Lepromatous leprosy masquerading as disseminated tuberculosis.

A patients with disseminated leprosy is described. A 57 year old man from Cuba presented with fever and pancytopenia. Bone marrow aspirate showed numerous acid-fast bacilli and a liver biopsy specimen contained multiple granulomas. The patient was considered to have tuberculosis and was treated with isoniazid and rifampin, with initial clinical improvement, only to have the fever recur and to show deterioration in hematologic and hepatic function. Failure to grow M. tuberculosis suggested a diagnosis of leprosy which was proved by skin biopsy. How lepromatous leprosy can masquerade as disseminated tuberculosis is discussed.

Shigellosis in the United States: ten-year review of nationwide surveillance, 1964-1973.

In the 10 years 1964-1973, 105,832 isolations of shigellae were reported to the Center for Disease Control through a nationwide surveillance system. The number reported increased by approximately 13% annually, from 5852 in 1964, when only 17 centers reported all 4 quarters; to 16,797 in 1973, when 52 centers reported each quarter. The rate of reported isolations varied from 4.6 per 100,000 persons in 1965 to 9.1 per 100,000 in 1973. Shigella sonnei accounted for 64% of all these isolates and for more than 80% of isolates in 1973. The majority of reported cases of shigellosis occurred in young children and in women of childbearing age. During the 10-year surveillance period, 35 epidemics in 25 states were investigated. Two-thirds of these outbreaks were the result of person-to-person spread; investigations of common-source outbreaks showed the importance of both water and foodstuffs, especially salads, as potential vehicles of contamination. Indian reservations, custodial institutions, and day-care centers were identified as special high-risk settings for the transmission of shigellosis. The emergence of R-factor-mediated antimicrobial-resistance patterns in recent years has necessitated antibiotic sensitivity testing to determine the drug of choice for treatment of individual cases. Initial testing of oral vaccines suggests these vaccines will have only limited usefulness in protecting certain high-risk populations. Public health education coupled with improvements in water and sewerage systems remains the most satisfactory means of control.

Shigellosis transmitted by nurses.

Twelve cases of Shigella sonnei infection, with two deaths, occurred at a custodial institution in Donelson, Tennessee, in April and May 1973. Nine of the cases and both deaths were in patients hospitalized at the institution's infirmary. The patients with nosocomial shigellosis were significantly younger and had been hospitalized significantly longer than controls. Epidemiologic investigation implicated staff members in the transmission of illness from one patient to another and identified the previous use of broad-spectrum antibiotics as a significant factor in placing patients at risk of acquiring shigellosis.

An epidemic of gastroenteritis traced to a contaminated public water supply.

Between January 1 and March 15, 1974, approximately 1200 cases of acute gastrointestinal illness occurred in Richmond Heights, Florida, a residential community of 6500 in south Dade County. Over one-third of all families in the area had at least one member affected. The findings of 10 culture-proven cases of shigellosis among those who became ill and clinical signs and symptoms in the others suggest that most of the other cases that were not cultured may have been shigellosis also. Epidemiologic investigation showed that consumption of tap water was associated with illness in the initial cases of affected families. Evaluation of the Richmond Heights public water supply disclosed numerous inadequacies in both design and operation. One of the wells providing water to the community was continuously contaminated with excessive levels of fecal coliforms from a nearby septic tank, and a breakdown in chlorination on January 14-15 caused approximately 1 million gallons of inadequately chlorinated water from the contaminated well to be distributed to the community 48 hours before the epidemic began. Correction of deficiencies in the water plant was undertaken by the utility company; the residents of Richmond Heights were instructed to boil their drinking water or to use commercially bottled water pending completion of corrective measures. A FUll scale study is planned for all similar public water supplies in Dade County.

Diagnostic value of indirect hemagglutination in the seroepidemiology of Shigella infections.

To evaluate the usefulness of the indirect hemagglutination (IHA) test in the epidemiological investigation of shigellosis, single serum specimens were tested from 50 patients with Shigella dysenteriae 1 (Shiga bacillus) infections, 103 asymptomatic contacts of these cases, 267 adult and 100 student control, and serum specimens collected during two outbreaks caused by S. sonnei and one outbreak due to S. flexneri 6. In patients with S. dysenteriae 1, 74% demonstrated titers of greater than or equal to 1:40, with 50% showing titers of greater than or equal to 1:160, whereas in the controls 10.4% had titers of greater than or equal to 1:40 and only 0.3% had titers of greater than or equal to 1:160. IHA titers in serum specimens collected from patients with S. sonnei and S. flexneri 6 were too low to be considered diagnostic for individual patients, but were useful in analysis of group results. Groups of ill individuals yielded titers significantly higher than non-ill groups; however, titers from ill groups were usually less than 1:40. The IHA test for S. dysenteriae 1 antibodies serves as a valuable adjunct to the diagnosis of Shiga bacillus dysentery. In our laboratory, an IHA titer of 1:40 or 1:80 is a "borderline positive." Shiga bacillus dysentery is strongly indicated when IHA titers are greater than or equal to 1:60.

Shigellosis in day-care centres.

Increasing numbers of outbreaks of shigellosis in day-care centres have been reported to the Center for Disease Control since 1972. Investigations reveal certain unique epidemiological features of shigellosis in this setting. Attack-rates tend to be higher than in outbreaks in primary schools, and epidemiologically these outbreaks resemble those in custodial institutions. Person-to-person transmission is the usual mode of spread; secondary spread within households is common, and there may also be significant spread to the community at large. Preventive measures should be directed at children, staff, and the day-care centre environment. Control of outbreaks may require closing the centre and must include separation of infected and uninfected persons, judicious use of antibiotics, and correction of deficiencies in hygiene and health education. Improved surveillance of shigellosis in day-care centres will be an aid in efforts toward controlling this increasingly important public-health problem.

A case of cholera in Texas, 1973.

The first naturally acquired case of cholera reported in the United States since 1911 occurred in a 51-year-old resident of Port Lavaca, Texas. Extensive epidemiologic investigation of the patient's contacts and environment did not identify a cholera carrier of elucidate a pathway of transmission, but several avenues of investigation suggested possible means by which the patient may have acquired his infection. No secondary spread resulted from this case, and its occurrence did not endanger the community at large.