Disseminated tuberculosis, CMV viraemia & haemophagocytic-lymphohistiocystosis syndrome in an adult patient with anti- IFNγ autoantibodies - case report and brief review.

We report a case of an adult female with disseminated tuberculosis, cytomegalovirus viraemia and haemophagocytic-lymphohistiocystosis syndrome associated with neutralizing anti- interferon gamma (IFNγ) autoantibodies demonstrated by absent IFNγ stimulated STAT1 phosphorylation in the presence of patient sera. A brief review of immunodeficiency caused by anti-IFNγ autoantibodies is also described.

Long-term follow-up of contacts exposed to multidrug-resistant tuberculosis in Victoria, Australia, 1995-2010.

SETTING: The effectiveness of public health strategies following exposure to multidrug-resistant tuberculosis (MDR-TB) is not clear. OBJECTIVE: To perform long-term follow-up of MDR-TB contacts and review individual outcomes and management approaches. DESIGN: Retrospective review of MDR-TB contacts identified by the Victorian Department of Health from 1995 to 2010. Health records, including personal medical and pharmacy records and statewide clinical and laboratory TB databases, were searched to identify management strategies and individual outcomes. RESULTS: A total of 570 contacts of 47 MDR-TB cases were identified, with a total follow-up period of 3093 person-years of observation (PYO) since exposure. Of 570 contacts, 49 (8.6%) were considered likely to have been infected with Mycobacterium tuberculosis from index cases, and 11/49 (22.5%) of these were prescribed preventive therapy tailored to isolate susceptibility. No MDR-TB cases occurred in those receiving preventive treatment, while two cases were observed in those not treated (incidence 2878/100 000 PYO during the first 2 years post exposure). CONCLUSIONS: The risk of MDR-TB transmission to close contacts in this low-prevalence setting highlights the potential for public health strategies involving preventive treatment.

Comparative genetic analysis of Mycobacterium ulcerans and Mycobacterium marinum reveals evidence of recent divergence.

Previous studies of the 16S rRNA genes from Mycobacterium ulcerans and Mycobacterium marinum have suggested a very close genetic relationship between these species (99.6% identity). However, these organisms are phenotypically distinct and cause diseases with very different pathologies. To investigate this apparent paradox, we compared 3,306 nucleotides from the partial sequences of eight housekeeping and structural genes derived from 18 M. ulcerans strains and 22 M. marinum strains. This analysis confirmed the close genetic relationship inferred from the 16S rRNA data, with nucleotide sequence identity ranging from 98.1 to 99.7%. The multilocus sequence analysis also confirmed previous genotype studies of M. ulcerans that have identified distinct genotypes within a geographical region. Single isolates of both M. ulcerans and M. marinum that were shown by the sequence analysis to be the most closely related were then selected for further study. One- and two-dimensional pulsed-field gel electrophoresis was employed to compare the architecture and size of the genome from each species. Genome sizes of approximately 4.4 and 4.6 Mb were obtained for M. ulcerans and M. marinum, respectively. Significant macrorestriction fragment polymorphism was observed between the species. However, hybridization analysis of DNA cleaved with more frequently cutting enzymes identified significant preservation of the flanking sequence at seven of the eight loci sequenced. The exception was the 16S rRNA locus. Two high-copy-number insertion sequences, IS2404 and IS2606, have recently been reported in M. ulcerans, and significantly, these elements are not present in M. marinum. Hybridization of the AseI restriction fragments from M. ulcerans with IS2404 and IS2606 indicated widespread genome distribution for both of these repeated sequences. Taken together, these data strongly suggest that M. ulcerans has recently diverged from M. marinum by the acquisition and concomitant loss of DNA in a manner analogous to the emergence of M. tuberculosis, where species diversity is being driven mainly by the activity of mobile DNA elements.

Identification of Mycobacterium ulcerans in the environment from regions in Southeast Australia in which it is endemic with sequence capture-PCR.

We recently described the use of PCR to identify the environmental source of Mycobacterium ulcerans during an outbreak of ulcerative disease that occurred in a localized region of southeast Australia. The PCR used was based on amplification of the M. ulcerans-specific insertion sequence, IS2404. In this study we developed a new test that is a substantial improvement over the original PCR method in terms of sensitivity, reliability, and ease of use. In the new method magnetic bead sequence capture-PCR is used to detect two M. ulcerans sequences (IS2404 and IS2606) and total mycobacterial 16S ribosomal DNA. We used sequence capture-PCR to test water and plant material collected over a 12-month period during 1998 and 1999 from sites near the centers of two distinct foci of M. ulcerans infections. A golf course irrigation system in one area and a small shallow lake in another area repeatedly were PCR positive for M. ulcerans. Nearby sites and sites unrelated to the endemic areas were negative. Based on the PCR data, a most-probable-number method was used to estimate the concentration of M. ulcerans cells in positive samples from both regions. This procedure resulted in average concentrations of 0.5 cell per 100 ml of water and 40 cells per 100 g of detritus. Loss of the PCR signal coincided with a decrease in ulcerative disease in each area. These results provide further evidence that M. ulcerans may be transmitted from a point environmental source and demonstrate the utility of magnetic bead sequence capture-PCR for identification of nonculturable microbial pathogens in the environment.

A simple PCR method for rapid genotype analysis of Mycobacterium ulcerans.

Two high-copy-number insertion sequences, IS2404 and IS2606, were recently identified in Mycobacterium ulcerans and were shown by Southern hybridization to possess restriction fragment length polymorphism between strains from different geographic origins. We have designed a simple genotyping method that captures these differences by PCR amplification of the region between adjacent copies of IS2404 and IS2606. We have called this system 2426 PCR. The method is rapid, reproducible, sensitive, and specific for M. ulcerans, and it has confirmed previous studies suggesting a clonal population structure of M. ulcerans within a geographic region. M. ulcerans isolates from Australia, Papua New Guinea, Malaysia, Surinam, Mexico, Japan, China, and several countries in Africa were easily differentiated based on an array of 4 to 14 PCR products ranging in size from 200 to 900 bp. Numerical analysis of the banding patterns suggested a close evolutionary link between M. ulcerans isolates from Africa and southeast Asia. The application of 2426 PCR to total DNA, extracted directly from M. ulcerans-infected tissue specimens without culture, demonstrated the sensitivity and specificity of this method and confirmed for the first time that both animal and human isolates from areas of endemicity in southeast Australia have the same genotype.

What is the cause of a rash after measles-mumps-rubella vaccination?

Surveillance and laboratory confirmation of measles will increase in importance as Australia implements enhanced measles control. We describe a 17-month-old child with fever and rash after measles-mumps-rubella vaccination. Detection of vaccine-strain measles virus in his urine by polymerase chain reaction confirmed the diagnosis of a vaccine reaction rather than wild-type measles. We propose that measles virus should be sought and identified as vaccine or wild-type virus when the relationship between vaccination and measles-like illness is uncertain.

Campylobacter upsaliensis-associated diarrhea in human immunodeficiency virus-infected patients.

Campylobacter upsaliensis was isolated from the feces of 20 human immunodeficiency virus (HIV)-infected patients with diarrhea over a 67-month period, representing 18.5% of fecal Campylobacter isolates from our HIV-seropositive patients. All isolates were recovered from feces by a 0.45-micron-membrane filtration method. Culture on Skirrow's selective medium incubated at 42 degrees C failed to support any growth. The mean CD4 cell count of the patient group was 185/mm3 (range, 0-840/mm3), and all patients had diarrhea for 1-60 days (mean, 19 days). Thirteen had no other enteric pathogen isolated, and three patients (CD4 counts, < or = 70/mm3) had persistent carriage for between 5 weeks and 3 months. All tested isolates were susceptible to erythromycin and doxycycline, but three isolates from two patients were resistant to ciprofloxacin. C. upsaliensis is associated with prolonged diarrhea of mild to moderate severity in HIV-infected patients.

Candidal epididymo-orchitis: case report and review.

We describe a case of epididymo-orchitis with candiduria and histologically proven epididymal abscesses due to Candida albicans and review six previously reported cases. Candidal epididymo-orchitis occurs in patients with recognized risk factors for candidal infection, often after instrumentation of the urinary tract. Cases caused by both C. albicans and Candida glabatra have been described. Drainage or orchidectomy may be required for definitive diagnosis and treatment. Treatment with oral antifungals alone has been effective in two cases.

Airport malaria in Cairns.

We report a patient with Plasmodium vivax malaria that was acquired in Cairns in October 1996. Rather than being "introduced" (i.e., derived from an imported case), we believe this is likely to have been a case of "airport malaria" (i.e., acquired from an infected mosquito imported in an aircraft). It is, to our knowledge, the first report of airport malaria in Australia.

Universal precautions: attitudes of Australian and New Zealand anaesthetists.

OBJECTIVE: To survey the attitudes of a group of Australasian anaesthetists to the risks of bloodborne infections, and their understanding of Universal Precautions. DESIGN: A questionnaire survey. SETTING: A conference on health risks to anaesthetists in August 1995. PARTICIPANTS: 162 Australian and New Zealand anaesthetists. RESULTS: Two-thirds of anaesthetists favoured preoperative HIV and hepatitis B and C testing; they rarely took "risk" histories from patients preoperatively. Only 37% always wore gloves while administering anaesthetics, and 67% reported they resheathed needles. Thirty-nine per cent had had needlestick injuries in the preceding 12 months; 43% did not always report them. The perceived needlestick accident rate was 1 in 1300 anaesthetics. Most (90%) were immunised against hepatitis B, but 20% of these had never had their serological response checked. Twelve per cent of anaesthetists had had occupational exposure to HIV. A high proportion of the anaesthetists understood the principles of Universal Precautions, but only half of them believed these to be practical. CONCLUSIONS: The current situation of Australasian anaesthetists not complying with Universal Precautions and not taking a risk history for bloodborne pathogens may carry the greatest risk of accidental infection.