Extensive pyomyositis secondary to paronychia-related MRSA infection: A case report

RATIONALE

Pyomyositis is characterized by an insidious and multifactorial inflammatory process, which is often caused by hematogenous pathogen. Predisposing risk factors include immunodeficiency, diabetes, malignancy, or trauma. The spectrum of clinical presentation depends on disease severity, typically presented by fever and hip pain. We hereby present a case with extensive pyomyositis secondary to chronic paronychia infection.

PATIENT CONCERNS

A 14-year-old immunocompetent male presented with fever and hip pain. The patient was initially surveyed for common infectious etiologies prior to the presentation of acute limping, which led to image confirmation of extensive pyomyositis.

DIAGNOSIS

The patient presented with acute pain in the right hip accompanied by headache, myalgia of the right leg, and intermittent fever for a week. Physical examination disclosed limping gait, limited range of motion marked by restricted right hip flexion and right knee extension, and chronic paronychia with a nail correction brace of the left hallux. Diagnosis of pyomyositis was confirmed by magnetic resonance image. Methicillin-resistant strains of Staphylococcus aureus was isolated from the patient's blood and urine cultures within 2 days of collection. The same strain was also isolated from the pus culture collected via sonography-guided aspiration.

INTERVENTIONS

Antibiotics treatment with oxacillin, teicoplanin, daptomycin, and fosfomycin were administered. Sonography-guided aspiration and computed tomography-guided pigtail drainage were arranged, along with nail extraction of his left hallux paronychia prior to discharge. Oral antibiotics fusidic acid was prescribed. Total antibiotics course of treatment was 4 weeks.

OUTCOMES

The patient gradually defervesced and was afebrile after drainage. Followed limb doppler sonography showed regression of the abscess at his right lower limb. Gait and range of motion gradually recovered without sequelae.

LESSONS

Ambulation and quality of life are greatly affected by the inflammatory process of pyomyositis. Detailed evaluation of predisposing factors should be done, even in immunocompetent individuals. Timely diagnosis is vital to successful treatment.

Immunogenicity and safety of a quadrivalent inactivated influenza vaccine in healthy subjects aged 3 to 17 years old: A phase III, open label, single-arm study

BACKGROUND

Quadrivalent influenza vaccines are particularly valuable during seasons in which a mismatch occurs between the predicted influenza B lineage for the trivalent influenza vaccine and the circulating strain. This study evaluated the immunogenicity and safety of a quadrivalent inactivated influenza vaccine AdimFlu-S manufactured in Taiwan for the 2016-2017 influenza season in healthy children.

METHODS

A total of 174 healthy children aged 3 to 17 years old were separated into 3 groups (Group A: 3-8 years old, vaccine naïve; Group B: 3-8 years old, vaccine non-naïve; Group C: 9-17 years old, any vaccine status). Sera was collected pre and post vaccination for each participant. A hemagglutination inhibition (HAI) assay was utilized to calculate geometric mean titer (GMT), seroprotection rate, and seroconversion rate.

RESULTS

All enrolled participants completed the study. For the four vaccine strains four weeks after the last vaccination, geometric mean titer ratios (GMTRs) were between 2.9 and 20.9, seroconversion rates were between 42.9% and 90.9%, and seroprotection rates were all above 96.4%. This achieved all immunogenicity endpoints and fulfilled the criteria of the European Medical Agency's Committee for Medicinal Products for Human Use (CHMP). No serious adverse events (AEs) were reported during the follow-up period of 6 months.

CONCLUSION

This quadrivalent influenza vaccine is demonstrated to be well tolerated and displays robust immunogenicity for each influenza strain. This could potentially improve protection against the antigenically distinct B/Yamagata and B/Victoria lineages.

Viral etiologies of acute respiratory tract infections among hospitalized children - A comparison between single and multiple viral infections

Background

Acute respiratory tract infections are commonly caused by viruses in children. The differences in clinical data and outcome between single and multiple viral infections in hospitalized children were analyzed.

Methods

We retrospectively reviewed the medical records of hospitalized children who had fever and a xTAG Respiratory Virus Panel (RVP) test over a 2-year period. The clinical data were analyzed and compared between single and multiple viral infections. Viral etiologies in upper and lower respiratory infections were analyzed and compared.

Results

A total of 442 patients were enrolled. Patients with positive viral detection (N = 311) had a significantly lower rate of leukocytosis (p = 0.03), less evidence of bacterial infection (p = 0.004), and shorter duration of hospitalization (p = 0.019) than those with negative viral detection. The age of patients with multiple viral infections was younger than those with single viral infection; however, there were no significant differences in duration of fever, antibiotics treatment and hospitalization between these two groups.

The most commonly identified virus was human rhinovirus. About 27% (n = 83) of patients had multiple viral infections. Overall, the highest percentage of human bocavirus infection was detected in multiple viral infections (79%). Lower respiratory tract infection (LRTI) was independently associated with multiple viral infections (p = 0.022), respiratory syncytial virus (RSV) infection (p = 0.001) and longer hospitalization duration (p = 0.011).

Conclusion

Multiple viral infections were associated with younger age and a higher risk of developing LRTI. However, multiple viral infections did not predict a worse disease outcome. More studies are needed to unveil the interplay between the hosts and different viruses in multiple viral infections.

Immunogenicity and safety of an inactivated enterovirus A71 vaccine in children 3-6 years and 2-35 months of age- an open-label, randomized phase IIb clinical trial

BACKGROUND

Enterovirus A71 (EV-A71) infection can cause severe debilitating complications and even death in young children. The immunogenicity and safety of an inactivated whole EV-A71 virus vaccine were assessed in children 2 months to 6 years of age.

METHODS

This was an open-label, multi-center and randomized phase IIb study, which divided into part A and B. In part A, children 36 months to 6 years of age were enrolled and randomized into 3 groups, receiving 0.5 μg total viral protein (TP) with adjuvant Al(OH)3, 1.0 μg TP with Al(OH)3 or 1.0 μg TP only. Two doses of vaccines were administered at a 28-day interval and blood was taken before immunization, at week 4, 8, 28 and 52 (optional) for virus neutralization assay. Safety profiles were also monitored. After safety profiles had shown no concerns, children 2 months to 35 months of age (part B) were subsequently enrolled following the same protocol.

RESULTS

A total of 135 children completed two doses of immunization, including 58 in part A and 77 in part B. Both adjuvanted 0.5 μg and 1.0 μg TP elicited significant raise of neutralizing antibody titers and seroconversion rate was up to 93.75-100.0% after 2 doses of immunization. Adjuvanted 1.0 μg TP induced higher titers of neutralizing antibodies than adjuvanted 0.5 μg TP. By contrast, non-adjuvanted 1.0 μg TP was not immunogenic. No major adverse events were reported.

CONCLUSIONS

This EV-A71 vaccine containing adjuvant is immunogenic and safe in children 2 months to 6 years of age.

CLINICAL TRIALS REGISTRATION

NCT03268083.

Incidence and risk factors of osteomyelitis in adult and pediatric systemic lupus erythematosus: a nationwide, population-based cohort study

OBJECTIVE

The objective of this paper is to investigate the incidence rate, risk factors and outcome of osteomyelitis among patients with systemic lupus erythematosus (SLE).

MATERIALS AND METHODS

We conducted a cohort study using data for patients enrolled in the Taiwan National Health Insurance Database from 2000 to 2012. Patients with SLE and age- and sex-matched controls without SLE were enrolled. Primary endpoint was the first occurrence of osteomyelitis. Risks of osteomyelitis in SLE patients were analyzed with Cox proportional hazards regression models, including age, sex, comorbidities and medications.

RESULTS

Among 24,705 SLE patients (88.4% women, mean age 35.8 years) with a median follow-up of 9.1 years, 386 patients had osteomyelitis. The incidence rate ratio (IRR) of osteomyelitis in the SLE group vs the control group was 8.52 (95% confidence interval (CI) 7.24-10.05). The SLE group had higher incidence rates of osteomyelitis than the control group, especially in pediatric subgroups (IRR 41.1 95% CI 18.57-107.35). Compared to controls, SLE patients experienced osteomyelitis at a younger age (42.3 vs 58.1 years) but did not have an increased risk of mortality (hazard ratio 0.7; 95% CI 0.21-2.38). Age >60 years, male gender, malignancy within five years, prior bone fracture and higher daily prednisolone dose (>7.5 mg) cumulatively for >180 days increased risk for osteomyelitis.

CONCLUSIONS

SLE patients have a higher IRR of osteomyelitis than controls. Pediatric and elder SLE patients, patients with a history of bone fracture, malignancy within five years and higher-dose glucocorticoid use have a higher risk of osteomyelitis and should be carefully monitored.

Invasive aspergillosis in patients with systemic lupus erythematosus: a retrospective study on clinical characteristics and risk factors for mortality

Objective

The objective of this paper is to analyze the clinical features, outcomes, mortality risk factors, and all-cause mortalities of invasive aspergillosis (IA) in patients with systemic lupus erythematosus (SLE).

Methods

Medical records were reviewed to identify SLE patients with IA from January 2006 to June 2017, at Taipei Veterans General Hospital, Taiwan. A total of 6714 SLE patients were included. Clinical/laboratory parameters and treatment outcomes were analyzed.

Results

Four patients (19.0%) had definite and 17 had probable (81.0%) IA. Seven patients (33.3%) survived and 14 died (66.7%). Concurrently, there were 19 pneumonias (90.5%), 17 cases of other infections (81.0%), eight bacteremia (38.1%), nine cytomegalovirus (CMV, 42.7%) and six Candida (28.6%) infections. In all 55 blood cultures, 38 (69.1%) yielded gram-negative bacilli, of which carbapenem-resistant A. baumannii accounted for eight (21.1%); 17 (30.9%) yielded gram-positive cocci, of which methicillin-resistant S. aureus accounted for six (35.3%); and vancomycin-resistant Enterococcus accounted for four (23.5%). Daily steroid dose ≥ 20 mg (hazard ratio (HR) 2.00), recent pulse steroid therapy (HR 2.80), azathioprine (HR 2.00), rituximab (HR 2.00), plasmapheresis (HR 2.00), acute respiratory distress syndrome (HR 2.00), concurrent infections (HR 5.667) and CMV viremia (HR 1.75) were higher in the fatality group. All p values were less than 0.05. Septic shock ( n = 7, 50% in the fatality group) is the most common cause of mortality.

Conclusions

High daily steroid dosing, recent pulse steroid therapy, azathioprine, rituximab, concurrent infections, and CMV viremia were mortality risk factors for IA in SLE.

Associations between environmental heavy metal exposure and childhood asthma: A population-based study

BACKGROUND/PURPOSE

The health risks of environmental heavy metals have been of concern are well known. The greater likelihood of heavy metal contamination in the physical environment increases the risk of asthma, especially in children. This cross-sectional, population-based study sought to investigate associations between heavy metal exposure and childhood asthma or wheezing.

METHODS

Data from 5866 subjects, stratified into age groups of 2-5, 6-11, and 12-15 years, from the National Health and Nutrition Examination Survey 2007-2012 conducted by the Centers for Disease Control and Prevention were analyzed retrospectively. The primary outcome was active asthma. Variables included demographics, anthropometric, and clinical data. Univariate and multivariate logistic regression analyses were used to identify associations between blood heavy metal concentrations and adjusted odds (aORs) of active asthma.

RESULTS

Higher concentration of blood lead was associated with higher adjusted odds of having asthma (aOR = 1.08, 95% CI = 1.00-1.16), but no significant effect was shown for current wheezing or whistling. Age-stratified analysis showed that higher blood lead concentration was associated with higher risk for active asthma (aOR = 1.24, 95% CI = 1.08-1.42) and current wheezing or whistling (aOR = 1.19, 95% CI = 1.04-1.38) in the 6-11 years age group, while higher blood mercury concentration was associated with lower risk of current wheezing or whistling (aOR = 0.95, 95% CI = 0.90-0.99). The medium concentration of blood lead was associated with decreased risks of current wheezing or whistling (aOR = 0.54, 95% CI = 0.30-0.96) in the 2-5 years age group.

CONCLUSION

Higher concentrations of blood lead are associated with higher odds of asthma in children aged 2-15 years.

Risk of complications of ultrasound-guided renal biopsy for adult and pediatric patients with systemic lupus erythematosus

Objective The objective of this paper is to identify the risk of complications of real-time ultrasound-guided renal biopsy in adult and pediatric patients with systemic lupus erythematosus (SLE). Materials and methods This retrospective study examined outcomes of 296 renal biopsy procedures in 275 SLE patients. Imaging-confirmed symptomatic hematoma was regarded as a major complication when intervention (blood transfusion, angiographic embolization, or surgery) was required or as a minor complication otherwise. Clinical and laboratory data were compared between groups with or without complications after initial or subsequent renal biopsy. Binary logistic regressions were used to evaluate complication risk of initial renal biopsy. Results Overall complication rate of initial renal biopsy was 8.7% (major: 2.9%, minor: 5.8%). Three patients expired from pulmonary hemorrhage, thrombotic microangiopathy, and pneumonia. Pediatric SLE patients tended to have a higher rate of major complications (12.5%) than adult patients (2.3%). According to multivariable analysis results, elevated serum creatinine (SCr) level (OR 1.45; 95% CI 1.17-1.81 per mg/dl), prolonged prothrombin time (PT) (OR 2.2; 95% CI 1.05-4.62 per second), and thrombocytopenia (OR 4.3; 95% CI 1.56-11.9) increased overall complication risk of initial renal biopsy. Age < 18 years (OR 8.43; 95% CI 1.21-58.8), thrombocytopenia (OR 16.4; 95% CI 2.44-110.5), and elevated SCr level (OR 1.97; 95% CI 1.36-2.86 per md/dl) increased risk of major complications. Thrombocytopenia, prolonged PT, and elevated SCr level were associated with complications after subsequent renal biopsy (all p = 0.01). Conclusions SLE patients, particularly patients under 18 years old or with elevated SCr level, prolonged PT, or thrombocytopenia, have an increased risk of complications after initial or subsequent renal biopsy.

Risk of cancer in patients with genital warts: A nationwide, population-based cohort study in Taiwan

Background

Condyloma acuminata currently affects around 1% of sexually active adults, and its incidence is increasing. The coexistence of genital warts (GW) and certain cancers and an association between human papillomavirus (HPV) and various malignancies have been reported. Therefore, we conducted this large national study to analyze the risk of malignancies among men and women with GW in Taiwan.

Methods and findings

Between January 2000 and December 2013, approximately 3 million patients were reported to the National Health Insurance Research Database of Taiwan. Of these patients, 21,763 were diagnosed with GW. In the same time period, a total of 213,541 cancer cases were reported to the registry, of which 1002 were recorded among patients with GW. The age-specific incidence rates of GW and standardized incidence ratios (SIRs) of malignancies compared to the general population were calculated. Women acquired GW earlier than men, with a mean age at diagnosis of 32.63±12.78 years. The highest incidence rate for both genders peaked at 20–29 years. Of the 1002 patients with GW and malignancies, the SIR was 1.95 (95%CI 1.83–2.07). The most markedly increased risk was found for HPV-related cancers, with a SIR of 9.74 (95%CI 3.70–15.77). Significantly elevated risks were also noted for smoking-related cancers, anogenital cancers, cervix in situ, colon, rectum, lung, kidney, and prostate cancers. Most cancers developed within 10 years after the diagnosis of GW.

Conclusions

Patients with GW have an increased risk of HPV-related cancers, especially anogenital malignancies in Taiwan. The elevated risk of other cancers highlights differences in exposure and risk factors among patients with GW compared to the general population. Cancer screening and HPV vaccination programs should be emphasized for at-risk patients.

A cluster of Mycobacterium massiliense keratitis in foundry workers

Three consecutive workers from the same foundry had Mycobacterium massiliense keratitis. The strains isolated from each patient were identical. This is the first report of a non-surgery-related outbreak of non-tuberculous mycobacterial ocular infection. An investigation revealed that injured cornea with exposure to aerosolized non-tuberculous mycobacteria might account for this outbreak.

Clinical analysis of fever of unknown origin in children: A 10-year experience in a northern Taiwan medical center

BACKGROUND

Fever of unknown origin (FUO) was first described in 1961 as fever >38.3°C for at least 3 weeks with no apparent source after 1 week of investigations in the hospital. Infectious disease comprises the majority of cases (40-60%). There is no related research on FUO in children in Taiwan. The aim of this study is to determine the etiologies of FUO in children in Taiwan and to evaluate the relationship between the diagnosis and patient's demography and laboratory data.

METHODS

Children under 18 years old with fever >38.3°C for >2 weeks without apparent source after preliminary investigations at Taipei Veterans General Hospital during 2002-2012 were included. Fever duration, symptoms and signs, laboratory examinations, and final diagnosis were recorded. The distribution of etiologies and age, fever duration, laboratory examinations, and associated symptoms and signs were analyzed.

RESULTS

A total of 126 children were enrolled; 60 were girls and 66 were boys. The mean age was 6.7 years old. Infection accounted for 27.0% of cases, followed by undiagnosed cases (23.8%), miscellaneous etiologies (19.8%), malignancies (16.6%), and autoimmune disorders (12.7%). Epstein-Barr virus (EBV) and cytomegalovirus (CMV) were the most commonly found pathogens for infectious disease, and Kawasaki disease (KD) was the top cause of miscellaneous diagnosis.

CONCLUSIONS

Infectious disease remains the most common etiology. Careful history taking and physical examination are most crucial for making the diagnosis. Conservative treatment may be enough for most children with FUO, except for those suffering from malignancies.

Pneumonia caused by Aeromonas species in Taiwan, 2004-2011

We investigated the clinical characteristics of patients with pneumonia caused by Aeromonas species. Patients with pneumonia caused by Aeromonas species during the period 2004 to 2011 were identified from a computerized database of a regional hospital in southern Taiwan. The medical records of these patients were retrospectively reviewed. Of the 84 patients with pneumonia due to Aeromonas species, possible Aeromonas pneumonia was diagnosed in 58 patients, probable Aeromonas pneumonia was diagnosed in 18 patients, and pneumonia due to Aeromonas was conclusively diagnosed in 8 patients. Most of the cases of Aeromonas pneumonia developed in men and in patients of advanced age. A. hydrophila (n = 50, 59.5 %) was the most common pathogen, followed by A. caviae (n = 24, 28.6 %), A. veronii biovar sobria (n = 7, 8.3 %), and A. veronii biovar veronii (n = 3, 3.6 %). Cancer (n = 37, 44.0 %) was the most common underlying disease, followed by diabetes mellitus (n = 27, 32.1 %). Drowning-associated pneumonia developed in 6 (7.1 %) patients. Of 47 patients who were admitted to the intensive care ward, 42 patients developed acute respiratory failure and 24 of those patients died. The overall in-hospital mortality rate was significantly associated with liver cirrhosis, cancer, initial presentation of shock, and usage of mechanical ventilation. In conclusion, Aeromonas species should be considered as one of the causative pathogens of severe pneumonia, especially in immunocompromised patients, and should be recognized as a cause of drowning-associated pneumonia. Cirrhosis, cancer, and shock as the initial presenting symptom are associated with poor outcome.

Skin and soft-tissue infections caused by Aeromonas species

This study investigated the clinical characteristics of patients with skin and soft-tissue infections (SSTIs) due to Aeromonas species. Patients with SSTIs caused by Aeromonas species during the period from January 2009 to December 2011 were identified from a computerized database of a regional hospital in southern Taiwan. The medical records of these patients were retrospectively reviewed. A total of 129 patients with SSTIs due to Aeromonas species were identified. A. hydrophila (n = 77, 59.7 %) was the most common pathogen, followed by A. veronii biovar sobria (n = 22, 17.1 %), A. veronii biovar veronii (n = 20, 15.5 %), A. caviae (n = 9, 7.0 %), and A. schubertii (n = 1, 0.8 %). The most common isolates obtained from patients with polymicrobial infections were Klebsiella species (n = 33), followed by Enterococcus spp. (n = 24), Enterobacter spp. (n = 21), Escherichia coli (n = 17), Staphylococcus spp. (n = 17), Streptococcus spp. (n = 17), and Acinetobacter spp. (n = 15). Liver cirrhosis and concomitant bacteremia were more common among patients with monomicrobial Aeromonas SSTIs than among patients with polymicrobial SSTIs. Nine (7 %) patients required limb amputations. The in-hospital mortality rate was 1.6 %. In conclusion, Aeromonas species should be considered as important causative pathogens of SSTIs, and most infections are polymicrobial. In addition, the clinical presentation differs markedly between patients with monomicrobial and those with polymicrobial Aeromonas SSTIs.

Biliary tract infections caused by Aeromonas species

This study investigated the clinical and microbiological characteristics of patients with Aeromonas infections of the biliary tract. Patients with bile cultures positive for Aeromonas species during the period July 2004 to December 2011 were identified from a computerized database of a hospital in Taiwan. Patients with Aeromonas infections of the biliary tract were further identified. During the study period, a total of 1,142 isolates of Aeromonas species were obtained from 750 patients. Of those patients, 91 (12.1 %) had Aeromonas infections of the biliary tract. The annual incidence (episodes per 10,000 patient-days) of biliary tract infections caused by all Aeromonas species was 0.31 in 2007, 0.12 in 2010, and 0.27 in 2011. A. hydrophila was the most common species isolated (n = 41, 45.1 %), followed by A. caviae (n = 30, 33.0 %), A. veronii biovar sobria (n = 15, 16.5 %), and A. veronii biovar veronii (n = 5, 5.5 %). The majority of patients (n = 77, 84.6 %) had polymicrobial infections. Hepatobiliary stones (n = 50, 54.9 %) and hepatobiliary cancer (n = 38, 41.8 %) were the most common underlying diseases, followed by diabetes mellitus (n = 29, 31.9 %) and liver cirrhosis (n = 7, 7.7 %). The in-hospital mortality rate was 8.8 %. Infection-related mortality was associated with underlying immunocompromised condition (p = 0.044) and use of mechanical ventilation (p = 0.004), but was not associated with inappropriate antibiotic usage or concomitant bacteremia (n = 8, 8.8 %). In conclusion, biliary tract infections caused by Aeromonas species are not uncommon and can develop in both immunocompromised and immunocompetent patients; however, patients with underlying hepatobiliary diseases are particularly susceptible to these infections.

Protein-losing enteropathy and premature ovarian failure in a young woman with systemic lupus erythematosus

Protein-losing enteropathy (PLE) and autoimmune oophoritis are unusual manifestations of systemic lupus erythematosus (SLE). Autoimmune oophoritis may result in menstrual disturbance and spontaneous premature ovarian failure. However, there is no validated examination to confirm the diagnosis and it is easily neglected in patients with ovarian insufficiency. A 31-year-old woman with SLE presented with PLE and autoimmune oophoritis during the long course of flares and remissions in her lupus activity. The synchronism implied the association between the two. Moreover, both conditions simultaneously had a good response to cyclosporine A (CsA) therapy.

Infections caused by Gordonia species at a medical centre in Taiwan, 1997 to 2008

The inability of conventional identification systems to accurately identify Gordonia spp. often results in the misdiagnosis of infections by these rare pathogens, which require genomic sequencing for precise identification. In the present study, we describe nine cases of the various types of infection caused by Gordonia spp. From 1997 to 2008, 66 isolates (from 30 patients) initially identified as Rhodoccus spp. by conventional biochemical methods, by the Bacteriology Laboratory of National Taiwan University Hospital, were retrospectively analysed to assess the accuracy of species identification. Fifteen of these isolates (from nine patients) were later found to be Gordonia spp. by two molecular methods: PCR-restriction fragment length polymorphism for heat shock protein gene (hsp65) and the 16S rRNA gene sequencing analysis. Gordonia sputi (n = 8) was the most common species, followed by Gordonia terrae (n = 7). Most of the isolates were isolated from blood (n = 11), followed by soft tissue (n = 2) and eye (n = 2). Five patients presented with bacteraemia and two of these had catheter-related bloodstream infection. Two patients had soft tissue infections and another two patients had infective keratitis and conjunctivitis. The random amplified polymorphic DNA patterns for isolates from different patients were different, indicating that they were genetically unrelated. Accurate identification with molecular methods is required if the role of Gordonia spp. in causing infection is to be recognized.

A neural network for linear matrix inequality problems

Gradient-type Hopfield networks have been widely used in optimization problems solving. This paper presents a novel application by developing a matrix oriented gradient approach to solve a class of linear matrix inequalities (LMIs), which are commonly encountered in the robust control system analysis and design. The solution process is parallel and distributed in neural computation. The proposed networks are proven to be stable in the large. Representative LMIs such as generalized Lyapunov matrix inequalities, simultaneous Lyapunov matrix inequalities, and algebraic Riccati matrix inequalities are considered. Several examples are provided to demonstrate the proposed results. To verify the proposed control scheme in real-time applications, a high-speed digital signal processor is used to emulate the neural-net-based control scheme.

Diagnostic performance of an enzyme-linked immunospot assay for interferon-gamma in extrapulmonary tuberculosis varies between different sites of disease

OBJECTIVES

To evaluate diagnostic performance of an enzyme-linked immunospot assay for interferon-gamma (T SPOT-TB) in patients with suspected extrapulmonary tuberculosis (TB).

METHODS

From January 2007 to December 2008, patients with suspected extrapulmonary TB were prospectively enrolled from 2 tertiary care hospitals.

RESULTS

A total of 138 patients with suspected extrapulmonary TB were enrolled; 50 patients had positive culture for Mycobacterium tuberculosis and 39 patients had probable TB. The sites of infection were lymph node (n = 20), pleura (n = 19), bone/joint (n = 15), urinary tract (n = 7), peritoneum (n = 7), meninges (n = 6), disseminated (n = 5), intestine (n = 3), pericardium (n = 2), skin (n = 2), throat (n = 1), neck (n = 1), and genitalia (n = 1). The overall sensitivity and specificity were 79.8% (71/89) and 81.6% (40/49). The sensitivity ranged from 100% for tuberculous meningitis, tuberculous pericarditis, and intestinal TB, 95% for lymphadenitis, to 42.9% for tuberculous peritonitis. The sensitivity of the T SPOT-TB assay was 70.6% in immunocompromised patients and 85.5% in immunocompetent patients (p = 0.09).

CONCLUSIONS

The T SPOT-TB assay can be a useful tool for diagnosing extra-pulmonary TB in immunocompetent and immunocompromised patients, particularly for tuberculous meningitis, pericarditis, lymphadenitis, and intestinal TB.

Skin and soft tissue infection caused by non-tuberculous mycobacteria

SETTING

A medical centre in Taipei, Taiwan.

OBJECTIVE

To investigate the trend and characteristics of patients with non-tuberculous mycobacteria (NTM) related skin and soft tissue infection.

DESIGN

A total of 63 patients with culture-proven diseases were identified from January 1997 to December 2004. The medical records of all patients were reviewed.

RESULTS

Twenty-seven patients were infected with rapidly growing mycobacteria (RGM), 19 with Mycobacterium marinum, six with M. avium complex (MAC), five with M. kansasii and six with other species. Most patients presented with a protracted cutaneous lesion without systemic symptoms, and two thirds of the patients had a history of exposure. Seventy-three per cent of the lesions involved the extremities. Underlying illness with suppressed immunity was documented in 30.2% of the patients, and was most prevalent in patients with MAC (100%) and M. kansasii (60%). Of the patients, 62% underwent at least one surgical intervention, and 77.8% received treatment with different antimicrobial combinations. Most patients (86%) recovered completely. Granulomatous inflammation was found in 88.9% of biopsied tissue associated with M. marinum infection, 31.8% with RGM and 25.0% with MAC.

CONCLUSION

A combination of surgery and antimicrobials cured most patients with microbiologically proven localised NTM skin and soft tissue infection.

An intelligent tutoring system for trauma management (Trauma-Teach): a preliminary report

Trauma-Teach is an interactive software for tutoring surgical trainees on medical trauma management procedures. Users of the system interact with a virtual patient suffering from trauma injuries. The task of the user is to stabilise the virtual patient, discover the underlying injuries and decide on an appropriate management plan. Artificial intelligence techniques are used to simulate the patient's pulmonary and cardiovascular systems in real time, determine the responses and results of treatments and diagnostics accordingly, model the patient deterioration if wrong actions are taken, and give a measure of reality to the system by selecting actual trauma cases from the hospital's database.

Double-clad Cr4+:YAG crystal fiber amplifier

A novel double-clad Cr4+:YAG crystal fiber is demonstrated by use of a codrawing laser-heated pedestal growth method. Up to 10 dB of gross gain at a wavelength of 1.52 microm is achieved at a pump power of 0.83 W, which, to our knowledge, is the first Cr4+-doped fiber amplifier in the optical fiber communication band.

Elevated levels of soluble adhesion molecules in sera of patients with acute bronchiolitis

The mechanisms of migration of neutrophils into the airway lumen are crucial in the development of airway injury of acute bronchiolitis and are mediated by adhesion molecules. In this study, we have attempted to evaluate the role of serum concentrations of the soluble form of intercellular adhesion molecule-1 (sICAM-1) in the disease activity in acute bronchiolitis and in respiratory syncytial virus (RSV) infection. Circulating levels of sICAM-1 in sera from 10 normal control subjects, and from 47 hospitalized acute bronchiolitis patients at admission, and from 25 patients on the day of discharge were determined by use of commercially available enzyme-linked immunosorbent assay kits. The mean serum level of sICAM-1 in bronchiolitis patients was significantly higher than in the 10 healthy control infants (345.8 +/- 99.7 microg/mL vs 237.1 +/- 81.7 microg/mL; p<0.05). However, the mean sICAM-1 concentration was similar between RSV-positive and RSV-negative patients (337.5 +/- 99.6 microg/mL vs 350.9 +/- 101.1 microg/mL; p=0.65). Although the mean clinical severity score of RSV-positive patients was significantly higher than that of RSV-negative patients (5.94 +/- 1.83 vs 3.48 +/- 1.70; p<0.05). The improvement of clinical severity score was not well correlated with the change of sICAM-1 level (r=0.22). This study provides evidence that serum levels of sICAM-1 are increased in acute bronchiolitis and further confirms the role of adhesion molecules involved in the pathogenesis of the disease. However, the serum concentrations of the soluble adhesion molecules could not reliably reflect the clinical severity of the disease.

Quality of life in patients of nasopharyngeal carcinoma: validation of the Taiwan Chinese version of the EORTC QLQ-C30 and the EORTC QLQ-H&N35

The authors followed the guidelines of translation and pilot testing of the EORTC QLQ-C30 and EORTC-QLQ-H&N35 questionnaires. The questionnaires were given to 50 nasopharyngeal carcinoma patients under active treatment and 50 under follow-up at our institution from November 2000 to June 2001. A retest was conducted 2 weeks after the first interview/form completion for the follow-up group. The intraclass correlation coefficients of the two questionnaires were moderate to high in the follow-up group. Cronbach's alpha coefficients of all scales of the two questionnaires were > or = 0.70 except that of cognitive functioning. Correlation of scales measuring similar dimensions of the QLQ-C30 and the SF-36 were moderate to high, while that of the QLQ-H&N35 and the QLQ-C30 and the SF-36 were moderate to low. Patients in the active treatment group had more serious acute problems due to disease and chemotherapy. Patients in the follow-up group had more serious chronic problems due to radiation therapy. We concluded that the Taiwan Chinese version of the EORTC QLQ-C30 and the EORTC QLQ-H&N35 had moderate to high test-retest reliability, high internal consistency in most scales, and could show the expected differences between patients in active treatment and follow-up group.

Sympathoinhibitory action of nociceptin in the rat spinal cord

1. Whole-cell patch recordings were made from antidromically identified sympathetic preganglionic neurons (SPN) of immature rat spinal cord slices. Bath application of nociceptin (0.1-1 micromol/L) suppressed excitatory postsynaptic potentials (EPSP) and hyperpolarized a population of SPN; these effects were naloxone (1 micromol/L) insensitive. 2. Nociceptin suppressed the amplitude of EPSP without causing a concomitant change in glutamate-induced depolarizations, suggesting a presynaptic inhibitory action. 3. Analysis of current-voltage relationships showed that nociceptin hyperpolarized SPN by increasing an inwardly rectifying K+ current. 4. Intrathecal injection of nociceptin (3, 10 and 30 nmol) to urethane-anaesthetized rats dose-dependently reduced the mean arterial pressure and heart rate; these effects were not prevented by prior intravenous injection of naloxone (1 mg/kg). 5. Results from our in vitro and in vivo experiments suggest that nociceptin suppresses spinal sympathetic outflow either by attenuating excitatory synaptic responses or hyperpolarizing SPN.

Antimicrobial activity of four root canal sealers against endodontic pathogens

The antibacterial effects of various types of widely used endodontic sealers have not been compared systematically on facultative or obligate anaerobic endodontic pathogens. The aim of this study was to evaluate the antimicrobial properties of four commonly used endodontic sealers: two epoxy-resin-based sealers (AH26, AH plus), one zinc-oxide eugenol-based sealer (N2), and one calcium hydroxide-based sealer (Sealapex). The testing microbes were four facultative anaerobic species (Streptococcus mutans, Streptococcus sanguis, Escherichia coli, and Staphylococcus aureus) and four obligate anaerobic species (Porphyromonas gingivalis, Porphyromonas endodontalis, Fusobacterium nucleatum, and Prevotella intermedia). The freshly mixed sealers were placed into the prepared wells of agar plates inoculated with the test microorganisms. After varying periods of incubation (2 days for facultative anaerobic species and 7 days for obligate anaerobic species), the zones of growth inhibition were observed and measured. All the sealers were distinctly different from each other in their antimicrobial activity. The sealers showed different inhibitory effects depending on the types and bacterial strains. N2 containing formaldehyde and eugenol proved to be the most effective against the microorganisms. The extreme antimicrobial potency of this root canal sealer must be weighted against its pronounced tissue toxic effect.

Suppression of choroidal neovascularization by adeno-associated virus vector expressing angiostatin

PURPOSE

To test the efficacy of a recombinant adeno-associated virus (rAAV) vector that expresses mouse angiostatin in suppressing experimental choroidal neovascularization (CNV) in a rat model.

METHODS

An rAAV vector, rAAV-angiostatin, was constructed to deliver the mouse angiostatin gene. rAAV-angiostatin and a control virus, rAAV-lacZ, were delivered in vivo by subretinal injection in Brown Norway rats, and the delivery was confirmed by reverse-transcriptase polymerase chain reaction (RT-PCR). For a CNV suppression experiment, CNV was generated by fundus krypton laser photocoagulation 7 days after the viral vector injection and was evaluated by fluorescein angiography (FA) and histology. Apoptosis in retina was analyzed using the TUNEL assay. Inflammation in the retina was investigated by immunohistochemistry, using antibodies that recognize lymphocytes.

RESULTS

rAAV-angiostatin injection led to sustained expression of the angiostatin gene in chorioretinal tissue for up to150 days. FA analysis revealed significant reduction of the average sizes of CNV lesions in rAAV-angiostatin-injected eyes when compared with rAAV-lacZ-injected eyes at both 14 (P = 0.019) and 150 (P = 0.010) days after injection. Moreover, histologic analysis of CNV lesions also revealed significantly smaller lesions in rAAV-angiostatin-injected eyes (P = 0.004). As for adverse effects, rAAV-angiostatin injection did not cause inflammation or apoptosis of cells in retina and choroid.

CONCLUSIONS

This is the first report that subretinal injection of rAAV-angiostatin can significantly reduce the sizes of CNV lesions. This and the absence of apoptosis and inflammation in chorioretinal tissue indicate the feasibility of a gene therapy approach for treatment of CNV disease.

Gender difference in cytoprotection induced by estrogen on female and male bovine aortic endothelial cells

Before menopause, women have a lower risk of cardiovascular diseases than men. Studies attribute this gender difference to estrogenic protection in the female cardiovascular system. We have demonstrated that 17beta-estradiol (E2) protects female bovine aortic endothelial cells against oxidative injury, probably through the induction of antioxidant enzyme activities. In this study, we examined whether E2 confers a differential protection on male and female cells. Bovine aortic endothelial cells from both genders were preconditioned for 24 h with E2 (1 nM to 10 microM), and their resistance to paraquat (1 mM, 3 h), a superoxide generator, was measured using an MTT assay. In contrast to the protection observed in female bovine aortic endothelial cells, there was no protective effect by E2 on male bovine aortic endothelial cells at physiologic concentrations. However, E2 at 1-10 microM attenuated paraquat's toxicity in both male and female cells, probably through its direct antioxidant activity. E2 at 1 nM increased in female, but not in male, cells the activities of superoxide dismutase, catalase, glutathione peroxidase, and glutathione reductase, which was associated with decreased levels of reactive oxygen species during subsequent paraquat exposure. This suggests that antioxidant enzyme induction plays some role in E2-augmented oxidative resistance in female endothelial cells.

A rapid and successful treatment for airbag-related traumatic macular hole

A 28-year-old female was diagnosed as having an airbag-related traumatic macular hole in the right eye 9 days subsequent to a traffic accident. Four weeks after the trauma, the patient's visual acuity was deteriorating to 20/600. Following vitrectomy, membrane peeling, use of autologous serum and intraocular gas tamponade, the hole healed within 12 days, more rapidly than the expected interval for the treatment of a traumatic macular hole. The visual acuities at the 3-month and 1-year follow-up examinations were 20/50, much better than the conventional surgical treatment of idiopathic macular hole and comparable to previous reports of the treatment of traumatic macular hole. Vitrectomy procedure has been proved to be effective for the treatment of traumatic macular hole. Vitrectomy combined with membrane peeling, autologous serum and intraocular gas tamponade can heal the traumatic macular hole more rapidly than the conventional treatment with vitrectomy only.

Ocular ischemic syndrome

BACKGROUND

The purpose of this study was to investigate the clinical features and management of ocular ischemic syndrome (OIS) and factors influencing its development.

METHODS

Ten patients (12 eyes) with OIS underwent detailed medical and ocular histories, complete ophthalmic evaluation including fluorescein angiography, internal carotid artery evaluation by duplex ultrasonography, and management. The following outcome measures were considered: visual acuity, anterior segment neovascularization, lens status, retinal and choroidal changes, and carotid artery stenosis or occlusion.

RESULTS

The mean age of the patients was 63 +/- 8 years. Presenting visual symptoms included gradual (82.5%) or sudden (17.5%) onset of vision loss. At initial visit, eyes with OIS had visual acuity less than or equal to counting fingers in 50%, iris neovascularization in 58%, and neovascular glaucoma in 42%. Initially associated systemic diseases in these patients included arterial hypertension (60%), diabetes mellitus (40%), coronary artery disease (20%), previous stroke (30%) and hemodialysis (10%). Complete occlusion or severe occlusion (70-99%) of the internal carotid artery was seen in 75% on the side of OIS. Panretinal photocoagulation did not prevent OIS from progressing but vitreous hemorrhage and rubeosis iris regressed. Carotid endarterectomy had some benefit in stabilizing or improving vision in patients with OIS.

CONCLUSION

OIS has a poor visual prognosis. It is imperative that the clinician be aware of the signs and symptoms of carotid disease in order to facilitate prompt diagnosis and appropriate referral, because OIS may be the presenting sign of serious ischemic cerebrovascular and ischemic heart disease.

Malignant melanoma of the eustachian tube

The case report describes the diagnosis and the management of malignant melanoma of the eustachian tube. This is an exceedingly rare condition that was treated with endoscopic surgery and post-operative radiotherapy. During a 15-month follow-up, there was no evidence of recurrence.

A pilot study of neonatal screening by electrospray ionization tandem mass spectrometry in Taiwan

Amino acid and acylcarnitine profiling of dry blood specimens using electrospray tandem mass spectrometry (ESI/MS/MS) has been recognized as an useful tool for screening inherited metabolic defects of newborns. In this pilot study, we introduced this technology to screen 2100 newborns to establish the normal amino acid and acylcarnitine level. Based on the upper cutoff level (average + 4*SD), twenty-nine samples studied were considered as abnormal. After follow-up samples and urine GC/MS analysis, only two were confirmed as true inborn errors. One was identified as hyperphenylalaninemia, and the other as isovaleric acidemia. The positive rate of true inborn metabolic error was 0.09% (2/2100), and the false positive rate 1.28% (29/2100) in this study. ESI/MS/MS is proven to be an adequate tool for inborn metabolic error screening.

Pulmonary function during exercise in obese children

BACKGROUND

Obesity imposes additional stress to ventilation during exercise. The purpose of this study is to evaluate the pulmonary function changes with graded exercise and the habitual level of physical activity in obese children.

METHODS

This study recruited 42 obese and 10 normal students, aged 11, from Tamsui Elementary School. Measurements of cardiopulmonary fitness were recorded after a jump rope test. Height, weight and body mass indices were determined before testing.

RESULTS

A significant correlation was found between triceps skin-fold thickness and the body mass index (BMI; r = 0.65, p < 0.05). Blood systolic pressure significantly increased in the obese subjects in their post-exercise test. There was no significant difference between the obese and the non-obese groups in any of the lung function test measurements. Forced expiratory volume in the first second (FEV1), peak expiratory flow rate (PEFR) and forced vital capacity (FVC) were similar in both groups.

CONCLUSIONS

Physiologic responses are not sufficiently different from between the obese subjects and the non-obese children. We should pay more attention to fostering confidence in the obese child exercise.

Induction of heme oxygenase-1 by Ginkgo biloba extract but not its terpenoids partially mediated its protective effect against lysophosphatidylcholine-induced damage

In this study, we examined whether Ginkgo Biloba Extract and its terpenoid constituents protect against oxidative stress through actions on heme oxygenase (HO) gene expression and activity. HO-1 and glutathione peroxidase (GPx) gene expressions were examined by reverse transcription polymerase chain reaction (RT-PCR) analysis, HO activity and GPx enzyme activity were analysed by spectrophotometric assay. Pretreatment of H9c2 myocytes with 100-500 microgml(-1)Ginkgo Biloba Extract caused induction of HO-1 gene expression and a significant increase in HO activity; 30 microgml(-1)ginkgolide B and 30 microgml(-1)bilobalide had little effect. Treatment with Ginkgo Biloba Extract for 24 h also significantly increased GPx gene expression and GPx enzyme activity. Pretreatment with Ginkgo Biloba Extract, ginkgolide B and bilobalide protected myocytes against lysophosphatidylcholine (LPC)-induced damage. The protective effect of Ginkgo Biloba Extract against LPC-induced damage was partially suppressed by a HO inhibitor, Zinc protoporphyrin-IX (ZnPP-IX), while ZnPP-IX did not suppress the protective effect of ginkgolide B or bilobalide. Furthermore, pretreatment with hemin, biliverdin or bilirubin reduced cytotoxicity induced by LPC. These results suggest that induction of HO-1 by Ginkgo Biloba Extract but not its terpenoid constituents may play a beneficial role in oxidative stress. The mechanism of Ginkgo Biloba Extract-induced HO-1 gene expression and the increase in HO activity may be related to alteration of intracellular glutathione levels.

Rapid monitoring assay of congenital adrenal hyperplasia with microbore high-performance liquid chromatography/electrospray ionization tandem mass spectrometry from dried blood spots

17-hydroxyprogesterone (17OHP) is the most important plasma parameter for diagnosing and monitoring congenital adrenal hyperplasia (CAH) caused by 21-hydroxylase deficiency. A rapid, simple, and specific method based on microbore high-performance liquid chromatography/electrospray ionization tandem mass spectrometry (micro-HPLC/ESI-MS/MS) was developed to determine the presence of 17OHP on dried filter-paper blood samples from patients with CAH caused by 21-hydroxylase deficiency. 17OHP from dried blood spots formed by the action of Girard reagent P (GirP) turned out to be a water-soluble hydrazone complex. Derivatization with GirP led to higher ESI sensitivity for 17OHP. The LC/MS/MS detection of GirP-derivatized 17OHP (GirP-17OHP) was rapid (<3 min). The method is repeatable and reproducible, with CVs <7% and 12%, respectively. This new method was used for direct determination of 17OHP in dried blood specimens obtained from abnormal children and infants of various ages with a detection limit of 10 ng/mL ( approximately 12 microL blood). The method described allows for rapid and reliable measurements of 17OHP in dried blood specimens from patients affected by CAH.

A traumatic macular hole secondary to a high-energy Nd:YAG laser

A case is reported of a traumatic macular hole caused by a high-energy Nd:YAG laser. The initial ocular examination revealed an explosive, crater-shaped, full-thickness macular hole surrounded by local edema and detachment. By the 12th day after the injury, the hole had shrunk progressively and was covered by a thin fibrin-like membrane. A thick epiretinal membrane covered the injured area 1 month after the injury. Nine months after the injury, the macular hole closed spontaneously with a partially detached epiretinal membrane. This case demonstrates one of the natural healing processes of a traumatic macular hole. Although the hole finally closed, the patient did not regain his vision because of the severe damage to the photoreceptors, retinal pigment epithelium, and choroid.

Regulation of endothelial heme oxygenase activity during hypoxia is dependent on chelatable iron

The regulation of heme oxygenase (HO) activity and its dependence on iron was studied in bovine aortic endothelial cells (BAEC) subjected to hypoxia-reoxygenation (H/R). HO activity was induced by hypoxia (10 h) and continued to increase during the reoxygenation phase. HO-1 protein levels were strongly induced by hypoxia from undetectable levels and remained elevated at least 8 h postreoxygenation. Addition of the Fe(3+) chelator desferrioxamine mesylate (DFO) or the Fe(2+) chelator o-phenanthroline during hypoxia alone or during the entire H/R period inhibited the induction of HO activity and HO-1 protein levels. However, DFO had no effect and o-phenanthroline had a partial inhibitory effect on HO activity and protein levels when added only during reoxygenation. Loading of BAEC with Fe(3+) enhanced the activation of the HO-1 gene by H/R, whereas loading with L-aminolevulinic acid, which stimulates heme synthesis, had little effect. These results suggest that chelatable iron participates in regulating HO expression during hypoxia.

The platelet-derived growth factor beta receptor as a target of the bovine papillomavirus E5 protein

The 44-amino acid E5 protein of bovine papillomavirus is a homo-dimeric, transmembrane protein that transforms cells by activating the platelet-derived growth factor ss receptor in a ligand-independent fashion. The E5 protein induces receptor activation by forming a stable complex with the receptor, thereby inducing receptor dimerization, trans-phosphorylation of tyrosine residues in the cytoplasmic domain of the receptor, and recruitment of cellular SH2 domain-containing proteins into a signal transduction complex. Direct interactions between specific transmembrane and juxtamembrane amino acids in the E5 protein and the PDGF ss receptor appear to drive complex formation and dimerization of the receptor. Further analysis of this unique mechanism of viral transformation promises to yield new insight into the regulation of growth factor receptor activity and cellular signal transduction pathways.

Dietary oxidized oil influences the levels of type 2 T-helper cell-related antibody and inflammatory mediators in mice

The aim of this present study was to investigate the effect of amount and degree of oxidation of dietary oil on type 2 T-helper cell (TH)-related immune responses. Four groups of BALB/c mice were fed either 50 g soyabean oil/kg (50-S), 50 g oxidized oil/kg (50-O), 150 g soyabean oil/kg (150-S) or 150 g oxidized oil/kg (150-O). After 14 weeks consuming the experimental diets, the mice were immunized with ovalbumin (OVA) plus Al and antigen-specific immunoglobulin (Ig)E, IgG1 and IgG2a, inflammatory mediators such as prostaglandin (PG) E2 and leukotriene (LT)B4 were determined. Higher hepatic microsomal cytochrome P450 was noted in mice fed 150 g oxidized oil/kg compared with those of other groups. OVA-specific IgG1 and IgE were higher in mice fed 150 g oxidized oil/kg compared with those of the other groups. The data suggested the interleukin (IL)-4: interferon (IFN)-gamma ratio was higher in mice fed 50 g dietary oxidized oil/kg compared with that of the 50-S group. The IL-5:IFN-gamma ratios were higher in the 150-S and 150-O groups than in the 50-S and 50-O groups. PGE2 and LTB4 produced by macrophages stimulated by lipopolysaccharide were highest in mice in the 150 g oxidized oil/kg group. The data suggested that an increased intake of oxidized oil might exert an unfavourable effect on the TH2 response involved in allergic disease.

Local immunosuppression prolongs survival of RPE xenografts labeled by retroviral gene transfer

PURPOSE

To determine whether local immunosuppression with Cyclosporin A can influence the survival of human fetal retinal pigment epithelium (RPE) xenografts in the rabbit's subretinal space.

METHODS

Cultured human fetal RPE cells were transduced with the gene for green fluorescent protein (GFP) using a lentiviral vector. The RPE was transplanted into the subretinal space of rabbits that received intravitreal cyclosporine either by weekly injections (0. 25-0.5 mg) or by slow release (approximately 2 microg/d) from a capsule sutured into the vitreal cavity after prior cryopexy. The transplanted RPE was followed by GFP fluorescence scanning laser ophthalmoscopy and by histology of the transplant site.

RESULTS

RPE xenografts in eyes receiving intravitreal cyclosporine survived longer (several months) than they did in control eyes without cyclosporine. Survival was as long with slow release capsules as it was with weekly intravitreal injections at much higher concentrations of cyclosporine.

CONCLUSIONS

Local immunosuppression of the eye with cyclosporine prolongs the survival of RPE xenografts in the subretinal space of rabbits, implying that rejection involves activated T lymphocytes. Local immunosuppression with slow release capsules is as effective as weekly injections at much higher concentrations.