[A randomized controlled trial of the use of CRP rapid test as a guide to treatment of respiratory infections in general practice]

INTRODUCTION

The aim was to assess whether the frequency of antibiotic prescriptions to patients with respiratory infections is reduced when general practitioners (GPs) use a CRP rapid test to support their clinical assessment, and to examine whether the use of the test would have any effect on the course of disease.

MATERIAL AND METHOD

A randomised controlled trial was carried out by 35 general practices in the County of Funen, Denmark, with 812 patients with respiratory infection. The main outcome measures were frequency of antibiotic prescriptions and morbidity one week after the consultation, as stated by the patients.

RESULTS

The frequency of antibiotic prescriptions was 43% (179/414) in the CRP group and 46% (184/398) in the control group (NS, OR = 0.9). At one week, increased or unchanged morbidity was stated more frequently in the CRP group (12%) than in the control group (8%) (OR = 1.6, p = 0.05). In the control group, the variable having the greatest influence on whether the GP prescribed antibiotics was the patient's general well-being (OR = 2.9, p < 0.0001), whereas in the CRP group the CRP value had the greatest influence (OR = 1.1 per unit increase [mg/l], p < 0.0001).

CONCLUSION

From on the present study, the use of a single CRP rapid test to support possible antibiotic treatment of respiratory infections in general practice cannot be recommended.

Cytochrome P450 down-regulation by serum from humans with a viral infection and from rabbits with an inflammatory reaction

Serum from humans with an upper respiratory viral infection (HS(URVI)) and from rabbits with a turpentine-induced acute inflammatory reaction (RS(TIAR)) reduces the activity of hepatic cytochrome P450 (P450) following 4 h of incubation. The aim of the present study was to assess the effect of HS(URVI) and RS(TIAR) on P450 activity and expression following 24 h of incubation with hepatocytes from control (H(CONT)) and rabbits with a TIAR (H(INFLA)). RS(TIAR) incubated with H(CONT) for 24 h reduced P450 content and activity, and CYP3A6 by 45%, without changing CYP1A1 and 1A2; when incubated with H(INFLA), RS(TIAR) decreased P450 content and activity without affecting CYP1A1 or 1A2. HS(URVI) incubated for 4 h with H(CONT) decreased P450 activity without affecting the amounts of CYP1A1, 1A2, or 3A6, although when incubated for 24 h, P450 activity and CYP3A6 amount decreased. HS(URVI) incubated with H(INFLA) for 4 h reduced P450 content and activity, and incubated for 24 h reduced activity, P450 content, and amount of CYP1A1 and 1A2 proteins. The present study demonstrates that 1) the effect of RS(TIAR) and HS(URVI) depends upon the susceptibility of the hepatocyte, i.e., H(CONT) or primed H(INFLA); 2) P450 down-regulation is preceded by a decrease in P450 activity; 3) the nature of the inflammatory reaction determines the repercussions on P450 activity and expression; and 4) CYP3A6 is more vulnerable than CYP1A1 and 1A2 to the down-regulation provoked by an inflammatory challenge.

The relationship between the occurrence of undifferentiated bovine respiratory disease and titer changes to bovine coronavirus and bovine viral diarrhea virus in 3 Ontario feedlots

Serological evidence of previous viral exposure (titer at arrival) and current viral exposure (titer increase) during a 28-day study period, was used to determine if bovine coronavirus (BCV) or bovine viral diarrhea virus (BVDV) was associated with the occurrence of undifferentiated bovine respiratory disease (UBRD) in feedlot calves. Neutralizing antibody titers to BCV and BVDV were determined for 852 animals from 3 Ontario feedlots. Calves at 2 of the 3 feedlots (n = 753) received a modified live 4-way viral vaccine containing BVDV. On arrival at the feedlots, 90% of animals were seropositive for BCV, while 39% of animals were seropositive for BVDV. This evidence of previous exposure to both viruses was associated with reduced subsequent UBRD risk. Evidence of exposure to BCV during the study period was common, as 50% of animals showed a 16-fold or greater titer increase; however, treatment for UBRD was not associated with titer change. Although the majority of animals were vaccinated for BVDV at arrival, within a feedlot, animals treated for UBRD had larger titer increases to BVDV than non-treated animals. Based on our findings we infer that BCV was not causally related to UBRD occurrence, however consistent with other literature, BVDV may be causally related to UBRD occurrence.

Laboratory diagnosis of respiratory diseases: PCR versus serology

We present a comparison between serology and genetic detection of three bacterial pathogens causing lower respiratory tract infection (LRI). We evaluated serology and PCR for the detection of Mycoplasma pneumoniae, Bordetella pertussis and Chlamydia pneumoniae from 1712 nasopharyngeal and serum samples. For 856 nasopharyngeal samples, average PCR time was 7.2 days, the parallel serum samples was 13 days. Automated extraction of nucleic acids reduces average PCR time to 6.7 days.

Determination of cefditoren (ME 1206) in the plasma of elderly patients with multiple diseases using high-performance liquid chromatography

In the present study we developed a new sensitive and selective HPLC-assay for the determination of cefditoren (ME 1206) in the plasma. The column switching technique was used to regenerate the pre-column and the analytical column separately. This method is suitable for pharmacokinetic studies and for drug monitoring. Thus, we measured plasma samples of 15 elderly patients (age range: 67-88 years), receiving cefditoren-pivoxil therapy because of infections of the respiratory tract. In addition, these patients were treated with several co-medications because of further diseases. With our HPLC-method no interfering peaks could be detected at the retention time of cefditoren (10.67 min) or of the internal standard (16.62 min). The lowest plasma concentration of cefditoren to be quantified was 25 ng/ml (R.S.D.= 15.5%, n = 5).

Acute respiratory tract infections and mannose-binding lectin insufficiency during early childhood

CONTEXT

Hospital-based studies have found that increased susceptibility to certain infections is associated with low serum levels of mannose-binding lectin (MBL) due to MBL variant alleles. However, the contribution of MBL insufficiency to incidence of common childhood infections at a population level is unknown.

OBJECTIVE

To investigate the effect of MBL insufficiency on risk for acute respiratory tract infection (ARI) in unselected children younger than 2 years.

DESIGN AND SETTING

Population-based, prospective, cohort study conducted in Sisimiut, Greenland.

PARTICIPANTS

Two hundred fifty-two children younger than 2 years who were followed up weekly between August 1996 and August 1998 for morbidity surveillance.

MAIN OUTCOME MEASURE

Risk of ARI, based on medical history and clinical examination, compared by MBL genotype, determined from blood samples based on presence of structural and promoter alleles.

RESULTS

A 2.08-fold (95% confidence interval [CI], 1.41-3.06) increased relative risk (RR) of ARI was found in MBL-insufficient children (n = 13) compared with MBL-sufficient children (n = 239; P<.001). The risk association was largely restricted to children aged 6 to 17 months (RR, 2.92; 95% CI, 1.78-4.79) while less effect (RR, 1.47; 95% CI, 0.45-4.82) and no effect (RR, 1.00; 95% CI, 0.42-2.37) was shown among children aged 0 to 5 months and 18 to 23 months, respectively.

CONCLUSION

These data suggest that genetic factors such as MBL insufficiency play an important role in host defense, particularly during the vulnerable period of childhood from age 6 through 17 months, when the adaptive immune system is immature.

[Microcirculatory and hemostatic disturbances in patients with influenza and respiratory infections aggravated with coexisting diseases]

Microcirculatory disorders (MD) and hemostasis (HS) were studied in patients with influenza and acute respiratory viral infection (ARVI). The patients also suffered from ischemic heart disease (IHD), essential hypertension (EH) and diabetes mellitus (DM). Among 241 patients 63.9% were middle-aged and old. 45 patients under 60 years of age without coexisting diseases served control. In acute influenza and ARVI the majority of the postcapillary veins and capillaries were affected with sludge syndrome, there were marked perivascular and vascular changes. Convalescence was accompanied with reduced permeability and intravascular aggregation of erythrocytes, microvessels improved tonicity. HS responded to the acute infections with depression of fibrinolysis, in convalescence platelet aggregation activated. IHD patients had disseminated intravascular red cell aggregation, slowing of the microflow, hypercoagulation. Patients with postmyocardial infarction cardiosclerosis (PIC) had more severe affection of microcirculation and hemostasis in convalescence. In hypertensive patients microcirculation and hemostasis were similar to those with IHD. In diabetics platelet aggregation improved but sludge phenomenon and slow blood flow persisted. Thus, ARVI for IHD, EH DM patients are a risk factor for the disease aggravation. In influenza and ARVI, IHD patients, especially with PIC and EH are contraindicated active physical exercise, intake of dysaggregant drugs is desirable. Diabetics should take drugs improving blood rheology early in acute period of ARVI.

Prothrombotic changes in hemostatic parameters and C-reactive protein in the elderly with winter acute respiratory tract infections

Mortality rates attributable to cerebrovascular and ischemic heart disease increase among older adults during the winter. Prothrombotic changes in the hemostatic system related to seasonal factors, such as ambient temperature changes, and winter acute respiratory tract infections, may contribute to this excess seasonal mortality. A prospective nested case-control study was conducted to assess the impact of winter acute respiratory tract infections on fibrinogen, factor VII, factor VIIa, D-dimer, prothrombin fragment 1.2, PAI-1, soluble P-selectin and C-reactive protein (CRP) in older adults. The change in laboratory parameters from baseline (fall) to the time of infection in both middle-aged and elderly individuals was compared with matched non-infected controls. In older adult participants with winter acute respiratory tract infections, significant increases occurred in fibrinogen and C-reactive protein, but not in any other markers. The mean fibrinogen increased 1.52 g/L (38%) and the mean CRP increased 37 mg/L (370%) over baseline (both p <0.001). In a multivariate analysis, both infection and season were associated with the increase in fibrinogen, but only infection was associated with the CRP increase. Old age magnified the increase in CRP but not in fibrinogen. Winter acute respiratory tract infections induce an exaggerated inflammatory response in older adults. The associated increase in fibrinogen, an independent risk factor for ischemic heart disease, may be partly responsible for the excess winter vascular mortality.

Titres of specific antibodies to poliovirus type 3 and tetanus toxoid in saliva and serum of children with recurrent upper respiratory tract infections

A study of antibody levels (in saliva and blood) against common vaccine antigens was performed in a population of 32 children suffering from recurrent upper respiratory tract infections (URTI). None of the patients had primary or secondary immunodeficiency syndromes or other known predisposing factors for respiratory diseases. Titres of the isotype-specific antibodies immunoglobulin A (IgA), immunoglobulin M (IgM), and immunoglobulin G (IgG) against two vaccine antigens--poliovirus type 3 (P3) and tetanus toxoid (TT), a viral antigen and a bacterial antigen, respectively--were measured in unstimulated saliva and serum, both in patients and in 24 healthy children (controls), by using a standard enzyme-linked immunosorbent assay (ELISA). In addition, levels of total IgA and avidity of IgA antibodies to both P3 and TT in saliva were evaluated. No difference was found between patients and controls as to levels of total IgA, or specific IgA and IgM antibodies against both P3 and TT in saliva. Furthermore, the avidity of salivary IgA antibodies against the two antigens did not differ between the two populations. However, the average concentrations of saliva-specific IgG antibodies to both the viral and the bacterial antigen were significantly lower (p <0.01 for P3 and p <0.05 for TT, respectively) in saliva of children with recurrent URTI, whereas no difference was found in serum for any immunoglobulin isotype determined compared with healthy individuals. The results of the present study provide suggestive evidence for the existence of subtle IgG-restricted defects in antibody responses at the mucosal level, but not at the serum level, in some children with undue susceptibility to URTI.

The inverse association between serum anti-streptolysin-O titers and the frequency of exacerbations of asthma in childhood

BACKGROUND

The decline in infections in childhood may contribute to the rising severity and prevalence of atopic disorders in developed countries. Support for this hypothesis has been obtained from findings of an inverse association between tuberculin responses and atopy and from findings of high prevalence of asthma in certain islands with low prevalence of respiratory infections. With this regard, we investigated the association between serum anti-streptolysin-O (ASO) titers and the frequency of exacerbations of asthma in childhood.

METHODS

Thirty atopic asthmatic children who has no sign of upper respiratory tract infection at the time of presentation or during the previous two months were included in the study. Serum ASO titer was measured as an indicator of past streptococcal upper respiratory tract infections. ASO titer > or = 200 Todd units was accepted as positive.

RESULTS

A statistically significant association is found between high anti-streptolysin-O titers and decreased number of exacerbations in those children.

CONCLUSIONS

Our data suggests that streptococcal infections might be a factor attenuating asthma in childhood.

Soluble transferrin receptor levels and soluble transferrin receptor/log ferritin index in the evaluation of erythropoietic status in childhood infections and malignancy

Soluble transferrin receptor (sTfR) is a new diagnostic tool for determining iron status and erythropoietic activity. The increased concentrations of sTfR in patients with iron deficiency reflect the hyperplasia of erythroid precursors. The objective of this study was to evaluate sTfR and sTfR/log ferritin index (sTfR-F) values in healthy children (n = 64), full-term neonates (n = 18), children with iron deficiency (n = 16), hemolytic anemia (n = 7), beta-thalassemia traits (n = 18), respiratory infections (n = 41) and malignancies (n = 13), and to compare these parameters for the different subgroups with those of healthy children. The sTfR levels were increased in children with iron deficiency in the same way as in adults (p < 0.0001) and in cases of increased erythropoietic activity, such as during the neonatal period (p < 0.0001), and of hemolytic anemias (p = 0.006). The index was significantly increased in iron deficiency (p < 0.0001) and decreased in neonates (p = 0.011). Children carriers of beta-thalassemia were found to have increased sTfR values (p = 0.015), but not sTfR/log ferritin index (p = 0.491), a finding suggesting that use of both parameters is necessary for distinguishing between those with and those without iron deficiency. In children with upper respiratory infection, the sTfR levels were close to normal, while the index was found to be low. In order to evaluate the iron status in infections, we further subdivided the children into two groups according to the value of ferritin, with the cut-off point at 35 microg/L. Children with ferritin level above 35 microg/L experienced normal sTfR levels but very low index, a finding which could enable the use of these two parameters for distinguishing patients with infection without concomitant iron deficiency. In the group of malignancies under chemotherapy both indices were low (p = 0.005, p < 0.0001) mainly due to myelosuppression.

CONCLUSION

The interpretation of both sTfR and sTfR/log ferritin index is useful in the evaluation of iron status and erythropoietic activity, especially in children with heterozygous beta-thalassemia, infection and malignancies.

Acute exacerbations of chronic obstructive pulmonary disease are accompanied by elevations of plasma fibrinogen and serum IL-6 levels

BACKGROUND

Respiratory tract infections may acutely increase risk from coronary heart disease (CHD), though the mechanisms have not been defined. Patients with chronic obstructive pulmonary disease (COPD) are prone to repeated exacerbations that are often associated with respiratory infections. These patients also have increased cardiovascular morbidity and mortality. We hypothesized that transient acute increases in plasma fibrinogen, an independent risk factor for CHD, could occur at COPD exacerbation (mediated through a rise in IL6) and thereby provide a mechanism linking respiratory infection to risk of coronary heart disease.

METHODS

93 COPD patients [mean (SD) age 66.8 (8.1) years] were followed regularly over one year, with daily diary card monitoring of respiratory symptoms and peak expiratory flow rate (PEFR); 67 patients [mean FEV1 1.06 (0.44) l, FVC 2.43 (0.79) l] were seen during 120 exacerbations. At each visit spirometry was measured and blood samples taken for plasma fibrinogen and Interleukin-6 (IL-6) levels.

RESULT

At baseline, the mean (SD) plasma fibrinogen was elevated at 3.9 (0.67) g/l in the 67 patients with exacerbations during the study and the median (IQR) IL-6 at 4.3 (2.4 to 6.8) pg/ml. Plasma fibrinogen increased by 0.36 (0.74) g/l at exacerbation (p <0.001). with IL-6 levels rising by 1.10 (-2.73 to 6.95) pg/ml (p = 0.008). There was a relation between the changes in fibrinogen at exacerbation and IL-6 levels (r = 0.348, p <0.001). Multiple regression revealed significantly greater rises in fibrinogen when exacerbations were associated with purulent sputum (b = 0.34 g/l; p = 0.03), increased cough (b = 0.31 g/l, p = 0.019) and symptomatic colds (b = 0.228; p = 0.024).

CONCLUSIONS

Plasma fibrinogen levels were elevated in stable patients with COPD and may contribute to the increased cardiovascular morbidity and mortality in these patients. COPD exacerbations increased serum IL-6 levels, leading to a rise in plasma fibrinogen. Thus acute rather than chronic infection may have a role in predisposing to coronary heart disease or stroke.

Procoagulant activity of endothelial cells after infection with respiratory viruses

Influenza virus epidemics are associated with excess mortality due to cardiovascular diseases. There are several case reports of excessive coagulation during generalised influenza virus infection. In this study, we demonstrate the ability of respiratory viruses (influenza A, influenza B, parainfluenza-1, respiratory syncytial virus, adenovirus, cytomegalovirus) to infect lung fibroblasts and human umbilical vein endothelial cells in culture. All viral pathogens induced procoagulant activity in infected endothelial cells, as determined in a one-stage clotting assay, by causing an average 55% reduction in the clotting time. When factor VII deficient plasma was used clotting time was not reduced. The induction of procoagulant activity was associated with a 4- to 5-fold increase in the expression of tissue factor, as measured by the generation of factor Xa. Both experiments indicate that the procoagulant activity of endothelial cells in response to infection with respiratory viruses is caused by upregulation of the extrinsic pathway. Although both enveloped viruses and a non-enveloped virus (adenovirus) induced procoagulant activity in endothelial cells by stimulating tissue factor expression, the role of the viral envelope in the assembly of the prothrombinase complex remains uncertain. We conclude that both enveloped and non-enveloped respiratory viruses are capable of infecting cultured human endothelial cells and causing a shift from anticoagulant to procoagulant activity associated with the induction of tissue factor expression.

A pharmacodynamic model to support a 12-hour dosing interval for amoxicillin/sulbactam, a novel oral combination, in the treatment of community-acquired lower respiratory tract infections

We evaluated, by time-kill studies, the pharmacodynamics of amoxicillin/sulbactam (AMX/SUL, 875 mg/125 mg), a novel oral combination, against the major respiratory pathogens in 12 volunteers receiving a single dose. The sera corresponding to 50% of a 12-h dosing interval displayed either bactericidal or inhibitory activity against both a penicillin-susceptible and a penicillin-intermediate Streptococcus pneumoniae strain (penicillin MIC of 0.03 and 0.25 microg/ml, respectively), as well as against a beta-lactamase-positive Moraxella catarrhalis and a beta-lactamase-negative Haemophilus influenzae strain. Both the peak samples and those corresponding to 4 h after dose (i.e. 33% of a 12-h dosing interval) proved active against both a penicillin-resistant S. pneumoniae (MIC, 2 microg/ml) and a beta-lactamase-positive H. influenzae strain. The AMX-SUL formulation evaluated in this study showed pharmacodynamic features that support clinical trials to assess its efficacy in the treatment of lower respiratory tract infections with a 12-h dosing interval regimen.

[C-reactive protein and infections in general practice]

C-reactive protein (CRP) is a sensitive and non-specific inflammatory marker. The serum level of CRP starts to rise 6-12 hours after the start of an inflammatory stimulus. Sequential CRP measurements will have greater diagnostic value than a single measurement, and changes of the CRP values often reflect the clinical course. In use in general practice the diagnostic value of CRP is found to be high in adults with pneumonia, sinusitis and tonsillitis, however it is found to be low regarding otitis and pneumonia in children. As to urinary tract infections and salpingitis the value is still undefined. Measurement of CRP is an important diagnostic test but the analysis should not stand by itself but be evaluated together with the patient's history and clinical examination.

Randomised controlled trial of CRP rapid test as a guide to treatment of respiratory infections in general practice

OBJECTIVE

To assess whether the frequency of antibiotic prescriptions to patients with respiratory infections is reduced when general practitioners (GPs) use a C-reactive protein (CRP) rapid test in support of their clinical assessment, and to study whether using the test will have any effect on the course of disease

DESIGN

Randomised controlled trial.

SETTING

35 general practices, County of Funen, Denmark.

PATIENTS

812 patients with respiratory infection.

MAIN OUTCOME MEASURES

Frequency of antibiotic prescriptions and morbidity 1 week after the consultation, as stated by the patients.

RESULTS

In the CRP group the frequency of antibiotic prescriptions was 43% (179/414) compared with 46% (184/398) in the control group (odds ratio (OR) = 0.9, NS). After 1 week, increased or unchanged morbidity was stated more frequently in the CRP group (12%) than in the control group (8%) (OR = 1.6, p = 0.05). In the control group, the variable having the greatest influence on whether the GP prescribed antibiotics was the patients' general well-being (OR = 2.9, p < 0.0001), whereas in the CRP group the CRP value had the greatest influence (OR = 1.1 per unit increase (mg/l), p < 0.0001).

CONCLUSION

Based on the present study, the use of the CRP rapid test in support of a possible antibiotic treatment for respiratory infections in general practice cannot be recommended.

[Serological screening examinations of atypical pathogens (Mycoplasma pneumoniae, Chlamydia pneumoniae) in respiratory tract infection]

Lower respiratory tract infections are a heterogeneous group of disorders induced by plenty of pathogens. Atypical bacteria play an important role in the respiratory tract pathology. In our study 90 patients with acute infection of the respiratory tract were examined in serological screening test for Mycoplasma pneumonia and Chlamydia pneumoniae. It was confirmed that in 21 patients with community acquired pneumonia Mycoplasma pneumonia antibodies were detected in 38% and Chlamydia pneumoniae in 10%. In our opinion this screening serological tests are useful for early diagnosis of atypical bacterial infections of the respiratory tract.

An unusual complication of tapping a ventriculoperitoneal shunt

A case is reported describing a complication of an unsuccessful attempt to aspirate the reservoir of a ventriculoperitoneal shunt system with a suspected shunt infection. This arose due to a misunderstanding of the anatomy of the shunt and resulted in an intracerebral haematoma. The complications of cerebrospinal fluid shunting and the difficulty in the diagnosis thereof are outlined. We discuss the role and method of shunt tapping in diagnosing shunt problems before reviewing the literature describing the rationale. The variation in shunt design is emphasized. Guidelines are then proposed not to dissuade physicians from tapping shunts but to ensure that the procedure is performed safely and in collaboration with neurosurgical units.

[Serum procalcitonin and respiratory tract infections]

The aim of our study was to evaluate the prognostic value of serum procalcitonine (PCT) assay in adult respiratory infections. Forty-nine patients admitted with pleurisy, community-acquired pneumonia, tuberculosis, infection were included in this prospective study. PCT was assayed on admission and discharge. Biological and clinical parameters of gravity were also evaluated. Twenty patients had elevated PCT of more than 0.50 ng/ml. In 29 patients, PCT was undetectable. The serum PCT level was normal in the patients with tuberculosis, infection, pneumocytosis. PCT did not correlate with the biological and clinical markers of the disease severity but the evolution of PCT correlated with the evolution of C-reactive-protein (r = 0.58, p < 0.05). PCT seems to be an early marker of the evolution of respiratory infections, but it does not help to establish prognosis. Further studies are necessary to assess the potential value of PCT in more severe respiratory infections requiring assisted ventilation.

Tissue distribution and turnover of [3H]riboflavin during respiratory infection in mice

Studies in children and mice suggest that respiratory infections cause a mobilization of riboflavin from the tissues to the blood, resulting in increased urinary loss of this vitamin. To verify this observation, the tissue distribution and turnover of [3H]riboflavin were investigated in control and low-riboflavin-fed mice infected with Klebsiella pneumoniae. Infection significantly reduced [3H]riboflavin levels in the liver and kidney of low-riboflavin-fed mice and in the liver of control mice. Such changes were not observed in tissues such as muscle, small intestine, and brain. Urinary excretion of [3H]riboflavin increased significantly during the acute phase of infection and the biological half-life of [3H]riboflavin was shorter in the low-riboflavin-fed group. The results confirm that the mobilization of riboflavin from tissues to blood during infection results in a deterioration of riboflavin status. Thus, the study supports the hypothesis that respiratory infection is a nondietary factor contributing to the high prevalence of subclinical riboflavin deficiency in children of developing countries like India.

[Lupus anticoagulant in children. Report of 4 cases]

OBJECTIVE

We present four cases of lupus anticoagulant (AL) in children. In addition, as a result of the lack of literature published on the subject in our country. We also evaluate the epidemiological, clinical and prognostic characteristics of AL in children.

PATIENTS AND METHODS

The diagnostic criteria established by the "Subcommittee for the Standardization of Lupus Anticoagulant" were followed.

RESULTS

Over a ten-year period (1988-1998), 46 cases of children with TTPA prolongation were documented. Nine children showed circulating anticoagulant, 4 of which were lupus type anticoagulants. The age of the patients ranged from 4 to 13 and there was a prevalence of males (3/4). Half of the children had a family history of bleeding dyscrasia and it was these who showed hemorrhage or thrombotic symptoms. The case that started with ecchymosis and hemorrhaging showed prothrombin prolongation due to factor II deficit. In 3 of the 4 children, AL was linked to acute respiratory infections and was transitory. The other coincided with two thrombotic episodes of the lower extremities in a healthy child. Positive anticardiolipin antibodies were detected in two patients, both showing repeated AL episodes, one with thrombosis and the other always asymptomatic.

CONCLUSIONS

Diagnosis of AL in children is difficult and has probably been underestimated. Although it is usually transitory, it can appear in repeated episodes. Its early detection is important as it can be linked to both prothrombin deficit, as well as significant symptoms of hemorrhaging.

Evaluation of two serological tests for the diagnosis of chlamydial respiratory disease

Serological tests for chlamydial infection are one of the most frequently used methods in the diagnosis of atypical respiratory infections. Use of serological tests has implicated chlamydial infections in asthma, arthritis and coronary heart disease, but the specificity of chlamydial serology tests has been questioned. The immunofluorescence test is the most sensitive and specific serological test available for detection of chlamydial antibodies. This study compares two commercially available immunofluorescent antibody tests. The SeroFIA test using purified elementary bodies of Chlamydia pneumoniae, C. psittaci and C. trachomatis, detected 24 cases of acute C. pneumoniae infection, whereas the Spot IF test using whole cell antigen of C. psittaci and C. trachomatis, misdiagnosed 20 of these as psittacosis and missed four cases.

Clinical and immunological evaluation of patients with mild IgG1 deficiency

Serum IgG subclass concentrations were determined in patients visiting, the pulmonology out-patient clinic with chronic respiratory tract problems. A total of 24 patients with a serum IgG1 concentration < 4.9 g/l (i.e. below the reference range) and normal values for IgG2, IgM and IgA were included. Patients with a selective IgG1 deficiency were vaccinated with a 23-valent pneumococcal polysaccharide vaccine. There were nine patients with a poor antibody response to pneumococcal capsular polysaccharide antigens. Responsiveness to protein antigens was intact in all patients. Patients with pneumonia showed a significantly lower anti-polysaccharide response in the IgG2 subclass than patients without pneumonia. Patients with recurrent sinusitis showed a significantly lower response in the IgA isotype after vaccination with pneumococcal polysaccharide vaccine compared with non-sinusitis patients. It can be concluded that patients with recurrent sinopulmonary infections and a mild IgG1 subclass deficiency have an impaired IgG1 anti-polysaccharide response, which can extend to decreased IgG2 and IgA anti-polysaccharide responses.