Salmonella mycotic aneurysm: a rare cause of fever and back pain in elderly

An 85-year-old man with history of hypertension presented with fever, cough and abdominal pain. Unfortunately fever and leukocytosis persisted despite treatment. Blood cultures obtained on admission grew Salmonella enteritidis. Subsequently he developed increasing back pain and transoesophageal echocardiography (TOE) was performed, demonstrating a complex ulcer at the aortic arch with multiple small mobile strandlike densities suggestive of vegetation. Contrast thoracic CT scan confirmed an ulcerated atherosclerotic plaque which progressively increasing in size over 3 months despite antibiotics. Therefore, a stent was deployed in view of high risk of perforation and he was placed on prolonged antibiotics. Post-stenting CT scan a few months later showed a patent stent with the aneurysm remained stable in size. Cardiovascular infections develop in approximately 25 % of patients with Salmonella bacteremia. Most patients with Salmonella aortitis have preexisting atherosclerosis at the site of the subsequently infected aneurysm. The diagnosis of S. aortitis can be challenging, because the clinical course may be indolent and the symptoms are nonspecific. A high index of suspicion is required to make the diagnosis of S. aortitis, especially in patients with Salmonella bacteraemia, fever, back pain and/or abdominal pain. This case highlights the usefulness of TOE in the evaluation of diseases involving the thoracic aorta, leading to a successful intervention.

Pyomyositis in the upper Negro river basin, Brazilian Amazonia

Pyomyositis remains poorly documented in tropical Latin America. We therefore performed a retrospective review of cases admitted to a hospital in the upper Negro river basin during 2002-2006. Seasonality was assessed by the cosinor model and independent predictors of outcome were identified by logistic regression. Determinants of time-to-fever resolution were analysed using Cox regression. No seasonal trend was observed (p=0.284) among 82 hospitalised patients. The disease predominated in young males and the most commonly affected part of the body was the lower limb (68 [63.5%] out of 107 lesions). Staphylococcus aureus was the only identified infecting organism (18 of 20 culture results, 90%). Complications occurred in 17 patients (20.7%) and the case fatality rate was 2.4%. Children were more likely to present with eosinophilia than adults (OR= 4.20, 95% CI 1.08-16.32, p=0.048), but no other significant differences regarding clinical presentation and outcomes were observed. The time-to-fever resolution was the only independent determinant of poor outcome (OR=1.52, 95% CI 1.22-1.92, p<0.001) and was significantly longer in patients treated with combined antibiotic therapy than in those treated with single antibiotics (HR=0.523, 95% CI 0.296-0.926, p=0.026). Further studies to determine the best antibiotic therapy modality for the treatment of pyomyositis are required.

Severe invasive listeriosis--case report

Listeriosis is a rare food borne infection which, in the invasive form, presents as bloodstream infection, central nervous system infection, materno-fetal infection, or focal infection. Certain immunosuppressive conditions have been identified as risk factors for severe invasive disease. The invasive forms of listeriosis are associated with a high case fatality rate. We present the case of a 62-year-old male with an unremarkable medical history admitted to the Iasi Infectious Diseases Hospital for fever. headache, ataxia, and diplopia. Physical examination revealed high temperature, confusion, relative bradycardia, and signs of meningeal irritation. Laboratory test showed leukocyt osis with neutrophilia. pathological CSF findings (high WBC count with predominance of neutrophils, low glucose and high protein levels), increased liver enzymes (ALAT, ASAT, AP, gammaGT), and important renal impairment (normal levels at presentation). No abnormalities at chest x-ray, cranial CT and abdominal ultrasound. CSF and blood cultures were positive for Listeria monocytogenes. Under antibiotics (ampicillin and ciprofloxacin), the course was marked by respiratory failure requiring mechanical ventilation, coma, hypotension, tachycardia. and death 12 days after admission. The particularity of this case consists in the association of the two classical forms of invasive listeriosis, meningitis and bacteriemia, with a focal infection. acute hepatitis, and a course marked by multiple organ dysfunction syndromes and exitus in a previously apparently healthy individual.

Clinical features and course of bacterial meningitis in children

AIM

To analyze the clinical features and course of and to define the risk factors for bacterial meningitis in children.

MATERIAL AND METHODS

Retrospective study of 100 cases of bacterial meningitis in patients aged 0-18 years admitted to the Iasi Infectious Diseases Hospital between 2005 and 2010.

RESULTS

We found a clear prevalence in male children (58%) from rural area (67%), with the highest incidence in the age group 2-5 years. A significant percentage of patients (43%) had previous hospitalization, condition which is known as predisposing factor for bacterial meningitis, the most common being ear infections (20%) and height and weight deficit (9%). 71% of patients were admitted within the first 48 h. The most common onset clinical manifestations were fever (84%), vomiting (70%), signs of meningeal irritation (59%), somnolence (23%), loss of appetite (19%), and coma in 5% of patients. In 36% of cases CSF was opalescent with moderate pleocytosis (35%); in 29% of patients CSF albumin level ranged between 0.7-1.0 g, the majority presenting normal glycorahia (71%). In only 21% of cases the microbial agent was identified (pneumococcal and meningococcal etiology, 8% and 6%, respectively). The course was generally favorable, and mortality rate was low (5%). Complications occurred in 3% of patients consisting in hydrocephalus and brain abscess.

CONCLUSIONS

Bacterial meningitis remains a disease with potentially severe course. Clinical onset, most commonly atypical in children, requires differential diagnosis at the time of admission in order to initiate the most appropriate antibiotic therapy.

Penicilliosis in lupus patients presenting with unresolved fever: a report of 2 cases and literature review

Penicilliosis is a rare occurrence among non human immunodeficiency virus (HIV) infected patients. We report here two cases of Penicillium marneffei infection in patients with systemic lupus erythematosus (SLE). Both patients had a recent flare of lupus and were on immunosuppressive drugs when they presented with prolonged fever without an obvious foci of infection, unresponsive to broad-spectrum antibiotics. They were leucopaenic upon admission, with rapid deterioration during the course of the illness. Diagnosis of penicilliosis via fungal isolation from blood culture was delayed resulting in the late initiation of antifungal agents. While both patients ultimately recovered, the delay in diagnosis led to a prolonged hospital stay with increased morbidity. Clinicians should be aware of this uncommon but emerging fungal pathogen in SLE patients and maintain a high index of suspicion in diagnosing this potentially fatal but treatable disease.

[Rickettsiosis is a neglected cause of fever in returned travellers]

We present two cases of rickettsial infections in travellers caused by Rickettsia typhi and R. africae respectively. The two cases illustrate the widely varying symptomatology and aetiology. Incidence and treatment of the disease are discussed. The diagnosis is complex, and we believe that rickettsiosis is an underestimated cause of fever in returned travellers from the tropics. In the past two years only 26 cases have been diagnosed in Denmark. Whenever rickettsiosis is clinically suspected, empiric treatment with doxycycline should be initiated.

[Rickettsiosis should be considered as a differential diagnosis in patients having fever related to travelling]

Rickettsial diseases are increasingly reported in international travellers. Prospective studies have shown that 2-4 % of travellers returning with fever have a rickettsiosis. We discuss epidemiology, clinical findings, diagnostics, treatment and prevention of rickettsiosis. In conclusion, rickettsiosis should be considered in the returned traveller with fever, especially when malaria, dengue fever and typhoid fever have been excluded. There is a possibility that doxycycline may have a prophylactic effect on rickettsiosis, but this thesis is only imaginary and needs further investigation.

Antipyretic, analgesic and anti-inflammatory activity of Viola betonicifolia whole plant

BACKGROUND

Pyrexia, algesia and inflammation are associated with several pathological conditions. Synthetic drugs available for the treatment of these conditions cause multiple unwanted effects. Several studies are ongoing worldwide to find natural healing agents with better safety profile. The current study was thus aimed at evaluating antipyretic, analgesic and anti-inflammatory activities of the methanolic extract of whole plant of V. betonicifolia (VBME).

METHODS

VBME was employed to assess antipyretic activity in yeast induced hyperthermia. Analgesic profile was ascertained in acetic acid induced writhing, hot plat and tail immersion test. Nevertheless, the anti-inflammatory activity was tested in carrageenan induced paw edema and histamine induced inflammatory tests. BALB/c mice were used at test doses of 100, 200 and 300 mg/kg body weight intra peritoneally (i.p).

RESULTS

In yeast induced pyrexia, VBME demonstrated dose dependently (78.23%) protection at 300 mg/kg, similar to standard drug, paracetamol (90%) at 150 mg/kg i.p. VBME showed a dose dependent analgesia in various pain models i.e. acetic acid, hot plat and tail immersion having 78.90%, 69.96% and 68.58% protection respectively at 300 mg/kg. However, the analgesic action of VBME was completely antagonized by the injection of naloxone like opiate antagonists. Similarly carrageenan and histamine induces inflammation was significantly antagonized by VBME, 66.30% and 60.80% respectively at 300 mg/kg.

CONCLUSIONS

It is concluded that VBME has marked antipyretic, analgesic and anti-inflammatory activities in various animal models and this strongly supports the ethnopharmacological uses of Viola betonicifolia as antipyretic, analgesic and anti-inflammatory plant.

Urinary tract infections in children: a review

Febrile urinary tract infection is the most common serious bacterial infection in childhood, but the most appropriate evaluation of children with this condition is still unclear, overall regarding the best long-term management of children after a first UTI. Here we review current recommendations for the diagnosis, treatment, imaging evaluation and use of antibiotic prophylaxis in children with the first febrile urinary tract infection. Nevertheless, the development of a universally accepted diagnostic protocol remains elusive.

Type 2 lepra reaction as a cause of pyrexia of unknown origin

Leprosy, a commonly encountered disease, can rarely present as a reactional state de novo with fever as the main presenting feature. Here we describe an uncommon presentation of leprosy [with type 2 lepra reaction] as pyrexia of unknown origin with prominent rheumatologic manifestations [acute polyarthritis], renal involvement and generalized lymphadenopathy with rare presentation of type 2 lepra reaction without the classic skin lesions of erythema nodosum leprosum, occurring in a treatment naive patient without prior history of leprosy.

Separating the chaff from the grain (Tularemia)

A case of ulcero-glandular tularemia is presented. Discussion is based on the differential diagnosis of a patient presenting with cutaneous lesions, regional lymphadenopathy and fever.

Tularemia in children: evaluation of clinical, laboratory and therapeutic features of 27 tularemia cases

Tularemia is a zoonotic disease caused by Francisella tularensis. We aimed to explicate the clinical and laboratory findings of 27 consecutive tularemia patients who were included into the study. The average duration between onset of symptoms and diagnosis was 19.1 +/- 7.3 days. Sore throat (100%), fever (93%) and myalgia (100%) were the most frequently observed symptoms, while lymphadenopathy (100%), pharyngeal hyperemia (85%), tonsillitis (74%), and rash (7%) were the most frequently observed physical findings. Treatment failed in 6 patients: 1/13 streptomycin- (changed to doxycycline + streptomycin), 1/7 ciprofloxacin- (changed to streptomycin), and 4/7 gentamicin- (changed to streptomycin) receiving patients who had longer duration to treatment (26.5 +/- 2.9 days) than the 21 successfully treated cases (17.0 +/- 6.8 days). Tularemia should to be taken into account in the differential diagnosis in cases having tonsillopharyngitis and cervical lymphadenopathy without response to beta lactam/macrolide-group antibiotics in rural areas. We believe that streptomycin should be the first-line antibiotic in the treatment of pediatric tularemia cases, but it should be supported by comprehensive studies with larger patient series.

Bacteremia in feverish children presenting to the emergency department: a retrospective study and literature review

AIM

To evaluate the incidence of bacteremia, and the isolated pathogens, in well-appearing children with fever without source (FWS) presenting to the pediatric emergency department (PED), after pneumococcal conjucate vaccine - 7 valent (PCV-7) widespread introduction in the Veneto region of north-eastern Italy, and to review the main literature contributions on the subject.

METHODS

Blood cultures performed at the PED of Padova from 1 June 2006 to 31 January 2009 in febrile children aged 1-36 months were retrospectively retrieved. Medical records of previously healthy well-appearing children with FWS were identified and reviewed.

RESULTS

The study finally included 392 patients. Bacteremia rate was 0.34% (95% CI 0-1) in the age group 3-36 months and 2% (95% CI 0-4.7) in infants 1-3 months. No Streptococcus pneumoniae was isolated. The literature review identified 10 relevant studies carried out in the USA and Spain showing an overall bacteremia rate <1% for feverish children aged 3-36 months, with values <0.5% in settings with high PCV-7 coverage.

CONCLUSION

Overall bacteremia rate is currently <0.5% in well-appearing children aged 3-36 months with FWS attending the PED in areas with PCV-7 widespread vaccination and is sufficiently low to preclude laboratory testing in favour of close follow-up. Further research is needed to evaluate a more conservative approach in infants 2-3 months of age.

Diagnosis and management of febrile infants (0-3 months)

OBJECTIVES

To review the evidence for diagnostic accuracy of screening for serious bacterial illness (SBI) and invasive herpes simplex virus (HSV) infection in febrile infants 3 months or younger; ascertain harms and benefits of various management strategies; compare prevalence of SBI and HSV between different clinical settings; determine how well the presence of viral infection predicts against SBI; and review evidence on parental compliance to return for followup assessments (infants less than 6 months).

DATA SOURCES

MEDLINE, CINAHL, Embase, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, abstracts, and unpublished materials.

REVIEW METHODS

Two independent reviewers screened the literature and extracted data on population characteristics, index/diagnostic test characteristics. Diagnostic test accuracy studies were assessed using Quality Assessment of Diagnostic Accuracy Studies.

RESULTS

Eighty-four original studies were included. The combined clinical and laboratory criteria (Rochester, Philadelphia, Boston, and Milwaukee) demonstrated similar overall accuracy (sensitivity: 84.4 percent to 100.0 percent; specificity: 26.6 percent to 69.0 percent; negative predictive value: 93.7 percent to 100.0 percent; and positive predictive value: 3.3 percent to 48.6 percent) for identifying infants with SBI. The criteria based on history of recent immunization or rapid influenza test demonstrated higher sensitivity but lower specificity compared with criteria based on age, gender, and the degree of fever. The overall accuracy of C-reactive protein was greater than that for absolute neutrophil count and absolute band counts , white blood cell, and procalcitonin. For correctly identifying infants with and without SBI (or bacteremia), the Boston, Philadelphia, and Milwaukee criteria/protocol showed better overall accuracy when applied to older infants versus neonates. The Rochester criteria were more accurate in neonates than in older infants. Evidence on HSV was scarce. Most of the criteria/protocols demonstrated high negative predictive values and low positive predictive values for correctly predicting the absence or presence of SBI. In studies reporting outcomes of delayed treatment for infants with SBI initially classified as low risk, all infants recovered uneventfully. The reported adverse events following immediate antibiotic therapy were limited to drug related rash and infiltration of intravenous line. There was a higher prevalence of SBI in infants without viral infection or clinical bronchiolitis compared to infants with viral infection or bronchiolitis. The prevalence of SBI tended to be higher in the emergency departments versus primary care setting offices. The parental compliance to followup for return visits/reassessment of infants after initial examination across four studies ranged from 77.4 percent to 99.8 percent. There was no evidence to determine the influence of parental factors and clinical settings on the degree of parental compliance.

CONCLUSIONS

Overall, the focus of the literature has been on ruling out SBI. Harms associated with testing or management strategies have been less well studied. Combined criteria showed fairly high sensitivity and (therefore) reliability in not missing possible cases of SBI. Attempts to identify high-risk groups specifically, described in a minority of reports, were not as successful. There is very little literature on factors associated with compliance to followup care, although that information could be crucial to improving management strategies in the low-risk group. Future studies should focus on identifying the risks associated with testing and management strategies and factors that predict compliance.

Mannose-binding lectin 2 polymorphisms do not influence frequency or type of infection in adults with chemotherapy induced neutropaenia

Background

Mannose-binding Lectin protein (MBL) has been suggested to be relevant in the defence against infections in immunosuppressed individuals. In a Swedish adult cohort immunosuppressed from both the underlying disease and from iatrogenic treatments for their underlying disease we investigated the role of MBL in susceptibility to infection.

Methods

In this cross sectional, prospective study, blood samples obtained from 96 neutropaenic febrile episodes, representing 82 individuals were analysed for single nucleotide polymorphism (SNP) in the MBL2 gene. Concurrent measurement of plasma MBL protein concentrations was also performed for observation of acute response during febrile episodes.

Findings

No association was observed between MBL2 genotype or plasma MBL concentrations, and the type or frequency of infection. Adding to the literature, we found no evidence that viral infections or co-infections with virus and bacteria would be predisposed by MBL deficiency. We further saw no correlation between MBL2 genotype and the risk of fever. However, fever duration in febrile neutropaenic episodes was negatively associated with MBL2 SNP mutations (p<0.05). Patients with MBL2 SNP mutations presented a median febrile duration of 1.8 days compared with 3 days amongst patients with wildtype MBL2 genotype.

Interpretation

We found no clear association between infection, or infection type to MBL2 genotypes or plasma MBL concentration, and add to the reports casting doubts on the benefit of recombinant MBL replacement therapy use during iatrogenic neutropaenia.

Serologic evidence of human leptospirosis in and around Kolkata, India: a clinico-epidemiological study

OBJECTIVE

To investigate the prevalence of leptospirosis among patients from within and outside Kolkata, India, attending the Calcutta School of Tropical Medicine, for treatment during August 2002 to August 2008.

METHODS

The leptospirosis cases were determined on the basis of clinical, epidemiological, and biochemical factors, and were tested for leptospiral antibodies using IgM ELISA. Serum samples with absorbance ratio ≥ 1.21 were interpreted as reactive.

RESULTS

The commonest presentation involved fever, headache and jaundice. The male-female ratio was 61:46. A total of 65(64.20%) cases had abnormal liver and renal functions respectively, and 57.1% had both the abnormalities. The highest incidence (75, 35.04%) was recorded in September-October followed by July-August (53, 24.77%). The reactive cases had absorbance ratios between 1.21 and 8.21, and 53 showed equivocal result, while IgM non reactivity were seen in 90 patients (absorbance ratios 0.10-0.90). The patients responded to treatment with parenteral antibiotics, penicillin, ceftriaxone and cefotaxime; follow up did not reveal case fatality.

CONCLUSIONS

The cardinal signs of leptospirosis help in making clinical diagnosis, but in any hyper-endemic situation any patient reporting with acute fever and signs of pulmonary, hepatic or renal involvement should be suspected to have leptospirosis and investigated accordingly. Increased awareness, and early diagnosis and treatment, can reduce mortality due to leptospirosis.

[Pediatrics]

Several preliminary studies suggest that prophylactic administration of probiotics reduces the incidence of necrotizing enterocolitis (NEC) in preterm infants, and several neonatology units have introduced this treatment under strict surveillance. Nonetheless, breast milk feeding remains the mainstay of NEC prevention. The beta-blocker propranolol, known for its effectiveness on cutaneous hemangiomas, is also proving useful for the treatment of subglottic or visceral hemangiomas. Following the decrease in severe bacterial infections thanks to widespread vaccinations, the McCarthy clinical score has regained importance in the prediction of the risk of bacterial infection in febrile infants. It is easy to use, economical, and has a diagnostic value comparable to laboratory tests. The new WHO growth charts have been introduced in Switzerland in 2011 to take into account the increasing regional and ethnic variations in our country. Any significant change in growth velocity should prompt an evaluation of the need of further investigations.

Oxacillin or cefalotin treatment of hospitalized children with cellulitis

Cellulitis is an important cause of hospitalization in pediatrics. Because Staphylococcus aureus is the main pathogen of cellulitis, medicinal therapeutics should take the changing resistance profile of this organism into consideration. The aim of this study was to evaluate the progression and outcomes of children hospitalized for cellulitis and treated with oxacillin or cefalotin. This retrospective cohort study enrolled 218 children, hospitalized between 2001 and 2008 in Salvador, Northeast Brazil. All were diagnosed with cellulitis and treated with oxacillin or cefalotin (≥100 mg/kg/day). The median age was 2 years and 56.9% were males. Frequencies of signs and symptoms used in the clinical diagnoses were as follows: swelling (91.3%), redness (81.7%), warmth (47.2%), and tenderness (31.7%). All patients were discharged due to clinical recovery and the mean length of hospitalization was 7 ± 4 days. None of the patients died, needed intensive care, or had sequelae. By comparing the daily frequency of clinical findings during hospitalization, significant decreases were found in the frequencies of fever (admission day [42.2%], first day [20.8%], second day [12.9%], third day [8.3%], fourth day [6.1%]), toxemia, irritability, somnolence, vomiting, tachycardia, and need for intravenous hydration. In conclusion, oxacillin or cefalotin remain the drugs of choice for treating uncomplicated cellulitis in regions where community-acquired methicillin-resistant S. aureus is infrequent (<10%).

Infection profile of patients undergoing autologous bone marrow transplantation in a Brazilian institution

CONTEXT AND OBJECTIVE

Hematopoietic stem cell transplantation (HSCT) has been widely used for treating oncological and hematological diseases. Although HSCT has helped to improve patient survival, the risk of developing infection during hospitalization is an important cause of morbidity and mortality. This study aimed to analyze the infection profile during hospitalization and the associated risk factors among patients undergoing autologous HSCT at the University Hospital, Universidade Federal de Juiz de Fora.

DESIGN AND SETTING

This was a cross-sectional study on patients undergoing autologous HSCT at a public university hospital.

METHODS

Patients with febrile neutropenia between 2004 and 2009 were retrospectively evaluated regarding their infection profile and associated risk factors.

RESULTS

Infection occurred in 57.2% of 112 patients with febrile neutropenia. The main source of infection was the central venous catheter (25.9%). Infection was chiefly due to Gram-positive bacteria, although Gram-negative-related infections were more severe and caused a higher death rate. Sex, age, skin color, nutritional status and underlying disease were not associated with the development of infection. Patients with severe mucositis (Grades III and IV) had a higher infection rate (P < 0.001). Patients who developed pulmonary complications during hospitalization had higher infection rates (P = 0.002). Infection was the main cause of death (57.1%) in the study sample.

CONCLUSION

Strategies aimed at reducing infection-related mortality rates among patients undergoing autologous HSCT are necessary.

Analgesic, anti-inflammatory and antipyretic effects of the ethanol extract of Acalypha wilkesiana leaves in rats

The leaves of Acalypha wilkesiana are commonly used for the treatment of pain, fever and ulcer by traditional medical practitioners without any scientific data to evaluate the appropriateness of some of the practices. Therefore, this study was carried out to determine whether the ethanol extract of Acalypha wilkesiana has analgesic, anti-inflammatory and antipyretic as well as anti-ulcer effects. The hot plate latency assay and formalin- induced paw licking models were used to evaluate analgesic effects. Animals were divided into groups comprising of five rats each. There were control (administered saline) and reference (administered indomethacin) groups. Also there were three extract groups administered 25, 50 or 100 mg/Kg body weight of extracts. Ulcer was induced using absolute ethanol followed by pylorus ligation in all animals; inflammation was induced using carrageenan while pyrexia was induced by injecting brewer's yeast intramuscularly into the dorsal part of the abdominal cavities of the rats. Different sets of rats were used for the anti-ulcer, anti-inflammatory and antipyretic studies although animal grouping for extract administration were as in analgesic studies. The results show that the extract produced dose-dependent and significant (p<0.05) analgesic and anti-inflammatory activities. The extract also significantly protected against ethanol induced ulcer. Likewise, the extract significantly (p<0.05) reduced the pyretic states of the animals. This study has therefore further provides evidences that may support the ethnomedicinal uses of the ethanolic extracts of Acalypha wilkesiana leaves.

Anti-inflammatory, analgesic and antipyretic properties of Thespesia populnea Soland ex. Correa seed extracts and its fractions in animal models

ETHNOPHARMACOLOGICAL RELEVANCE

Thespesia populnea Sol. ex Correa (Malvaceae) is commonly known as "Indian tulip tree". The plant has been used as an astringent, antibacterial, anti-inflammatory, antinociceptive and hepatoprotective in Indian system of traditional medicine.

MATERIALS AND METHODS

Thespesia populnea seeds were successively extracted by soxhlet extraction using petroleum ether (40-60 °C) (TPO) and ethanol (TPE). Unsaponifiable matter (TPOUM) and fatty acids were separated from seed oil. A GC-MS analysis of fatty acid methyl esters was carried out. Ethanolic extract was fractionated using CHCl(3), EtOAc, n-BuOH and H(2)O. Acute arthritis was induced by sub-plantar injection of carrageenan into the left hind paw of rats. The paw volume was measured using plethysmometer. Analgesic activity was assessed by heat induced pains (tail immersion model) and antipyretic activity assessed using brewers yeast-induced pyrexia model.

RESULTS

Oral administration of TPO and TPE at 200 and 400 mg/kg b.w. and tested fractions at 200mg/kg significantly reduced carrageenan induced paw edema and brewers yeast-induced pyrexia. In tail immersion method also extracts and fractions showed significant analgesic activity. Amongst all fractions EtOAc showed most significant results. TPOUM showed significant anti-inflammatory and analgesic activity. GC-MS analyses showed the presence of fourteen fatty acids, predominant fatty acids were palmitic and stearic acid.

CONCLUSION

These results highlighted anti-inflammatory, analgesic and antipyretic effects of Thespesia populnea seeds.

[Current clinical practice in the treatment of febrile neutropenia (FN)]

Because of the refractory and recurrent nature of febrile neutropenia (FN), definite diagnosis and early empiric treatment with antibiotics are important for FN patients. With this background, guidelines for FN treatment have been published in Japan and overseas, although a treatment method appropriate for clinical practice in Japan has not yet been established. Therefore, we conducted a survey of actual practice, including trends in prescription of antibiotics for FN, in the hope that it would help establish a definitive treatment for FN in Japan. The survey results confirmed that FN patients under care of hematology departments accounted for the largest proportion, followed by pediatrics (hematology), pulmonary medicine, medical oncology, and respiratory surgery, and the proportions of patients diagnosed with FN and those receiving antibiotics in hematology departments are larger than in other departments. Across all departments, cefepime (CFPM) is most frequently used as the initial treatment of choice, accounting for 35.9% of prescriptions, followed by meropenem (MEPM) (24.3%). These drugs are selected because they exhibit high potency and wide coverage against organisms that are presumed to cause FN, and their costs are covered by insurance, while the existence of insurance coverage is the major determining factor for treatment in Japan. Among second-line drugs, MEPM is most frequently used, accounting for 46.3% of prescriptions. The guidelines are commonly used as the basis for treatment, accounting for 52.0% of all departments, especially the guidelines established by the Japan Febrile Neutropenia Study Group. On the other hand, the percentage of departments that have introduced a hospital protocol and clinical path is only 13.0% in total. To provide appropriate treatment for FN patients, insurance coverage and introduction of a hospital protocol and clinical path based on guidelines and evidence are essential. The current situation, in which these are not implemented, is not desirable. The survey results show that the guidelines need to be revised to more closely reflect the actual situation in Japan and hospital protocols and clinical paths need to be introduced.

Ingestion of Lactobacillus strain regulates emotional behavior and central GABA receptor expression in a mouse via the vagus nerve

There is increasing, but largely indirect, evidence pointing to an effect of commensal gut microbiota on the central nervous system (CNS). However, it is unknown whether lactic acid bacteria such as Lactobacillus rhamnosus could have a direct effect on neurotransmitter receptors in the CNS in normal, healthy animals. GABA is the main CNS inhibitory neurotransmitter and is significantly involved in regulating many physiological and psychological processes. Alterations in central GABA receptor expression are implicated in the pathogenesis of anxiety and depression, which are highly comorbid with functional bowel disorders. In this work, we show that chronic treatment with L. rhamnosus (JB-1) induced region-dependent alterations in GABA(B1b) mRNA in the brain with increases in cortical regions (cingulate and prelimbic) and concomitant reductions in expression in the hippocampus, amygdala, and locus coeruleus, in comparison with control-fed mice. In addition, L. rhamnosus (JB-1) reduced GABA(Aα2) mRNA expression in the prefrontal cortex and amygdala, but increased GABA(Aα2) in the hippocampus. Importantly, L. rhamnosus (JB-1) reduced stress-induced corticosterone and anxiety- and depression-related behavior. Moreover, the neurochemical and behavioral effects were not found in vagotomized mice, identifying the vagus as a major modulatory constitutive communication pathway between the bacteria exposed to the gut and the brain. Together, these findings highlight the important role of bacteria in the bidirectional communication of the gut-brain axis and suggest that certain organisms may prove to be useful therapeutic adjuncts in stress-related disorders such as anxiety and depression.

Diagnostic accuracy of a loop-mediated isothermal PCR assay for detection of Orientia tsutsugamushi during acute Scrub Typhus infection

Background

There is an urgent need to develop rapid and accurate point-of-care (POC) technologies for acute scrub typhus diagnosis in low-resource, primary health care settings to guide clinical therapy.

Methodology/Principal Findings

In this study we present the clinical evaluation of loop-mediated isothermal PCR assay (LAMP) in the context of a prospective fever study, including 161 patients from scrub typhus-endemic Chiang Rai, northern Thailand.

A robust reference comparator set comprising following ‘scrub typhus infection criteria’ (STIC) was used: a) positive cell culture isolate and/or b) an admission IgM titer ≥1∶12,800 using the ‘gold standard’ indirect immunofluorescence assay (IFA) and/or c) a 4-fold rising IFA IgM titer and/or d) a positive result in at least two out of three PCR assays.

Compared to the STIC criteria, all PCR assays (including LAMP) demonstrated high specificity ranging from 96–99%, with sensitivities varying from 40% to 56%, similar to the antibody based rapid test, which had a sensitivity of 47% and a specificity of 95%.

Conclusions/Significance

The diagnostic accuracy of the LAMP assay was similar to realtime and nested conventional PCR assays, but superior to the antibody-based rapid test in the early disease course. The combination of DNA- and antibody-based detection methods increased sensitivity with minimal reduction of specificity, and expanded the timeframe of adequate diagnostic coverage throughout the acute phase of scrub typhus.

There is an urgent need for alternative diagnostic methods for scrub typhus, but evaluation of these is hampered because the current serological gold standard (IFA) is imperfect. In a study from Thailand, 3 of 20 (15%) patients with fever had a positive Orientia tsutsugamushi PCR result despite negative serology. These findings could reflect potential benefits of the PCR assay in detecting rickettsaemia before antibody responses set in and/or a diagnostic advantage in endemic areas with high background levels of antibody in the population. Serology is complicated by the heterogeneity of strains present in Southeast Asia, but high resource costs and training make realtime PCR assays impractical for many areas where scrub typhus is endemic. This is where the new LAMP methodology has potential: it is inexpensive, simple to perform and requires only a waterbath or simple heating block instead of a thermocycler. In the context of a prospective fever study in a scrub typhus-endemic area in Thailand, the results support the validity of LAMP methodology for the diagnosis of scrub typhus, highlight the difficulties in comparing antibody- with DNA-based methods and also contribute towards understanding the dynamics of bacteraemia in this under recognised and under studied disease.

[Treatment and prevention of infections in cancer patients with neutropenia]

Prognosis of malignant diseases is significantly influenced by infectious morbidity and mortality. Thus, up to date management of cancer patients, in addition to other supportive care modalities, should also incorporate diagnostic methods and therapy of infections. In order to improve outcome, patients developing febrile neutropenia following antitumour treatment should be adequately informed regarding the risk of infections. At the same time, centres responsible for cancer patient care should set up written protocols for basic workup and empirical antibiotic therapy. Here general characteristics of neutropenic infections developing in solid tumour patients are outlined and key points for risk assessment are highlighted. In addition, options and limits of anti-infective therapy as well as prophylaxis of infections are reviewed. Importance of a fully functional institutional infection control system and multidisciplinary patient management is also emphasised.

Utility of multiplex PCR in detecting the causative pathogens for pediatric febrile neutropenia

Febrile neutropenia (FN) is a life-threatening complication, and the primary cause of FN is considered to be microbial infection. Therefore, prompt and appropriate antimicrobial therapy is crucial. Clinicians usually prescribe antimicrobial therapy on the basis of presumptive and empirical data. This is because the causative pathogen for FN in blood culture (BC) analysis is detected several days after sampling. Polymerase chain reaction (PCR) analysis has been used for detecting the causative bacteria of infections. Here, we examined whether multiplex PCR is useful for detecting the causative pathogens for FN patients. We extracted DNA from the patients' whole blood and performed multiplex PCR. In total, 128 samples of 40 patients clinically diagnosed with FN were used in this study. Multiplex PCR analysis revealed the causative pathogen in 3 patients with FN; the DNA fragments amplified were those of Pseudomonas aeruginosa in 2 cases and Psedomonas putida in 1 case. These patients could be started on appropriate antimicrobial therapy a few hours after sampling. However, the DNA fragment of the causative pathogen could not be amplified by PCR in 2 patients, although BC analysis did detect the causative bacteria. Thus, we conclude that multiplex PCR is serviceable in case of FN because of its rapidness. However, BC is also indispensable to treating FN owing to its high sensitivity.

[Comparison of two protocols of febrile urinary tract infection management in children]

PURPOSE

To compare two first febrile urinary tract infection (UTI) management protocols with regards to the diagnosis of high-grade vesicoureteral reflux (VUR) and cost.

METHODS

This study compared two cohorts of children under 16 years of age, admitted for a first episode of febrile UTI. The first group (in 2005) was managed according to previous recommendations (IV treatment and cystography performed for all children under 3 years of age). The second group (in 2006) was managed according to age and procalcitonin level. High-grade VUR frequency, UTI recurrence, hospitalization rate, and cost were compared between the two cohorts.

RESULTS

A total of 225 children were included in 2005 and 116 in 2006. High-grade VUR was found in 6.2 and 9.5% of the patients in 2005 and 2006, respectively (P=0.274). There was no statistically significant difference in the UTI recurrence rate between the two cohorts (5.3% in 2005 and 8.6% in 2006; P=0.237). The mean cost of an episode of febrile UTI was not significantly different in 2005 and 2006 (€2235 in 2005, €2256 in 2006; P=0.902), but was lower for children older than 6 months in 2006 (€1292 versus €1882 in 2005; P=0.0042).

CONCLUSION

Our management protocol for a first febrile UTI episode in children based on procalcitonin levels seems to be suitable for the diagnosis of high-grade VUR. The hospitalization rate and the mean cost of management for children older than 6 months of age was significantly reduced in 2006. The management guidelines for a first occurrence of febrile UTI in children should be reconsidered.

Teicoplanin dosing strategy for treatment of Staphylococcus aureus in Korean patients with neutropenic fever

PURPOSE

The present study was conducted to determine and compare the target attainment rate (TAR) between microorganism-nonspecific (C(trough)) and microorganism- specific (AUC24/MIC) targets over two weeks of teicoplanin administration according to several dose regimens for the treatment of Staphylococcus aureus in Korean patients with neutropenic fever.

MATERIALS AND METHODS

One thousand virtual concentrations were obtained for each dose using the population pharmacokinetic parameters of teicoplanin adopted from a published study. Simulation of 1,000 virtual MICs was performed using the MICs of 78 clinical isolates of S. aureus collected from a hospital in Korea. Thereafter, these simulated MICs were randomly allocated to 1,000 virtual patients in whom the TARs for AUC24/MIC>125 [or 345] and C(trough)>10 [or 20] mg/L were determined. The relationship of the maintenance dose with the steady-state TAR was predicted with respect to the AUC24/MIC>125 [or 345] using logistic analysis.

RESULTS

The standard dose regimen of teicoplanin showed TARs of about 70% [or 33%] and 70% [or 20%] at steady-state in cases with AUC24/MIC>125 [or 345] and C(trough)>10 [or 20] mg/L, respectively.

CONCLUSION

The current standard dose regimen was predicted to be insufficient to adequately treat S. aureus in Korean patients with neutropenic fever. To assure at least an 80% TAR in this population, dose adjustment of teicoplanin should be considered.

Predictive model for bacteremia in adult patients with blood cultures performed at the emergency department: a preliminary report

BACKGROUND

Useful predictive models for identifying patients at high risk of bacteremia at the emergency department (ED) are lacking. This study attempted to provide useful predictive models for identifying patients at high risk of bacteremia at the ED.

METHODS

A prospective cohort study was conducted at the ED of a tertiary care hospital from October 1 to November 30, 2004. Patients aged 15 years or older, who had at least two sets of blood culture, were recruited. Data were analyzed on selected covariates, including demographic characteristics, predisposing conditions, clinical presentations, laboratory tests, and presumptive diagnosis, at the ED. An iterative procedure was used to build up a logistic model, which was then simplified into a coefficient-based scoring system.

RESULTS

A total of 558 patients with 84 episodes of true bacteremia were enrolled. Predictors of bacteremia and their assigned scores were as follows: fever greater than or equal to 38.3°C [odds ratio (OR), 2.64], 1 point; tachycardia greater than or equal to 120/min (OR, 2.521), 1 point; lymphopenia less than 0.5×10(3)/μL (OR, 3.356), 2 points; aspartate transaminase greater than 40IU/L (OR, 2.355), 1 point; C-reactive protein greater than 10mg/dL (OR, 2.226), 1 point; procalcitonin greater than 0.5 ng/mL (OR, 3.147), 2 points; and presumptive diagnosis of respiratory tract infection (OR, 0.236), -2 points. The area under the receiver operating characteristic curves of the original logistic model and the simplified scoring model using the aforementioned seven predictors and their assigned scores were 0.854 (95% confidence interval, 0.806-0.902) and 0.845 (95% confidence interval, 0.798-0.894), respectively.

CONCLUSION

This simplified scoring system could rapidly identify high-risk patients of bacteremia at the ED.

[Melioidosis: a poorly known tropical disease]

A 35 year-old man was admitted to the hospital for fever upon returning from the Caribbean area. He died 48 hours later, after developing pulmonary lesions that were complicated by multi-organ failure, despite rapid diagnosis of melioidosis by mass spectrometry on blood cultures. Melioidosis is a rare bacterial disease in the traveller that is caused by Burkholderia pseudomallei. Although the clinical presentation is variable, pneumonia is the most frequent finding. Diagnosis may be considered in travellers returning from tropical and subtropical regions, especially during rainy seasons. Accordingly, when confronted with a patient who presents with fever after travelling, it is important to carefully specify the regions visited, potential expositions, and rapidly offer adequate laboratory testing.

Occurrence & antibiogram of Salmonella Typhi & S. Paratyphi A isolated from Rourkela, Orissa

BACKGROUND & OBJECTIVES

Almost round-the-year occurrence of Salmonella Typhi and Salmonella Paratyphi A has been noticed in Rourkela since last 13 and five years respectively. The incidence of infection along with the antibiogram of these two serotypes in this area were carried out.

METHODS

The study was carried out at Ispat General Hospital, Rourkela, India, between January 2005 and December 2008 with 5340 blood samples collected from patients with suspected enteric fever and pyrexia of unknown origin. Isolation, identification and antibiogram of the causative organisms were performed according to standard bacteriological procedures.

RESULTS

A total of 298 Salmonella isolates showed an overall per cent positivity of 5.58. Multidrug resistance was found in 11.96 per cent and 15.62 per cent isolates of S. Typhi and S. Paratyphi A respectively. Less than 2 per cent isolates of Salmonella showed resistance to ciprofloxacin. A resistance of 3.0 to 6.25 per cent against third generation cephalosporins was observed among the salmonella isolates.

INTERPRETATION & CONCLUSION

A round-the-year occurrence of Salmonella spp. in Rourkela might have been due to the presence of a considerable number of carriers in the locality, poor sanitation in nearby slum areas, and inadequate and contaminated community water supply at times. Higher degree of susceptibility among S. Typhi isolates against various antibiotics was encouraging, but increasing trend of resistance observed among S. Paratyphi A isolates was a matter of concern.

Efficacy and safety of micafungin for treating febrile neutropenia in hematological malignancies

Less toxic antifungal drugs are required for empirical antifungal therapy. Micafungin is an echinocandin drug that is effective against both Candida and Aspergillus, and preliminary clinical studies have shown good antifungal activity. We prospectively examined the effect and safety of micafungin against febrile neutropenia with suspected fungal infection in 53 patients (median age, 56 years) who had undergone chemotherapy. The administered dose of micafungin was 150 mg/day, and its effect was evaluated as fever resolution as well as the results of chest imaging and serum fungal tests. Micafungin levels were measured on day 4 after the first administration using high-performance liquid chromatography. We also measured trough levels of micafungin. Underlying diseases comprised acute lymphoblastic leukemia (n = 4), acute myeloid leukemia (n = 20), multiple myeloma (n = 3), and non-Hodgkin's lymphoma (n = 26). The overall efficacy of micafungin was 70%. Breakthrough fungal infections were documented in two (3.8%) patients, both of whom died of invasive mycosis. None of the patients were switched to other antifungal drugs due to events unrelated to adverse effects. Plasma levels of micafungin and the degree of hepatic or renal dysfunction did not correlate. Micafungin is safe and effective for the empirical antifungal therapy of febrile neutropenia in patients with hematological malignancies.

Outcomes of respiratory diphtheria in a tertiary referral infectious disease hospital

BACKGROUND

Diphtheria is a fatal disease and may cause serious complications if not recognized early and treated properly.

OBJECTIVES

To study the epidemiology, clinical features, complications, and outcomes in respiratory diphtheria.

MATERIALS AND METHODS

Diphtheria cases admitted in the infectious disease hospital, Beliaghata, Kolkata, India between January 2009 to January 2011 were evaluated in respect to demographic profile, immunization status, clinical features, complications, and outcomes.

RESULTS

200 diphtheria cases were studied. 150 (75%) patients had history of an adequate immunization, and 100 (50%) patients were from lower socio-economic groups. Common clinical features observed were throat pain in 148 (74%) cases and fever in 112 (56%) cases. Complications observed were myocarditis in 136 (68%) cases, neuropathy in 30 (15%) cases, and respiratory compromise in 14 (7%) cases. Death occurred in 5 (2.5%) patients.

CONCLUSIONS

diphtheria is still a public health problem in many developing countries. Strict public health measures like an increased immunization coverage, improvement of socio-economic status, easy availability of anti-diphtheritic serum (ADS), early recognition and effective treatment-all may reduce the incidence and mortality.

Causative pathogens of fever in neutropenic patients at King Chulalongkorn Memorial Hospital

BACKGROUND

Infections cause substantial morbidity and morbidity in neutropenic patients. In King Chulalongkorn Memorial Hospital, Gram-negative bacteria remained the most common causative pathogen of febrile neutropenia in all three studies conducted before 2002. However, Gram-positive bacteria have become more commonly isolated etiologic pathogens, and the incidence of fungal infection has been increasing since 2005.

OBJECTIVE

Determine the infectious etiology of fever in neutropenic patients at King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

MATERIAL AND METHOD

A retrospective chart review of all medical records of febrile neutropenic patients hospitalized at Department of Medicine between January 1 and December 31, 2006 in accompanying with microbiologic, radiologic, and serologic results was analyzed.

RESULTS

There were 125 patients (61 males and 64 females) and 172 episodes of febrile neutropenia with a mean age of 46.5 +/- 18.5 years (range: 15-81 years). The three most common primary diseases associated with neutropenia were acute myeloid leukemia, non-Hodgkin's lymphoma, and acute lymphoblastic leukemia (36.6%, 33.1%, and 10.5%). Infections could be documented microbiologically and clinically in 84 episodes (48.8%), and primary bacteremia or fungemia was the most common cause of infection (40.5%). Gram-negative bacteria were the most frequently isolated pathogens (63.9%), followed by Gram-positive bacteria (29.9%) and fungi (6.2%). Escherichia coli (46.8%) and coagulase-negative Staphylococcus (27.6%) were the most common isolates among Gram-negative and Gram-positive bacteria, respectively. Among 53 episodes (30.8%) of bloodstream infections, Gram-negative bacteria were the most commonly isolated pathogens (38 episodes, 71.7%), followed by Gram-positive bacteria (19 episodes, 35.8%) and Candida tropicalis (1 episode, 1.9%). Surprisingly, invasive mold infections were noted in eight episodes (5, 1, and 2 episodes of proven, probable, and possible infections, respectively). The overall mortality was 19.2%.

CONCLUSIONS

Although Gram-negative bacteria are the most common etiology of fever in neutropenic patients, the occurrence of infections caused by coagulase-negative Staphylococcus and molds has been increasing in comparison with the observations from previous studies in King Chulalongkorn Memorial Hospital. To authors knowledge, the present study is the first in Thailand to determine the occurrence of invasive fungal infections using the standard criteria recommended by EORTC/MSG.

[Febrile algo-eruptive illness in a French foreign legionnaire returning from Djibouti: gonococcal arthritis]

A French foreign legionnaire returning from Djibouti developed feverish polyarthritis with acral purpura. Diagnostic workup demonstrated gonococcemia contracted during unprotected fellatio. Based on this case report, diagnostic and therapeutic management is described.

Antipyretic, analgesic, anti-inflammatory and antioxidant activities of two major chromenes from Melicope lunu-ankenda

AIM OF THE STUDY

Melicope lunu-ankenda (Gaertn.) T.G. Hartley is used in Indian traditional medicine for fever, improving complexion and as a tonic. Previous studies have isolated fungicidal, antifeedant, anti-inflammatory and immunomodulatory compounds from Melicope lunu-ankenda. This study is aimed at the isolation and biological activity screening of potential molecules from the volatile oils and extracts of Melicope lunu-ankenda in the light of traditional applications.

MATERIALS AND METHODS

Volatile oil of Melicope lunu-ankenda leaves was isolated by hydrodistillation, characterized by GC-FID, GC-MS, LRI determination, Co-GC and database searches. Major chromene-type compounds in Melicope lunu-ankenda leaf oil, evodione and leptonol, were isolated by preparative TLC and characterized by UV-Vis, IR, 1H-, 13C-, 13C-DEPT NMR and EIMS. They were also isolated from the petroleum ether and acetone extracts of the leaves of Melicope lunu-ankenda by column chromatography in petroleum ether-ethyl acetate. Their contents in leaf oil, leaf and inflorescence extracts were estimated by HPTLC. Antipyretic (Baker's yeast-induced fever test), analgesic (acetic acid-induced writhing, tail immersion assays), anti-inflammatory (carrageenan-induced paw edema) and in vitro antioxidant (DPPH radical, superoxide radical scavenging) activities of evodione and leptonol were tested.

RESULTS AND CONCLUSIONS

Gas chromatographic analyses found 50.7% monoterpene hydrocarbons, 0.4% oxygenated monoterpenes, 3.2% sesquiterpene hydrocarbons, 0.7% oxygenated sesquiterpenes and 43.7% chromene-type compounds in Melicope lunu-ankenda leaf oil, with evodione (20.2%) and leptonol (22.5%) as its two major constituents. HPTLC estimations in the petroleum ether, acetone extracts (leaf, inflorescence) and leaf oil found evodione 1.0% (dr. wt., leaf), 1.1% (inflorescence), 0.04% (fr. wt. leaves, leaf oil), and leptonol 0.3% (leaf), 0.3% (inflorescence) and 0.04% (leaf oil). Leptonol (200 mg/kg) showed good antipyretic activity. DPPH radical scavenging assay found moderate activity for leptonol (68.7%, 500 microM), whereas evodione showed near-zero activity. A very similar trend was found in superoxide radical scavenging activity of leptonol (64.5%) and evodione (10.3%), both at 100 microg/ml. Evodione and leptonol showed moderate analgesic activities in acetic acid-induced writhing and tail immersion assays. Moderate anti-inflammatory activity was found for both evodione (59.4%) and leptonol (49.0%) at 100 mg/kg.

ETHNOPHARMACOLOGICAL RELEVANCE

Biological activities of evodione and leptonol isolated from Melicope lunu-ankenda justify its traditional uses as a remedy for fever, inflammation and as a tonic.