Chlamydia trachomatis genotypes A and B from urogenital specimens of patients in Spain: molecular characterization

OBJECTIVES

Chlamydia trachomatis ompA genotypes A and B, primarily associated with trachoma, were unexpectedly detected in urogenital samples of patients in Spain, a trachoma-free country. In this study, we aimed to explain this finding using analysis of organotropism-related genes and a multilocus sequence typing (MLST) technique.

METHODS

C. trachomatis genotypes A or B were detected in 8/930 (0.9%) infection episodes between 2006 and 2012. In these strains, organotropism-related genes (polymorphic membrane protein gene H, tryptophan synthase gene A, CTA0934, and cytotoxin) were studied. Further, the strains were analysed by MLST, using a polymerase chain reaction that amplifies five highly variable genomic loci (hctB, CT058, CT144, CT172, and pbpB). Amplicons were sequenced and phylogenetic analysis was conducted.

RESULTS

Seven strains were detected in the eight infection episodes (in one patient, an identical strain being found in two episodes). Analysis of organotropism-related genes showed that these strains shared genetic features characteristic of genitotropic genotypes but not of trachoma strains. Three strains of genotype A showed a unique and new MLST-sequence type (ST551, allele profile 8-8-2-27-69). The four strains of genotype B belonged to ST138.

CONCLUSIONS

C. trachomatis ompA genotypes A and B associated with trachoma, but detected sporadically in urogenital samples in trachoma-free countries, may be the result of recombination between strains adapted to trachoma and strains adapted to sexual transmission.

Incidence of varicella zoster virus infections of the central nervous system in the elderly: a large tertiary hospital-based series (2007-2014)

The aim of the study was to describe the clinical and epidemiological characteristics of the central nervous system (CNS) infection by varicella zoster virus (VZV) in patients older than 65 years in a tertiary community hospital. We retrospectively analysed the results of cerebrospinal fluid (CSF) testing in patients older than 65 years between 2007 and 2014 with clinically suspected VZV infection with CNS involvement. Patients whose CSF samples were positive for VZV DNA were included, as were those with negative results who simultaneously presented herpes zoster and CSF or magnetic resonance imaging findings suggestive of CNS infection, and in whom other possible aetiologies had been ruled out. The study included 280 patients. The disease was considered to be caused by a VZV infection in 32 patients (11.4%), of which 23 cases were virologically confirmed (detection of VZV DNA in CSF). The most frequent diagnosis of the patients with VZV CNS infection was encephalitis (83.3%), followed by meningitis (13.3%) and cerebellitis (3.3%). The mean annual incidence of VZV CNS infection was 3.0 cases per 100,000 inhabitants. VZV was the most common cause of encephalitis and viral meningitis, ahead of herpes simplex virus (n = 9). At the time of discharge, 12 (40%) patients showed neurological sequelae. Five patients (20%) died during hospitalization, all with encephalitis. Patients with a fatal outcome had significantly higher median age and longer delay before initiating acyclovir. In conclusion, VZV was the first cause of encephalitis in our elderly population. Despite acyclovir treatment, there was a high rate of case fatality and sequelae at discharge.

Minimum spread of the new Swedish variant of Chlamydia trachomatis and distribution of C. trachomatis ompA genotypes in three geographically distant areas of Spain, 2011-2012

PURPOSE

The aim of this study was to determine the presence of the new Swedish Chlamydia trachomatis (C. trachomatis) variant (nvCT) and the distribution of C. trachomatis ompA genotypes in three geographically distant regions of Spain.

METHODS

The genotypes of strains causing 624 episodes of infection (January 2011-September 2012) were studied using a nested PCR that amplifies a fragment of the ompA gene, followed by sequencing. To detect nvCT, a real-time PCR was used that amplifies a fragment of the cryptic plasmid with a 377 base pair deletion, which identifies the nvCT.

RESULTS AND CONCLUSION

The ompA genotype was identified in 565 (90.5%) episodes. Eleven genotypes were detected, of which nine were found in all three regions. Only one nvCT strain was detected (0.4%), despite the predominance of genotype E (41%). Other frequent genotypes were genotypes D (19%), F (13%), G (11 %), and J (7%). Genotype L2b, causing lymphogranuloma venereum, was detected in men who have sex with men (MSM) in all three regions. Genotypes E and F were more frequent in women and heterosexual men, and genotypes D, G, J and L2b in MSM. In men, the main factor causing differences in the distribution of C. trachomatis was sexual behavior (MSM versus heterosexual men), while the distribution of C. trachomatis genotypes was similar in women and heterosexual men.

Viral infections of the central nervous system in Spain: a prospective study

The aim of the study was to determine the incidence of viruses causing aseptic meningitis, meningoencephalitis, and encephalitis in Spain. This was a prospective study, in collaboration with 17 Spanish hospitals, including 581 cases (CSF from all and sera from 280): meningitis (340), meningoencephalitis (91), encephalitis (76), febrile syndrome (7), other neurological disorders (32), and 35 cases without clinical information. CSF were assayed by PCR for enterovirus (EV), herpesvirus (herpes simplex [HSV], varicella-zoster [VZV], cytomegalovirus [CMV], Epstein-Barr [EBV], and human herpes virus-6 [HHV-6]), mumps (MV), Toscana virus (TOSV), adenovirus (HAdV), lymphocytic choriomeningitis virus (LCMV), West Nile virus (WNV), and rabies. Serology was undertaken when methodology was available. Amongst meningitis cases, 57.1% were characterized; EV was the most frequent (76.8%), followed by VZV (10.3%) and HSV (3.1%; HSV-1: 1.6%; HSV-2: 1.0%, HSV non-typed: 0.5%). Cases due to CMV, EBV, HHV-6, MV, TOSV, HAdV, and LCMV were also detected. For meningoencephalitis, 40.7% of cases were diagnosed, HSV-1 (43.2%) and VZV (27.0%) being the most frequent agents, while cases associated with HSV-2, EV, CMV, MV, and LCMV were also detected. For encephalitis, 27.6% of cases were caused by HSV-1 (71.4%), VZV (19.1%), or EV (9.5%). Other positive neurological syndromes included cerebellitis (EV and HAdV), seizures (HSV), demyelinating disease (HSV-1 and HHV-6), myelopathy (VZV), and polyradiculoneuritis (HSV). No rabies or WNV cases were identified. EVs are the most frequent cause of meningitis, as is HSV for meningoencephalitis and encephalitis. A significant number of cases (42.9% meningitis, 59.3% meningoencephalitis, 72.4% encephalitis) still have no etiological diagnosis.

Measles genotypes D4 and G3 reintroduced by multiple foci after 15 years without measles virus circulation, Gipuzkoa, the Basque Country, Spain, March to June 2011

During a three-month period in spring 2011, 23 cases of measles occurred in seven independent outbreaks in a region in Spain with around 700,000 inhabitants, where the disease had been eliminated since 1997. High vaccination coverage and rapid diagnosis allowed implementation of containment measures and this prevented spread of the disease. Except for the first outbreak which affected 10 cases, each of the other six outbreaks caused a maximum of three secondary cases.

Measles genotypes D4 and G3 reintroduced by multiple foci after 15 years without measles virus circulation, Gipuzkoa, the Basque Country, Spain, March to June 2011

During a three-month period in spring 2011, 23 cases of measles occurred in seven independent outbreaks in a region in Spain with around 700,000 inhabitants, where the disease had been eliminated since 1997. High vaccination coverage and rapid diagnosis allowed implementation of containment measures and this prevented spread of the disease. Except for the first outbreak which affected 10 cases, each of the other six outbreaks caused a maximum of three secondary cases.

Human parechoviruses in infants with systemic infection

Human parechoviruses (HPeVs) are RNA viruses related to neonatal sepsis, meningoencephalitis and other infections in young children. Little clinical and epidemiological information is available on these viruses. HPeVs were sought in cerebrospinal fluid from 397 infants aged less than 12 months from whom a sample was obtained to exclude meningitis or encephalitis from 2006 to 2009. HPeV infections were also tested in stool samples from 271 children aged less than 3 years old with gastroenteritis from November 2008 to March 2009. HPeV detection was by real-time polymerase chain reaction assay (region 5'UTR), followed by genotyping (region VP3/VP1). HPeVs were detected in the cerebrospinal fluid of nine infants (2.3%), one aged 6 months and eight aged 14-55 days old. All were admitted to hospital for febrile syndrome with abrupt clinical deterioration and suspected systemic infection without clear laboratory signs of meningeal inflammation. The same virus was detected in all the available nasopharyngeal aspirates, stool, and/or serum samples from each patient. At least eight of the nine cases were caused by HPeV3. HPeVs were detected in stool samples from 17 children (6.3%), the most prevalent types being types 1 and 3. In conclusion, HPeV infection is common in the Basque Country (Spain) and HPeV3 is a significant cause of hospital admission due to systemic infection in the first few months of life. In these patients, HPeVs should be investigated as part of routine tests for enterovirus.

Residual immunity in older people against the influenza A(H1N1)--recent experience in northern Spain

The 2009 pandemic influenza A(H1N1) virus has a higher incidence in children and young adults, a pattern that has also been reported in seasonal influenza caused by the influenza A(H1N1)virus. We analysed age at infection in symptomatic patients with influenza in the Basque Country (northern Spain), reported through the sentinel influenza surveillance system which monitors 2.2-2.5%of the population. Between September 1999 and August 2009,influenza A(H3N2) or seasonal influenza A(H1N1) was detected in 941 patients, and from April to August 2009, pandemic influenza A(H1N1) was detected in 112 patients. The H3/H1 seasonal influenza ratio was between 3.3 and 3.4 in the under 60 year olds,but 9.8 in older individuals, suggesting that people born before 1950 have residual immunity against the influenza A H1N1 subtype (both seasonal and pandemic).

Rapid spread of drug-resistant influenza A viruses in the Basque Country, northern Spain, 2000-1 to 2008-9

A worldwide increase of adamantane-resistant influenza A(H3N2) and oseltamivir-resistant influenza A(H1N1) viruses has been observed in recent years. The aim of this study was to analyse the prevalence of antiviral drug-resistant influenza A in a region of northern Spain. Resistance to adamantanes was detected in 45.3% (68/150) of influenza AH3 viruses analysed for the period from 2000-1 to 2008-9. Adamantane-resistance was absent in our region during the 2000-1 to 2002-3 influenza seasons. However, after the first adamantane-resistant virus (characterised as A/Fujian/411/2002) was detected in the 2003-4 season, a rapid increase in the proportion of resistant strains was observed (4.9% [2/41], 80% [8/10] and 100% [53/53] in the 2004-5, 2006-7 and 2008-9 seasons, respectively). Four of the first five adamantane-resistant AH3 viruses detected were isolated from adult patients, but the subsequent spread was observed mainly among children. No resistance to adamantanes was detected among the 65 influenza AH1 viruses analysed throughout the study period. Among the 172 influenza A (76 AH1 and 96 AH3) viruses analysed, five strains (AH1 with mutation H274Y) showed oseltamivir resistance, and all were detected in the last season. Amantadine use was very scarce in our region, and oseltamivir was not used at all; therefore the increase of resistance was attributed to imported drug-resistant influenza viruses.

A swimming pool-related outbreak of pharyngoconjunctival fever in children due to adenovirus type 4, Gipuzkoa, Spain, 2008

An outbreak of pharyngoconjunctival fever affecting 59 children was detected in a municipality of northern Spain in July 2008. The outbreak was related to insufficient doses of water disinfectant in the municipal swimming pool. Adenovirus was detected in the pharyngeal swabs of five of six affected children and the four strains that were sequenced were all Adenovirus type 4.

A swimming pool-related outbreak of pharyngoconjunctival fever in children due to adenovirus type 4, Gipuzkoa, Spain, 2008

An outbreak of pharyngoconjunctival fever affecting 59 children was detected in a municipality of northern Spain in July 2008. The outbreak was related to insufficient doses of water disinfectant in the municipal swimming pool.

Q fever in the Netherlands - what matters is seriousness of disease rather than quantity

As the number of detected cases may be closely related to the intensity of the search and the methods and criteria used in the diagnosis, we believe that exhaustive surveillance under pressure from the media could lead to over-diagnosis and unnecessary treatments which, like that of pregnant women, are not free of risk.

A PCR-restriction fragment length polymorphism assay to genotype human metapneumovirus

Human metapneumovirus (hMPV) genotypes A and B show epidemiological and probably clinical differences. This report describes a fast and simple PCR-restriction fragment length polymorphism (PCR-RFLP) assay, involving digestion of the fusion protein gene with Tsp509I, that allows lineages A1, A2, B1 and B2 to be distinguished. The assay should help in elucidating the epidemiology of hMPV, and possibly in predicting the severity of clinical infection.

Robustness of measles immunity in parturient women in Gipuzkoa, Basque Country, Spain, in the post-vaccination era

The infants of mothers with vaccine-induced immunity lose passive acquired measles antibodies earlier than infants of naturally infected mothers. This study included two cohorts of parturient women: one composed of women who gave birth in 1990 (end of the epidemic period), and another comprising women who gave birth in 2006 (after eight years without virus circulation). Immunoglobulin G (IgG) antibodies against measles (IgG-AM) were investigated by enzyme immunoassay in stored serum samples (-40°C). Measles-IgG titres of >400 mIU/mL were found in all 185 parturient women who gave birth in 1990, all with natural immunity. Of 185 women who gave birth in 2006, most of whom had vaccine-induced protection, measles-IgG were undetectable in 4.9% (

Gipuzkoa, Basque Country, Spain (1984-2004): a hyperendemic area of Q fever

Overall 1,261 cases of Q fever were diagnosed between 1984 and 2004 in Gipuzkoa (Basque Country, Spain). Most (75.5%) of the cases ocurred in subjects 15-45 years of age. A total of 79.5% of the cases (n = 1003) ocurred between January and June. The annual incidence for acute Q fever in Gipuzkoa was 7.7, 15.8, 9.6, and 5.7 for the periods 1984-1989, 1990-1994, 1995-1999, and 2000-2004, respectively. In 94% of the cases IgM titer was >/=1/256. The most frequent clinical manifestation was pneumonia (79%). Only two cases of chronic Q fever were detected during the 21 years studied.

Risk factors for hospitalization due to respiratory syncytial virus infection among infants in the Basque Country, Spain

This study analysed the role of several risk factors for hospitalization due to community-acquired, respiratory syncytial virus (RSV) infection. The risk factors detected in infants hospitalized for RSV infection in the first 24 months of life were compared with those in the general infant population in our region. There were 361 episodes of hospitalization in 357 infants. Eighty per cent of the infants did not present underlying conditions for severe RSV infection and only 10 (3%) were candidates for palivizumab prophylaxis. In multivariate analysis, birthweight of <2500 g was independently associated with hospitalization for RSV infection and was the most commonly detected medical risk factor. Other risk factors were maternal age at delivery <25 years, birth in the second half of the year, prematurity, suburban residence and congenital heart disease. In conclusion, together with well-known risk factors, we found that low birthweight was an independent factor for severe RSV infection.

Influenza-related hospitalisations among children aged less than 5 years old in the Basque Country, Spain: a 3-year study (July 2001–June 2004)

This population-based study evaluated the incidence of virologically confirmed influenza-related hospitalisation in children aged <5 years between July 2001 and June 2004 in a region of southern Europe. Forty-nine children with influenza virus infection were hospitalised. The annual hospitalisation rates per 1000 inhabitants for each period were 5.1, 0 and 7.3 for infants aged less than 6 months, 0.9, 0.2 and 0.9 for children aged 6-23 months, and 0.7, 0.1 and 0.8 for those aged 24-59 months. Most of the children were hospitalised in the epidemic waves caused by the influenza A/H3N2 virus and were previously healthy. This study supports the need to introduce measures to reduce the burden of disease due to influenza virus infection in young children. New vaccines or vaccination strategies that could be applied in infants should be developed.

Características clínicas de los niños hospitalizados por infección por virus Influenza

BACKGROUND

The clinical manifestations of influenza virus are fairly nonspecific and are similar to those of other viral infections, respiratory processes due to other causes and even septic disease in neonates. Few studies have been performed of the clinical characteristics of influenza virus infection in hospitalized children.

OBJECTIVE

To evaluate the clinical characteristics of children hospitalized for influenza virus infection in four consecutive epidemic waves (2000-2004).

MATERIAL AND METHODS

We retrospectively reviewed the medical records of children hospitalized for influenza A and B virus infection confirmed by cell culture and polymerase chain reaction. Age, sex, symptoms on admission, complementary investigations, diagnosis and outcome were evaluated.

RESULTS

Eighty-four children were hospitalized, of which 74 had influenza virus type AH3, five had influenza virus type AH1 and five had influenza B virus. A total of 42.8 % were aged less than 6 months. The main symptoms were fever (75 patients), cough (56 patients) and ENT involvement (53 patients). The most frequent causes of admission were febrile syndrome (75 patients), bronchiolitis (19 patients), pneumonia (13 patients) and bronchitis (8 patients). In 21 patients viral or bacterial coinfection was found, the most frequent of which was respiratory syncytial virus (10 patients). Few differences were found among age groups except for pneumonia and prolonged fever (more frequent in children older than 6 months) and lymphocytosis (in children younger than 6 months). The greatest number of complementary investigations in younger children was performed for acute febrile syndrome in neonates aged less than 6 months. Risk factors for hospitalization were found in only three children, all of whom were older than 6 months. Outcome was favorable in all children.

CONCLUSIONS

Influenza virus infection in hospitalized children is most frequent in previously healthy neonates with fever and nonspecific signs and symptoms that are similar to those of other infectious processes. Specific microbiological diagnostic techniques are required for an early diagnosis. Healthy infants aged less than 24 months are most at risk for hospitalization for influenza virus infection.

Increase of immunity to rubella and interruption of rubella transmission in Gipuzkoa (Basque Country, Spain) after an enhanced vaccination programme

In Spain, vaccination against rubella was initiated in schoolgirls in the mid-1970s. In Gipuzkoa, subsequent extensions to the vaccination schedule culminated in 1992 with the introduction of the two-dose measles, mumps and rubella vaccine in children and adolescents of both sexes. Moreover, in 1985 a programme for the identification and vaccination of non-immune parturient women was implemented in the region's main hospital. The prevalence of rubella-susceptible parturient women decreased from 3.7 % at the beginning of the study to < 1.5 % by 1992. Despite this overall decrease, 4.8 % of adolescent parturients were susceptible to rubella during 2001--2002. From 1984, the number of reported cases of rubella (children and adults) progressively decreased until 1997, after which there have been no cases of indigenous rubella. There have been no cases of reported congenital rubella since 1984. These results indicate that the vaccine policy carried out in this geographical area has been effective in achieving considerable progress towards rubella elimination.

Interruption of measles transmission in Gipuzkoa (Basque Country), Spain

Measles vaccine was introduced in Gipuzkoa (Basque country, Spain) in 1978 and was replaced by the measles, mumps, and rubella (MMR) vaccine for children aged 12-15 months in 1981. A second dose of the MMR vaccine was introduced in 1992. Both doses of the MMR vaccine were well accepted by the population and high coverage was achieved (95% and 91% for the first and second doses respectively for the period 1993-2002). Measles virus circulation was interrupted in the second half of the 1990s: no cases of indigenous measles were notified between 1998 and 2003, and only imported cases have been confirmed during this period. These data indicate that the measles vaccination programme implemented has been effective. Nevertheless, to avoid measles outbreaks following viral introduction, high MMR vaccine coverage levels for the two doses have to be maintained (>95%).

Interruption of measles transmission in Gipuzkoa (Basque Country), Spain

Measles vaccine was introduced in Gipuzkoa (Basque country, Spain) in 1978 and was replaced by the measles, mumps, and rubella (MMR) vaccine for children aged 12-15 months in 1981. A second dose of the MMR vaccine was introduced in 1992. Both doses of the MMR vaccine were well accepted by the population and high coverage was achieved (95% and 91% for the first and second doses respectively for the period 1993-2002). Measles virus circulation was interrupted in the second half of the 1990s: no cases of indigenous measles were notified between 1998 and 2003, and only imported cases have been confirmed during this period. These data indicate that the measles vaccination programme implemented has been effective. Nevertheless, to avoid measles outbreaks following viral introduction, high MMR vaccine coverage levels for the two doses have to be maintained (&gt;95%).

Hospitalization for respiratory syncytial virus in the paediatric population in Spain

The aim of this population-based retrospective study was to determine the incidence of hospitalization for community-acquired, laboratory-confirmed respiratory syncytial virus (RSV) infection in an unselected paediatric population from southern Europe. The study was performed in an area with 15,700 children aged less than 5 years attended by a single hospital. The presence of RSV in nasopharyngeal aspirates from children with acute respiratory infection treated in the hospital was investigated in four seasons (July 1996-June 2000). A total of 390 episodes of hospitalization for RSV infection were detected and 83.3% of the children were aged less than 1 year old. The annual hospitalization rate was 37/1000 for infants aged less than 6 months and 25/1000 for those aged less than 1 year. During the study period, 2.5% of the infants younger than 1 year and approximately 5% of those younger than 3 months were hospitalized for RSV infection. The mean length of hospital stay was 5.9 days. Seven per cent of the patients required admission to the intensive care unit and more than half of these children were aged less than 1 month. In Spain, community-acquired RSV infection is a highly frequent cause of hospitalization in young children, especially in those aged less than 1 year. Prevention of RSV infection, through the development of vaccines and/or other strategies, should be a public health priority.

Mumps outbreak in vaccinated children in Gipuzkoa (Basque Country), Spain

A mumps outbreak occurred in a group of vaccinated children aged 3-4 years in San Sebastián (Gipuzkoa, Basque Country, Spain) in 2000 during the same period as a revaccination campaign against measles-mumps-rubella (MMR) was performed. The clinical cases were confirmed by viral culture, detection of viral RNA and/or specific IgM. Eighty-eight percent of the children had been vaccinated with the Rubini strain and the remainder with the Jeryl-Lynn strain. The attack rate was 47.9% (35 cases in 73 school-attending children of this age). The outbreak was caused by an H genotype strain of mumps virus which was circulating at the same time as a D genotype strain that caused sporadic cases. By sequencing the small hydrophobic (SH) gene, the strains of the clinical cases were identified as wild-type mumps virus with heterologous genotypes in comparison to the vaccine strains used in our area.

Decrease in human fascioliasis in Gipuzkoa (Spain)

From 1981 to 2000 sixty-one cases of human fascioliasis were detected in the province of Gipuzkoa (Spain), most of them during the period of parenchymal invasion. Four family outbreaks were recorded. Thirty, 15, 13 and three cases were detected during the four consecutive 5-year periods. The decrease in this infection over the years is probably related to the change in eating habits.

Lack of relationship between infection by Helicobacter pylori and vomiting that usually occurs during pregnancy, although possible relationship with severe forms of emesis

OBJECTIVE

It has been reported that infection by Helicobacter pylori may cause severe vomiting during pregnancy (hyperemesis gravidarum). Two studies were carried out in order to examine the relationship between this infection and less severe vomiting.

DESIGN AND METHODS

The first study was a retrospective study involving 3438 women who required admission to the hospital during pregnancy. In 178 women, vomiting was recorded as one of the diagnoses at the time of discharge. In 162 of these women, a serum specimen was available to study the presence of anti-Helicobacter pylori antibodies (anti-HP Ab). The second study examined the presence of vomiting and anti-HP Ab in an additional 250 pregnant women who were admitted to the Maternity Ward for childbirth. In this study, the duration and intensity of emesis during the previous months was recorded.

RESULTS

In the first study, no significant difference was found between the prevalence of anti-HP Ab in the 162 women in the study and a control group of women without emesis (43.2 vs 42.9%, p = NS). In the second study, there was no significant difference in seroprevalence between the women with emesis and the control group without vomiting, with the exception of the more severe cases (anti-HP Ab 77.8%, p < 0.05).

CONCLUSION

The results of this study do not show that there is a relationship between infection by Helicobacter pylori and less severe vomiting during pregnancy. Nevertheless, we believe that additional studies should carried out in order to determine the relationship between the more severe cases of emesis during pregnancy and this treatable infection.

[Fasciola hepatica. study of a series of 37 patients]

BACKGROUND

To analyze the clinical, bacteriologic, diagnostic and therapeutic features of patients with Fasciola hepatica (FH) in our hospital.

PATIENTS AND METHOD

We reviewed all the patients with a diagnosis of fascioliasis from 1975 to 1999 in the Aranzazu Hospital in San Sebastián (Guipúzcoa, Spain). Diagnosis was made by direct vision of adult parasites during surgery and/or the presence of ova in stool examinations and/or positive serologic tests in patients with symptoms consistent with parasitosis.

RESULTS

Thirty-seven patients were included (23 men and 14 women), aged 19 to 71 years. Ingestion of watercress was confirmed in 27. Seven cases occurred as part of familiar outbreaks. Thirty-two were in the liver invasive stage and in 5 the biliary tree was invaded. The most common features were eosinophilia (91.8%), malaise and weight loss (75.6%), elevated alkaline phosphatase (74.2%), and abdominal pain (72.9%). Adult worms in the biliary ducts were observed in 3 patients and ova in feces were observed in 6. In 13 of 27 patients indirect hemagglutination test was ( 1/1,280. Data significant to confirmation of liver involvement were provided by laparoscopy in 12 of 13 patients and by imaging techniques in 13 of 31 patients. Four patients had cholelithiasis and of these, 2 also showed adult parasites in the common bile duct. Three patients underwent surgery. Therapy with dehydroemetine and/or bithionol was followed by complete remission in 30 patients, although 6 required repeat treatment cycles. The remaining 4 patients were cured by praziquantel.

CONCLUSIONS

Most of the patients in these series reported consumption of watercress and all patients showed the symptoms typical of parasite disease. Imaging techniques proved to be of great utility in confirming the diagnosis of hepato-biliary disease. In most of the patients therapy with dehydroemetine and/or bithionol (in one or several cycles) was followed by complete remission.

Molecular evidence of homosexual transmission of HIV type 2 in Spain

Eight HIV-2-infected Caucasian men living in the same geographical area in Gipuzkoa (northern Spain) have been identified in the last 5 years. HIV-2 infection in this area is uncommon, and no other cases of HIV-2 infection have been found after extensive testing for HIV-1/2 antibodies. Epidemiological data suggested a possible link among the identified subjects, with homosexual contact being the most likely way of transmission. A genetic analysis of four of the subjects, from whom specimens were available, was conducted. Phylogenetic and signature pattern studies of the reverse transcriptase (RT) and env genes supported a single source of infection. Interindividual nucleotide variability ranged from 2.4 to 4.8% in the RT region and from 5.2 to 6.1% in the env gene, whereas the mean divergence between patient and control strains was 9.8 and 18.3%, respectively. The nucleotide and amino acid signature patterns were closely related in viruses from the four examined individuals. This is the first report of a cluster of HIV-2 infections with genetic sequence data support. The singularity of this cluster should alert clinicians on the possibility of HIV-2 outside endemic areas.

Incidence, seasonality and serotypes of rotavirus in Gipuzkoa (Basque Country), Spain. A 14-year study

Over a 14-year period (1984-97) the presence of rotavirus in stool samples from children under 15 years with acute gastroenteritis was studied by enzymoimmunoanalysis. Serotyping (G1-G4) was performed using monoclonal antibodies. A total of 17,348 children under 15 were investigated. Rotavirus was detected in 3637 (21.0%) specimens, 74.6% of which were from children younger than 2 years old. G1 and G4 were the most frequent serotypes. In 1991-7, the minimum incidence of rotavirus gastroenteritis in children under 4 years of age was 21.7 cases/1000 children/year. By the age of 5 years, at least 1 out of 11.3 children and probably 1 out of every 5-6 children in this area had experienced an episode of rotavirus gastroenteritis that required medical care. In the 1984-90 period a clear seasonality was not observed but in the second period of the study (1991-7), seasonality was marked, with peak activity in winter.

Mixed cryoglobulinaemia in patients with chronic hepatitis C infection: prevalence, significance and relationship with different viral genotypes

In order to analyse the prevalence and significance of cryoglobulinaemia in patients with chronic hepatitis C virus (HCV) infection and the possible relationship of cryoglobulinaemia with the genotypes of HCV, we studied 89 patients with chronic HCV infection, 42 healthy controls and 22 patients with alcoholic cirrhosis. The patients with HCV were divided into three different groups according to the presence of cirrhosis and alanine aminotransferase levels. Moreover, in 20 patients with HCV and cryoglobulinaemia, HCV RNA sequences were quantified in serum and in cryoprecipitate. Cryoglobulins were detected more frequently in patients with chronic HCV infection than in healthy controls (42.6% vs. 4.7%; P<0.0001). Cryoglobulins were present in 68.4% of patients with HCV-related cirrhosis, which was nearly twice the figure in noncirrhotic HCV-infected patients and alcoholic cirrhotic patients. There were no differences in age, sex, aminotransferase levels or HCV genotype distribution in HCV-infected patients with or without cryoglobulinaemia. Only 13% of patients with chronic HCV infection and cryoglobulins showed symptoms of cryoglobulinaemia. There was a linear association between HCV RNA concentration in sera and in cryoprecipitates (P<0.0005). Patients with chronic HCV infection had a high prevalence of cryoglobulinaemia, especially in advanced forms of the disease, but clinical findings are few. There was no relationship with the genotype of HCV. The presence of HCV RNA in cryoprecipitates supported the hypothesis on the aetiological role of HCV in mixed cryoglobulinaemia.

Human immunodeficiency virus type 2 infection in Spain. The HIV-2 Spanish Study Group

The first cases of human immunodeficiency virus type 2 (HIV-2) infection in Spain were identified in 1988, in 3 African immigrants living in Barcelona. Since then, up to December 1998, 92 individuals with HIV-2 infection have been reported in Spain. Most are adult men, infected through heterosexual contacts, originating from West African countries, and currently living in the largest urban Spanish cities. Fifteen individuals have developed AIDS, meanwhile the rest remain asymptomatic. For 22 subjects, HIV-2 subtyping was performed on proviral DNA, 16 being infected with subtype A (8 Spanish born and 8 African immigrants) and the remaining with subtype B (two Spanish born and 4 originating from Equatorial Guinea). Coinfection with HIV-1 was demonstrated in 9 individuals. In conclusion, HIV-2 is currently circulating in Spain with a low prevalence and without evidence for increase over time.

High seroprevalence of Coxiella burnetii infection in Eastern Cantabria (Spain)

BACKGROUND

Coxiella burnetii is the causative agent of Q fever, a worldwide zoonosis which shows a wide diversity of clinical manifestations. The objective of this seroepidemiological study was to estimate the prevalence of antibodies to C. burnetii in a representative population of the Eastern area of the Cantabrian Community (Northern Spain).

METHODS

A cross-sectional study was conducted in 595 subjects from Eastern Cantabria. Four different zones (one urban and three rural zones) were defined according to the geographical characteristics of the area and the economic activities of the population. The population sample for this study was collected between December 1994 and March 1995, and was stratified by age, sex and municipality of residence. IgG and IgM antibodies against C. burnetii were assayed by an indirect immunofluorescence technique.

RESULTS

The prevalence of anti-phase II Coxiella IgG (titre > or = 1:16) was 48.6% (95% confidence interval: 44.6-52.6%), with 81.3% havinga titre of > or = 1:64. The prevalence of IgG increased with age, ranging from 12.0% in people < 15 years to 70.3% in those > 65 years (P < 0.001). The antibody detection rate was higher in males (53.6%) than in females (43.3%) (P < 0.01). The prevalence of anti-phase II Coxiella IgG was less among subjects living in the urban zone (32.8%) than in those living in the other three rural zones: the two situated on the coast (54.0% and 54.9% respectively) and the inner mountainous zone (82.3%) (P < 0.001).

CONCLUSIONS

The prevalence of C. burnetii infection observed in this study is one of the highest reported in Europe. The eastern area of Cantabria is a hyperendemic area for Q fever.

Helicobacter pylori infection: a seroepidemiological study in Gipuzkoa, Basque Country, Spain

Helicobacter pylori is one of the most common bacterial infections worldwide. To evaluate the prevalence of this infection in Gipuzkoa (Basque Country, Spain) we studied the presence of antibodies against Helicobacter pylori (HPAb) using a second-generation EIA (Cobas Core). The study was performed on two groups of subjects: a middle-class group, 2-78 years-old (n = 1335) and a group of slum dwellers, 2-15 years-old (n = 89). In the middle-class group the prevalence of HPAb in children under 6 was 3.1% (3/96); the prevalence was significantly greater in older compared to younger age groups, reaching 84.3% (102/121) in adults 50-59 years. The geometric mean of the titer in seropositive subjects was also greater in older age groups. By logistic regression analysis the prevalence of HPAb was associated with age, educational level and geographic origin but not with sex, smoking, alcohol consumption, or use of nonsteroid anti-inflammatory drugs. The prevalence of HPAb was much higher in the slum-dwelling group 2-15 years-old (55.5% of children 2-5 years-old). The results indicate that H. pylori infection was more common in adult people from our geographic region than in those from other developed countries and show that socioeconomically deprived children constitute at present a group at high risk of acquiring infection in our region.

Epidemiology of human T-lymphotropic virus type II (HTLV-II) infection in Spain. HTLV Spanish Study Group

The human T-lymphotropic virus type II (HTLV-II) has recently been associated with the genesis of some subacute neurological syndromes and, rarely, with atypical T-lymphoid malignancies. The virus is endemic in some Amerindian and African tribes, and among intravenous drug users (IDUs) in North America and Europe. Given that HTLV-II is transmitted by the same routes as other human retroviruses, the screening of antibodies to HTLV-II in blood donors has became a matter of controversy in some countries. Herein, we describe the clinical, epidemiological and virological features of 113 individuals with HTLV-II infection identified in Spain up to September 1995. Most of them (94/113; 83%) were male, and all but seven were natives. Four were African immigrants living in Madrid and 3 had been born in other European countries. All but six subjects were IDUs, and sexual transmission of HTLV-II and transfusion were involved in five and one individual, respectively. Eighty-four percent of the IDUs infected with HTLV-II were co-infected by HIV-I (93/107). Clinical manifestations potentially linked to HTLV-II were absent, although an IDU male co-infected by HIV-1 and HTLV-II developed a severe non-inflammatory proximal myopathy. In conclusion, HTLV-II infection is present in Spain, mainly among IDUs, with a growing incidence and a current overall prevalence of 2.0 percent.

Genotyping of hepatitis C virus isolates from Basque Country, Spain

The genotype of HCV was determined in 161 chronic HCV-infected patients. The patients were classified into three groups on the basis of the origin of the HCV infection: 50 patients had a history of intravenous drug use (IVDU) but no HIV infection; 41 patients had received blood transfusions, and 70 patients had no known exposure. The distribution of HCV genotypes was associated with the origin of infection and age of patients: genotype 1b was predominant among patients who had received blood transfusions and those without evidence of parenteral exposure (84.6% and 67.7%, respectively), whereas genotype 3a was present in 65.3% of IVDUs. Patients with genotype 1b were older than those with genotypes 1a or 3a: 50.3 +/- 12 vs. 34.1 +/- 9.9 and 31 +/- 5.4 years, respectively. These findings suggest that the pattern of HCV genotypes in our region is changing and that genotype 1b may be substituted by 3a as the dominant genotype in the future.

Seroprevalence of Toxocara infection in middle-class and disadvantaged children in northern Spain (Gipuzkoa, Basque Country)

The prevalence of human toxocarosis in disadvantaged socioeconomic population in Europe is unknown. In Gipuzkoa the seroprevalence in middle-class children 2- to 5-years-old, and 6- to 16-year-olds, was zero (n = 135) and 4.4% (n = 320), respectively. In contrast, among socially and economically disadvantaged children the figures were 37% (n = 27) and 65.7% (n = 64). This high prevalence obliges us to consider toxocarosis as a public health problem.

Epidemiology of HIV-2 infection in Spain. The HIV-2 Spanish Study Group

Human immunodeficiency virus type 2 (HIV-2) infection is endemic in West Africa, where it is responsible for many cases of AIDS. HIV-2-infected subjects have been described in other countries, mainly African immigrants, although infection in native individuals has been reported as well. The first cases of HIV-2 infection in Spain were identified in 1988. Through December 1995, 56 HIV-2 infected individuals have been diagnosed, primarily in large urban areas (23 cases in Madrid and 18 in Barcelona). All are African immigrants, except for 12 natives (21.4%), six of whom acquired the infection in endemic areas; the remaining six (2 women with numerous sexual partners and 4 homo/bisexual men) acquired the infection in Spain. Heterosexual transmission was probable in all but seven cases: five homo/bisexual males, a subject who likely acquired infection through parenteral exposure, and a child born to an HIV-2-infected mother. Nine patients (all Spanish born) have developed AIDS (16%), six of whom have died. In conclusion, HIV-2 infection is present in Spain at a low rate, and there is little evidence supporting an emerging ongoing transmission outside the population of African immigrants.

[Follow-up of chronic hepatitis B carriers. Serological course and risk of reactivation]

AIM

To investigate serologic changes and risk of reactivation in hepatitis B chronic carriers.

PATIENTS AND METHODS

Two hundred chronic HBs-Ag positive patients were included (follow-up greater than 18 months). According to the HBeAg/Anti-HBe status at the moment of inclusion they were classified in 3 groups: I: 40 patients HBeAg positive, II: 158 anti-HBe positive and III: 2 HBeAg/Anti-HBe negatives. All patients were screened in the follow-up for biochemical test, hepatitis B, C and D virus serology, DNA.HBV by hybridization, alpha fetoprotein and abdominal ultrasound.

RESULTS

Mean age was 35 +/- 12 years (14-61), and mean follow-up 71 +/- 35.1 months (18-252). In the follow-up 28 patients in group I seroconverted HBeAg/Anti-HBe, 18 spontaneously (annual rate 10%). In group II four patients out off 158 were DNA HBV positive. Only 3 chronic HBV carriers lost HBsAg and developed Anti-HBs (annual rate 0,25%). Reactivation of viral activity was detected in 13 patients Anti-HBe positive, DNA.HBV negative. HBeAg appeared during reactivation in six, both HBeAg/Anti-HBe were negative in one, and six were unchanged. Reactivation was significantly more frequent in chronic carriers with high GPT activity (13 out off 75, 17.3%) than in patients with normal GPT (0 out off 107, 0%) (p < 0.0005).

CONCLUSIONS

Reactivation of HBV activity is frequent in HBsAg chronic carriers Anti-HBe positive, DNA.HBV negative and who are abnormal GPT levels; these patients should be considered at risk of reactivation. The control in the follow-up of HBV chronic carriers with persistently normal GPT, without advanced liver disease, may not be so frequent. The increased infectiousness during reactivation of HBV activity must be taken account for prophylaxis of HBV infection in chronic carriers contacts.

Serologic response to measles-mumps-rubella vaccine among children with upper respiratory tract infection

The influence of concurrent upper respiratory tract infection (URTI) on immune response to MMR (measles, mumps, rubella) vaccine was evaluated by measuring IgG levels for each viral component immediately before vaccination and 6 months after vaccination in 198 12-month-old children (101 children without URTI and 97 with URTI at time of vaccination). None of the children had antibodies to measles, mumps or rubella before vaccination. Seroconversion rates and the geometric means of the antibody titers in children without URTI and in children with URTI at the time of vaccination were similar. MMR vaccination should not be delayed in children with such infections.