Cryptococcosis in Denmark: an analysis of 28 cases in 1988-1993.

A total number of 31 events of systemic cryptococcal infection in 28 patients was identified in a nation-wide survey over 6 years from 1988 to the end of 1993. All medical records were reviewed, 24 of the patients were HIV-infected. Meningitis was diagnosed in 25 patients, and fungemia in 8 patients. The most frequent symptom was headache followed by fever. The median duration in days of fever, headache, and other neurological signs/symptoms before diagnosis was 12, 8 and 2 days, respectively, and, after diagnosis and start of treatments 7, 11 and 12 days, respectively. There was a significant correlation between the duration of headache and the duration of neurological signs/symptoms but not between headache and fever. More than 50% of the patients died within 5 months after the diagnosis. In 39% of the cases, the patients were orally treated with various antifungal drugs before the diagnosis. The rate of cryptococcosis (cumulative) in Danish AIDS patients was estimated to be 1.7%. The HIV-positive patients were, at the time of the cryptococcal diseases, profoundly immunocompromised, with a median CD4+ cell count of 18 (range: 0-78)/microliters. From 24 patients at least 1 isolate of Cryptococcus neoformans was typed, all being var. neoformans, identical with serotype A/D.

The disappearance of multiresistant Staphylococcus aureus in Denmark: changes in strains of the 83A complex between 1969 and 1989.

During the 1960s multiresistant strains of Staphylococcus aureus were problematic in Denmark and other countries. An analysis of the phage types and antibiotic resistance patterns of S. aureus strains collected from approximately 20,000 Danish patients per year has given us a general picture of the evolution of S. aureus in Denmark during the last 30 years. Multiresistant S. aureus (i.e., strains resistant to penicillin, streptomycin, and tetracycline and often to methicillin and erythromycin as well) belonged mostly to the 83A complex, a relatively homogeneous subset of group III strains that can be further divided into six subtypes. The disappearance of multiresistant strains in Denmark began with a decline in the frequency of isolation of the most resistant subtypes, which was followed by a gradual decrease in the resistance of all 83A subtypes; thus strains of the 83A complex ultimately became no more resistant than other strains. As the proportion of strains of S. aureus accounted for by the 83A complex declined from 24% in 1969 to 6% by the late 1980s, this complex was replaced by strains of type 95, the 94,96 complex, and group II, all of which only rarely show resistance to multiple agents.

Varicella among immigrants from the tropics, a health problem.

The incidence of varicella in Tamil refugees in Denmark was evaluated. Of 256 Tamils, 44% developed varicella infection in the first few months after arrival, representing 38% of the adults, and 68% of the children. During approximately four months' observation in Denmark, 75% of the refugees with no history of varicella developed a typical infection whereas only 2% of those with a history of varicella developed the disease. Tropical refugees with a negative history of varicella must therefore be considered nonimmune. Nine of 44 fertile women were pregnant. Two acquired the varicella infection during the first-trimester, none in relation to delivery. By organizing a health-check on arrival, prophylactic measures can reduce the health hazard of varicella infection in refugees from the tropics.

Salmonella and Shigella carriers among refugees from the middle east and Sri Lanka in Denmark.

One per cent of ten thousand refugees were asymptomatic carriers of Salmonella and Shigella species found by a differentiated health check programme at a Danish Red Cross arrival centre in Denmark 1985 and 1986. Six patients with typhoid fever and one with S. parathyphi-A septicaemia all fell ill within the first few weeks after arrival. A child of a chronic S. typhi carrier developed typhoid fever four months after arrival. Cases of sporadic and mild diarrhoea occurred due to Salmonella and Shigella species. The carriers were instructed in prophylactic, hygienic measures and no outbreaks developed. The health check system in this period seemed to be sufficient in relation to preventing outbreaks of infections caused by non-typhoid Salmonella and Shigella species. The relative cost-effectiveness of a more intensive S. typhi screening on arrival is questionable. The organization of health check systems should be reviewed regularly, as each refugee situation is different and will change in different periods.

Polymorphonuclear leucocyte dysfunction during short term metabolic changes from normo- to hyperglycemia in type 1 (insulin dependent) diabetic patients.

Polymorphonuclear leucocyte (PMN) ingestion of particles coated with lipopolysaccharide (LPS) from Escherichia coli was compared to other PMN functions in seven patients with insulin dependent diabetes mellitus (IDDM) during short-term controlled metabolic changes from normo- to hyperglycemia without ketoacidosis. Factors known to interfere with PMN functions were excluded. PMN ingestion of particles coated with both LPS and bovine serum albumin became reduced from normo- to hyperglycemia. PMN motility was impaired in IDDM, but did not seem to be affected by short-term changes in metabolic control. PMN metabolism did not change from normo-to hyperglycemia. Particle-uptake by diabetic PMN is impaired after short term hyperglycemia in the range normally occurring in diabetics in every-day life.

Mortality in the years following bacterial meningitis.

During the years 1966-1976, 875 patients were treated for bacterial meningitis at the University Clinic for Infectious Diseases, Copenhagen. By about January 1, 1980, all 782 surviving patients had been traced. 87 had died in the observation period of four to 15 years. Mortality in the years following meningitis was studied by means of a comparison with the expected mortality in a matched normal population, using a computer program for the determination of late excess mortality. Late excess mortality was significantly increased during the first two years following discharge after meningitis and was of the same magnitude in the major etiological groups. The cumulative five-year late excess mortality rate was higher in the group of patients between 30 and 60 years, in those transferred from other hospitals, in those in coma or somnolence on admission and in those developing convulsions during hospitalization. In the group of patients aged 30 to 60 years, 11 patients died during the first two years after discharge. In nine of these cases, the main cause or the concomitant causes of death were conditions predisposing to infections or bacterial meningitis. The frequency of the causes of death in the 87 patients who died was not significantly different from that among the general Danish population.

Pneumococcal meningitis: an evaluation of prognostic factors in 164 cases based on mortality and on a study of lasting sequelae.

During the period 1966-76, 164 patients with pneumococcal meningitis were admitted to the University Hospital, Copenhagen. Of 111 survivors 94 underwent a series of clinical examinations. The findings in each patient were assessed for their aetiological relationship to meningitis. Of these patients 54% had neurological sequelae, 42% had neuropsychological sequelae, 25% had otological sequelae and 16% had sequelae as judged by computer-assisted tomography of the brain. On the basis of the general clinical condition, each patient was evaluated for the presence of sequelae of meningitis by means of a rating of nil, mild, moderate or severe. These ratings and mortality rates were used to evaluate the prognostic significance of various features present during the acute illness. A fatal outcome was significantly associated with increasing age, concomitant pneumonia, altered consciousness on admission, transfer from another hospital and development of complications while in hospital. There was a statistically significant association between lasting sequelae and the female sex, the age group of 16-50 years, patients who had not received any pre-admission antibiotic therapy and those with positive bacterial cultures of specimens from sites other than blood or cerebrospinal fluid.

Effect of cimetidine on upper gastrointestinal bleeding after renal transplantation: a prospective study.

In 97 consecutive patients undergoing renal transplantation the incidence of upper gastrointestinal bleeding was registered over 180 days after allocation to treatment with either cimetidine or placebo. Bleeding episodes occurred in 12 patients, 11 of whom were receiving placebo and only one cimetidine (p less than 0.01). All bleeding episodes occurred during the first month after allotransplantation. Treatment with cimetidine did not lead to an increased incidence of rejection of the allograft. It is concluded that cimetidine is effective and safe in protecting against upper gastrointestinal bleeding after renal transplantation.

Plasma separation in patients with bronchial asthma, atopic dermatitis and hyperimmunoglobulinaemia E.

The effect of intensive plasma separation performed eight times within 5 weeks in four patients with atopic dermatitis, bronchial asthma and hyperimmunoglobulinaemia E was followed as regards clinical symptoms and changes in the concentrations of serum (S) IgE, S IgG, S IgA, S IgM, plasma complement C3 split products, S transferrin, blood eosinophils, chemotaxis of neutrophil cells and histamine metabolites in urine in samples obtained consecutively during the period of observation. The occurrence of circulating immune complexes (IC) was analysed by a polyclonal rheumatoid factor (pRF) agglutination inhibition assay and an IgE IC specific technique. IgE IC were demonstrated in three of the patients prior to plasma separation, complexed IgE was 2-3% of the total concentration of S IgE. In one patient complexes were detected by the pRF agglutination inhibition assay, also. In the three patients with IgE IC, the complexes disappeared during treatment, but recurred in two of the patients shortly after the last plasma separation. Shortly after eight separations the S IgE was reduced in all patients to a mean level of 46% of the pre-exchange concentrations. During the following 3 weeks the relative increase of S IgE in three of the patients was similar to the values obtained for S IgG. Serum IgG was subnormal in all patients during the period of treatment. Increasing numbers of eosinophils were observed in three of the patients after the fifth separation procedure. The histamine metabolite 1,4-methylimidazoleacetic (1,4- MIAA ) in urine was increased in all patients, but no significant changes were observed during the treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma and urine fibronectin concentration in kidney-transplanted patients.

Plasma and urine fibronectin concentration was determined by electroimmunoassay and ELISA-method in patients who received renal transplantation. The plasma fibronectin concentration decreased both after the transplantation, in relation to the acute rejection of the graft, and in the relation to immunosuppressive therapy. Urine fibronectin excretion increased in relation to the kidney transplantation and acute rejection of the graft. In association with improved kidney function, the urine fibronectin excretion decreased. It is suggested that it might be of clinical importance to determine the excretion of fibronectin into the urine in patients undergoing kidney transplantation.

Plasma fibronectin concentration in patients with chronic renal failure and treated with haemodialysis.

By quantitative electroimmunoassay the plasma fibronectin concentration was determined in 42 patients with chronic renal failure and treated with haemodialysis. The plasma fibronectin concentration was significantly reduced, independent of the haemodialysis, compared to a control group. Delayed wound healing seen in patients with chronic renal failure might be a result of the reduced plasma fibronectin.

875 cases of bacterial meningitis: diagnostic procedures and the impact of preadmission antibiotic therapy. Part III of a three-part series.

Data on the bacteriological findings, diagnostic measures and clinical course of 875 patients with bacterial meningitis are presented. Findings from the medical records and from a follow-up questionnaire survey of 667 of these cases revealed no significant difference between patients treated with antibiotics before admission (pretreated) and those who were not treated before admission (non-pretreated) with respect to clinical condition on admission, mortality and late sequelae. Pretreatment was, however, associated with a longer duration of symptoms. Apart from cases due to Neisseria meningitidis, there were no significant differences in diagnostic findings between pretreated and non-pretreated cases. In the group of pretreated meningococcal patients, however, positive blood cultures, pleiocytosis in the cerebrospinal fluid (CSF) and positive cultures from sites other than blood and CSF were less frequent than in the non-pretreated cases.

Sequelae from bacterial meningitis and their relation to the clinical condition during acute illness, based on 667 questionnaire returns. Part II of a three part series.

During the years 1966-1976, 875 patients with bacterial meningitis were treated at the Department of Infectious Diseases, Rigshospitalet, Denmark. In late 1979 and early 1980 a survey by questionnaire was conducted among survivors concerning the impact of the disease. Replies were received from 667 patients (96.4 per cent). The most common complaints after meningitis were headache (32 per cent) inability to concentrate (31 per cent), altered working capability (33 per cent) and loss of memory (24 per cent). Approximately 20 per cent suffered from impaired hearing, visual disturbances and dizziness. Five per cent had convulsions. Each questionnaire was evaluated for sequelae, and when present these were rated as mild, medium or severe. One-third of the patients had sequelae and in 6 per cent these were severe. Sequelae were most commonly associated with drowsiness, coma, agitation and confusion on admission to hospital.

Eight hundred and seventy-five cases of bacterial meningitis. Part I of a three-part series: clinical data, prognosis, and the role of specialised hospital departments.

Between 1966 and 1976, 875 patients with bacterial meningitis were treated at the Department of Infectious Diseases, Rigshospitalet. Among 495 patients admitted directly to the department, fatality rates were 0.4 per cent for meningococcal infections (including septicaemia), 3.7 per cent for haemophilus meningitis and 8.7 per cent for pneumococcal meningitis. The total fatality rate for directly admitted patients was 3.8 per cent, and 4.0 per cent had sequelae on discharge. Patients transferred from other hospitals often had complications, and their fatality rate (20.1 per cent) was markedly higher than that for directly admitted patients, but not significantly higher than that for patients treated elsewhere in Denmark (17.6 per cent). The low fatality at a specialised unit may reflect an open and swift admission procedure and the preparedness of staff familiar with the management of meningitis. During the first five years after discharge, the relative death risk was increased among meningitis patients but later declined to that found in the general population.

Viral hepatitis in southeast Asian refugees.

Five hundred sixty-four Vietnam refugees were studied for past or present infection with hepatitis A and B virus (HAV and HBV) by sensitive serological assays for hepatitis B surface and e-antigen and antibodies to HBsAg, HBeAg, HBcAg, and HAV. Fifteen percent of the men and 6% of the women were HBsAg-positive. Of these 66% were also positive for HBeAg. Serum transaminase values did not effectively differentiate between the infectious HBeAg carriers and the less infectious anti-HBe carriers. The HBsAg carrier rate did not increase by age after infancy, and among children, carriers clustered around HBsAg carrier mothers only. In contrast, the distribution of antibodies to the three HBV-associated antigens suggested continuous exposure throughout childhood, and a 90% prevalence rate was found at the age of 20 years. Screening for HBeAg in this new population group is necessary if appropriate precautions are to be taken, and if medical management of these patients is to be optimal. The prevalence of antibody to hepatitis A increases with age to 90% at 15 years. Among anti-HAV-positive children and adults IgM- anti-HAV was found in 8% of the children and none of the adults, indicating that only a few children may be in an infectious stage at the time of study, and therefore no specific prophylactic precautions are necessary.