misdiagnosed as malignant tumor. Clinical doctors should be vigilant of it, in order to diagnose and treat it in good season and to greatly improve the prognosis.

[Tuberculous meningitis in Chinese adults: a report of 100 cases].

OBJECTIVE: To investigate the clinical features, cerebrospinal fluid (CSF) changes, imaging characteristics, diagnostic methods, treatment regimens and outcomes of Chinese adult patients with tuberculous meningitis (TBM). METHODS: Clinical data of 100 cases of TBM admitted to Peking Union Medical College Hospital from January 1982 to December 2003 were investigated retrospectively. Data were collected with regard to the clinical, laboratory and demographic characteristics of the patients as well as the results of radiological investigations and data of clinical outcome. RESULTS: One hundred TBM cases were included in this study; there were 49 males and 51 females. The mean age was (31 +/- 11) years. Seventy percent of the patients was of chronic duration (11.1 +/- 9.2) weeks. Thirteen cases were definitely diagnosed through positive CSF culture and smear or brain biopsy, the remaining 87 cases were diagnosed clinically. Fever (97%), headache (92%), decreased level of consciousness (71%), meningeal irritation (77%) and impairment of cranial nerve function were the most frequent symptoms and signs. Thirty-five cases were accompanied with active pulmonary tuberculosis and 12 cases with extrapulmonary tuberculosis. Raised intracranial pressure was present in 86%. CSF was non-purulent with lymphocytic pleocytosis, marked elevation of protein concentration and significant decrease of glucose. Sixty-seven cases had imaging data; abnormalities were found in 52 with ventricular enlargement, hydrocephalus and infarction the most frequent findings. All the patients received anti-tuberculosis therapy, nine underwent neurosurgical drain due to hydrocephalus, eighty-one improved and seven died. CONCLUSIONS: TBM should be suspected when chronic meningitis was accompanied with active pulmonary or extrapulmonary tuberculosis. Differential diagnosis and trial anti-tuberculosis therapy may be of help for the diagnosis. Positive CSF smear and culture and biopsy of brain or meninges are the golden standards for the diagnosis of TBM. Early diagnosis and treatment are very important for improving the outcome.