Staphylococcus aureus with reduced susceptibility to vancomycin isolated from a patient with fatal bacteremia.

A Staphylococcus aureus isolate with reduced susceptibility to vancomycin was obtained from a dialysis patient with a fatal case of bacteremia. Comparison of the isolate with two methicillin-resistant S. aureus (MRSA) isolated obtained from the same patient 4 months earlier suggests that the S. aureus with reduced susceptibility to vancomycin emerged from the MRSA strain with which the patient was infected. Atypical phenotypic characteristics, including weak or negative latex-agglutination test results, weak or negative-slide coagulase test results, heterogeneous morphologic features, slow rate of growth, and vancomycin susceptibility (by disk diffusion test) were observed.

Human granulocytic ehrlichiosis in New York.

BACKGROUND: Human granulocytic ehrlichiosis (HGE), a potentially fatal tick-borne disease, was first described in the upper Midwest in 1994. Following reports of suspected cases of ehrlichiosis from New York physicians, descriptive and case-control studies were conducted to characterize the epidemiology and risk factors for HGE in New York residents. METHODS: Descriptive data were gathered from surveillance and laboratory reports and hospital records. A confirmed case was defined as either (1) a 4-fold change in total antibody titer to Ehrlichia equi by indirect immunofluorescence or (2) a polymerase chain reaction assay positive for Ehrlichia phagocytophila/E equi group DNA. A probable case was defined as an acute febrile illness and either (1) a single E equi titer greater than or equal to 80 or (2) morulae on a peripheral blood smear. The case-control study included patients with confirmed HGE 18 years of age or older with the onset of disease in 1995 and 2 to 3 neighborhood-matched controls. RESULTS: During 1994 and 1995, the New York State Department of Health, Albany, received reports of 241 residents who were tested for HGE; 30 met the confirmed case definition and 34 met the probable case definition. The median age of patients was 46 years (age range, 9-90 years), 35 (55%) were male, and 25 (45%) were hospitalized. Fever, headache, malaise, and myalgia were the most frequently reported symptoms. Fifty-six (88%) of the 64 patients resided in areas in which Lyme disease is hyperendemic. In the case-control analysis, cases were more likely than controls to have sustained a tick bite during 1995 (matched odds ratio, 5.0; 95% confidence interval, 0.9-49.8). Cases and controls did not differ by occupational exposure to ticks, underlying chronic diseases, or measures taken to prevent tick bites. CONCLUSIONS: This study, which, to our knowledge, is the first population-based study of HGE, demonstrates the recent recognition of HGE in the state of New York. Control measures should be integrated with those for Lyme disease and should focus on minimizing contact with ticks and obtaining early treatment for infection.

Swimming-associated haemorrhagic colitis due to Escherichia coli O157:H7 infection: evidence of prolonged contamination of a fresh water lake.

We describe an Escherichia coli O157:H7 outbreak associated with a fresh water lake at a county park. Campers were surveyed for diarrhoeal illness within 10 days of their visit, and a case-control study of day visitors was conducted. A confirmed case was a symptomatic person with a stool culture positive for E. coli O157:H7 and a probable case was a person with bloody diarrhoea. Clinical isolates of E. coli O157 were subtyped by pulsed field gel electrophoresis (PFGE). In the camper survey, 12 (38%) of 32 swimmers had a diarrhoeal illness (relative risk [RR] = 12.4; 95% confidence interval [CI] = 1.7-89.7). For the case-control study, the 12 cases were more likely than controls to have purposefully ingested lake water (odds ratio [OR] = 6.9, 95% CI = 0.9-55.8). The PFGE patterns of six clinical isolates were indistinguishable. This report further demonstrates that contaminated fresh-water lakes can be the source of community outbreaks of E. coli O157:H7.

An outbreak of hepatitis A associated with a bakery, New York, 1994: the 1968 "West Branch, Michigan' outbreak repeated.

In a community hepatitis A outbreak in the Rochester, New York area, 64 of 79 (81%) people with anti-hepatitis A IgM-antibodies and onset of symptoms from 9 April-31 May 1994, recalled eating food obtained from a retail buyer's club. Eleven (65%) of 17 households with cases contained club members compared with 7 (21%) of 34 neighbourhood-matched control-households (matched odds ratio 8.5; 95% CI 1.7-41.6). Club employees who ate sugar-glazed baked goods were at fourfold increased risk for hepatitis. The source of infection was an IgM-positive baker who contaminated baked goods while applying sugar glaze. Computer-generated purchase lists implicated 11-12 March and 21-24 March as the most likely dates when contamination occurred. This investigation demonstrates the importance of food workers adhering to established hygiene practices. Computer-generated commercial datasets can be useful in epidemiologic investigations.

Hantavirus S RNA sequence from a fatal case of HPS in New York.

In April, 1995, the second fatal case of hantavirus pulmonary syndrome (HPS) occurred in the northeast in a New York State resident. Using the patient's lung tissue obtained at autopsy, the S genomic RNA segment of a hantavirus, designated H-NY1, was amplified by reverse transcriptase-polymerase chain reaction (RT-PCR), cloned, and sequenced. The S RNA was found to contain 2084 nucleotides, 6 nucleotides longer than reported by Hjelle et al. (1995) for the virus associated with the first northeastern case (RI-1). There were 101 nucleotide differences in the S RNA between the H-NY1 and RI-1, which result in the prediction of a single amino-acid change in the nucleocapsid (N) protein. Rodents were trapped for serologic and virologic studies at the patient's residence and work site. The white-footed mouse (Peromyscus leucopus) was the most frequently captured species and more than 50% of those trapped near the patient's residence showed serologic evidence of hantavirus infection. Using RT-PCR it was possible to amplify hantavirus S RNA sequence from the lung tissues of 8 out of 11 seropositive animals. No difference in nucleotide sequence was found between the HPS patient sequence and the P. leucopus sequence (nucleotides 189 to 599). These data are consistent with those of Hjelle et al. (1995) in suggesting that P. leucopus is the primary rodent vector for the etiologic agent of HPS in the northeastern United States.

Assessment of surveillance for meningococcal disease in New York State, 1991.

Prevention of meningococcal disease relies in part on the prompt treatment of household and other close contacts of cases. New York State requires that all meningococcal disease cases be reported within 24 hours of diagnosis to ensure that chemoprophylaxis is given to all exposed persons. The authors used a capture-recapture method to assess completeness of reporting of meningococcal disease in 1991 by comparing persons reported to the Department of Health surveillance system with patients listed in the New York State computerized hospital discharge data set who had a discharge diagnosis of meningococcal disease. Medical records of persons identified from the discharge data set were reviewed to verify the diagnosis of meningococcal disease, and timeliness of reporting was assessed by reviewing surveillance case reports. In 1991, 110 cases of meningococcal disease were reported to the Department of Health and 197 patients were identified from hospital discharge data, of which charts were reviewed for 179 (91%). Of the charts reviewed, 116 (65%) had confirmed or probable meningococcal disease, and 57 (32%) did not have the disease. Completeness of reporting to the notifiable disease surveillance system was estimated to be 93%, and 78% were reported within 2 days of diagnosis. Errors of physicians and medical records departments contributed to the misclassification of medical records. The authors conclude that notifiable disease surveillance for meningococcal disease is relatively complete, but there is a delay in reporting some cases. Frequent errors may make invalidated hospital discharge data unsuitable for communicable disease surveillance.

Reptile-associated salmonellosis in New York State.

To determine the association between reptile ownership and salmonellosis caused by certain rare serotypes of Salmonella, we reviewed 1993 New York State Salmonella case reports and conducted a matched case-control study. Cases were persons identified from 1993 New York State laboratory records who had salmonellosis caused by Salmonella serotypes commonly isolated from reptiles. Controls were selected from 1993 New York State shigellosis cases and matched for age and date of diagnosis. Of 674 Salmonella case reports 27 (4%) noted reptile exposure before onset of illness. For the case-control study we identified 42 persons with selected Salmonella serotypes, of whom we contacted 24 (57%). Twelve of 24 case patients and 2 of 28 controls owned reptiles (matched odds ratio, 6.6; 95% confidence interval, 1.4 to 31.0). Ten case-patients but no controls owned iguanas (MOR = undefined; 95% confidence interval, 2.24-infinity). Ten of 12 case patients who owned reptiles were < or = 6 months of age. Salmonellosis caused by certain serotypes is associated with reptile exposure. Reptiles may be unfit pets for homes with infants.

Survival after pelvic lymphadenectomy and radical cystectomy in patients with lymph-node metastatic transitional-cell carcinoma of the bladder.

The objective of this study was to determine the clinical outcome of patients with invasive transitional cell carcinoma of the bladder and pelvic lymph node metastases treated by radical cystectomy and bilateral pelvic lymphadenectomy in a single institution. From January 1980 to December 1993, 116 patients with transitional cell carcinoma of the bladder underwent bilateral pelvic lymphadenectomy and radical cystectomy at the Montreal General Hospital. Of these patients, 25 (21.6%) were found to have nodal metastases and form the basis of this retrospective analysis. Extent of nodal disease was as follows: 7 (28%) with N1, 17 (68%) with N2, and 1 (4%) patient with N3 disease. Of the 25 patients, 9 (36%) were alive with no evidence of disease and 1 (4%) died at 42 months from cardiovascular disease without clinical evidence of cancer recurrence. The median follow-up interval for these 10 patients was 26.5 months (mean, 31.4 months; range, 7-104 months). Fourteen (56%) patients died of recurrent bladder cancer and one patient was alive with systemic disease at 14 months. The median survival was estimated at 27 months, with 73% alive at 1 year, 51% alive at 2 years, and 33% alive at 3 years. Our data suggests that long-term survival free of disease can be achieved by radical surgery in some patients with node-positive bladder cancer.

Apomorphine-induced penile tumescence in impotent patients--preliminary findings.

Apomorphine (Apo), a short acting dopamine (DA) receptor agonist induces penile erections in normal subjects. The erectile response to one or more doses of Apo HCl (0.25, 0.5, 0.75, 1.0 mg sc) or placebo was investigated in eight impotent subjects and penile tumescence monitored using a mercury strain gauge and strip chart recording. Four patients showed a full erection with Apo and one a partial response. Distressing side effects (nausea, sweating) were associated with non-response or partial response. Three responders to Apo were treated with low doses of the long acting DA receptor agonist, bromocriptine (2.5-3.75 mg/d po); all three showed complete recovery of erectile function within two weeks. A subgroup of impotent patients may have impaired central DA function. Testing with Apo may provide a diagnostic and predictive test to identify such patients who may respond to treatment with low doses of bromocriptine or other DA receptor agonist.

Effect of apomorphine, a dopamine receptor agonist, on penile tumescence in normal subjects.

Apomorphine HCl (Apo) (0.25, 0.5 or 0.75 mg sc), a dopamine (DA) receptor agonist, induced penile erections (PEs) (monitored by mercury strain gauges and continuous recording on paper strip charts) in 7 out of 9 normal subjects and placebo in 1 of these 9 (p less than 0.05). Apo-induced PEs recurred in each of the 6 subjects retested. Benztropine (2 mg iv) had no effect on Apo-induced penile tumescence (PT). These data suggest (a) DA mechanisms play a role in normal erectile function (b) DA-mediated PT is not modulated by cholinergic systems (c) evaluation of the erectile response to Apo may provide a simple ancillary test to the investigation of impotence and a way of identifying a subpopulation of impotent subjects with impaired DA function who may respond to long-acting DA agents (d) Apo-induced PT may provide a novel way of studying DA function in man.

Tumor growth inhibition in patients with prostatic carcinoma treated with luteinizing hormone-releasing hormone agonists.

Ten patients with prostatic carcinoma--six with stage C and four with stage D disease--were treated for 6 weeks to 12 months with agonistic analogues of luteinizing hormone-releasing hormone (LH-RH). [D-Trp6]LH-RH was given subcutaneously once daily at a dose of 100 microgram and [D-Ser(But)6]des-GlyNH2(10)-LH-RH ethylamide (HOE 766) was given subcutaneously (50 microgram once daily) or intranasally (500 microgram twice daily). In all patients, mean plasma testosterone levels showed a 75% suppression by the third week of treatment and remained low thereafter. This was followed by a decrease or normalization of plasma acid phosphatase levels by the second month of treatment and a 47% decrease in serum alkaline phosphatase by the 10th week of treatment in all but one patient. In patients with stage C disease presenting with prostatism or urinary outflow obstruction, there was a noticeable clinical improvement. In two such patients, a decrease in the size of the prostate was confirmed by ultrasonography. In patients with stage D disease manifested by diffuse bone metastases, there was relief of bone pain, and in one patient treated for greater than 12 months the improvement was documented by radioisotope bone imaging. It is concluded that superactive agonistic LH-RH analogues hold promise as therapeutic agents in patients with androgen-sensitive prostatic adenocarcinoma. Furthermore, the analogous of LH-RH may be used to assess the responsiveness of patients to surgical castration. Long-term administration of LH-RH analogues could become an alternative to surgical castration and estrogen therapy for the treatment of hormone-dependent prostatic carcinoma.