Mycobacterium avium-intracellulare pulmonary infection complicated by cutaneous leukocytoclastic vasculitis in a woman with anorexia nervosa.

A 53-year-old Caucasian woman with a history of anorexia nervosa developed a bilateral lower extremity rash comprised of palpable red to violaceous, sub-centimeter papular lesions that increased in quantity rapidly. She also noted a 2-month history of non-productive cough. Imaging modalities revealed a thin-walled cavitary lesion in the right lung apex and scattered nodular opacities. Acid fast bacilli (AFB) were found in sputum and subsequently identified by culture as Mycobacterium avium-intracellulare (MAI). Punch biopsies of her skin lesions yielded a histological diagnosis of small-to-medium vessel vasculitis. Stains and cultures for organisms were negative. Her skin lesions resolved quickly after the initiation of antimicrobial therapy for MAI. Hypersensitivity vasculitis associated with an atypical mycobacterial infection is unusual. The postulated underlying mechanism is the deposit of immune complexes and not the bacillus itself. While cutaneous leukocytoclastic vasculitis (CLV) due to MAI is certainly a rare entity, it should be entertained in patients with vasculitic skin lesions and a concomitant pulmonary disease.

Rapid, minimally invasive adult voluntary male circumcision: A randomised trial.

BACKGROUND: Voluntary medical male circumcision (VMMC) is a priority HIV preventive intervention. To facilitate male circumcision scale- up, the World Health Organization is actively seeking circumcision techniques that are quicker, easier, and safer than open surgical methods. OBJECTIVE: To compare conventional open surgical circumcision with suturing with a minimally invasive technique using the Gomco circumcision clamp plus tissue adhesive. METHODS: We conducted a non-blinded randomised controlled trial comprising 200 male volunteers >18 years of age, seen at the outpatient university teaching clinic of the Catholic University of Mozambique. We compared two interventions - open surgical circumcision with suturing v. Gomco instrument plus tissue adhesive. Our primary outcome was intraoperative time and our secondary outcomes included: ease of performance, post-operative pain, adverse events, time to healing, patient satisfaction and cosmetic result. RESULTS: The intraoperative time was less with the Gomco/tissue adhesive technique (mean 12.8 min v. 22.5 min; p<0.001). Adverse events were similar except that wound disruption was greater in the Gomco/tissue adhesive group, with no difference in wound healing at 4 weeks. Levels of satisfaction were high in both groups. The cosmetic result was superior in the Gomco/tissue adhesive group. CONCLUSIONS: This study has important implications for the scale-up of VMMC services. Removing the foreskin with the Gomco instrument and sealing the wound with cyanoacrylate tissue adhesive in adults is quicker, is an easier technique to learn, and is potentially safer than open surgical VMMC. A disposable plastic, Gomco-like device should be produced and evaluated for use in resource-limited settings.

Human meningitis from Streptococcus equi subsp. zooepidemicus acquired as zoonoses.

Streptococcus equi subsp. zooepidemicus rarely causes meningitis in humans by contact with domestic animals or their unpasteurized products. In this paper we reviewed the literature pertaining to the epidemiological and clinical aspects relating to this infection on previously reported cases of human disease. Additionally, the case of a 51-year-old female who acquired meningitis with this organism after contact with a horse is described. This patient was successfully treated with ceftriaxone, yet penicillin remains the treatment of choice. This aetiological agent should be considered in the proper epidemiological context.

[Meningitis caused by Toscana virus during a summer stay in Italy]. / Meningitis door Toscana-virus tijdens een zomers verblijf in Italië.

A 44-year-old woman suffered fever, headache and meningism during a summer stay in a region of central Italy where sand-fly fever is endemic. A few days after returning to the Netherlands, she appeared mentally and physically slow but had no fever. Because of the possibility of viral meningitis an examination of the cerebrospinal fluid (CSF) was carried out. This revealed a cell count of 1074/3 cells. Toscana virus antibodies of the IgG and IgM subclass were detected in two respective serum samples and in the CSF. This led to the diagnosis 'Toscana virus meningo-encephalitis'. Toscana virus is classified amongst the sandfly fever virus group. These viruses are transmitted by sand flies (Phlebotomus species) which reside in humid areas around the Mediterranean. Toscana virus is the main cause of viral meningoencephalitis in some areas of central Italy and possibly in southern Spain. The patient recovered within a few days without antiviral therapy. Toscana virus meningo-encephalitis should be included in the differential diagnosis of holidaymakers with neurological symptoms returning from the Mediterranean.

[A man with fatal Lassa fever following a stay in Sierra Leone]. / Een man met fatale Lassa-koorts na een verblijf in Sierra Leone.

A 48-year-old-man returned to the Netherlands from Sierra Leone and was admitted with nausea, crampy abdominal pain, myalgia, arthralgia, headache and watery diarrhoea. This was the first case of Lassa fever diagnosed in the Netherlands since 1980. Despite treatment with ribavirin, the patient died on the 16th day of illness. Prompt diagnosis of Lassa fever is critical for the timely administration of ribavirin which improves diagnosis considerably, and for the timely implementation of isolation measures. Recently, a reverse transcriptase polymerase chain reaction (RT-PCR) has become available for the rapid diagnosis of acute Lassa fever, which was implemented to diagnose this patient.

High titers of cytopathic virus in plasma of patients with symptomatic primary HIV-1 infection.

BACKGROUND: Primary infection with the human immunodeficiency virus (HIV-1) frequently causes an acute, self-limited viral syndrome. To examine the relations among viral replication, the immune response of the host, and clinical illness during this initial phase of infection, we undertook a quantitative, molecular, and biologic analysis of infectious HIV-1 in the blood and plasma of three patients with symptomatic primary infection and of a sexual partner of one of them. METHODS: During an eight-week period of primary infection, HIV-1 was cultured frequently in dilutions of plasma and peripheral-blood mononuclear cells (PBMC), and levels of HIV-1 antigen and antibody were determined sequentially by enzyme-linked immunosorbent assay and immunoblotting. Replication-competent HIV-1 proviruses were cloned and characterized biologically. RESULTS: Six to 15 days after the onset of symptoms, high titers of infectious HIV-1 (from 10 to 10(3) tissue-culture-infective doses per milliliter of plasma) and viral p24 antigen were detected in the plasma of all three patients. These titers fell precipitously by day 27, and the decline coincided with an increase in the levels of antiviral antibodies and the resolution of symptoms. Sequential isolates of virus from plasma and PBMC obtained throughout the period of primary infection, as well as virus derived from two molecular proviral clones, were highly cytopathic for normal-donor PBMC and immortalized T cells, despite the marked reduction in the titers of virus in plasma. CONCLUSIONS: Primary, symptomatic HIV-1 infection is associated with high titers of cytopathic, replication-competent viral strains, and during such infection potential infectivity is enhanced. Effective control of HIV-1 replication during primary infection implies the activation of clinically important mechanisms of immune defense that merit further examination in relation to the development of antiviral therapy and vaccines.

Direct evaluation of the microvascular actions of ANP in juxtamedullary nephrons.

The renal vascular actions of atrial natriuretic peptide (ANP) remain incompletely understood. The purpose of this study is to evaluate the effects of ANP on microvascular structures of the normal kidney. The in vitro blood-perfused juxtamedullary nephron technique was utilized to allow visualization of arcuate arteries and afferent and efferent arterioles. Donor rats were pretreated with captopril to eliminate possible interactions between angiotensin II and atriopeptin III (AP III). The effects of topical administration of 3 nM AP III were determined by videometric analysis of vessel inside diameters. Under control conditions, arcuate arterial diameter averaged 83 +/- 14 microns (n = 7), afferent arteriolar diameter was 20 +/- 4 microns (n = 7), and efferent arteriolar diameter was 16 +/- 2 microns (n = 7). During superfusion with AP III, arcuate arteries and afferent arterioles dilated 73 +/- 9 and 23 +/- 5%, respectively. Both returned to their control values when AP III was removed from the superfusate. Further experiments on arcuate arteries (n = 5) revealed that 0.3 nM AP III also vasodilated these vessels (26 +/- 9%); however, no significant effect was elicited by 0.03 nM AP III. In contrast to the vasodilator influence of AP III on preglomerular vessels, efferent arteriolar diameter was not altered by AP III exposure. These observations reveal that AP III can induce selective preglomerular vasodilation involving arcuate arteries as well as afferent arterioles, while efferent arteriolar diameter is not perceptibly influenced.