Managing atypical and typical herpetic central nervous system infections: results of a multinational study.

There have been many studies pertaining to the management of herpetic meningoencephalitis (HME), but the majority of them have focussed on virologically unconfirmed cases or included only small sample sizes. We have conducted a multicentre study aimed at providing management strategies for HME. Overall, 501 adult patients with PCR-proven HME were included retrospectively from 35 referral centres in 10 countries; 496 patients were found to be eligible for the analysis. Cerebrospinal fluid (CSF) analysis using a PCR assay yielded herpes simplex virus (HSV)-1 DNA in 351 patients (70.8%), HSV-2 DNA in 83 patients (16.7%) and undefined HSV DNA type in 62 patients (12.5%). A total of 379 patients (76.4%) had at least one of the specified characteristics of encephalitis, and we placed these patients into the encephalitis presentation group. The remaining 117 patients (23.6%) had none of these findings, and these patients were placed in the nonencephalitis presentation group. Abnormalities suggestive of encephalitis were detected in magnetic resonance imaging (MRI) in 83.9% of the patients and in electroencephalography (EEG) in 91.0% of patients in the encephalitis presentation group. In the nonencephalitis presentation group, MRI and EEG data were suggestive of encephalitis in 33.3 and 61.9% of patients, respectively. However, the concomitant use of MRI and EEG indicated encephalitis in 96.3 and 87.5% of the cases with and without encephalitic clinical presentation, respectively. Considering the subtle nature of HME, CSF HSV PCR, EEG and MRI data should be collected for all patients with a central nervous system infection.

Predictive value of serum and cerebrospinal fluid procalcitonin levels for the diagnosis of bacterial meningitis.

BACKGROUND: The value of serum and cerebrospinaL fluid (CSF) procalcitonin for differentiating between acute bacterial and viral meningitis was assessed and compared to other parameters which are usually used in clinical practice. PATIENTS: 45 adult patients (20 with bacterial and 25 with tick-borne encephalitis, TBE) were included in this prospective study. RESULTS: The median serum procalcitonin Level in patients with bacterial meningitis was 6.45 ng/ml (range 0.25-43.76 ng/ml) and in the group with viral meningitis 0.27 ng/ml (range 0.05-0.44 ng/ml). 11 patients with bacterial meningitis had an elevated procalcitonin concentration not only in serum, but also in CSF. A serum procalcitonin Level > 0.5 ng/ml had a positive predictive value for bacterial meningitis of 100% and a negative predictive value of 93%, while corresponding values for CSF procalcitonin were 100% and 74%, respectively. CONCLUSION: Serum and CSF procalcitonin concentrations > 0.5 ng/ml appear to be a reliable indicator of bacterial central nervous system (CNS) infection, with maximal positive predictive values and high negative predictive values.

The value of inspiratory-expiratory lateral decubitus views in the diagnosis of small pleural effusions.

AIM: To evaluate the usefulness of expiratory lateral decubitus views in the radiological diagnosis of small pleural effusions. MATERIALS AND METHODS: Patients referred for abdominal sonography for various reasons were examined for ultrasonographic features of pleural effusion. From November 1994 until May 1996, 36 patients were found to have pleural effusion not exceeding 15 mm in depth and were included in the study. Erect posteroanterior, lateral, and lateral decubitus (in inspiration and expiration) ragiographs were performed in all patients. RESULTS: The mean thickness of fluid was 4.3 mm on inspiratory lateral decubitus radiographs and 7.9 mm on expiratory lateral decubitus views (P < 0.005). In 31 of 36 patients (86%) there was a difference in the thickness of the fluid layer as measured in expiratory vs. inspiratory lateral decubitus radiographs. In 16% of patients, the fluid was not visible on inspiratory lateral decubitus projections. CONCLUSIONS: Expiratory lateral decubitus views may be useful for demonstrating small pleural effusions.

Tick-borne encephalitis: possibly a fatal disease in its acute stage. PCR amplification of TBE RNA from postmortem brain tissue.

Tick-borne encephalitis has occurred regularly in Europe since it was first diagnosed in 1931 by Schneider. The mortality rate of patients with this disease is 1-2%. Death usually occurs in the acute stage of illness. A case report of a 28-year-old patient from Slovenia, who died shortly after the onset of tick-borne encephalitis, is described. The clinical course of disease, results of serological tests, neuropathological findings and polymerase chain reaction amplification of parts of viral genome from postmortem brain tissues are presented.

Azithromycin versus doxycycline for treatment of erythema migrans: clinical and microbiological findings.

The effectiveness of azithromycin and doxycycline in the treatment of erythema migrans was compared in a prospective randomized trial. One hundred seven adult patients with typical erythema migrans, examined in the Lyme Borreliosis Outpatients' Clinic, University Department of Infectious Diseases in Ljubljana, were included in the study. Fifty-five patients received azithromycin (500 mg twice daily for the first day, followed by 500 mg once daily for four days) and 52 patients received doxycycline (100 mg twice daily for 14 days). The mean duration of skin lesions after the beginning of treatment was 7.5 +/- 5.9 days (median value 5, range 2-28 days) in the azithromycin group and 11.4 +/- 7.8 days (median value 9, range 2 days--8 weeks) in the doxycycline group (p < 0.05). Borrelia burgdorferi was isolated from erythema migrans in 28 patients before therapy: in 13 out of 52 in the doxycycline group and in 15 out of 55 in the azithromycin group. Three months after therapy, the culture was positive in four out of 13 patients treated with doxycycline and in one of the 15 patients who received azithromycin. A biopsy was repeated in all the patients with a positive isolation from the first skin specimen. During the first 12 months' follow-up, three patients treated with doxycycline but none in the azithromycin group developed major manifestations of Lyme borreliosis, while 15 doxycycline recipients and 10 azithromycin recipients developed minor consecutive manifestations.

Human leukocyte interferon alpha (HLI-alpha) for treatment of pleural effusion caused by non small cell lung cancer. A pilot study.

Fourteen patients with ipsilateral pleural effusion from non small cell cancer of the lung, 10 of them with generalized metastasis, were treated with local application of HLI-alpha in addition to other symptomatic treatment. Cytology of pleural fluid at the beginning of treatment yielded cancer cells in all but one. HLI-alpha, 2 x 10(6) International Units (I.U.) diluted in 20 ml of distilled water was injected intrapleurally each time. The mean survival of the HLI-alpha treated patients, measured from the first treatment of the pleural effusion, was 10.8 months. The performance status improved in 9 patients following HLI-alpha treatment. The pleural effusion eventually ceased accumulating in all patients. To judge from cytology of tapped pleural fluid, the cancer cells disappeared during treatment with HLI-alpha in 11 patients.

Aspirin decreases fibrinolytic potential during venous occlusion, but not during acute physical activity.

It has previously been observed that aspirin diminishes the increase in blood fibrinolytic activity during arm venous occlusion. We studied the duration of this inhibitory effect on fibrinolytic response during 20 minutes arm venous occlusion and its effect on fibrinolytic response during acute physical activity (standardized stress testing on treadmill) in 10 healthy male volunteers. Fibrinolytic activity was measured with euglobulin clot lysis time and fibrin plates before and after both stimuli, and t-PA release estimated as the difference between post- and prestimulation values (fibrinolytic potential: FP). Venous occlusions were performed before aspirin ingestion and then on the first, second, third, and fourth to eighth day after aspirin. Stress testing was carried out on two successive days before and after aspirin ingestion. Aspirin did not affect basal fibrinolytic activity, but significantly decreased FP during occlusion. This effect was sustained for the whole period of observation. To the contrary, aspirin did not influence FP during acute physical activity. The different effect of aspirin on fibrinolytic response during venous occlusion and physical activity suggested that different mechanisms were involved in t-PA release during both stimuli.

Pulmonary blebs and bullae in alcoholics: a possible alcoholic-specific lung phenomenon.

Chest x-ray films of 200 unselected severely alcoholic patients were studied in a search for a possible alcohol-lung syndrome. Fourteen instances of pulmonary blebs and bullae were encountered, an incidence substantially higher than usual. Functional airway obstruction has been previously identified in the lungs of alcoholics, and the present findings might be a radiologic manifestation of the same process. While the pathogenesis of blebs and bullae is uncertain, the phenomena should be included in the spectrum of respiratory pathology encountered on chest films of alcoholic patients.

Thin needle biopsy of chest lesions: time-saving potential.

Aspiration biopsy with the thin needle was performed on 182 patients who had 196 chest lesions suspected for malignancy. The needle biopsy was generally performed as the last step in the diagnostic process, after the traditional diagnostic methods failed to yield a reliable diagnosis. The mean delay from the first sign or symptom to the cytologic diagnosis was 3.2 months, the mean delay from the first hospital admission to the diagnosis was 2.7 months. On the average, 3.6 days passed from the time of the biopsy to the clinical decision about the treatment. The wisdom of spending time on inconclusive diagnostic procedure is questioned in view of the fct that smaller (ie, earlier) lung tumors carry better prognosis.

The usefulness of needle biopsy in chest lesions of different sizes and locations.

Needle biopsies were done on 125 chest lesions in 117 patients, for the purpose of evaluating the procedure in relation to size and location of the lesions. Fifty of these lesions were centrally located, and 75 were peripherally located. Sixty-four lesions, with diameters of 2 cm or less, were classified as "small," and 61 were classified as "large". In peripheral lesions diagnostic yield was higher, but accuracy was lower than it was in central lesions. Diagnostic yield was the same in small lesions as it was in large ones, although accuracy was higher in small lesions. The complication rate was lower in central lesions than it was in peripheral lesions; the rate did not differ between large and small lesions.

Thin needle biopsy of solid tumors in children.

Thin needle biopsy of a suspected tumor will usually yield material amenable to cytologic examination and sufficient for diagnosis. Sixty children with suspected solid malignant tumors were subjected to this procedure. The masses biopsied were in bone, abdomen, mediastinum, tongue, pharynx, soft tissue, and peripheral lymph nodes. The diagnostic yield was 66% on first biopsy and rose to 93% on repeated biopsies. The diagnostic accuracy was 97% in malignant tumors with histologic confirmation. There were no proved false-negative diagnoses, and two (3%) false-positive (for malignancy) diagnoses. All patients were followed up. There were no complications of note.

Transthoracic needle biopsy of mediastinal and hilar lesions.

Fifty patients, from 5 weeks to 7) years of age, were subjected to transthoracic thin needle biopsy of their mediastinal or hilar masses from May 1975 to May 1976. The material aspirated was satisfactory for cytological examination in 41 patients (82%). The cytological diagnosis could be made in 36 patients (72%) and could be confirmed by histological examination in 12 patients, and by the clinical course of the disease in 16 patients, while 7 patients are lost to follow-up. A false negative diagnosis was probably made in one patient. The complication rate was low, mainly pneumothorax (in eight patients) and hemoptysis (in six patients) of little clinical significance. The main drawback of the method seems to be its inability to provide enough material for reliable diagnosis of benign lesions.

Radiation dose to the human body from intravenously administered 75Se-sodium selenite.

The dose of radiation to the human body and some of its organs after intravenous administration of 75Se-sodium selenite for diagnostic purposes has been calculated on the basis of followup of 26 patients for as long as 517 days with measurements of: 1. The retention of 75Se in the whole body. 2. The retention of 75Se in the blood, liver, kidneys, ovaries, testicles, and hair. 3. The excretion of 75Se in urine and feces. Whole-body counting and profile scanning were done on the patients and samples of blood from different organs, urine, and feces were measured for radioactivity. The dose of radiation received was calculated for an average patient of 70 kg. These doses were found to be slightly higher than previously reported on a smaller number of patients and with a shorter follow-up. They were slightly lower than those from 75Se-methionine to the whole body but higher to the liver and kidneys. The margin of error in this investigation was estimated to be about 20% for the whole-body dose and probably higher for different organs, mostly due to the poorly known rate of retention of selenite in different organs.