Evidence for frequent focal and diffuse acute axonal injury in human bacterial meningitis.

AIMS: We aimed at quantifying acute axonal injury in victims of bacterial meningitis. METHODS: The brains of 26 autopsies with bacterial meningitis and of 10 control cases were studied by histology and quantitative immunohistochemistry for amyloid-beta precursor protein (APP). RESULTS: Mild to severe axonal injury in the white matter was present in 25 of 26 victims of meningitis. The area of axonal damage ranged from 0.0% to 1.38% (median = 0.08%, mean = 0.36%) of the total area studied in each individual case. In 4 of 10 age- and sex-matched control brains small areas also stained for APP (p = 0.0007). Axonal injury in meningitis was most prominent in the basal ganglia and pons, followed by the hippocampal formation, neocortex and the cervical spinal cord. The cerebellum was least affected. CONCLUSION: Axonal injury is a frequent complication of bacterial meningitis probably contributing to long-term sequelae in survivors.

Monoclonal antibodies for the detection of desialylation of erythrocyte membranes during haemolytic disease and haemolytic uraemic syndrome caused by the in vivo action of microbial neuraminidase.

Especially in childhood, the in vivo action of microbial neuraminidase may cause haemolytic anaemia or life-threatening haemolytic uraemic syndrome. The exposure of the Thomsen-Friedenreich (T) crypto-antigen and T-antigen polyagglutinability of erythrocytes has been described as the first sign of toxic cleavage of N-acetylneuraminic acid (Neu5Ac) from sialoglycoproteins of cell membranes. This phenomenon may, however, be too unspecific to initiate treatment for toxin elimination. The present study investigated the diagnostic effectiveness of a panel of three monoclonal antibodies (mcabs) for the estimation of the clinical significance of neuraminidase action in vivo. Depending on the amount of Neu5Ac released, the mcabs I-C4, II-Q9 and III-Y12 recognized different epitopes on erythrocyte asialoglycophorin. In 1345 patients, the mcab II-09 detected cleavage of Neu5Ac in 32 children who had T-antigen polyagglutinability and mild to moderate haemolytic anaemia. However, only 10 patients, whose erythrocytes were agglutinated by the mcabs III-Y12 or I-C4, developed severe haemolysis, thrombocytopenia, and finally the life-threatening haemolytic uraemic syndrome (p<0.0002). In conclusion, these mcabs provided an early marker of the in vivo action of neuraminidase. Two different degrees of erythrocyte desialylation, as defined by these mcabs, are suggested to reflect the severity of toxin-associated disease.

Autoimmune haemolytic anaemia in a child with MHC class II deficiency.

A 3 year old Turkish girl is described who was suffering from major histocompatibility complex (MHC) class II deficiency syndrome, which is characterised by the lack of expression of HLA class II antigens on mononuclear cells. The presence of HLA class II genes was demonstrable at the DNA level. Combined immunodeficiency was indicated by hypogammaglobulinaemia and the absence of delayed type hypersensitivity on skin testing. Further, she was unable to produce specific antibodies towards foreign antigens and suffered from recurrent pulmonary, gastrointestinal, and septic infections from the third month of life. The clinical course was complicated by a Coombs test positive haemolytic anaemia due to the production of autoantibodies against the rhesus "e' antigen, a non-glycosylated protein antigen. Haemolysis could be controlled by oral steroid treatment. This case is of interest as it shows that despite the absence of HLA class II antigens and combined immunodeficiency autoimmune reactions with production of specific autoantibodies directed to protein antigens are possible.

Haemolytic anaemia in association with Escherichia coli O157 infection in two sisters.

Two sisters, 2 and 5 years of age, suffered from acute haemolytic anaemia occurring after gastroenteritis with Escherichia coli O157. One patient developed clinical signs of severe and acute intravascular haemolysis and sepsis. She received transfusion and antibiotic therapy. The second patient presented with mild to moderate haemolytic symptoms only. None of them developed renal impairment. In serum of both children, elevated titres of short-lived agglutinins were demonstrated in the indirect haemagglutination assay consisting of sheep erythrocytes coated with lipopolysaccharide from E. coli O157. By immunoblot analysis IgM antibodies against the O157 lipopolysaccharide were demonstrated in the acute phase sera but not in follow up sera taken 2 months after disease. On erythrocyte membranes, adsorption of microbial antigens was detected by use of a pool-immunoglobulin fluorescence test. The immunological status of both patients was normal. Complete recovery from haemolytic disease was observed without further therapy. Microbial antigens attached to the cell surface were assumed to be the pathophysiological cause of E. coli O157 associated haemolytic anaemia in two siblings.

High-dose versus low-dose bovine surfactant treatment in very premature infants.

The aim of the study was to determine if high-dose bovine surfactant (Alveofact, initially 100 mg/kg birth weight) would improve oxygenation compared with low-dose surfactant (50 mg/kg birth weight) administered intratracheally within 1 h after birth. Inclusion criteria included gestational age 24-29 weeks and birth weight 500-1500 g, intubation and mechanical ventilation, absence of congenital malformations and bacterial infections. Retreatment was considered if the fraction of inspired oxygen (FiO2) was > 0.4 (dose 50 mg/kg birth weight). The primary endpoint was level of oxygenation (PaO2/FiO2) 2 h after treatment. The study design was a sequential analysis using a triangular test with alpha = 0.05 and 95% power to detect a 25% improvement in the endpoint. Oxygenation was improved significantly with high-dose (n = 42) compared to low-dose treatment (n = 48): 30.9 +/- 15.0 kPa (231.5 +/- 112.7 mmHg) versus 24.1 +/- 15.7 kPa (180.6 +/- 118.0 mmHg) (mean +/- SD). The survival rate was 83% in both groups and the incidence of pulmonary interstitial emphysema was 33% versus 14% with the high-dose treatment. We conclude that high-dose surfactant significantly improved oxygenation and reduced lung barotrauma. An initial dose greater than 50 mg/kg birth weight of surfactant is required for optimal acute response.

The acute infection-associated hemolytic anemia of childhood: immunofluorescent detection of microbial antigens altering the erythrocyte membrane.

The majority of acute infection-associated hemolytic diseases of infancy and childhood have been suggested to be caused by exogenic alterations of the erythrocyte surface, though laboratory methods for their further evaluation were not yet available. Investigating 96 children, the present study characterizes 72% of cases as corresponding to this type of acute acquired hemolytic anemia, which cannot be clearly related to autoantibodies against unmodified components of the host's own red cells. Using a new immunofluorescence test, the erythrocyte membrane of 80% of these children was found to be altered in vivo by nonspecific adsorption of foreign material released from the infectious micro-organisms. In 24% of cases additive binding of complement was detectable by an antiglobulin test. Thus, the adsorption of microbial antigens to the red cell surface is suggested to be one of the causes for the removal of altered erythrocytes due to phagocytosis or a complement-dependent destruction during the course of infection-associated hemolytic anemia. Especially in childhood, the immunofluorescent detection of an erythrocyte sensitization in vivo provides a further characterization of this type of mostly transient hemolytic disease, which probably can be treated without any immunosuppressive drug, merely by elimination of the underlying infection.

Early treatment of respiratory distress syndrome with bovine surfactant in very preterm infants: a multicenter controlled clinical trial.

OBJECTIVE: To determine the effect of bovine surfactant (SF-RI 1, Alveofact) administered during the first hour following birth to very premature infants [gestational age (GA), 25-30 weeks] in a multicenter, controlled trial. HYPOTHESIS: Survival without bronchopulmonary dysplasia (BPD; definition: ventilator dependency or FiO2 greater than 0.3 during spontaneous respiration) at day 28 is increased in surfactant-treated infants (sequential analysis). PATIENTS AND METHODS: Thirty-four infants [GA 28.0 +/- 1.5 SD weeks, birth weight (BW), 1,048 +/- 299 g] received 50 mg/kg BW surfactant, whereas 35 infants (GA, 27.6 +/- 1.5 weeks, BW 969 +/- 269 g) served as controls. Retreatment with surfactant (up to three identical doses) 12-24 hours after the previous dose was permitted if FiO2 was greater than 0.5. RESULTS: Survival without BPD was significantly higher in surfactant treated infants (26/34) compared to controls (14/35; P = 0.003), but in the incidence of pulmonary air leaks, patent ductus arteriosus, intracranial hemorrhage, and nosocomial infections they were not different. CONCLUSION: Bovine surfactant treatment improves survival without BPD in very premature infants at risk for neonatal respiratory distress syndrome (RDS).

Detection of metastatic breast carcinoma cells by immunofluorescent demonstration of Thomsen-Friedenreich antigen.

The Thomsen-Friedenreich antigen (TF-antigen), known as a precursor of the MN-blood-group system, has been suggested as a tumor-associated antigen of breast adenocarcinoma. In order to evaluate the TF-antigen as a tool in the histochemical detection of micrometastases, cryostat sections of 25 breast biopsies and 30 regionary lymph nodes were investigated. The study used a sensitive method for the fluorescent staining of the determining terminal disaccharide sequence of asialoglycophorin A by application of peanut agglutinin (PNA) and fluoresceinisothiocyanate-labeled F(ab')2 fragments of monospecific anti-PNA from rabbits. PNA binding was observed in 91% of the sections of predominantly ductal mammary carcinomas. In normal tissues and hyperplastic lesions, staining patterns were markedly different from that of malignant breast cells, and were confined to secretory glycoproteins. Lymph nodes, with histologically confirmed metastases of mammary carcinomas, showed specific PNA binding in the cytoplasm of tumor cells in 75% of cases. Even single malignant cells were demonstrable, which were not recognized at first by routine light microscopy. Fluorescent staining of lymph nodes, which were tumor-free in repeated histologic examinations, was confined to clearly diagnosible histiocytes in 3 of 15 cases. A sensitive indirect immunofluorescent technique demonstrating PNA binding is proposed to be of considerable value for the detection of single metastatic adenocarcinoma cells of the human breast.