Rapid shell vial culture for the detection of respiratory viruses from bronchoalveolar lavage in immunocompromised patients.

AIM: Viral lower respiratory tract infections (LRTI) are an important cause of morbidity in immunocompromised patients. The aim of this study was to evaluate the clinical impact of rapid shell vial cultures from bronchoalveolar lavage (BAL). METHODS: Sixty-seven BAL samples from 46 patients have been retrospectively examined: 51 from 31 transplant recipients and 16 from 15 immunocompromised patients. BAL were inoculated on human embryonic lung fibroblasts and VERO cells to isolate the following viruses: cytomegalovirus (CMV), herpesviruses, varicella-zoster virus, respiratory syncytial virus, adenovirus, Influenza viruses A and B and Parainfluenza viruses. Clinical, microbiological, laboratory, and radiological data were collected. RESULTS: A LRTI was present in 56.7% of cases: viral 40.3%, bacterial and/or fungal 23.9%, and mixed 7.5%. CMV accounted for 92.6% of viral LRTI. The prevalence of viral infections did not differ between symptomatic and asymptomatic patients; only bacterial and/or fungal infections were significantly more prevalent in symptomatic patients. No clinical, radiological or laboratory feature was significantly associated with the presence of a viral LRTI. In lung transplant recipients the rate of CMV infection was 50%. The result of BAL suggested commencement of antiviral chemotherapy in 25/67 episodes. CONCLUSION: Rapid shell vial culture and immunofluorescence techniques from BAL could play an important role in the clinical management of immunocompromised subjects.

Development and utilization of a quantitative polymerase chain reaction assay to evaluate human polyomavirus JC DNA load.

AIM: Quantitative polymerase chain reaction (PCR) analysis to evaluate virus load in comparison with the patient's base-line virus levels would be an optimal diagnostic approach to monitoring human polyomavirus infections and to investigate their possible involvement in the onset of nephropathy in this patient group. Studies on the correlation between viral burden and renal disease have pointed to the incidence of JC virus (JCV) related progressive multifocal leukoencephalopathy (PML) occurring in renal and haematopoietic stem cell transplant recipients. METHODS: We developed a reliable internally-controlled quantitative PCR assay to measure JCV-DNA in fluid samples of urine, serum and cerebrospinal fluid (CSF) by densitometric analysis of the amplification products. The assay was also used to evaluate the JCV load in CFS samples from patients with suspected demyelinating syndrome and in urine and serum samples from healthy subjects and renal transplant recipients. RESULTS: All CSF samples from the 51 patients with suspected demyelinating syndrome tested JCV-DNA negative: none of them had a diagnosed PML. Analysis of the prevalence of JCV-viruria and JCV-viraemia confirmed our previous data. JCV-viruria was detected in 17% of renal transplant recipients and 26.6% of healthy controls; JCV-viraemia was found in 3.4% of transplant patients and 0% in controls. Noteworthy was a lower prevalence of JCV-viraemia in the 116 (3.4%) renal transplant patients than the prevalence previously reported for the 51 (11.8%) patients with suspected demyelinating syndrome. The mean viral load of viruria was much higher in the healthy controls than in the transplant recipients [104020 DNA copies/mL (DS+/-62284) vs 4136 DNA copies/mL (DS+/-77371)]. CONCLUSIONS: The quantitative PCR assay developed in our lab offers in 2 h time a reliable true quantification of viral DNA by densitometric analysis of the amplification product. To check for the possible presence of potential Taq polymerase inhibitors an internal control (the homemade pJCV-C plasmid) is used. The relation between polyomavirus infections and their possible involvement in post-transplant pathologies need further investigation. It would be useful to monitor the JCV-DNA load in urine and serum from more renal transplant recipients, including patients with nephropathy or active graft rejection over a longer period of time.

Use of a T-cell-based test for detection of tuberculosis infection among immunocompromised patients.

The aim of this study was to compare the performance of the T-SPOT.TB test, a T-cell-based test, with the tuberculin skin test (TST) in the diagnosis of latent tuberculosis (TB) infection. The study was carried out in 138 immunosuppressed haematology patients who had been nosocomially exposed to a case of smear-positive TB. Overall, 44.2% of the contacts were positive by T-SPOT.TB test, and 17.4% by TST (concordance 67.8%). The apparent prevalence of infection fell from 25.9 to 14.5% with the TST with increasing immunosuppression, although this difference was not significant. In contrast, the apparent prevalence of infection with the T-SPOT.TB test was unaffected at 44.6 and 44.3%, respectively. The T-SPOT.TB test had an overall indeterminate rate of 4.3%, and this was also unaffected by the level of immunosuppression. This study suggests that the T-SPOT.TB test maintains its sensitivity and performance in immunocompromised patients, identifying a large number of truly infected patients anergic to the tuberculin skin test.

Direct rapid diagnosis of rifampicin-resistant M. tuberculosis infection in clinical samples by line probe assay (INNO LiPA Rif-TB).

M. tuberculosis is one of the leading causes of death worldwide and Multi Drug Resistant Tuberculosis (MDR-TB) is associated with a high case-fatality rate. Rapid identification of resistant strains is crucial to institute prompt appropriate therapy, and prevent the development of further resistance and spreading of MDR strains. The INNO-LiPA Rif. TB is a commercial reverse hybridisation line probe assay designed for rapid detection of rpoB gene mutations in clinical isolates. We applied this test directly to 44 smear-positive and 45 smear-negative clinical specimens collected from patients suspected of active TB. The capability of this technique to correctly identify local MDR-TB strains was tested on 50 MDR strains isolated in Italy. Results of the test were compared to conventional antibiogram performed on isolated strains. The concordance rate of the LiPA test results on clinical specimens with those obtained with "in vitro" sensitivity was 100%. These results show that the LiPA test can be useful in rapid detection and prompt management of tuberculosis when MDR disease is suspected.

Military ophthalmology in the Vietnam War.

This overview of the practice of military ophthalmology by US army ophthalmologists during the Vietnam War focuses on administrative management of eye and adnexal injuries, care of the wounded military and of Vietnamese civilians, and research activities. It concludes with improvements that have been subsequently adopted.

Granular cell tumor of the eyelid.

We present a case of granular cell tumor of the eyelid. Although commonly reported elsewhere in the body, this entity rarely occurs in the ocular adnexa.

Modified enucleation.

Standard enucleation techniques provide excellent results. Modifications can render the operative field bloodless and permit the performance of all manipulations under direct visualization. Standard enucleation has been postulated to disseminate choroidal malignant melanoma cells as a result of fluctuations in intraocular pressure incident to surgical manipulations. It is possible that the stabilization of intraocular pressure preceding induction of tumor freezing may decrease such dissemination and thereby increase survival.

Orbital cyst with pseudooptic nerve: CT features.

An 8-year-old boy developed a large orbital cyst, a rare complication, after enucleation. On CT there was a structure leading from the orbital apex to the posterior aspect of the cystic lesion corresponding in size and location to the contralateral optic nerve. The clinical findings and management of this case are discussed in detail and other reported cases are reviewed briefly.

Comparative study of the performances of X-ray and gadolinium 153 bone densitometers at the level of the spine, femoral neck and femoral shaft.

We investigated the precision of gadolinium 153 dual photon absorptiometry (DPA) and quantitative digital radiography (QDR) bone densitometers by determining in vitro and in vivo coefficients of variation (CV) of bone mineral density (BMD). In vitro, the long-term CV of spine phantom BMD measured weekly for 40 weeks was 1.2% and 0.7% for DPA and QDR, respectively. Stimulating soft-tissue thickness with water, the CV of 6 repeat measurements of spine phantom at depths from 0 to 27 cm in 1 cm steps (a total of 168 measurements) increased from 0.1% at 0 cm of water to 2.5% at 27 cm for DPA, and from 0.2% at 0 cm to 1.4% at 27 cm for QDR; mean CV of the 28 series (0-27 cm) was higher for DPA (1.2% +/- 0.8%, mean +/- SD) than for QDR (0.7% +/- 0.6%; P less than 0.001). With the hip phantom, femoral neck BMD was determined, and the CV was also dependent on water thickness; mean CV of the 20 series (0-10 cm) was 2.1% +/- 1.2% for DPA and 1.3% +/- 0.9% for QDR (not significant). In vivo, at the spine level, with DPA, mean CV of BMD measured 6 times after repositioning in 6 healthy volunteers was 3.8% +/- 1.9% and 2.1% +/- 0.7% with 153 Gd activity of 0.46 Ci and 1 Ci, respectively (BMD range: 0.796-1.247 g/cm2, no significant difference between the two groups).(ABSTRACT TRUNCATED AT 250 WORDS)

Metastatic melanoma within and to the conjunctiva.

Two patients with epibulbar juxtalimbal primary conjunctival melanomas experienced local intralymphatic metastases to the inferior cul-de-sac, and a hematogenous metastasis to the conjunctiva developed in five other patients with cutaneous melanomas. Whether reflective of a local or distant metastasis, all of the lesions histopathologically were located in the substantia propria, and were separated from the overlying epithelium by a thin mantle of collagen. There was no evidence of atypical intraepithelial melanocytic proliferation, as would be expected in association with a primary conjunctival melanoma. Two of the cutaneous metastases exhibited a binodular or multinodular appearance that correlated histopathologically with variably confluent micronodules suggestive of the origin of the clinical lesion from a shower of tumor cell emboli. Patients with local intralymphatic spread from a primary conjunctival melanoma may experience additional lesions in the conjunctival sac or eyelid skin and are at risk for regional or distant metastases. They should be examined closely several times a year. The patients with the distant metastases all had their previously diagnosed primary cutaneous tumors on the truncal skin (a similar tendency emerges from a review of previous ocular cases), typically had myriad other cutaneous lesions, and two of them had a neoplastic iridocyclitis and vitreitis. These patients tended to die of the disseminated tumors within 1 year after conjunctival metastases developed.

Clinicopathological findings in a growing optic nerve melanocytoma.

We present an unusual case of a melanocytoma of the optic disc that showed documented progressive growth over a period of six years. It reached the largest size of any reported optic nerve melanocytoma and the eye was enucleated because of the possibility of malignant degeneration. Optic nerve melanocytomas are locally invasive but are not known to undergo transformation into malignant melanoma. Follow-up should remain the primary approach in the management of patients with optic nerve melanocytomas, as previously advocated by Zimmerman.

Unusual eyelid tumors with sebaceous differentiation in the Muir-Torre syndrome. Rapid clinical regrowth and frank squamous transformation after biopsy.

An unusual eyelid tumor with sebaceous differentiation developed in two 70-year-old men and each had an earlier history of one or more colonic carcinomas--the so-called Muir-Torre syndrome. These eyelid tumors were both behaviorally and histopathologically different from previously documented cutaneous neoplasms in this syndrome. In the first case, a sebaceous adenoma took multifocal origin from the epidermis and exhibited an interanastomosing retiform growth pattern in the underlying dermis; the lesion rapidly recurred as a keratoacanthoma after subtotal excision. In the second case, a conjunctival tumor with features of a poorly differentiated squamous cell carcinoma manifested focal evidence of sebaceous differentiation. Again, after an incisional biopsy, the latter tumor rapidly regrew and transformed into a well-differentiated squamous cell carcinoma with massive central necrosis. Although sebaceous carcinoma of the eyelids does not appear to presage the Muir-Torre syndrome, any benign sebaceous or transitional squamo-sebaceous neoplasm should be considered a possible manifestation of this syndrome. Both clear-cut benign and transitional sebaceous neoplasms should also be recognized as having the potential to undergo an ominous clinical regrowth upon subtotal excision and a complete squamous transformation.

Ocular trauma modelling.

Non-ophthalmologists must know how to detect, diagnose, and initially manage acute eye and ocular adnexal injuries in order to minimize their morbidity. Such instruction can be provided medical students in part from dog eyes and lids injured so as to produce models of common forms of ocular trauma. We describe the generation of such models and the format of instruction employed at the Uniformed Services University of the Health Sciences.

Nonsurgical management of postoperative cicatricial lower lid ectropion.

Two patients with postoperative cicatricial lower lid ectropion were managed by having the patient massage the lower lid in an upward direction over a methyl-methacrylate scleral ring. The ectropion was corrected. Such nonsurgical management may be attempted as an alternate initial therapy for the patient who refuses or should not immediately undergo additional surgery.

A light-emitting diode array globe protector photostimulator.

Intraoperative visual-evoked potential recording has been a potentially useful procedure for monitoring the functional status of the visual pathways during certain neurosurgical procedures. Technical problems have limited its adoption. We report a light-emitting diode array globe protector photostimulator which enhances the stimulation component of the visual-evoked potential recording technique.