A cloudy bag and genital ulcers.

A 30-year-old patient treated with CCPD presented with genital ulcers and a culture-negative peritonitis. Herpes simplex virus type 2 (HSV-2) was cultured from the effluent and the genital lesions. Primary HSV-2 infection was diagnosed by serology. This is the first documented case of PD peritonitis caused by HSV-2. We speculate that cases of culture-negative PD peritonitis may be due to recurrences of genital herpes.

[A men with a Salmonella dublin-infected aneurysm of the abdominal aorta]. / Een man met een door Salmonella dublin geïnfecteerd abdominaal aneurysma aortae.

A 71-year-old male was diagnosed with a Salmonella dublin infection. He presented with abdominal pain with no diarrhoea, and sepsis, and was found to have an infected aneurysm of the infrarenal abdominal aorta. He was treated surgically with resection of the aneurysm and implantation of an extra-anatomic axillobifemoral bypass, followed by long-term antibiotic treatment. Nine months after the primary treatment, the patient died as a result of rupture of the aortic stump. S. dublin-infected aneurysm of the abdominal aorta is a rare condition with high mortality. Human S. dublin infections are associated with the consumption of unpasteurised dairy products from infected animals.

Human parvovirus B19: relevance in internal medicine.

Infection by the human parvovirus B19 can lead to several clinical manifestations which are relevant in internal medicine. These include aplastic crisis in chronic haemolytic anaemias, exanthemathous disease and arthropathy, mainly in women, and chronic anaemia in the immunocompromised host. After initial replication, probably in the respiratory tract, the virus enters its target cells in the bone marrow, erythroid precursor cells, through its receptor, the blood group P antigen. Viral replication in these cells leads to an arrest in erythropoiesis, normally lasting approximately 1 week. In this stage, an aplastic crisis can be produced in all patients under 'erythropoietic stress'. The viraemia disappears as specific antibodies to the virus become detectable in serum, which may give rise to a rash or arthralgia, symptoms that are probably immune-mediated. In immunologically normal individuals the infection is cleared by the humoral immune system within several weeks, whereafter detectable specific IgG confers lifelong immunity to reinfection. In patients with absent or dysfunctional humoral immunity to this virus, however, persistent infection can occur, which results in chronic suppression of erythropoiesis with chronic anaemia. Passive immunization, by means of normal immunoglobulin preparations has been reported to be effective in treating this condition. Diagnosis of parvovirus infection is usually possible by the detection of specific antibodies of IgM class in cases of recent infection. In patients with aplastic crisis and patients with chronic anaemia diagnosis rests upon the detection of parvovirus B19 DNA in serum by polymerase chain reaction. Parvovirus B19 is a ubiquitous virus. By the age of 15, about 50% of individuals have serologic evidence of a past infection, which may present as the common childhood disease erythema infectiosum. At the age of 70, seroprevalence reaches 80 to 100%. A vaccine against this virus is currently being developed.

Detection of parvovirus B19 infection in first and second trimester fetal loss.

Fetal and placental tissues and maternal sera from a series of 273 cases of first and second trimester fetal loss were collected to detect the frequency of parvovirus B19 infection. In addition, fetal tissues were studied for the presence of congenital anomalies. Serology of maternal sera, histology of fetal tissues and placenta, polymerase chain reaction (PCR), in situ hybridization (ISH), and immunohistochemistry (IHC) were used for the detection of parvovirus B19 infection. Sera were tested for B19-specific immunoglobulin M (IgM) and/or IgG using an enzyme-linked immunosorbent assay technique. Based on serology, 149 cases not related to B19 infection were excluded from further analysis. Two of the remaining 124 cases (0.7% of all 273 cases) had parvovirus B19-specific IgM and IgG at the time of abortion, indicating a recent maternal parvovirus B19 infection. In our histological examination, 10 cases contained nuclear vacuolization in fetal erythroid progenitor cells, either in fetal tissues (n = 2) or in placental tissue (n = 8). However, this vacuolization was considered a fixation artifact and not identical to parvovirus B19-specific nuclear inclusions described in previous reports. Only 1 of these 10 cases had parvovirus B19 DNA detectable in placental tissue by PCR analysis. Neither in this case nor in any of the other cases tested was parvovirus B19 DNA or protein detectable by ISH or IHC, respectively. In none of 41 cases in which fetal tissues were available were congenital anomalies found. In conclusion, the frequency of maternal parvovirus B19 infection in this series of fetal losses is low (0.8%). This low frequency does not allow any conclusions with regard to the occurrence of congenital anomalies resulting from parvovirus B19 infection and the usage of nuclear histology for the detection of fetal parvovirus B19 infection is considered a nonspecific parameter that requires confirmation by PCR.

Parvovirus B19 infection and idiopathic thrombocytopenic purpura.

The potential association of human parvovirus B19 infection with idiopathic thrombocytopenic purpura (ITP) was studied. All 60 adult patients presenting with ITP at the University Hospital Rotterdam - Dijkzigt during a 12-year period (41 with acute ITP, 19 with chronic ITP) were included. Patient files were retrospectively analyzed. Stored serum samples were tested for parvovirus B19-specific IgG and IgM anti-bodies, and for parvovirus B19 DNA. In only one patient (1.7%) was evidence of recent B19 infection found. Parvovirus B19 is not a frequent cause of adult ITP and should be tested for only when there are other indications of possible parvovirus B19 involvement.

A fetus with a parvovirus B19 infection and congenital anomalies.

A fetus with multiple structural defects was seen at prenatal ultrasound examination. After termination of the pregnancy a bilateral cleft lip, alveolus, and palate; micrognathia; and webbed joints were seen. Fetal tissues showed indications of infection, intranuclear inclusion bodies, chronic stress, haemolysis, arterial wall damage, and profuse haemorrhage. Parvovirus B19 DNA was detected in fetal tissues by dot hybridization after polymerase chain reaction. The possibility of parvovirus B19 infection leading to congenital malformations is discussed.

Human parvovirus B19 infection and unbalanced translocation in a case of hydrops fetalis.

In a case of hydrops fetalis, serological examination showed a recent maternal human parvovirus B19 infection. Amniocentesis revealed a unique unbalanced translocation between chromosomes 3 and 11 of the fetus. The mother proved to have a balanced reciprocal translocation between chromosomes 3 and 11. A grossly macerated hydropic male fetus was delivered with a flat nose and low implanted deformed ears. Histopathological examination revealed nuclear inclusion bodies in fetal erythroid cells, confirming human parvovirus B19 infection. Parvovirus B19 DNA was demonstrated by in situ hybridization in the nuclei of heart muscle cells. Our finding of two different disorders in one case illustrates the importance of a complete evaluation of every case of hydrops fetalis, especially concerning counselling on the outcome of future pregnancies. The human parvovirus B19 infection will not recur due to the acquired immunity of the mother, whereas the balanced reciprocal translocation will endanger future pregnancies.

An immunofluorescence assay for the detection of parvovirus B19 IgG and IgM antibodies based on recombinant viral antigen.

An indirect immunofluorescence assay for serum IgG and IgM antibodies to human parvovirus B19 was established using recombinant B19 viral antigen, the capsid protein VP1, which had been produced in a baculovirus expression system. This protein gives a strong and characteristic signal in the immunofluorescence assay, making it a suitable candidate for this test system. The test results showed a good correlation with results obtained with a solid-phase capture radioimmunoassay (Cohen et al., 1983). 76% of sera from a random selection of blood donors were positive for B19 IgG which agrees with previous findings. The course of the IgM and IgG antibody response to B19 infection could be followed with the immunofluorescence assay by determining the titers of series of sera taken after a recent B19 infection. Investigation of 24 sera containing rubella-specific IgM showed no cross-reactivity with the recombinant B19 VP1 used in this test system. The test described here has the advantage of being based on a renewable source of antigen and will be further evaluated for routine diagnostic use in comparison with radioimmunoassay.

Comparison of the automated Bactec NR-660 with a conventional blood culture system.

The Bactec NR-660 blood culturing system was compared with a conventional system using 347 consecutively obtained clinical blood samples tested simultaneously. Of 46 clinically relevant isolates, 12 were detected by the conventional system only, 5 by Bactec only and 29 by both methods (0.05 less than p less than 0.10). The difference could not be explained by the results of additional in vitro tests. Of 12 isolates considered contaminants, 7 were isolated in the conventional system only, 2 in the Bactec system only and 3 in both systems (0.05 less than p less than 0.10). The two systems were approximately equal in speed of detection. A high rate of false indications of growth in the Bactec system could be reduced by applying different CO2 cut-off values.

Fetal pathology in human parvovirus B19 infection.

In a current Netherlands study on the effects on mother and child of infection with the human parvovirus B19 during pregnancy, 10 pregnancies have been reported. Three of them ended before term: two in fetal death and one by elective abortion. In two of these fetuses B19 infection in cells other than those of the erythroid series was demonstrated, and in the one terminated, ocular malformation and extensive inflammatory reactions in all fetal and placental tissues were found. The presence of B19 DNA was demonstrated by dot hybridization in placental and fetal tissues. In the third no gross fetal abnormalities were found, although B19 DNA was detected in several fetal tissues by in-situ hybridization. Of the remaining seven pregnancies, six ended at term in the birth of apparently healthy babies. The other child was born near term with a low birthweight and multiple congenital malformations, but with no proof of intrauterine B19 infection. It is concluded that B19 infection in pregnancy can interfere with organ development and may lead to intrauterine fetal death.

Detection of parvovirus B19 DNA in fetal tissues by in situ hybridisation and polymerase chain reaction.

Attempts were made to detect human parvovirus B19-DNA by in situ hybridisation and the polymerase chain reaction in placental and fetal tissues from a case of intrauterine fetal death. In the in situ hybridisation experiments radioactive and non-radioactive (labelled with 2-acetyl-aminofluorene, AAF) DNA probes were used. B19-DNA was detectable in paraffin wax embedded fetal tissue from the liver, heart, lung, brain and thymus. The resolution with the AAF-labelled probes was higher than with the radiolabelled DNA. Parvovirus B19 DNA sequences were also detected in these tissues by an enzymatic in vitro amplification technique--the polymerase chain reaction. Amplification of a B19-DNA sequence before detection increases the rapidity and sensitivity of detection. The rapid, specific, and sensitive analysis of parvovirus B19 in normal and diseased tissues using these techniques may contribute considerably to determining the role of this virus as a risk factor in the outcome of pregnancy.

Embryonic malformations in a case of intrauterine parvovirus B19 infection.

An incomplete embryo of 9 weeks development from a woman infected by human parvovirus B19 during early pregnancy was histologically examined. B19-DNA was detected in both embryonic and placental tissue by dot-blot hybridization. Focal vascular endothelial damage was found throughout the entire embryo and placenta together with mononuclear infiltrations around the vessels. In the placenta these mononuclear cells belonged for the greater part to the cytotoxic and/or suppressor T-cell group. One eye showed lens abnormalities and retinal folds. The other eye was microphthalmic and aphakic and showed dysplasia of the sclera, anterior segment, and retina. The skeletal muscle cells displayed a general eosinophilic degeneration. Focally, similar changes were found in heart muscle and smooth muscle tissue. In several tissues pathologic effects at a cellular level were noted, as intranuclear vacuole-like inclusions and nuclear ballooning. On the basis of this study it is concluded that human parvovirus B19 may affect several fetal tissues and may even have teratological effects on a developing human embryo.

Human parvovirus B19 DNA in synovial fluid.

We describe a 33-year-old woman with a serologically proven human parvovirus B19 infection, who developed synovitis. Using a dot-blot hybridization technique, we detected B19 DNA in her synovial fluid. To our knowledge, this is the first report of the isolation of B19 from synovial fluid.