Acute renal artery and vein thrombosis after renal transplant, associated with a short partial thromboplastin time and factor V Leiden mutation.

Renal graft thrombosis is a rare but devastating complication of renal transplantation. It accounts for one-third to one-half of early graft losses. We report a patient with acute renal artery and vein thrombosis associated with abnormally short activated partial thromboplastin time (aPTT) and factor V Leiden mutation. Vascular thrombosis developed on the ninth post-transplant day and led to a graft loss. Before transplantation, the patient had three episodes of thrombosis of arteriovenous access for hemodialysis. Our case illustrates the importance of investigating pretransplant patients for hypercoagulable states, particularly those with short aPTT.

Preferential recognition of human myocardial antigens by T lymphocytes from rheumatic heart disease patients.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are autoimmune sequelae of upper respiratory infections with group A streptococci (GAS). To gain a better understanding of the pathogenesis of these diseases, we examined the in vitro proliferative responses of peripheral blood mononuclear cells (PBMC) from RHD patients to human myocardial proteins in a T-cell Western assay. A number of myocardial proteins fractionated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis were recognized by PBMC from both patients and controls. However, PBMC from a significant percentage of RHD patients (40%) responded to a discrete band of myocardial proteins migrating with an apparent molecular mass of 50 to 54 kDa while none of the control subject PBMC responded to this protein band (P < or = 0.0001). To further investigate the link between infections with GAS and autoimmune carditis, we studied the proliferative responses of PBMC from patients and controls to myocardial proteins before and after in vitro stimulation of the cells with opsonized GAS isolated from ARF patients. Priming of PBMC with rheumatogenic GAS caused the percentage of RHD patients responding to the 50- to 54-kDa myocardial proteins to increase from 43 to 90% (P < or = 0.0284). By contrast, PBMC from control subjects failed to recognize the 50- to 54-kDa myocardial proteins even after stimulation with the opsonized streptococci (P < or = 0.0001). The assay sensitivity was increased from 40 to 90% after priming of a patient's cells with opsonized GAS, but the positive predictive value was 100% in both unprimed and primed cultures. Antibodies generated to partially purified 50- to 54-kDa myocardial proteins did not cross-react with either streptococcal homogenates, purified M protein, myosin, laminin, or vimentin, suggesting a lack of cross-reactivity at the humoral level. This study suggests that the 50- to 54-kDa myocardial proteins contain a putative antigen that is preferentially recognized by T cells from RHD patients and demonstrates that exposure to streptococcal antigens enhances the ability of patients to recognize these proteins.

Resistance patterns of Streptococcus pneumoniae and Haemophilus influenzae isolates recovered in Egypt from children with pneumonia. The Antimicrobial Resistance Surveillance Study Group.

Treatment of childhood pneumonia in developing countries requires knowledge of susceptibility patterns for Streptococcus pneumoniae and Haemophilus influenzae. Between October 1991 and April 1993, a surveillance survey of antimicrobial resistance was performed at two fever hospitals in Egypt; nasopharyngeal swab and blood specimens obtained from 1,635 children with pneumonia were cultured for these organisms. Susceptibility testing of these organisms was performed. At least one of these organisms was isolated from nasopharyngeal swab specimens from 73% of the children; 3.7% of blood cultures were positive. For S. pneumoniae strains, 70.9% of nasopharyngeal isolates were calculated to be susceptible to penicillin vs. 77.6% of blood isolates; the percentages of isolates susceptible to co-trimoxazole were 73.0% and 75.0%, respectively. For H. influenzae strains, 93.0% of nasopharyngeal isolates were calculated to be susceptible to ampicillin vs. 100% of blood isolates; the percentages of isolates susceptible to co-trimoxazole were 84.9% and 100%, respectively. Although most S. pneumoniae and H. influenzae strains associated with childhood pneumonia in Cairo were susceptible to penicillins and co-trimoxazole, antimicrobial resistance did not occur.

[Coronary-cardiac fistula as a cause of tricuspid endocarditis treated by mitral homograft]. / Fistule coronaro-cardiaque à l'origine d'une endocardite tricuspide traitée par homogreffe mitrale.

The authors report a rare case which is interesting from three points of view: tricuspid valve endocarditis in a child complicating a fistula between the right coronary artery and right ventricle with negative blood cultures but a positive serology for Coxiella burnetii. This mutilating tricuspid endocarditis was complicated by multiple pulmonary embolism of the right lung. After two months of antibiotic therapy the coronaro-cardiac fistula was closed and the tricuspid valve replaced with a mitral homograft. All cases of blood culture negative endocarditis require serological investigation to detect intracellular organisms which are difficult to diagnose and justify specific prolonged antibiotic therapy. Control serological tests are essential in the long-term because of the risk of chronic infection, especially in cases with prosthetic intracardiac material. Treatment, based mainly on tetracyclines, should be continued for at least two years.

[Outcome of 77 live born children with cardiac or rhythmic anomalies diagnosed in the prenatal period. Apropos of 77 cases]. / Devenir d'enfants nés vivants atteints d'anomalies cardiaques ou rythmiques diagnostiquées en anténatal. A propos de 77 cas.

Seventy-seven live born children (September 1988 to May 1993) had prenatally detected morphological cardiac malformations (61 cases) and/or arrhythmias (17 cases). The outcome of these children was analysed with an average follow-up of 21.4 months (range: 1 day to 11 years). The parameters studied were age and condition of prenatal diagnosis, the term of pregnancy, the extracardiac malformations associated and the outcome of the live born children. Fifty-two children survived with a mean follow-up of 28.2 months (range: 5 months to 11 years) and 25 children died at a mean age of 3.3 months (range: 1 day to 32 months). The cardiac malformations correlated with the postnatal diagnosis in 59 children (60 cardiac malformations). They included left or right outflow tract obstruction in 22%, septal defects or Tetralogy of Fallot with or without pulmonary atresia in 18.4%, arterial malposition in 12.9% and arrhythmias or conduction defects in 20.7% of cases. The main reason for the high mortality was the complexity of the cardiac malformations with, in particular, ventricular hypoplasia with right or left outflow tract obstruction (41% of mortality). The functional consequences of these abnormalities were only partially appreciated at prenatal diagnosis. The extracardiac malformations, more easily diagnosed, contributed less to this mortality rate. The favourable prognosis of the arrhythmias or conduction defects diagnosed prenatally was confirmed but was, however, associated with a mortality rate of 12%.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemophilus influenzae and Streptococcus pneumoniae as causative agents of pneumonia in Egyptian preschool children: analysis and serotyping of Hemophilus isolates from hospital patients in Cairo, 1991-93.

The Hemophilus influenzae blood culture and nasopharyngeal isolates, collected during a limited Surveillance of Antimicrobial Resistance in 1991-1993 from 1,635 Egyptian children under 5 years of age, presenting with pneumonia to Embaba and Abbassia Fever Hospitals, were serotyped. The 8 blood culture isolates confirmed H. influenzae to be responsible for 0.5% of the cases of pneumonia, versus 50 Streptococcus pneumoniae blood culture isolates from the same population that confirmed it responsible for 3.1% of the cases. The invasive Hemophilus strains were exclusively isolated from infants below 1 year, from one hospital (Embaba), on one winter season (January to March, 1992). On serotyping, 50% of the blood culture isolates were found to be non-b by latex agglutination. Some 297 nasopharyngeal isolates from cases of pneumonia were also serotyped and 45% were found to be non-b, thus confirming the invasive strains findings. Furthermore, the typing results from ARI-free controls nasopharyngeal isolates--though limited--were consistent with the findings and showed a 43% proportion of non-b. These findings put a question mark on the benefit of a large scale use of the available H. influenzae type b polysaccharide and conjugated vaccines in Egypt. But before interpreting out data in terms of vaccine needs, more specifically designed epidemiological studies need to be conducted to assess the role of H. influenzae as a pathogen in Egypt.

Identification and characterization of Schistosoma mansoni antigens recognized by T and B lymphocytes of humans with early active intestinal and/or urinary schistosomiasis.

Schistosome antigens selected as vaccine candidates should induce in the majority of humans T and B cell-mediated immunity that results in protection against infection. As a first step towards the identification of such antigens, we attempted to define and characterize the soluble adult Schistosoma mansoni worm antigen (SAWA) bands that are recognized by serum antibodies and/or peripheral blood mononuclear cells of Egyptian children with early active S. mansoni and/or S. haematobium infection. Considerable inter-subject variation was observed in the SAWA bands recognized by antibodies and T lymphocytes, as demonstrated by Western blotting and T cell Western assays, respectively. The humoral response rate for the separated SAWA bands varied between 0% and 88% of infected subjects. The bands of 153, 144, 38 and 32 kDa reacted with the sera of 60 to 88% of infected subjects but not with the sera of uninfected controls. The bands of 144, 38, 32 and 18 kDa elicited proliferative responses in the lymphocytes of 42-63% of infected subjects. It was thus concluded that the SAWA bands of 144, 38 and 32 kDa are likely to carry T and B cell epitopes that could stimulate immune responses in a majority of individuals. The selected bands (144, 38 and 32 kDa) were found to include glycoproteins containing D-mannopyranosyl or glycosyl residues, and respectively 62.5, 46 and 55% amino acids by weight. The amino acid molar ratios of these bands were completely different.

Identification of Schistosoma mansoni antigens recognized by spleen cells of C57B1/6 mice immunized with ultraviolet-irradiated cercariae.

Spleen cells of C57B1/6 mice immunized twice with Schistosoma mansoni cercariae attenuated by ultraviolet irradiation proliferated and produced interleukin-(II)-2 and/or II-4 in response to both soluble schistosomular and adult worm antigens of 72-68, 60-62, 50, 45, 29.5 and 28 kDa. All of these bands, except the 45 kDa, were also recognized by serum antibodies in Western blotting.

Identification of Schistosoma mansoni antigens recognized by T cells of C57BL/6 mice immunized with gamma-irradiated cercariae.

Immunization of C57Bl/6 mice with gamma-irradiated Schistosoma mansoni cercariae induces highly significant protection against subsequent challenge with unattenuated living cercariae. The antigens that evoke T cell-mediated immunity in this model are vaccine antigen candidates since T lymphocytes mediate antibody-independent immune responses and control the production of most antibodies. To identify these antigens, spleen cells of mice immunized twice with gamma-irradiated cercariae were tested for proliferative responsiveness and production of interleukins (Il) and interferon-gamma (IFN-gamma) following incubation with separated soluble schistosomular (SSA) and adult worm (SAWA) antigens in T cell western assays. Data obtained at 3, 4, 5, and 6 wk post-secondary immunization in 2 experiments indicated that SSA and SAWA bands of 62-60, 50, and 45 kDa reproducibly elicited T cell proliferation and production of Il-2, Il-4, and IFN-gamma by spleen cells from immunized, but not unimmunized, mice. Bands of 72-68, 29.5, and 28 kDa elicited proliferation and production of Il-2 and Il-4, but not IFN-gamma. Bands of 35-33 and 24 kDa induced either proliferation or Il production at some intervals.

Schistosoma mansoni: identification and protective immunity of adult worm antigens recognized by T lymphocytes of outbred Swiss mice immunized with irradiated cercariae.

Percutaneous exposure of outbred Swiss mice to 500 Schistosoma mansoni (Egyptian strain) cercariae attenuated by 25,000 rad gamma radiation, twice at a 4-week interval, led to 80% protection against challenge with 100 live unattenuated cercariae compared to unimmunized control mice. The S. mansoni molecules that induce protective immunity in this model are not as yet identified. The capacity of an immunogen to induce efficient protective immunity depends largely on its T-cell-activating potential, as T cells are required both for eliciting long-lasting antibody formation and for antibody-independent cell-mediated immunity. To define such T cell antigen in S. mansoni, soluble adult worm antigens (SAWA) were separated by SDS-PAGE and electrotransferred onto nitrocellulose paper. Thirteen bands, identified by their M(r) were tested in T cell Western assays for their ability to stimulate proliferation of lymph node cells from 23 mice immunized with irradiated cercariae for the second time 2-5 weeks earlier. Lymphocytes from all mice responded to only a few (maximum of 6) bands. The response rate for the 13 SAWA bands tested ranged from 0-43%. These findings suggest a heterogeneity in T cell responses of individual mice to each of the SAWA bands and have implications that should be considered in the selection of immunogens to be assayed for anti-Schistosomiasis mansoni protective capacity. A highly significant protection against S. mansoni challenge in outbred Swiss mice was obtained exclusively following vaccination with a cocktail of soluble adult worm T cell immunogens that are recognized by 30-40% of individuals.

Identification of Schistosoma haematobium soluble egg antigens that elicit human granuloma formation in vitro.

Schistosoma haematobium soluble egg antigens (SH SEAs) induce intense granulomas in human hosts that often culminate in severe disease. In an attempt to identify the SH SEA fractions that are responsible for pathology, we combined T-cell Western blotting and an in vitro model of granuloma formation. Whole SH SEAs were dotted onto nitrocellulose pieces or were separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and electrotransferred onto nitrocellulose paper. Horizontal strips bearing the separated antigens were solubilized in dimethylsulfoxide and precipitated in carbonate/bicarbonate buffer. Antigen-free and antigen-bearing particles were used to stimulate peripheral blood mononuclear cells (PBMCs) obtained from S. haematobium-infected patients and sex- and age-matched healthy controls to form granulomas in vitro. Whole SH SEA-bearing nitrocellulose particles elicited in vitro formation of granulomas by PBMCs from infected donors. The response was similar in sensitivity, specificity, and reproducibility to that evoked by SH SEA-bound polyacrylamide beads. The results obtained in samples form 30 patients and 10 controls tested with SH SEA-separated fractions revealed that SEA bands of 84,000, 63,000, 57,000, 55,000, 40,000, 30,000, and 28,000 Da elicited in vitro granuloma reactions by PBMCs of almost all infected patients. Conversely, separated soluble adult-worm antigens failed to stimulate PBMCs of infected patients to form granulomas. This study is the first to identify the SH SEA fractions that evoke in vitro granuloma formation and represents an initial step toward the development of an anti-urinary schistosomiasis pathology vaccine.

Identification of the Schistosoma haematobium soluble egg antigens inducing antibody production and/or T cell proliferation in humans.

Soluble antigens were prepared from Schistosoma haematobium eggs collected from urine of 6-16 year-old children with urinary schistosomiasis. The electrophoretic profile of the soluble egg antigen (SEAH) preparation was almost identical to that (SEAh) obtained from UNDP/World Bank/WHO, Switzerland and prepared from S. haematobium eggs retrieved from intestines of infected hamsters. Reactivity of 50 individual patients with S. haematobium in Western blots led to the identification of the SEA protein bands carrying human B cell epitopes. Some, but not all, of these SEA proteins initiated peripheral blood T lymphocyte proliferation in T cell Western assays. These antigens are probably the ones inducing granulomatous response in vivo, and that are responsible for the immunopathology of the disease.

Bordetella pertussis FHA antibodies in maternal/infants sera and colostrum.

The high incidence of pertussis in the first year of life confirms that susceptibility remains high for children in this age group despite > 90% pertussis vaccine compliance. In this respect, immunoresponse to Bordetella pertussis was investigated. Filamentous hemagglutinin (FHA) antibodies were studied due to their important protective role, in blocking the adherence of the bacteria to respiratory tract ciliated cells. The relative rate of detection and degree of positivity of IgG and IgA antibodies to Bordetella pertussis FHA were studied in maternal and infant sera and in colostrum samples of the respective mothers. The study comprised 143 mothers of child bearing age and 25 newborns. The highest percentages of serum IgG and IgA were present in the younger females group (15-25 yrs). Both IgG and IgA were detected in the same mother in 60% of them. The study showed that 96.9% of colostrum samples who were positive for IgA, were associated with IgA positivity in serum, also an increase in the degree of serum IgA positivity was associated with a higher rate of detection of IgA in colostrum. Maternal serum IgA could therefore be used as a marker for the future presence of IgA in colostrum. This work demonstrated that newborns show little passive immunity to pertussis, evidenced by the low placental transfer of IgG (35.7%) and the low rate of detection of IgA in the colostrum (41%). We concluded that, it would be advantageous to reimmunize pregnant women, without adequate serum antibody to Bordetella pertussis, with appropriate new vaccine which would offer a better passive immunity to their infants.

An arthroscopic technique of demonstrating the pathomechanics of the suprapatellar plica.

The suprapatellar plica or incomplete suprapatellar septum of the knee is a recognized cause of knee pain in some patients and appears to exist in others without causing any symptoms. To date no clear method of demonstrating the pathomechanics of the suprapatellar plica by arthroscopic means has been described. This article describes a new technique of visualizing this structure arthroscopically and demonstrating the mechanism of its morbidity. By the use of a proximal viewpoint via the lateral suprapatellar portal, we have shown that the suprapatellar plica impinges on the medial femoral condyle and is trapped between the quadriceps mechanism and the femoral trochlea when the knee is flexed beyond 70 degrees. We conclude that our arthroscopic method may show the mechanism of production of symptoms of the pathological suprapatellar plica.

[Percutaneous transluminal valvuloplasty in pulmonary valve stenosis]. / Valvuloplastie transluminale percutanée des sténoses valvulaires pulmonaires.

Forty five patients with moderate or severe pulmonary valvular stenosis had been treated by percutaneous balloon valvuloplasty. The age of these patients varied between 55 days and 24 years. Nine patients (group 1) had a right ventricular/pulmonary artery gradient (RV/PA) between 25 and 50 mmHg, thirty six patients (group 2) had a RV/PA gradient superior to 50 mmHg. Fourty nine dilatations had been practised. The right ventricular pressure failed from 106.31 +/- 46.03 mmHg to 61.11 +/- 32.62 mmHg. The RV/PA gradient passed from 86.02 +/- 45.64 mmHg to 39.58 +/- 32.16 mmHg and the ratio of right ventricular pressure/systemic pressure passed from 0.98 +/- 0.44 to 0.49 +/- 0.23. The difficulties, failures, and the results are discussed together with predilectory factors.

A suggested vaccine formulation for the control of pneumococcal meningitis in Egypt.

Mortality rates of pneumococcal meningitis ranges from 13-60% in different parts of the world. Reports of pneumococci with multiple antibiotic resistance add urgency to the need for developing means of primary prevention. A 14-valent pneumococcal vaccine was licensed in 1977, and a 23-valent pneumococcal vaccine in 1983. In the present work 131 strains of pneumococci isolated from meningitis cases in Egypt were identified and serotyped by Quellung reaction. The most frequently isolated serotype was serotype 1 (32%). Serotypes 6A, 9L, 12A, 19A and 29 were next in prevalence. The age groups 0-18 years were the most frequently affected groups (79%) and over 18 years of age were only 21% of total cases. A vaccine formulation is suggested to have a coverage rate against pneumococcal meningitis cases of 79.3% and 89.3% of a proposed 14-valent vaccine and 23-valent vaccine versus to coverage rate of 48% and 54% of 14-valent and 23-valent International vaccines respectively. According to the age distribution of cases and the isolated serotypes a vaccination could be recommended during the first two years of age in order to protect the most frequently infected groups.

Effect of combined low dose praziquantel and oxamniquine on different stages of schistosome maturity.

Combined low doses of praziquantel and oxamniquine were tested against different stages of Schistosoma mansoni in infected Swiss albino mice. The effect of combination therapy (1/3 the curative dose of praziquantel plus 1/3 the curative dose of oxamniquine) was compared with the effect of each drug alone, in reduced or full dose. Comparison with infected untreated controls was also made. Drug effects were evaluated on different growth stages of schistosomes by administering the drugs 24 h before infection and 4 h, 1, 2, 3, 4 and 5 weeks after infection. Animals were killed 8 weeks after infection. Worm burden, distribution, tissue egg load and oogram pattern were used in assessing drug efficacy. A potentiating effect was observed in animals receiving combination therapy. The combination regimen was most effective 4 h after infection, producing 96% worm reduction; eggs were not detected in the liver or intestine. Five weeks after infection the same regimen resulted in 98% reduction in the tissue egg load.

Escherichia coli K51 and K93 capsular polysaccharides are crossreactive with the group A capsular polysaccharide of Neisseria meningitidis. Immunochemical, biological, and epidemiological studies.

Eleven Escherichia coli strains, crossreactive with the capsular polysaccharide (CPS) of Neisseria meningitidis group A (GrA), were detected among 645 stool isolates from healthy families in Cairo, Egypt. 10 of these strains were of the O107:K93:H27 or O107:K93:SP serotypes and may be considered descendents of a single bacterium or as a clone. The remaining crossreactive strain was of the O7:K51:H18 serotype. None of the 11 strains produced enterotoxins and none were enteroinvasive. The purified CPS of these E. coli strains, as well as a polysaccharide (PS) from B. pumilis, strain Sh17, precipitated with equine GrA (H49) antiserum. A partial identity between the E. coli K93, K51 and Sh17 PS on the one hand and the GrA CPS on the other was observed by double immunodiffusion when reacted against the H49 antiserum. Four K93 strains and one K51 strain were found among 320 E. coli strains from patients at the Clinical Center, National Institutes of Health, and three K93 strains were found in 105 stool samples from children in Copenhagen. The data from these three surveys suggest that these crossreactive E. coli are common organisms and could serve as a stimulus for "natural" GrA CPS antibodies. Quantitative precipitation analysis showed that K51, K93, and Sh17 PS precipitated 25, 46.8, and 50% of H49 antibodies, respectively. Absorption of H49 antiserum with the GrA CPS removed its precipitating activity with the E. coli K93, K51, and Sh17 PS. Absorption of H49 antiserum with either K51 CPS or Sh17 PS removed the homologous crossreactivity only, whereas K93 CPS absorbed both K93 and K51 reactivities. Antibodies, raised by intravenous injection of formalinized E. coli K93 or K51 cells into rabbits, precipitated with GrA CPS and were bactericidal against GrA meningococci. The crossreaction between the E. coli K93 and the GrA CPS was unexpected since these two CPS are compositionally so dissimilar.

Bacterial meningitis in Egypt: analysis of CSF isolates from hospital patients in Cairo, 1977-78.

Bacterial meningitis remains a major cause of mortality and morbidity in many countries of the world despite effective antimicrobial therapy. Studies of the etiology and some laboratory characteristics of bacterial meningitis in Egypt were conducted during 1977-1978. All patients suspected of having bacterial meningitis were studied at the time of admission to the two fever hospitals of Cairo. Direct culture, serological identification of the capsular type, and countercurrent-immunoelectrophoresis of 1627 CSF specimens were done. Of these, 276 had bacteria identified either by culture or Gram stain. Pneumococci were the most common and the serotype distribution was similar to that reported from other parts of Africa; second were meningococci with groups C and B predominating; in third place was Haemophilus influenzae type b which caused the highest mortality and had an unusually young age distribution. There were 77 bacterial isolates (22%), including 11 species, designated as "other" because there was no predominant species. There were many "clear" CSF specimens that were found to contain pneumococci, meningococci or H. influenzae type b, confirming the need for more comprehensive laboratory facilities for accurate diagnosis of the etiology of bacterial meningitis.