Internal transcribed spacer sequencing versus biochemical profiling for identification of medically important yeasts.

In this study, we established an in-house database of yeast internal transcribed spacer (ITS) sequences. This database includes medically important as well as colonizing yeasts that frequently occur in the diagnostic laboratory. In a prospective study, we compared molecular identification with phenotypic identification by using the ID32C system (bioMérieux) for yeast strains that could not be identified by a combination of CHROMagar Candida and morphology on rice agar. In total, 113 yeast strains were included in the study. By sequence analysis, 98% of all strains were identified correctly to the species level. With the ID32C, 87% of all strains were identified correctly to the species or genus level, 7% of the isolates could not be identified, and 6% of the isolates were misidentified, most of them as Candida rugosa or Candida utilis. For a diagnostic algorithm, we suggest a three-step procedure which integrates morphological criteria, biochemical investigation, and sequence analysis of the ITS region.

Follow-up of epidemiological data of cryptococcosis in Austria, Germany and Switzerland with special focus on the characterization of clinical isolates.

The present survey in Austria, Germany and Switzerland continued the survey of cryptococcosis set up by the European Confederation of Medical Mycology (ECMM) in 1997. From 2000 to 2003 77 cases have been reported. An HIV infection is still the most important risk factor (68%). Young HIV+ women from ASIA contributed to the increase of cryptococcosis in females. A total of 129 clinical isolates of both surveys were genotyped by PCR fingerprinting to study the prevalence of different genotypes. The prevalence of Cryptococcus neoformans var. grubii (serotype A) with the genotypes VNA1 and VNA2 was higher in Germany and Austria (74.5%) than in Switzerland (52%), while in Switzerland the Cr. neoformans hybrids AD (26%) and Cr. neoformans var. neoformans (serotype D) (22%) were more prevalent compared with Germany and Austria (8 and 17.5% respectively). Cryptococcus gattii isolates were studied by FT-IR spectroscopy. DNA in the ITS region was sequenced to get further information about Cr. neoformans serotype AD strains and about the geographical origin of the Cr. gattii isolates. The ITS sequence of the serotype AD isolates of the genotypes VNAD1, VNAD2 and VNAD4 is usually identical to serotype A or serotype D respectively. In the three isolates of the genotype VNAD3 a genotype-specific sequence pattern was detected. Two autochthonous infections due to Cr. gattii could indicate that the genotype VGIV with the ITS type 'Asia 2' might be endemic in Europe.

Disseminated Fusarium oxysporum infection in hemophagocytic lymphohistiocytosis.

The portal of entry of disseminated Fusarium spp. infections is still not clearly defined. We report on a disseminated Fusarium oxysporum infection occurring during a long period of severe neutropenia in a child with hemophagocytic lymphohistiocytosis. A nasogastric feeding tube was the possible source of entry of the fungus.

[Urinary incontinence in the woman--pathophysiology and diagnosis]. / Harninkontinenz der Frau--Pathophysiologie und Diagnostik.

Since urinary incontinence is one of the most frequent female health problems and may severely affect a woman's life quality, knowledge about its pathophysiology, evaluation and therapy is very important. Even basic diagnostic tests can determine the type of incontinence (stress or urge urinary incontinence) thus permitting appropriate therapy to be initiated. The patients history, micturition diary, clinical evaluation, perineal ultrasound and urinalysis are important parts of these basic diagnostic tests. The positive stress cough test and the typical symptoms such as urine loss during physical activity point to the diagnosis of stress urinary incontinence. Frequency, nocturia and urgency with or without urine loss as well as more objective criteria such as micturition diaries and urinalysis indicate urge incontinence. Questions to help determine how quality of life is affected by the incontinence symptoms aid in deciding how urgent the treatment is. An urodynamic evaluation together with perineal ultrasound and cystoscopy is performed in patients with complex or recurrent urinary incontinence after surgery or with micturition disorders.

[Fever after a tick bite: clinical manifestations and diagnosis of acute tick bite-associated infections in northeastern Switzerland]. / Fieber nach Zeckenstich: Klinik und Diagnostik von akuten Zeckenstich-assoziierten Infektionskrankheiten in der Nordostschweiz.

BACKGROUND: Different tick-borne infections can cause an acute febrile illness. The study objectives were to investigate the clinical manifestations and diagnosis of infections among patients who presented with fever after a tick-bite, and to detect newly described pathogens, including Ehrlichia, Babesia and Rickettsia helvetica, in North-Eastern Switzerland. PATIENTS AND METHODS: : We studied 75 patients (41 male, 34 female, median age 38 years, among them 10 children) who had fever within 3 weeks after a tick-bite. Paired sera were tested for antibodies to Borrelia burgdorferi, tick-borne encephalitis virus, Anaplasma (Ehrlichia) phagocytophila, Babesia microti, B. divergens, and Rickettsia helvetica. In addition, microscopy and polymerase chain reaction was used to detect Ehrlichia. Clinical data were obtained at baseline and at 1 and 2 year follow-up. RESULTS: Tick-borne infections were confirmed or possible in 36 (48 %) patients: 7 (9 %) Erythema migrans, 6 (8 %) other specific manifestations of Lyme borreliosis, 6 (8 %) Lyme borreliosis presenting as non-specific febrile illness, 8 (11 %) tick-borne encephalitis, 7 (10 %) granulocytic ehrlichiosis, 1 B. microti infection in a traveler from the US and 6 (8 %) dual infections. In 8 (11 %) patients serological findings were suggesting possible acute or past R. helvetica infection. CONCLUSION: Among patients with fever after a tick-bite, Lyme borreliosis was most frequently found. There was no evidence for babesiosis among the resident population. Serologic data suggest that human granulocytic ehrlichiosis and R. helvetica infections may be endemic in Switzerland. Among 50 % of the patients no tick-borne infections could be diagnosed.

Epidemiological data of cryptococcosis in Austria, Germany and Switzerland: part of the ECMM survey in Europe. European Confederation of Medical Mycology.

The data raised for Cryptococcus neoformans and cryptococcosis in Austria, Germany and Switzerland during the period from July 1997 to December 1999 are presented and analysed according to the epidemiological criteria. This is part of the ECMM survey in Europe.

[Serologic and clinical evidence for endemic occurrences of human granulocytic ehrlichiosis in North-Eastern Switzerland]. / Serologische und klinische Daten weisen auf das endemische Vorkommen der humanen granulozytären Ehrlichiose in der Nordostschweiz hin.

BACKGROUND: Tick-borne human granulocytic ehrlichiosis (HGE) has not been diagnosed in Switzerland, although the HGE agent has been identified in ticks and animal reservoirs and human infections have been suspected on the basis of serological surveys. METHODS: We retrospectively tested sera of 48 persons with antibodies to B. burgdorferi and/or tick-borne encephalitis virus for the presence of antibodies to E. phagocytophila (a surrogate marker of the agent of HGE), and reviewed their charts with regard to clinical manifestations possibly associated with a tick-borne infection. We then prospectively examined EDTA blood of 80 patients who presented with fever 7 to 21 days after a tick bite for the presence of the HGE agent (using nested PCR and microscopic examination of blood smears) and anti-E. phagocytophila antibodies. We also collected clinical data. RESULTS: The retrospective study revealed 12 persons (25%) with anti-E. phagocytophila antibody titers > or = 1:80, suggesting coinfection with HGE and either Lyme Borrelia or tick-borne encephalitis virus. Among these, 7 patients presented with clinical manifestations compatible with HGE disease. The prospective investigation identified 8 patients (10%) with anti-E. phagocytophila antibody titers > or = 1:80, and 7 of these presented with signs and symptoms suggesting HGE. The HGE agent, however, was detected neither by PCR nor by microscopic examination. CONCLUSIONS: Serological and clinical data suggest the occurrence of an HGE-like agent as well as of coinfections with HGE and B. burgdorferi or tick-borne encephalitis virus in Switzerland. However, the HGE agent was not identified in persons living in Switzerland.

Use of 3D ultrasound as a new approach to assess obstetrical trauma to the pelvic floor.

OBJECTIVE: To determine whether 3D ultrasound examination of pelvic floor anatomy after vaginal delivery allows detection of childbirth trauma. STUDY DESIGN: Pelvic floor anatomy was examined in 16 women during the puerperium with a 3D transrectal ultrasound probe. Images were acquired via the vaginal route for the assessment of anal morphology and the transrectal route to determine paravaginal fixation. Images of the anterior pelvic floor were calculated from the information stored in the volume block. Paravaginal defect is defined as a descent of the lateral vaginal wall below the suburethral vagina, whereas sphincter defects are characterised as thinning, or as gap formation of the anterior part of the internal anal sphincter. RESULTS: This new approach allowed the examination of a horizontal plane through the urethra and the periurethral tissue which is inaccessible with 2D ultrasound techniques. Morphology of the normal and traumatised anal sphincter could be demonstrated using reference planes perpendicular to the anal canal. CONCLUSIONS: Whereas in the past, defects of the vaginal attachment to the pelvic side wall could not be examined sonographically, 3D ultrasound can now be used to examine pelvic floor anatomy and to detect changes associated with trauma to the pelvic floor following vaginal delivery.

Aspergillus spondylodiscitis in an immunocompetent paraplegic patient.

A case of an immunocompetent 60 year old patient is reported, who suffered extensive thoracic spinal injury and paraplegia after polytrauma. In the course of rehabilitation he developed aspergillus spondylodiscitis in a part of the thoraco-lumbar spine which was primarily uninjured. The diagnostic assessment and therapeutic approach of this rare disorder is elucidated and discussed in the context of paraplegia and polytrauma. Possible mechanisms of inoculation and spreading of the moulds as well as predisposing factors of the disease are discussed in this paper and a review of the recent literature is provided.

[Chronic mycoses of the paranasal sinuses--value of endonasal paranasal sinus surgery]. / Chronische Mykosen der Nasennebenhöhlen--Stellenwert der endonasalen Nasennebenhöhlenchirurgie.

BACKGROUND: Many host factors even in immunocompetent patients may have an influence on development of a fungal diseases within the paranasal sinuses. Fungal sinusitis can occur in an acute form or more often to a chronic type of the disease. These mainly relatively asymptomatic chronic forms and further divided into a chronic noninvasive, chronic allergic, and chronic invasive disease. Endonasal microsurgery has significantly changed the management of chronic fungal sinusitis and allows adequate removal of pathologic tissue even in advanced situations. The aim of this study was to analyze the efficacy of endonasal surgery in chronic fungal sinusitis. MATERIAL AND METHODS: In a retrospective study we assessed a group of 40 patients who had endonasal surgery for chronic fungal sinusitis. Patient records, CT and MRI scans, microbiology and histology as well as the postoperative clinical follow-up including endoscopic photo documentation were evaluated over a period of 5 years. All patients underwent endonasal surgery using endoscopic techniques. The microscopic was of additional help in a few cases with extended disease and multiple dehiscences of the skull base. RESULTS: Twenty-four patients had a chronic noninvasive of fungal sinusitis and 16 patients had a chronic invasive form. All these patients underwent endonasal surgery without external incision. The fungal disease was erradicated in 39 cases, and revision surgery was required in only one case in which involvement of the contralateral side was not initially detected. in two cases scar tissue in the middle meatus was later excised but without evidence of residual fungal disease. Only in 6 cases was antifungal chemotherapy required, where the disease had spread into surrounding tissue or the patient had severe symptoms. CONCLUSIONS: Endonasal microsurgical techniques are today the appropriate approach for managing chronic fungal sinus disease even in severe cases with radiologic evidence of expansion or invasion of surrounding tissue. Additional antifungal chemotherapy is only rarely indicated, specifically when the fungal disease invades surrounding tissue.

Serological evidence of human granulocytic ehrlichiosis in Switzerland.

To investigate whether human granulocytic ehrlichiosis (HGE) is prevalent in Switzerland, 1515 human serum samples from individuals with different risks for tick exposure were tested for antibodies to Ehrlichia phagocytophila, a surrogate marker of the agent of HGE. The distribution of titres showed marked differences between sera of individuals with no or low risk for tick exposure and those with a high risk. The results of serological testing provided evidence of HGE in Switzerland as well as evidence of two types of coinfections: those with the agent of HGE and Borrelia burgdorferi, and those with the agent of HGE and the central European tickborne encephalitis virus.

[Comparison of gynecologic and perineal ultrasound examination of women with stress incontinence]. / Gynäkologische und perinealsonographische Untersuchung bei Frauen mit Stressinkontinenz--ein Vergleich.

UNLABELLED: A COMPARISON AIM: To determine how well results of gynecological and perineal sonographic examinations of the urethrovesical junction correlate. METHOD: 186 women with urodynamically verified stress incontinence underwent a perineal ultrasound and then a gynecologic examination. Standardised procedures were used for both. The findings of the gynecological examination were compared with measurement values and morphological findings from perineal ultrasound. RESULTS: There was agreement on the cystocele grade in 69% of the cases. The position of the bladder neck as assessed by the ultrasound image revealed typical measurement values for this disorder. The expected bladder neck funneling was detected in 49% of these women. CONCLUSION: In stress-incontinent women there is good correlation between the findings of the gynecological and perineal sonographic examinations. Bladder neck funneling-a morphological sign of stress incontinence-can be detected with perineal ultrasound in nearly one-half of the cases.

[Ovarian metastasis of extragenital tumors at the Zurich University Gynecologic Clinic 1978-1990]. / Ovarielle Metastasierung extragenitaler Tumoren an der Universitätsfrauenklinik Zürich 1978-1990.

37 cases of extragenital tumours metastatic to the ovaries are analysed from a clinicopathological viewpoint. In 25 out of 334 patients who were operated on between 1978 and 1990 because of a palpable malignant ovarian tumour, ovarian involvement from extragenital cancer was diagnosed. The most frequent primary sites were the stomach (n = 7), colon (n = 6) and breast (n = 6). 4 of the 6 patients with metastatic colon carcinoma had previously documented diagnosis of colon cancer with a time interval between diagnosis of primary tumours and secondary ovarian tumour ranging up to 11 years. Only one patient had a previously known stomach cancer, operated on 32 months earlier. All our patients with gastrointestinal primary tumour died within 1 year (gastric origin) of detection of metastases and 2 years (colon carcinoma) except for one patient with metastasis of colon carcinoma, who is still living after more than 4 years and one patient with gastric carcinoma who survived 34 months after oophorectomy. Surprisingly, ovarian metastases of breast cancer were detected before the primary tumour in 2 out of 6 cases. The other 4 patients were operated on because of an ovarian tumour but had a known and previously operated breast cancer. 27 patients had therapeutic ovarian ablation in metastatic breast cancer without a palpable pelvic mass. None of these patients had symptoms related to the ovaries. In 12 (40%) patients we found microscopic metastases which were bilateral in 9 cases. Metastases to the ovary may not infrequently mimic primary ovarian tumour and are difficult to diagnose preoperatively. We hope that some clinical features described by us (nationality, patient's history, bilateral ovarian tumours in young women) will alert the clinician to investigate further in order to achieve the best possible therapeutic management, because some patients may benefit from adequate treatment and survive for a long time.

[African histoplasmosis in a patient with HIV-2 infection]. / Afrikanische Histoplasmose bei Patient mit HIV-2-Infektion.

9 months after immigration into Switzerland, a 38-year-old male patient from Liberia/West Africa developed granulomatous and subsequently ulcerative nodules in the face. The heterosexual patient, with no history of i.v. drug abuse, tested positive for HIV-2. Histology of a skin biopsy revealed superficial colonization by numerous fungal elements described as spores and hyphae that were compatible with the initial isolation of Candida parapsilosis. The definite diagnosis of African histoplasmosis was established 3 weeks later after review of the PAS-stained direct smear and after cultures had grown a cream-colored mold subsequently identified as Histoplasma capsulatum var. duboisii. There were no signs of disseminated disease. The lesions cleared under therapy with itraconazole (200 mg q 24h for 2 weeks, subsequently 100 mg q 24h) as well as ketoconazole and Aqua Dalibour (A. zinco-cuprica) locally for 2 months. Follow-up was not possible. Despite alarmingly increasing numbers of HIV-positive patients in Africa, the general incidence of African histoplasmosis seems to be stable with only a few cases per year. To our knowledge only four cases of disseminated African histoplasmosis have been reported in HIV-positive patients; localized cutaneous infection as in our patient, seems to be the exception. The low incidence of this infection is in contrast to the substantial number of HIV-positive patients with disseminated histoplasmosis by H. capsulatum var. capsulatum in the United States.

[Stewart-Treves syndrome after breast carcinoma]. / Stewart-Treves-Syndrom nach Mammakarzinom.

The Stewart-Treves syndrome is an angiosarcoma that occurs due to chronic lymphoedema which in most cases is a complication after mastectomy with axillary node dissection and postoperative radiation. Prognosis for this rare tumour is poor. The best therapy is early and radical excision. Chronic lymphoedema seems to be an important pathogenetic factor. We report on a 70-year old patient with early stage lymphangiosarcoma who had a lumpectomy with axillary node dissection and postoperative radiation five years ago.

[Analysis of indications and results of fractional curettage in a large gynecological cohort]. / Analyse der Indikationen und Resultate der fraktionierten Kürettage an einem grossen gynäkologischen Krankengut.

AIM: To determine whether the term "fractional D&C" is justified with respect to the uterine cervix and corpus fractions, and what indications and results are found when a large population at a university hospital is analyzed. METHODS: In this retrospective study covering a 3-year period at the Department of Gynecology, University Hospital of Zurich, indications and results of fractional D&C were obtained from hospital records stored in a data bank. The curettage results of hysterectomized women were compared with the histological findings of the hysterectomy specimens. RESULTS: 938 women (mean age 52 years) underwent fractional D&C. 38% had postmenopausal, 36% premenopausal and 13% perimenopausal abnormal bleeding. For 5% there was a sonographic finding without bleeding disorders, 4% had cervical polyps, 1% breast cancer, and 3% other diagnoses. In 13% of the cases the corpus curettage material could not be evaluated. For 43%, the corpus material appeared normal and in 5% a malignancy was found. In 74% of the cervical fractions nothing abnormal was detected, in 14% no conclusive evaluation of the material was possible, and in 3% the histological report showed a malignancy. In 20% of the cases the cervix curettage material was contaminated with material from the uterus cavum. CONCLUSIONS: For cases with cancer of the cervix, the sensitivity of fractional D&C was 80%, compared with a specificity of 66.7%. With a positive predictive value of 52.2%, the term "fractional D&C" is in many cases not justified. Our data and recent literature have prompted us to draw up new criteria for evaluation of abnormal vaginal bleeding, or a new set of indications for fractional D&C and hysteroscopy.

[Gynecological management of patients over 80 years old. Results of a prospective study]. / Die gynäkologische Behandlung von über 80jährigen Patientinnen. Resultate einer prospektiven Studie.

OBJECTIVE: Diagnosis and therapy of gynecologic inpatients who were over 80 years of age were analyzed with respect to the desired and the actual management. METHODS: A general assessment protocol for diagnostic and therapeutic steps which were not carried out in individual cases was drawn up and used for the 96 patients analyzed. The desired therapy corresponded to the ideal management of a 60-year-old patient. RESULTS: In two thirds of the cases, the desired therapy could be given. For 32 patients, there was a reduction of 5-50%; for only 2 patients one of > 50%. The most frequent deviation from the ideal therapy was for the oncologic patients. CONCLUSIONS: Our conclusions agree with those reported in the literature, namely that age alone can not be taken as an argument against standard treatment of a patient with a gynecologic disorder. For patients over 80 years of age, the individual risks and benefits of a particular therapy, especially when surgery is involved, should be carefully considered.