Disseminated tuberculosis: still a diagnostic challenge.

Disseminated tuberculosis is notoriously difficult to diagnose and, with the decrease in tuberculosis incidence in Australia, familiarity with its manifestations has dwindled. We describe four bacteriologically proven cases which illustrate the range of presentations and diagnostic difficulties. Surprisingly, immunosuppressive therapy need not cause rapid deterioration. Disseminated tuberculosis should be considered in any patient with multisystem illness who is at risk of tuberculosis, particularly if born overseas. In the absence of confirmatory results, a prompt therapeutic trial may be life-saving.

Comparison of two automated systems for the isolation of mycobacteria from clinical specimens.

The Bactec MGIT 960 (Becton-Dickinson, UK) automated mycobacterial liquid culture system was compared with the Bactec 9000 MB (Becton-Dickinson) in order to assess ease of use, diagnostic reliability and safety features. One thousand twenty-nine clinical specimens were cultured in parallel, yielding a total of 125 (12.1%) mycobacterial isolates, including 71 Mycobacterium tuberculosis and 18 Mycobacterium avium. The Bactec MGIT 960 demonstrated a mycobacterial recovery rate and speed of detection equivalent to that of the Bactec 9000 MB for clinically important isolates. The Bactec MGIT 960 integrates smoothly into laboratory workflow, does not require needle inoculation and has a much larger capacity than the Bactec 9000 MB.

Isolation of Burkholderia cepacia by enrichment.

Burkholderia cepacia is a recognised cause of respiratory failure in patients with cystic fibrosis. The value of routine use of selective enrichment broth to increase the yield of B cepacia from cystic fibrosis sputa was investigated. Two hundred sputa from 86 adult and paediatric patients were cultured onto B cepacia selective agar and also in enrichment broth. The enrichment broths were subcultured after incubation onto B cepacia selective agar. Fourteen sputa from eight patients yielded B cepacia. In all cases the isolate was recovered from the primary selective agar as well as the enrichment broth subcultures. The routine use of enrichment for cystic fibrosis sputa is of unproven benefit and increases laboratory costs.

Transmission and prevalence of Burkholderia cepacia in Welsh cystic fibrosis patients.

From 1987 to 1994, 16 of 162 cystic fibrosis (CF) patients attending CF clinics at three different hospitals in South Wales, U.K. were found to have respiratory secretions colonized with Burkholderia cepacia (B. cepacia). Bacteriological typing by polymerase chain reaction (PCR) ribotyping demonstrated seven strains of B. cepacia among these 16 CF patients. This typing confirmed that cross-infection was the mechanism of colonization in six of the nine patients who were colonized at the paediatric CF clinic at the University Hospital of Wales in Cardiff, and in three of the six patients who were colonized at the adult CF clinic at Llandough Hospital in Cardiff (cross-infection rate nine of 16 patients or 56%). A search was made for a nosocomial source, with screening of wards and clinics. Swabs from fomites produced four positive cultures for B. cepacia. Two isolates had the same PCR ribotype as that of the previous CF room occupant. To establish prevalence of B. cepacia among CF children living throughout Wales, respiratory secretions were cultured from 151 of 186 CF children (age < 16 years). This failed to demonstrate B. cepacia colonization other than in the CF patients already identified.

A novel simple method for quantifying bacteria from endotracheal aspirates.

A convenient dipstrip method (Bacteruritest; Mast Diagnostics) for bacterial quantification was evaluated with 42 endotracheal aspirates. For 31 specimens, the dipstrip method yielded counts within a 10-fold range of surface plate counts. Two specimens yielded counts by the dipstrip within a 100-fold range of plate counts. Six specimens yielded confluent growth at the greatest dilution tested by the dipstrip method, and counts > 10(10) cfu/ml in the surface plate method. Three specimens yielded no detectable growth by the dipstrip and surface plate counts < 10(2) cfu/ml. Dipstrips provide a cheap, convenient method for the routine quantification of the bacterial load in endotracheal aspirates.

Characterisation of Burkholderia cepacia from cystic fibrosis patients living in Wales by PCR ribotyping.

Polymerase chain reaction (PCR) ribotyping detects differences in the intergenic spacer between the 16S and 23SrRNA genes. This method was applied to Burkholderia cepacia isolates from 16 Welsh cystic fibrosis (CF) patients attending three different clinics. Amplification of the intergenic spacer followed by an additional digestion step with TaqI restriction endonuclease identified seven distinct electrophoretic patterns among the patient isolates. Each of the seven patterns was distinct from that of the so called "epidemic strain" commonly isolated from patients attending clinics elsewhere in the UK. Two environmental isolates from the hospital clinics and four NCTC reference strains gave different patterns. The simplicity of the method lends itself to use in a general microbiological laboratory.

A multicentre study of the in-vitro activity of cefotaxime, cefuroxime, ceftazidime, ofloxacin and ciprofloxacin against blood and urinary pathogens.

The in-vitro susceptibilities of aerobic bacteria isolated from 1804 blood and 4529 urine specimens collected at nine hospitals in the UK were examined. An agar dilution method was used to determine the MICs of each isolate to three cephalosporins, cefotaxime, cefuroxime and ceftazidime, and to two fluoroquinolones, ofloxacin and ciprofloxacin. Sensitivities were then calculated using British Society for Antimicrobial Chemotherapy recommended breakpoints. Of the cephalosporins tested cefotaxime was the most active against the Enterobacteriaceae. All the systemic staphylococcus isolates collected were sensitive to both cefotaxime and cefuroxime. As expected, ceftazidime was the only cephalosporin active against the Pseudomonas isolates. Both quinolones were highly active against the Enterobacteriaceae and Pseudomonas spp. They also demonstrated good Gram-positive activity, particularly against Staphylococcus aureus and Enterococcus spp.

Two different IFN-gamma nonresponsive variants derived from the B-cell lymphoma 70Z/3.

The kappa immunoglobulin (Igk) light chain locus is transcriptionally silent in the mouse B-cell lymphoma 70Z/3. However, exposure to lipopolysaccharide (LPS) or interferon-gamma (IFN) causes a marked increase in Igk transcription. By immunoselection, we isolated two variants that are nonresponsive to IFN. One variant, AT7.2, has retained its response to LPS (IFN-LPS+), whereas the other, AT3.3, is also nonresponsive to LPS (IFN-LPS-). Stable transfection of an intact Igk gene does not rescue the phenotype of either variant. Both variants have intact Igk genes and neither is deficient in the binding or uptake of IFN. Nuclear extracts from LPS-treated wild-type 70Z/3 cells show strong increases in three transcription factors: OTF-2, NF-kappa B, and kBF-A. Remarkably, when the IFN-LPS- variant is treated with LPS, all three transcription factors are still observed in the nuclear extracts. Treatment of wild-type cells with either LPS or IFN also causes a decrease in nuclear complexes that bind to two other regions of the Igk intron enhancer, the octenh and the E kappa MHCIC regions. Both of these changes are also observed after LPS or IFN treatment of the IFN-LPS- variant. Thus, this variant transduces the IFN and LPS signals at least into the nuclear compartment, but still fails to activate Igk transcription. In contrast, the IFN-LPS+ variant decreases neither the octenh nor the E kappa MHCIC binding complexes in response to IFN. This variant may be defective in transducing the IFN signal to the nucleus. These variants will be useful in studying the activation of Igk transcription and the IFN signaling pathway in B cells.

Plasmodium falciparum: a simple polymerase chain reaction method for differentiating strains.

Laboratory studies of the protozoan parasite Plasmodium falciparum have been hampered by difficulties in defining differences between isolates. We have developed a method based on the polymerase chain reaction (PCR) that allowed us to identify quickly the various strains with which we routinely work. We also adapted methods for easily purifying enough DNA to produce a PCR product from a small volume of culture: 100 microliters of an in vitro culture infected at 1% parasitemia. The primers were chosen from conserved regions flanking the variable repeats in four cloned genes, RESA, MSA-1, MSA-2, and CSP. The PCR products amplified from three of these genes differed in size and allowed us to identify particular isolates on this basis alone. The variation was between strains, and not a reflection of genetic instability during in vitro culture of one isolate. The method is sufficiently sensitive to detect a 1% contamination of one strain with another, an advantage for monitoring the integrity of strains when different isolates are grown in the same laboratory. The technical ease and speed of this assay and the small amount of culture required make it ideal for monitoring strains in the laboratory.

Multiple breakpoint method for measuring effect of antibiotics on endocarditis strains of streptococci.

The activity of penicillin alone and combined with aminoglycoside on endocarditis strains of streptococci was examined. Good assay reproducibility was obtained by the use of logarithmic phase cultures standardised by opacity, careful inoculation of well-plates, removal of antibiotic by membrane transfer and incubating survival counts in hydrogen plus carbon dioxide. The use of 10-fold intervals for penicillin concentration simplified assay design without loss of efficiency.

Isolation of mucoid strains of Pseudomonas aeruginosa from non-cystic-fibrosis patients and characterisation of the structure of their secreted alginate.

When the incubation period of primary isolation plates was extended to 48 h, mucoid strains of Pseudomonas aeruginosa were found in specimens from various infected sites in patients who did not have cystic fibrosis. The 17 mucoid isolates were characterised in terms of mucoid type, pyocin type, and their sensitivity or resistance to seven beta-lactam and two aminoglycoside antibiotics. The carbohydrate, uronic acid (alginate) and protein content of the water-soluble extracellular material of 15 strains was determined. This material was fractionated by ion-exchange chromatography, and the presence of alginate confirmed by the chemical assay of uronic acids and their quantitation by gas-liquid chromatography. Uronic acids were absent from a non-mucoid revertant of one strain. The strains produced alginate with a high content of mannuronic acid and substituted with O-acetyl groups. By proton nuclear magnetic resonance (1H-nmr) analysis the alginate from three strains was shown to lack polyguluronate blocks in its structure. These properties are also found in the alginate of mucoid P. aeruginosa strains from patients with cystic fibrosis.