Pyogenic vertebral osteomyelitis: report of a series of 23 patients.

Vertebral osteomyelitis, an infectious disease with vague manifestations, can be difficult to diagnose. Although vertebral osteomyelitis represents only 2-4% of bone infections, the consequences are often grave and disabling, even fatal, when untreated. A series of 23 cases is reported in which patient records were reviewed to determine the etiology and appropriateness of diagnosis and management. Information on treatment and follow-up after discharge was obtained from outpatient progress notes, records from subsequent hospital admissions, and telephone interviews of patients. Pyogenic vertebral osteomyelitis was diagnosed by positive needle or open biopsy tissue cultures, positive blood cultures in the appropriate clinical setting, or diagnostic histopathology. Staphylococcus aureus was grown from 75% (15/20) of patient cultures, Escherichia coli from 15%, and Staphylococcus epidermidis from 10%. Overall, 87% (20/23) of these patients were disease-free at follow-up. The experience with this series of patients demonstrates that early diagnosis aided by MRI ensures a high cure rate and low complication rate.

Antivirals for the chemoprophylaxis and treatment of influenza.

Influenza virus infections are one of the leading causes of morbidity and mortality in the United States. Several antiviral agents, amantadine, rimantadine, and ribavirin, have been shown to be either therapeutically or prophylactically effective in influenza virus infections. Amantadine and rimantadine are effective, via the oral route, in treating and preventing influenza A infections. Aerosolized preparations of amantadine and rimantadine have also shown therapeutic efficacy against influenza A. Oral ribavirin has slight therapeutic efficacy in influenza A, but has also shown promising results in therapy of influenza B infections. Aerosolized ribavirin has also shown promise in treatment of patients who are severely ill with influenza A and B.

Pharmacokinetics of a single dose of rimantadine in young adults and children.

Single doses of rimantadine were given to children and young adults to evaluate the safety and pharmacokinetics of this antiviral compound. The half-life of rimantadine in young adults was 27.7 +/- 4.9 h for tablets and 27.8 +/- 8.0 h for syrup preparations. A total of 10 children, 5 to 8 years old, received a syrup preparation of rimantadine. The half-life of rimantadine in children was 24.8 +/- 9.4 h. A single dose of rimantadine was well tolerated in young adults and children.

Superiority of tissue-culture-grown antigens over egg-grown antigens for serologic diagnosis of influenza B virus infections.

Acute and convalescent sera obtained from 10 adults and 21 children who were infected with influenza B virus were tested by hemagglutination inhibition. Of four antigens used, two tissue-culture-grown antigens were superior to either egg-grown or egg-grown, ether-treated antigens in detecting fourfold antibody rise during influenza B virus infection.

Serological diagnosis of influenza A/USSR/77 H1N1 infection: value of ELISA compared to other antibody techniques.

Serologic diagnosis of influenza is an important but imperfect tool. During an outbreak of natural H1N1 A/USSR/77 infection, volunteers who received either amantadine, rimantadine, or placebo were tested to determine serologic response to infection by four different antibody techniques. Hemagglutination inhibition (HAI) and complement fixation (CF) were least sensitive, detecting only about half of the virus-positive subjects, whereas neutralization detected 81% and enzyme-linked immune peroxidase (ELISA) detected 95%. Failure to detect significant antibody response was associated with a higher titer of antibody in acute serum specimens and with a history of receipt of A/New Jersey/76 Hsw1N1 vaccine. Although antibody response measured by ELISA was of lower magnitude in vaccinees, it still was sufficient to be diagnostic. Thus, in situations where there is no access to viral isolation facilities, ELISA antibody techniques appear to be an excellent measure of assessing the rate of influenza infection.

Live attenuated influenza A virus vaccines in children: results of a field trial.

One hundred three young children were inoculated intranasally with either influenza A/California/10/78 cold-recombinant vaccine (10(6.7) 50% tissue culture infective doses [TCID50] per child), CR-37 (H1N1), or influenza A/Washington/897/80 cold-recombinant vaccine (10(6.5) TCID50 per child), CR-48 (H3N2). The vaccine was well tolerated. Of the 51 children vaccinated with CR-37 (H1N1), 45 were initially seronegative for this virus; 33 of the 45 became infected with the vaccine virus, as indicated by a fourfold rise in antibody titer or by shedding of vaccine virus. Of the 52 children vaccinated with CR-48 (H3N2), six were initially seronegative and all were infected; 46 were initially seropositive and 25 of these children developed fourfold rises in antibody titer. An outbreak of influenza A (H3N2 type predominated) occurred in Huntington one to three months after the children were vaccinated. Significantly fewer febrile illnesses occurred in the CR-48 (H3N2) vaccine group than among the CR-37 (H1N1) vaccine group. Hemagglutination inhibition antibody (titer, greater than or equal to 1:32) to H3N2 was significantly associated with protection from illness and infection with influenza A/H3N2.

Cold-recombinant influenza A/California/10/78 (H1N1) virus vaccine (CR-37) in seronegative children: infectivity and efficacy against investigational challenge.

Forty-seven seronegative children were inoculated intranasally with influenza A/California/10/78 (H1N1) cold-recombinant vaccine (CR-37). Doses ranged from 10(3.2) to 10(7.2) TCID50 per child. The dose necessary to infect 50% of children (one HID50 ) was approximately 10(3.5) TCID50. Only two of eight children given 10(3.2) TCID50 became infected, and neither shed virus. The majority of children who were given 10(4.2), 10(5.2), 10(6.2), or 10(7.2) TCID50 of CR-37 became infected. Twenty-four of 39 children given greater than one HID50 of CR-37 shed vaccine virus. Overall, 31 of 39 became infected, as indicated by shedding of virus or antibody response or both. Although virus was shed for up to 12 days postinoculation, shedding of revertant virus was not detected. Six months after primary vaccination 26 children were challenged intranasally with 10(6.2) TCID50 of CR-37. Of 21 children previously infected with CR-37, only eight had further antibody increase, and none shed vaccine virus. In contrast, five of five (P less than .05) children not infected with CR-37 at the time of initial inoculation were infected with the challenge inoculum (as indicated by a fourfold rise in antibody titer) and three of five children shed vaccine virus. Previous infection with CR-37 conferred significant protection from challenge with a high dose of CR-37.

Impact of viral respiratory diseases on infants and young children in a rural and urban area of southern West Virginia.

Acute viral respiratory disease occurring in children residing in the community of Huntington, West Virginia (urban children) or in the hollows surrounding Huntington (rural children) was evaluated from September 1978 through March 1980. Cohorts of ambulatory children residing in each area were studied for the occurrence of mild to moderate respiratory disease. All children admitted to hospitals were evaluated for the occurrence of severe viral respiratory disease. Respiratory secretions were obtained from children for isolation of viruses. Epidemics of illnesses occurred simultaneously in the urban and rural groups of children. Among both the urban and rural ambulatory children, adenoviruses were the most common viruses isolated, and respiratory syncytial virus was the second most common viral pathogen isolated. Among the urban and rural hospitalized children, respiratory syncytial virus was the most common virus isolated. The distribution of the diagnoses, pneumonia, bronchiolitis, or croup, was similar among the urban and rural children who required hospitalization. The risk of hospitalization because of respiratory disease was found to be one in every 20 children during the first four years of life, and the estimated risk of hospitalization because of respiratory syncytial virus infection was one in 30. No differences were detected in the incidence of severe viral respiratory disease among children residing in urban or rural areas in southern West Virginia.

Comparison of enzyme-linked immunosorbent assay and neutralization techniques for measurement of antibody to respiratory syncytial virus: implications for parenteral immunization with live virus vaccine.

The sensitivity of an enzyme-linked immunosorbent assay (ELISA) to detect low levels of antibody to respiratory syncytial (RS) virus was compared with a tube dilution neutralization test (NEUT) on sera obtained from children who received a parenteral live RS virus vaccine. Among the children who developed antibody in response to live RS virus vaccine. ELISA was as sensitive as NEUT at detecting antibody increases. Some children who did not have detectable prevaccine ELISA antibody possessed NEUT antibody; these children were generally less than 12 months old, suggesting that they had low levels of maternal antibody. Low levels of NEUT or ELISA antibody were associated with the absence of antibody increases after injection of live RS virus vaccine. The quantity of antibody stimulated by this live RS virus vaccine was small compared with that which was stimulated by naturally acquired RS virus infection. We concluded that ELISA is a satisfactory test for determining antibody to RS virus in vaccine field trials, given the understanding that low levels of preexisting antibody are not detected in some instances.

Administration of a highly attenuated, live respiratory syncytial virus vaccine to adults and children.

A highly attenuated respiratory syncytial virus (RSV) experimental vaccine, RSV ts-2, was sequentially evaluated in adults, seropositive children, and finally, fully susceptible seronegative children. The vaccine was administered intranasally in doses ranging from 10(5.2) to 10(6.3) PFU/ml. In both adults and children, the vaccine proved to be poorly infectious. Although poor infectivity would not have been predicted from tissue culture studies of RSV ts-2 growth, the human experience closely parallels the experience in a series of animal models, including the chimpanzee. The poor infectivity of this RSV vaccine virus preparation suggests that the postulated defect in the RSV ts-2 fusion protein may be important in determining in vivo infectivity of RSV.

Serological diagnosis of influenza B virus infection: comparison of an enzyme-linked immunosorbent assay and the hemagglutination inhibition test.

The sensitivity of an enzyme-linked immunosorbent assay (ELISA) for the detection of antibody to influenza B virus was compared with that of the hemagglutination inhibition test on acute- and convalescence-phase sera obtained from adults and children infected with influenza B virus. Two whole virus, tissue culture-grown antigen preparations were used in the ELISA, influenza B/West Virginia/81 and influenza B/Hong Kong/72. Four antigens were used in the hemagglutination inhibition test. These included the tissue culture-grown whole virus antigens that were used in the ELISA. In addition the standard egg-grown antigens, influenza B/Singapore/79 and influenza B/Hong Kong/72, were included for comparison. The ELISA antibody titer was significantly correlated to the hemagglutination inhibition antibody titer, and 10 of 10 adults and 17 of 21 children infected with influenza B had fourfold antibody increases as detected by ELISA with either antigenic type of tissue culture-grown whole virus. Increases in geometric mean antibody titers of 16- to 71-fold were detected by ELISA. Increases in geometric mean antibody titers of 3- to 10-fold were detected by hemagglutination inhibition depending on the type of antigen utilized. We found that ELISA with whole virus antigens was a sensitive and specific test for the detection of antibody to influenza B virus.

Parenteral administration of live respiratory syncytial virus vaccine: results of a field trial.

A live respiratory syncytial virus (RSV) vaccine administered parenterally was evaluated for efficacy in a double-blind, placebo-controlled field trial in 510 children six to 47 months of age. Among the 233 recipients of live RSV vaccine, 68 of 98 initially seronegative children (as determined by enzyme-linked immunosorbent assay) developed antibody to RSV; 25 of the 30 initially seronegative children who did not develop antibody were less than 12 months old, which suggested that very low levels of maternal antibody (undetectable by enzyme-linked immunosorbent assay) inhibited replication of the vaccine virus. The children were monitored for the occurrence of naturally acquired RSV infection in two RSV epidemics, and there was no difference in the frequency of upper or lower respiratory tract disease caused by RSV between the live RSV vaccine recipients who developed vaccine-induced antibody and the placebo vaccine recipients. Thus, this live RSV vaccine administered parenterally was not efficacious.

Nosocomial influenza B virus infection in the elderly.

A hospital-acquired outbreak of influenza-like illness that involved 29 patients during 4 weeks was detected in March 1980. The average age of the patients was 63 years. Eighteen of the 29 patients with symptoms had influenza B virus infection documented by virus isolations, fourfold or greater hemagglutination inhibition antibody increases, or both. The attack rate among all hospitalized inpatients was 20%. Absenteeism of the hospital staff because of influenza-like illnesses preceded the outbreak by several weeks, suggesting staff-to-patient transmission. The patients' sera during acute illness had low hemagglutination inhibition antibody titers (geometric mean titer of 1:21) against contemporary influenza B virus antigens, indicating that the patients were highly susceptible to influenza B virus. Only one patient had received trivalent influenza vaccine during the preceding year. The excess hospital cost resulting from the outbreak was +13 270 or +458 per patient. Our observations show that the elderly are at risk of developing nosocomial influenza B virus infection and that these illnesses are costly. Continued efforts to develop efficient influenza immunization programs for elderly persons and hospital staff are worthwhile.

Complicated aortic arch syndrome and ischemic optic neuropathy presenting as giant cell (temporal) arteritis.

An acute loss of vision accompanied by signs of optic nerve head ischemia in an elderly patient should alert the examiner to suspect the presence of temporal arteritis until it can be proven otherwise. The patient presented here had ischemic optic neuropathy that was initially thought to be due to temporal arteritis, but eventually was proven to be associated with pronounced atherosclerotic aortic arch disease. The diagnosis was complicated by the severe loss of vision and by an elevated erythrocyte sedimentation rate (ESR). A temporal artery biopsy was normal, and other findings implicated the pronounced diffuse atherosclerosis as the cause of the ischemia of the optic nerve head. Therapy was directed toward the vascular occlusive disease, and involved an aortoinnominate bypass graft.

Successful treatment of naturally occurring influenza A/USSR/77 H1N1.

Forty-five university students with proved influenza A/USSR/77 H1N1 infection were randomly treated with either amantadine hydrochloride (14 students), rimantadine hydrochloride (19 students), or placebo (12 students). By 48 hours after initiation of therapy, amantadine and rimantadine recipients had significantly less fever and greater improvement compared with subjects given the placebo. Minor reversible CNS side effects at the end of the five-day course of therapy were observed in one third of the amantadine-treated subjects. However, both amantadine and rimantadine recipients returned to classes earlier and shed smaller amounts of virus than placebo recipients. Thus, both drugs exerted a notable therapeutic effect. Hence, during an influenza outbreak, five days of empirical therapy with amantadine or rimantadine for persons with an influenza-like syndrome should ameliorate clinical symptoms and might decrease spread of virus.