Pulmonary coccidioidomycosis: import illness and the importance of travel history.

A 35-year-old man presented at the outpatient department of pulmonary diseases with fever, rhinitis and coughing. He had recently been on holiday in California. Except for a body temperature of 39.7 degrees C there were no other abnormal findings at the physical examination. Chest X-ray showed a consolidation in the left upper lobe. Under antibiotic treatment his clinical condition deteriorated. Coccidioidomycosis was the suspected diagnosis and confirmed by the results of CT scanning and culture of bronchoalveolar lavage fluid. Treatment with itraconazole resulted in lasting improvement. The case stipulates the importance of travel history.

[A man who contracted hepatitis E in the Netherlands]. / Een man met in Nederland opgelopen hepatitis E.

A 55-year-old man was admitted to our hospital because of malaise, jaundice en cholestatic liver function impairment, 4 days after his return from vacation in Surinam. Serological tests were positive for IgG and IgM antibodies to hepatitis E virus (HEV) and serum PCR was positive, consistent with HEV infection. The infection was acquired in the Netherlands and not abroad, considering the incubation period. The patient recovered spontaneously. HEV infection is rare in the Netherlands and is associated with travel to tropical or subtropical areas. The virus is transmitted by the faecal-oral route through contaminated water or food. Since 2000 there have been cases reported in the Netherlands, without any association with travelling abroad and in which the infection might be related to zoonotic transmission. The diagnosis is primarily based upon serologic tests for the detection of IgM and IgG antibodies to HEV in serum confirmed by immunoblot. It is important that HEV infection is considered in patients with acute hepatitis in whom no other cause can be found for hepatitis, even without any travel history to endemic areas.

Cryptosporidiosis leading to an unsuspected diagnosis of AIDS.

We describe a 68-year-old woman with an episode of diarrhoea, malaise and weight loss, caused by infection with Cryptosporidium. The diagnosis was hampered because this patient had a low risk of HIV infection, a two-year history of Crohn's disease, and a simultaneous candidal infection. An infection with Cryptosporidium was demonstrated with electron microscopic examination, and subsequent tests revealed positive HIV serology. AIDS was probably contracted through her husband.

[Recurrent otitis media and mastoiditis due to atypical mycobacteria]. / Recidiverende otitis media en mastoïditis door atypische mycobacteriën.

An eleven-year-old girl was operated on due to right-sided chronic otitis media with effusion. After three months, an impressive enlargement of the mucosal lining developed, for which thorough debridement of the middle ear and mastoid was performed. Histological examination revealed a granulomatous inflammation, with negative Ziehl-Neelsen staining. Standard bacteriological cultures revealed no pathogenic micro-organisms. Three weeks later the same clinical picture developed, once again followed by extensive surgical debridement. After a thorough diagnostic work-up an atypical mycobacterium was found, namely Mycobacterium abscessus--formerly named M. chelonei subspecies abscessus. Following appropriate antibiotic therapy the patient was symptom-free. Mycobacterial infections should be part of the differential diagnosis of persistent otorrhoea.

[Tubercular granulomas of the liver in a Somalian patient notwithstanding a chronic hepatitis C]. / Granulomen in de lever bij een Somalische patiënt met chronische hepatitis C toch veroorzaakt door tuberculose.

A 44-year-old male Somalian immigrant was admitted to hospital for evaluation of upper abdominal pain and painful joints (neck and shoulders). Chronic active hepatitis caused by hepatitis C virus was diagnosed. Further examination was instituted because of the simultaneous finding of granulomas in a liver biopsy. In hepatitis C liver granulomas may be found. Infection by Mycobacterium tuberculosis was established, however, after extensive investigation. Treatment was started with tuberculostatic drugs, after which the complaints of the patient disappeared, liver enzyme levels decreased and granulomas in the liver disappeared. No side effects of the tuberculostatic treatment were seen on the course of the hepatitis C.

[Toxic shock-like syndrome in two adults caused by group A beta-hemolytic streptococci]. / Toxischeshock-achtig syndroom door beta-hemolytische streptokokken uit groep A bij twee volwassenen.

In two patients, a woman aged 34 and a man aged 38, toxic shock-like syndrome was diagnosed. This is a serious and potentially lethal disease characterized by multiorgan failure, fever, skin lesions and shock and caused by the exotoxin of Streptococcus pyogenes. Both patients had an invasive Lancefield group A beta haemolytic streptococcal infection. The first patient presented with a skin wound at the right knee and later developed shock and thrombosis, in the second a flu-like disease was complicated by respiratory insufficiency, rhabdomyolysis and acute renal insufficiency. Timely recognition of this infection may reduce the risk of complications such as adult respiratory distress syndrome, disseminated intravasal coagulation and necrotizing fasciitis. Both patients eventually recovered after antibiotic and intensive supporting therapy. This infection can be life-threatening and the fatality rate is 15-35% even if patients received appropriate antimicrobial therapy, supportive care, and, where necessary, surgical debridement.

Multicentre in-vitro evaluation of the susceptibility of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis to ciprofloxacin, clarithromycin, co-amoxiclav and sparfloxacin.

Seven laboratories, including a reference laboratory, tested the susceptibility of Moraxella catarrhalis, Streptococcus pneumoniae and Haemophilus influenzae strains to ciprofloxacin, clarithromycin, co-amoxiclav and sparfloxacin with the Etest. A total of 976 strains were collected. The results with ciprofloxacin and sparfloxacin were consistent for all laboratories, while those with clarithromycin and co-amoxiclav were not. The agreement between Etest MICs and broth microdilution was: ciprofloxacin and sparfloxacin, >95%; clarithromycin for all species, 71-85%; co-amoxiclav for H. influenzae, 31%. MIC90 values (broth dilution, mg/L) for M. catarrhalis, S. pneumoniae and H. influenzae were: sparfloxacin, 0.06, 0.5, 0.03; ciprofloxacin, 0.12, 2.0, 0.03; co-amoxiclav, 0.25, 0.25, 0.25; clarithromycin 0.25, 0.25 and 16.

[A tropical ulcer; cutaneous diphtheria]. / Een ulcus uit de tropen; cutane difterie.

A 43-year-old woman, born in the Netherlands, developed ulcers on her left foot during a holiday in Gambia and Senegal. She had been bitten bij insects. The ulcers were caused by Corynebacterium diphtheriae. The patient was treated with antibiotics and recovered fully. A grey pseudomembrane covering the ulcer is a characteristic feature of cutaneous diphtheria. The treatment is with antibiotics and, after toxin tests have indicated that the bacterium is toxigenic, with antitoxin. In some cases screening of social contacts is advised.

[Typing of methicillin-resistant Staphylococcus aureus strains for epidemiological studies using the polymerase chain reaction]. / Typering van meticilline-resistente Staphylococcus aureus-stammen voor epidemiologisch onderzoek met behulp van de polymerase-kettingreactie.

OBJECTIVE: To determine whether polymerase chain reaction (PCR) fingerprinting can be used to gain insight into the epidemiology of methicillin resistant Staphylococcus aureus (MRSA). DESIGN: Retrospective DNA analysis of MRSA strains. BACTERIAL STRAINS: MRSA strains were collected in two Dutch and one Belgian hospital (Reinier de Graaf Gasthuis, Delft; St. Antonius Ziekenhuis, Nieuwegein; St. Jan Ziekenhuis, Brugge). METHODOLOGY: MRSA DNA was isolated by standard procedures. Differences in genomic organisation were detected with the aid of exponential enzymatic synthesis of intrinsically variable DNA domains. This so-called PCR fingerprinting, a relatively new technique, was performed in direct comparison with phage typing. The latter is the current golden standard for S. aureus typing. RESULTS: The results of both PCR fingerprinting and phage typing appeared to be useful for strain identification. All results were consistent with other epidemiological data. CONCLUSION: Genotyping MRSA with PCR fingerprinting is complementary to phage typing. In some instances PCR fingerprinting is even to be preferred to the other technique. PCR fingerprinting is well suited for the analysis of MRSA spreading.

A randomized study on the effect of bladder irrigation with povidone-iodine before removal of an indwelling catheter.

We have evaluated the effect of povidone-iodine (PVP-I) bladder irrigation prior to catheter removal on subsequent bacteriuria. Of 264 patients, 138 received PVP-I irrigation and 126 were controls. Both groups were similar with respect to duration of catheterization and bacteriuria before removal of the catheter. Of 497 cultures taken after catheter removal 99 (20%) were positive. This included 52 of 233 in the control group (22%) and 47 of 264 in the study group (18%). Patients with positive cultures had a significantly longer period of catheterization. Our trial did not demonstrate that PVP-I bladder irrigation before catheter removal reduces subsequent bacteriuria.

The influence of subminimal inhibitory concentrations of netilmicin and ceftriaxone on the interaction of Escherichia coli with host defences.

The effect of sub-MICs of netilmicin and ceftriaxone on the interaction between encapsulated and unencapsulated strains of Escherichia coli and certain host defence mechanisms, i.e. complement activation, opsonization, phagocytosis by human polymorphonuclear leucocytes (PMN), and serum bactericidal activity have been studied. Experiments were carried out testing antibiotics either alone or in combination. Non-capsulated strains of E. coli activated complement rapidly and were easily phagocytosed and killed after opsonization in human pooled serum. Pretreatment of these strains with sub-MICs of antibiotics did not change the rate of opsonization or the degree of uptake by PMN, but did enhance serum sensitivity. Capsulated strains of E. coli were both poorly opsonized and resistant to serum bactericidal activity. Treatment of these strains with sub-MICs of antibiotics enhanced complement consumption as well as phagocytosis by PMN, but did not affect serum-resistance.

Antibodies raised against rough mutants of Escherichia coli and Salmonella strains are opsonic only in the presence of complement.

The opsonic capacity of antisera raised in rabbits against rough (R) mutants and smooth (S) parent strains of Escherichia coli and Salmonella typhimurium were studied. All specific antibodies in the antisera belonged to the immunoglobulin G (IgG) class. Radioactively labeled bacteria were preincubated in various dilutions of antisera, in which complement was inactivated. Fresh normal rabbit serum, as a standard complement source, was used in some experiments. After preincubation, washed bacteria were added to normal human neutrophils. Opsonization of R mutants for 5 min in 5% fresh normal rabbit serum resulted in effective phagocytosis; S strains needed at least a 30-min opsonization time or 20 to 50% serum. After incubation for 5 min in diluted, homologous antisera, phagocytosis of S strains was optimal, but preincubation of R mutants in diluted, homologous antisera did not lead to amelioration of phagocytosis compared with that of bacteria preincubated in buffer only. However, when fresh normal serum was added to homologous antisera, uptake of R mutants occurred at a faster rate than that of bacteria opsonized in fresh serum alone. Using six clinical isolates of members of the family Enterobacteriaceae, we found that, with or without complement, antisera raised against E. coli J5 or S. typhimurium Re had, with the exception of one strain, no opsonic activity for these strains. Thus, the protective effect of R antisera in gram-negative bacteremia, as shown by several investigators, is unlikely to be mediated through enhanced opsonization of invading bacteria by IgG antibodies directed against these R mutants.

Complement activating and opsonic capacity of monoclonal antibodies raised against Escherichia coli O111 and its rough mutant J5.

Six monoclonal antibodies raised against Escherichia coli O111 and against its rough mutant J5 (chemotype Rc) were studied. One IgG2A, one IgM anti-J5, and one IgG2A anti-O111 monoclonal antibody did not bind to lipopolysaccharides of the homologous strain, but cross-reacted with heterologous gram-negative rods in an enzyme-linked immunosorbent assay. These three monoclonal antibodies activated complement when incubated with homologous or heterologous strains, but were opsonic neither in the presence nor in the absence of complement. The other three monoclonal antibodies were directed against lipopolysaccharide of the homologous strain, but showed no cross-reactivity. The IgG3 and one IgM anti-J5 monoclonal antibodies activated complement and were opsonic only in the presence of complement. The IgM anti-O111 monoclonal antibody activated complement and was opsonic both in the presence and absence of complement. Thus, the outcome of the interaction between bacteria, antibodies, and complement is influenced primarily by whether antibodies are directed against lipopolysaccharides or against other cell wall components.

Detection of antibodies against lipopolysaccharides of Escherichia coli and Salmonella R and S strains by immunoblotting.

Antisera raised against several smooth and rough strains of Escherichia coli and Salmonella typhimurium were tested against lipopolysaccharides (LPS) of homologous and heterologous strains. The LPS were separated by sodium dodecyl sulfate-gel electrophoresis, transferred to nitrocellulose paper, and overlaid with antisera. The results showed that antisera raised against smooth strains reacted with high- as well as low-molecular-weight bands of their corresponding LPS and showed very few cross-reactions. Anti-E. coli J5 antiserum cross-reacted with few strains in the core region. But, anti-S. typhimurium Ra antiserum cross-reacted with many more strains. When these sera were absorbed with either the homologous- or a heterologous-positive strain, reactions were abolished. It appears that reactions of anti-E. coli J5 antiserum and anti-S. typhimurium Ra antiserum with homologous and heterologous strains were not due to the same antibody. This immunoblotting technique proved to be a useful method to distinguish different antibodies in antiserum raised against LPS of gram-negative bacteria.

Host-parasite interaction in serious infections due to gram-negative bacteria.

Gram-negative rods such as Enterobacteriaceae and Pseudomonadaceae are normal habitants of the digestive tract. However, if defense mechanisms of the host are compromised by underlying diseases such as malignant neoplasms, renal insufficiency, extensive traumata, or immunosuppressive therapy, invasion of the blood-stream can occur. Gram-negative septicaemia is associated with high morbidity and mortality, despite intensive care and administration of potent antibiotics. A central role in the pathophysiology of life-threatening bacteriaemia is attributed to endotoxin, a constituent of the gram-negative cell wall. This paper reviews current concepts of septic shock, the acquisition of gram-negative bacteraemia and the role of endotoxin. It also deals with a new approach to prevention and control of severe gram-negative infections using serotherapy based on the structure of endotoxin.