Reduced susceptibility to penicillin of viridans group streptococci in the oral cavity of patients with haematological disease

The occurrence of oral penicillin-resistant viridans group streptococci (VGS) was studied in 50 patients with either newly diagnosed acute leukaemia or autologous peripheral stem cell transplants. One patient was excluded because of Staphylococcus aureus growth in the stem cell harvest. VGS were isolated from the oral cavity of 48 of the remaining 49 patients. Of these 48 patients, 12 (25%) yielded VGS resistant (MIC > 2 mg/L) to penicillin. These 12 patients had a higher frequency of septicaemia (p 0.04) and more days of treatment with trimethoprim-sulphamethoxazole (p 0.04) than patients who harboured susceptible or intermediately resistant VGS (MIC 2 mg/L). There were no other statistically significant differences between the two groups. It is important to be aware of the high level of penicillin resistance in oral VGS in patients with haematological disease, and this parameter should be considered when selecting antibiotic therapy for cases of septicaemia caused by VGS in immunocompromised patients.

Polymerase chain reaction for diagnosis of cerebral toxoplasmosis in cerebrospinal fluid in HIV-positive patients

It is important but sometimes difficult to establish a diagnosis of toxoplasma encephalitis (TE) in an HIV-positive immunodeficient patient. The most promising non-invasive method is polymerase chain reaction (PCR) for Toxoplasma gondii in cerebrospinal fluid (CSF). In a retrospective study PCR was used to analyse CSF for the presence of T. gondii DNA in 5 HIV-infected patients with a clinical suspicion of TE (group 1), 8 patients with other HIV-associated symptoms (group 2) and 7 other patients with neurological disorders (group 3). PCR was positive in 2/4 patients with a final diagnosis of TE and negative in all remaining patients in all 3 groups. The 2 patients with positive PCR had a fulminant course and experienced treatment failure. The albumin index was elevated in 4/5 patients in group 1, of whom 3/4 had a final diagnosis of TE, with suspected TE in 1. This small study confirms earlier data indicating that the PCR test has a low sensitivity but a high specificity.

[Extrapulmonary tuberculosis--an infection of concern in most clinical settings]

In a retrospective study at the Department for Infectious Diseases at Huddinge Hospital, 57 patients with extrapulmonary tuberculosis were identified from 1992 to 1997. Two categories of patients were found: young persons born abroad (the largest group) and elderly persons born in Sweden. Most patients showed a positive PPD, and the diagnosis was verified through bacteriological culture in 42/51 (82 per cent). Patients had sought help in a number of different clinical settings. Only four patients were shown to have resistant strains. This study demonstrates the difficulties inherent in the diagnostic process, with a long interval between appearance of symptoms to start of treatment: median 8 weeks but with a wide range. For one quarter of the patients, data sufficient to warrant conclusions regarding completed treatments are lacking. Efforts to increase knowledge on the part of medical personnel, compliance on the part of patients, and improvements in follow-up are essential in order to halt the spread of tuberculosis, to reduce morbidity and to prevent the development of resistance.

[Tuberculosis a threat again. Multiresistance in the Baltic States and in Russia; Nordic countries initiate cooperation to prevent transmission]

The incidence of tuberculosis (TB) has more than doubled in the Baltic States during the last decade and is now 10-15 times higher than in Sweden. It is also a serious problem in Russia. Strains resistant to one or several of the anti-tuberculous drugs are common as is multi-drug resistance (MDR), i.e. strains resistant to the two most effective drugs rifampicin and isoniazid. MDR-TB is very difficult to treat; the mortality rate is high. Initiatives have been taken in the Nordic countries in order to help to control and improve the situation by way of supportive measures.

[Shortages in Swedish tuberculosis care. Good results only in 71 percent of cases after 12-month treatment as shown in a current study]

During the period August 1994-December 1995 783 cases of active tuberculos (TB) were notified to the health authorities in Sweden. By means of questionnaires sent to the consulting physicians (92 per cent response rate) the treatment outcome was studied twelve months after the diagnosis. Out of 676 patients only 71 per cent were reported to have completed the treatment and be cured of TB. This indicates that there is room for improvement as regards monitoring patients, if necessary by Directly Observed Therapy (DOT), in order to make sure that prescribed treatment is adhered to.

Endocarditis: clinical outcome and benefit of trans-oesophageal echocardiography

The improved prognosis for infective endocarditis (IE) seen in the last decade is due partly to more active surgical treatment and partly to improved diagnosis by echocardiography. To evaluate the clinical value of repeated trans-oesophageal echocardiography (TEE) 34 patients with 35 episodes of suspected IE were included in a prospective part of the study (group A). TEE was carried out for diagnosis, at discharge and about 5 months after hospitalization. Endocarditis was classified using Duke's criteria. In a retrospective part of the study 32 other patients with 34 episodes of IE were included (group B). Both groups were analysed regarding mortality, frequency of surgery and classification according to Duke. The diagnosis was regarded as definite in 49 and possible in 20 episodes. Vegetation-size decreased significantly (p < 0.001) during treatment. In contrast, no significant changes in valvular insufficiency were found. In episodes diagnosed as definite, the mortality was 2/49 (4.1%). The low mortality might be explained by the high frequency of surgery (22%), the inclusion of patients with right-sided IE, and 'early diagnosis'. The first TEE was important for correct diagnosis in patients with small vegetations and for those needing surgery. The clinical value of the additional investigations was low in native valve endocarditis.

Prospective study of prognostic factors in community-acquired bacteremic pneumococcal disease in 5 countries

To define the influence of prognostic factors in patients with community-acquired pneumococcal bacteremia, a 2-year prospective study was performed in 5 centers in Canada, the United States, the United Kingdom, Spain, and Sweden. By multivariate analysis, the independent predictors of death among the 460 patients were age >65 years (odds ratio [OR], 2.2), living in a nursing home (OR, 2.8), presence of chronic pulmonary disease (OR, 2.5), high acute physiology score (OR for scores 9-14, 7.6; for scores 15-17, 22; and for scores >17, 41), and need for mechanical ventilation (OR, 4.4). Of patients with meningitis, 26% died. Of patients with pneumonia without meningitis, 19% of those with >/=2 lobes and 7% of those with only 1 lobe involved (P=.0016) died. The case-fatality rate differed significantly among the centers: 20% in the United States and Spain, 13% in the United Kingdom, 8% in Sweden, and 6% in Canada. Differences of disease severity and of frequencies and impact of underlying chronic conditions were factors of probable importance for different outcomes.

Salivary sIgA response in HIV-1 infection

Local and systemic production of total and HIV-1 specific IgA was determined in whole saliva and serum from 45 HIV-1-infected individuals and 15 healthy controls. The antigenic domains important for sIgA and IgG binding, respectively, was investigated with epitope mapping using synthetic peptides of HIV-1 proteins. Decreased levels of total sIgA in saliva were found among patients with low CD4+ cell counts in advanced stages of acquired immunodeficiency. HIV-1 specific IgA response, predominantly directed to the envelope proteins, was found in saliva and serum also at later stages of disease. Analyses using peptide enzyme-linked immunosorbent assays (ELISA) showed that the sIgA antibody response in saliva was mainly directed to the V4 region (aa 385-409) and a more C-terminal part of the V3-region (aa 325-344) compared with the IgG response, which predominantly was directed to a more central part of the V3 loop (aa 308-325). A similar picture was seen for immunoglobulins of the two isotypes derived from serum. We have in this study shown IgA epitope-specific immune response within HIV-1 gp160, indicating that antibodies of IgA isotype may recognize somewhat different antigenic domains compared to IgG antibodies.

Shedding of cytomegalovirus and herpesviruses 6, 7, and 8 in saliva of human immunodeficiency virus type 1-infected patients and healthy controls

We used the polymerase chain reaction to study the presence of DNA from cytomegalovirus (CMV) and human herpesvirus (HHV)-6, HHV-7, and HHV-8 in saliva from 44 human immunodeficiency virus (HIV) type 1-infected patients at different stages of disease and in 15 healthy HIV-seronegative controls. CMV DNA, HHV-6 DNA, and HHV-7 DNA were found in all groups, but HHV-8 DNA was found only in symptomatic HIV-1-infected patients (5 [17%] of 29). One of the patients with HHV-8 DNA in saliva had oral Kaposi's sarcoma at the time of sampling, and another later developed the tumor. CMV DNA was found most often in the patients with AIDS. HHV-6 shedding tended to be less frequent among HIV-1-infected patients than among healthy controls. HHV-7 DNA was detected least frequently in the group of patients with AIDS. The presence of viral DNA was not correlated either with antiherpesvirus drug therapy or with oral symptoms, apart from Kaposi's sarcoma.

Virulence factors of Staphylococcus aureus in the pathogenesis of endocarditis. A comparative study of clinical isolates

It is now generally accepted that adherence of microorganisms to various components of cardiac valve surfaces or vegetation lodging on the heart valves is an important early event in the pathogenesis of infective endocarditis. 120 clinical isolates of S. aureus obtained from patients with endocarditis and wound infections and from nasopharyngeal carriers were quantitatively analysed in vitro for their ability to bind to fibronectin and to produce protein A and alpha-toxin. Both cell-bound and extracellular protein A were measured and alpha-toxin was determined as antigen and as haemolytic activity. The highest fibronectin binding ability was found in carrier strains while no significant differences between strains were observed regarding the production of protein A. Strains isolated from patients with endocarditis produced significantly lower amounts of alpha-toxin than did strains from the other two groups. An inverse relationship between the production of protein A and of alpha-toxin was noticed in the material. Animal passage of five strains in an experimental endocarditis model showed a good reproducibility of the test systems and one strain was upregulated in its fibronectin binding ability and in alpha-toxin production. These in vitro results indicate that the fibronectin binding ability is not the decisive adherence factor and question the role of alpha-toxin as a virulence factor in endocarditis.

[Policy program to minimize spread of infection. Prolonged cough may be a sign of tuberculosis]

In a worldwide epidemiological perspective, Sweden is well favoured with an annual tuberculosis incidence of approximately six cases per 100,000 of the population. Neither the impact of the HIV pandemic nor the occurrence of multiresistant strains of Mycobacterium tuberculosis has yet become a major problem in the care of tuberculosis patients in Sweden. Only a few per cent of HIV patients have developed tuberculosis, and during the period, 1991-94, only one per cent of M. tuberculosis isolates in Sweden were resistant to such antimycobacterials as isoniazid and rifampicin. However, the epidemiological situation in the neighbouring Baltic states is a matter for concern. Bovine tuberculosis has been eradicated in Sweden, the last case having been diagnosed in 1978. Although the reported efficacy of BCG (bacillus Calmette-Guérin) tuberculosis vaccine varies according to the population studied, protective rates of 70-85 per cent have been reported for Sweden and other west European countries. Re-vaccination of tuberculin-negative individuals has not been shown to yield added protection. The aim of a national programme for protection against tuberculosis is to preserve our favourable epidemiological situation by early detection of new cases, effective contact tracing, and BCG vaccination of children in population groups at risk. The primary means of achieving this is the education of health care personnel to retain tuberculosis as a differential diagnosis. Moreover, national guidelines for contact tracing must be duly observed, and immigrants from high prevalence areas need to be screened for tuberculosis. Registration of all cases of tuberculosis should be maintained at regional and national levels, and follow-up must be meticulous until a successful outcome of treatment is accomplished. Recommendations for dealing with tuberculosis should be made available and duly implemented at all hospitals caring for tuberculosis patients, in order to avoid nosocomial transmission. Although BCG vaccination at birth was formerly general in Sweden, since 1975 only children considered to be at risk have been vaccinated. Thus, non-vaccinated young adults are now entering the health care sector as students or employees, and should be offered BCG vaccination. Moreover, the epidemiological situation both in Sweden and in neighbouring countries needs to be monitored carefully in order that recommendations concerning BCG vaccination and other preventive measures can be modified if necessary.

Prevalence and risk factors for HTLV-II infection in 913 injecting drug users in Stockholm, 1994

The prevalence and risk factors for acquisition of human T-cell lymphotropic virus type I and II (HTLV-I and II) were investigated in a prospective study of 913 injecting drug users (IDUs) in Stockholm in 1994. Epidemiologic data were recorded, and blood samples were tested for antibodies against HTLV-I and HTLV-II; human immunodeficiency virus (HIV) types 1 and 2; and hepatitis A (HAV), B (HBV), C (HCV), and D (HDV). Positive serologic results for HTLV were confirmed by Western blot (WB) and polymerase chain reaction (PCR). Of the 905 participants with conclusive HTLV-II status, 29 (3.2%) were HTLV-II positive, and all but three were of Nordic descent. None was HTLV-I infected. One person was infected as early as 1981, before HIV had reached the IDU population in Sweden. The prevalence of HTLV-II infection was 12% among HIV-1-seropositive and 1.8% among HIV-1-seronegative participants. The overall seroprevalences were 14% for HIV-1, 0% for HIV-2, 41% for HAV, 75% for HBV, 92% for HCV, and 8% for HDV. Although amphetamine has been the main injecting drug in Sweden for several decades, heroin abuse combined with a debut of injecting drugs before 1975 was identified as the most important risk factor associated with HTLV-II infection. HAV and HIV seropositivity were also independent risk factors.

Penicillium marneffei infection in a Swedish HIV-infected immunodeficient narcotic addict

We report a case of Penicillium marneffei infection, acquired in Thailand, in a Swedish HIV-infected immunodeficient heroin addict. This is the first case of penicilliosis marneffei diagnosed in Sweden. The patient had fever without focal symptoms. Cultures from bronchoalveolar lavage fluid and a mediastinal lymph node yielded the dimorphic fungus Penicillium marneffei. Treatment with amphotericin B followed by itraconazole was successful. Penicillium marneffei infection should be considered in HIV patients with fever who have visited Southeast Asia, especially northern Thailand and southern China.

Acyclovir and prednisolone treatment of acute infectious mononucleosis: a multicenter, double-blind, placebo-controlled study

Ninety-four patients with infectious mononucleosis and symptoms < or = 7 days were randomized to treatment with oral acyclovir (800 mg 5 times/day) and prednisolone (0.7 mg/kg for the first 4 days, which was reduced by 0.1 mg/kg on consecutive days for another 6 days; n = 48), or placebo (n = 46) for 10 days. Oropharyngeal Epstein-Barr virus (EBV) shedding was significantly inhibited during the treatment period (P = .02, Mann-Whitney rank test). No significant effect was observed for duration of general illness, sore throat, weight loss, or absence from school or work. The frequency of latent EBV-infected B lymphocytes in peripheral blood and the HLA-restricted EBV-specific cellular immunity, measured 6 months after onset of disease, was not affected by treatment. Thus, acyclovir combined with prednisolone inhibited oropharyngeal EBV replication without affecting duration of clinical symptoms or development of EBV-specific cellular immunity.

Multiple serovars of Mycobacterium avium complex in patients with AIDS

Mycobacterium avium complex (MAC) was isolated and serotyped from 127 samples from 43 HIV-infected patients with disseminated disease in Sweden. Thirteen different serovars were observed. Serovar 6 was the most common, followed by 4, 9 and 11. Serovar 8 was rare. In 22 of the patients the same serovar was found in blood and at other sites. Clinical symptoms and outcome were compared in patients with different serovars. Analysis of patient records revealed no association between clinical picture and any specific serovar. The median survival time after MAC infection was 7 months. Somewhat shorter survival was observed in patients with serovar 4 than in those with serovar 6.

Classification of infective endocarditis by Duke's criteria and transesophageal echocardiography: a 1-year retrospective analysis

A sensitive, specific, and rapid diagnosis of infective endocarditis (IE) is important for prognosis, and to exclude IE and thus avoid prolonged treatment with antibiotics. The diagnostic system for IE according to Duke's university includes echocardiographic results and classifies patients in 3 categories--'definite', 'possible', and 'rejected'--by combining pathologic, echocardiographic, clinical, and blood culture findings. Transesophageal echocardiography (TEE) has better diagnostic sensitivity compared to transthoracic echocardiography. Duke's criteria were used on 83 patients examined by TEE in a retrospective study. Of 83 patients with suspected IE, 49 episodes in 48 patients were classified as 'rejected' and were not treated. The remaining 37 patients (15 of whom were intravenous drug users) were treated and classified as follows: 'definite', 26 episodes in 24 patients, 'possible', 11 episodes in 11 patients; and 'rejected', 2 episodes in 2 patients. In this retrospective analysis Duke's criteria were easy to apply. A negative TEE made IE unlikely and a positive TEE made IE probable when other signs of infection were present.

Clinical manifestations and treatment of mycobacterium avium-intracellulare complex infection in HIV-infected patients

Disseminated infection caused by Mycobacterium avium-intracellulare complex is a common late opportunistic infection in HIV-infected patients. The clinical manifestations are non-specific, with fever, respiratory and gastrointestinal tract symptoms and weight loss. Blood culture is an easy and safe way of diagnosing the infection. Treatment can reduce symptoms and probably increase the quality of life and survival. An optimal treatment regimen is not established and has to be identified in comparative studies. According to the available data, the first line of drugs is ethambutol, clarithromycin or rifabutin and the second amikacin, clofazimin, azitromycin. Combination therapy must contain at least two or three drugs.

HTLV infections among Swedish intravenous drug users in 1992

Serum samples collected in 1992 from 1158 intravenous drug users (IVDUs) in Stockholm, Sweden, were tested retrospectively for antibodies to human T-lymphotropic virus type I and II (HTLV-I and II). The overall prevalence rate of HTLV infections was 2.4% (28/1158). A majority of the HTLV infections were caused by HTLV-II (27/28). A significant association between HTLV-II and HIV-1 seropositivity was found, the prevalence of HTLV-II infection being 11.4% (11/96) in HIV-seropositive individuals compared with 1.5% (16/1062) in HIV-seronegative persons (p < 0.001). All the HTLV-infected individuals were of Scandinavian origin. No significant differences in age and sex distribution were observed in HTLV-infected persons compared to seronegative individuals. This study confirms that HTLV-II infection is present in the Swedish IVDU population and the findings provide baseline information for future epidemiological studies.

Elevated levels of circulating tumor necrosis factor alpha in human immunodeficiency virus type 1-infected Africans living in Sweden

Elevated levels of tumor necrosis factor alpha in serum were found in human immunodeficiency virus type 1 (HIV-1)-infected Africans to a higher extent than in matched HIV-1-infected Caucasians, both groups living in Sweden. The results suggest that factors not related to the environment contribute to enhanced synthesis of tumor necrosis factor alpha in HIV-1-infected patients.

Deaths in bacteremic pneumococcal pneumonia. A comparison of two populations--Huntington, WVa, and Stockholm, Sweden

The case fatality rate in bacteremic pneumococcal pneumonia (Pnb) has been reported to be lower in Sweden than in the United States. We retrospectively compared 231 adult Pnb patients in Stockholm (STO), Sweden, with 107 patients infected with the same serotypes or groups in Huntington, WVa (HWV). The total case fatality rate was 11/231 (5 percent) in STO versus 28/107 (26 percent) in HWV (p < 0.001), being significantly lower in STO for all age groups. Patients from HWV more often had preexisting chronic diseases, while alcoholism was more prevalent in STO. The case fatality rate was similar among alcoholics in STO and HWV, while it was much higher in nonalcoholic patients with chronic diseases in HWV (22/73;30 percent) than in STO (2/88;2 percent) (p < 0.001). No bias was found that could account for more than a small part of the higher case fatality rate in HWV. Thus, underlying chronic diseases in HWV accounted for some of the increased risk of death in this patient group. However, the major part of the difference in death rates between HWV and STO remains unexplained.

Efficacy of triple drug regimen of amikacin, ethambutol and rifabutin in AIDS patients with symptomatic Mycobacterium avium complex infection

Treatment with ethambutol 15 mg/kg, rifabutin 6 mg/kg and amikacin 15 mg/kg (IV for 2-4 weeks) in 31 HIV infected patients with severe immunodeficiency and infection caused by Mycobacterium avium complex (MAC) was evaluated in a retrospective study. The patients had one or more of the following clinical features: fever 31, weight loss 13, cough 10, pleurisy I, pericarditis 2, diarrhoea 12, peritonitis I. MAC was cultured from blood in 29, bone marrow in six, sputum in nine, faeces in 15, bowel biopsy in six and liver biopsy in four patients. Twenty-two of the 31 patients showed treatment response after a median time of 14 days, and five had a relapse successfully treated with another course of amikacin. Median survival time was 8 months.

Erythromycin for treatment of ornithosis

Patients with pneumonia not responding to treatment with betalactam drugs and patients where an "atypical" etiology is suspected from the beginning, are often given erythromycin to cover mycoplasma and legionella. Erythromycin has also been effective for Chlamydia pneumoniae. If, however, ornithosis is suspected the recommended drug has been tetracycline. Since we noted that several patients had a favourable course on erythromycin despite a final serological diagnosis of ornithosis, we retrospectively studied patients admitted with acute lower respiratory tract infection and a 4-fold titer rise to C. psittaci. We found 35 patients treated with a betalactam drug (n = 12), tetracycline (n = 2), or erythromycin (n = 5) alone, or with a betalactam, which because of non-responsiveness was followed by either tetracycline (n = 4) or erythromycin (n = 12). The data were analysed with survival analysis by a Cox' regression model. There was a significant (p less than 0.001) effect of treatment on the time to defervescence, mainly due to a difference between the erythromycin treated group and the betalactam treated group. We found erythromycin to be at least as effective as tetracycline for treating C. psittaci pneumonia. Since erythromycin has to be used to cover legionella in patients with severe pneumonia when an atypical etiology cannot be excluded, it is an important conclusion that this drug seems to cover C. psittaci as well.

Treatment of HIV-1 Infected Patients with Peptide T

In a pilot study 10 human immunodeficiency virus type 1 (HlV-1)-infected patients were studied. Three CDC group IVa and four CDC group IVc patients were treated with the octapeptide T (D-Ala-Ser-Thr-Thr-Thr-Asn-Tyr-Thr-NH2) by intravenous infusion for 4 weeks. Three CDC group IVa patients served as controls and received placebo. HIV was isolated from the blood of all patients before as well as after treatment. In two of five peptide T-treated patients with demonstrable HIV p24 antigen in serum there was a significant decline of antigen levels followed by a rise after discontinuation of treatment. There was a transient rise in the CD4+ cell count in three of the treated patients and a continuous significant decline in one of the control patients. Of the six peptide T-treated patients, evaluated by MRI, four had reduced the area of altered brain white matter. Also, there was a tendency towards improvement of neuropsychiatric symptoms in the treated group of patients. One patient showed improvement of psoriatic lesions during peptide T treatment. Taken together, the data indicated improvement in four of seven treated patients but in none of the controls. These results do not constitute firm evidence that peptide T has clinical or antiviral effect in HIV-1 infecton. However, in view of its apparent non-toxicity and in particular its possible effect on CNS function, expanded clinical trials with peptide T seem justified.

Predictive markers of AIDS: a follow-up of lymphocyte subsets and HIV serology in a cohort of patients with lymphadenopathy

From 1982 to 1985, 89 HIV-1 seropositive men with persistent generalized lymphadenopathy (PGL) were enrolled into a prospective longitudinal study. In February 1988, after a mean observation time of 45 months, 23 patients had progressed to AIDS with opportunistic infection (AIDS/OI), 4 had developed Kaposi's sarcoma, 47 had developed HIV-related symptoms, 14 still had PGL as only symptom, and 1 was lost to follow-up. Patients with CD4 lymphocytes less than or equal to 0.40 x 10(9)/l as well as patients with HIV antigenaemia and those lacking antibodies to p24 all had a significantly higher risk of developing AIDS/OI within 30 months of observation than other patients. HIV antigen was present in 70% and antibodies to p24 were lacking in 61% of the patients at the time of AIDS/OI diagnosis. All but one (96%) of the AIDS/OI patients had CD4 numbers less than or equal to 0.20 x 10(9)/l at the same time. The estimated median time to AIDS/OI in patients with HIV antigenaemia was 21 months and in patients lacking p24 antibodies 27 months. In patients with CD4 numbers less than or equal to 0.20 and 0.40 x 10(9) cells/l the estimated median time to AIDS/OI was 14 months and longer than 30 months, respectively.

Dermatitis of the face, yellow toe nail changes, hairy leukoplakia and oral candidiasis are clinical indicators of progression to AIDS/opportunistic infection in patients with HIV infection

In a prospective longitudinal study of 89 men with HIV infection and persistent generalized lymphadenopathy (PGL) we tried to find clinical signs predictive of development to AIDS/opportunistic infection (OI). The mean observation time was 47 months. 27 patients (30%) developed AIDS/OI after a mean of 37 months. The estimated median time from diagnosis of PGL to AIDS/OI was 68 months. Four clinical signs of progression towards AIDS/OI were identified: dermatitis of the face, yellow toe nail changes, hairy leukoplakia and oral candidiasis. One or more of these signs were recorded in 25/27 (93%) of the patients before the development of AIDS/OI. The estimated median time from registration of each sign to AIDS/OI was: dermatitis of the face, 29 months; yellow toe nail changes, 21 months; hairy leukoplakia, 18 months; and oral candidiasis, 10 months. The estimated median time from herpes zoster to AIDS was only slightly shorter than the estimated time from diagnosis of PGL to AIDS/OI.

Pneumocystis carinii pneumonia in Stockholm, Sweden: treatment, outcome, one-year-follow-up and pyrimethamine prophylaxis

In 33 consecutive AIDS patients with a first episode of Pneumocystis carinii pneumonia (PCP) we evaluated treatment, outcome, recurrence rate and pyrimethamine as chemoprophylaxis in a 1-year follow-up. Only 2 patients had a CD4 lymphocyte cell count greater than 0.2 X 10(9)/l. Trimethoprim-sulfamethoxazole (TMP-SMX) was initially given to 32 patients but in 20 of these patients severe adverse reactions caused us to discontinue treatment. Of these 20 patients 11 were started on i.v./i.m. pentamidine but in 6 adverse reactions forced us to withdraw pentamidine. Patients were retrospectively divided with regard to duration of therapy into 2 groups. We could not find any difference between patients in Group 1 treated for less than or equal to 14 days and patients in Group 2 treated for greater than 14 days when comparing outcome, number of recurrences and mean time until recurrence. In 16/21 patients given only TMP-SMX initially in a high dose (means = 16 mg trimethoprim/kg/day), dose reduction was performed to means = 10.5 mg trimethoprim/kg/day after a mean time of 6.9 days. The case-fatality rate for these patients was 10% (2/21) and the overall case-fatality rate was 15% (5/33). We chose pyrimethamine (50-175 mg/week) as secondary prophylaxis for PCP. At 1-year follow-up another 16 patients had died (21/32) and 9/27 (33%) discharged patients had had one recurrence each of PCP. All recurrences occurred among patients treated with only TMP-SMX for the acute episode of PCP. Of these 27 discharged patients 23 had been given pyrimethamine and 8 (36%) of these had experienced a recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

The value of C-reactive protein as a marker of bacterial infection in patients with septicaemia/endocarditis and influenza

In order to evaluate the capacity of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC) and polymorphonuclear neutrophils (PMNs) to differentiate between bacterial and viral infection we studied 176 patients with septicaemia/endocarditis (SE), 59 patients with uncomplicated influenza (UI) and 22 patients with complicated influenza (CI) retrospectively. All 4 parameters were significantly more elevated in SE and CI than in UI. Among patients with SE 10 176 had a CRP value less than 50 mg/l and in patients with UI 5/56 had a CRP value greater than 100 mg/l. Patients with SE caused by pneumococci had the highest CRP levels and patients with alfa-haemolytic streptococci the lowest. The sensitivity and specificity favours the use of CRP as an indicator of bacterial superinfection in influenza.

Elevated serum beta-2-microglobulin--a prognostic marker for development of AIDS among patients with persistent generalized lymphadenopathy

For evaluation of its prognostic value, the level of serum beta-2-microglobulin was determined in early serum samples from 88 patients with persistent generalized lymphadenopathy in a prospective longitudinal study. Patients with serum beta-2-microglobulin greater than 2.6 mg/l were found to have a significantly higher risk of developing AIDS earlier when compared to patients with a lower level (p less than 0.001).

Bacteremic pneumococcal pneumonia in Sweden: clinical course and outcome and comparison with non-bacteremic pneumococcal and mycoplasmal pneumonias

279 patients with 285 episodes of bacteremic pneumococcal pneumonia (Pnb), treated at the 2 departments for infectious diseases in Stockholm, Sweden, were reviewed retrospectively. Almost half of all episodes were caused by serotypes 3, 9 and 4 (in that order). The overall mortality rate was 7% and as low as 5% if patients with extrapulmonary complications were excluded. As in other studies male sex, alcoholism and absence of leukocytosis on admission to hospital were all associated with a higher mortality rate. However, the prognosis for old patients was much better than in most other studies. This was true also when the infecting strain was of serotype 3. For 89 consecutive patients out of the 279 ones with Pnb the clinical, laboratory and chest X-ray data were compared with those of 44 patients with non-bacteremic pneumococcal pneumonia (Pn) and 27 patients with Mycoplasma pneumoniae pneumonia (MP). Within the pneumococcal group almost all non-bacteremic patients had respiratory tract symptoms compared to less than half of the patients with bacteremic disease. High age, alcoholism, chills, pleuritic chest pain, a leukocyte count of greater than 15 x 10(9)l and an elevated CRP were factors significantly more common among those with pneumococcal pneumonia than among the MP patients. On chest X-ray an alveolar pattern was seen in all but 2 of the totally 133 patients with a pneumococcal pneumonia, but also in half the patients with MP.

Septicemia and endocarditis, 1965-1980, in a Swedish university hospital for infectious diseases

A 16-year (1965-1980) retrospective clinical study of septicemia and endocarditis was performed at a hospital for infectious diseases. 634 patients (74.5%) had septicemia, 138 (16.2%) endocarditis and 79 (9.3%) suspected endocarditis. The mean age was 55 years, 472 were males and 379 females. Predisposing underlying conditions were recognized in 89.2%. Gram-positive cocci (62.3%) dominated over gram-negative rods (29.5%). The most common causative organisms of septicemia were Staphylococcus aureus (22.4%) and Escherichia coli (20.2%), and of endocarditis, S. aureus (47.1%) and alpha haemolytic streptococci (21.0%). The overall fatality rate was 17.7% and was highest in infections caused by gram-negative rods and S. aureus. In septicemia the rate was 15.3% and in endocarditis 37.0%. Unfavourable prognostic factors were high age, endocarditis and underlying conditions such as haematological diseases and various other factors.

Acyclovir treatment in infectious mononucleosis: a clinical and virological study

Fifty-six patients with a clinical and laboratory diagnosis of infectious mononucleosis who had not been ill for more than seven days, were randomised for peroral treatment with acyclovir (800 mg five times daily) or placebo for seven days in a double blind trial. Clinical, virological and immunological parameters were monitored in each patient for six months. During treatment, shedding of Epstein-Barr virus' as assessed in 36 patients, was significantly reduced (p less than 0.001). However, virus production in the oropharynx returned to pre-treatment levels one week after the cessation of therapy. Virus was detected in 35 patients at enrollment and in 28 of 36 patients at the six-month control. No effect on the clinical course of the disease was noticed. The virus-specific antibody response was also unaffected. A significant reduction in spontaneous outgrowth of in vivo Epstein-Barr virus-infected B-lymphocytes was found at 180 days after treatment in four acyclovir-treated patients compared to six controls (p less than 0.001). In another three patients with over-whelming clinical symptoms causing airway obstruction and/or disseminated intravascular coagulopathy, treatment with intravenous acyclovir (10 mg/kg three times daily) was combined with prednisolone (0.7 mg/kg daily) for ten days. Virus shedding ceased transiently during treatment, but returned to initial levels within one week. A dramatic clinical effect on the pharyngeal oedema and general health of the two patients with airway obstruction was noticed, but was much less evident in a patient with intravascular coagulopathy.

Suppurative Staphylococcus aureus thyroiditis

Suppurative thyroiditis with septicaemia caused by Staphylococcus aureus in a 65-year-old male patient with diabetes mellitus was diagnosed by needle aspiration. Antibiotic treatment and surgical drainage cured the patient.

Are white blood cell count, platelet count, erythrocyte sedimentation rate and C-reactive protein useful in the diagnosis of septicaemia and endocarditis?

In 851 predominantly adult patients with septicaemia or endocarditis data regarding white blood cell (WBC) count, platelet count, ESR and C-reactive protein (CRP) obtained within 3 days of admission were analyzed retrospectively. Among 232 patients with complete laboratory data none had the combination of normal ESR, negative CRP and lack of both leukocytosis and thrombocytopenia. CRP was positive (greater than 10 mg/l) in 93%, ESR was elevated (greater than 20 mm/h) in 90%, leukocytosis (WBC greater than 9 X 10(9)/l) was present in 60% and thrombocytopenia (platelets less than 150 X 10(9)/l) in 35% of the patients. Patients with pneumococcal infection had generally higher ESR and CRP values and WBC counts than patients with other infections.

Occurrence of P-fimbriated Escherichia coli in patients with bacteremia

The case history of 88 patients with blood cultures positive for Escherichia coli and evidence of systemic disease was reviewed, and the Escherichia coli blood isolates tested for P-fimbriation. Fifty-five strains (63%) were P-fimbriated. Patients with a positive urine culture had a higher incidence of P-fimbriated Escherichia coli strains (53/75, 71%) than patients with a negative urine culture (2/13, 15%). Patients with no predisposing factors, such as instrumentation of the urinary tract or a chronic disease, had a significantly higher frequency of P-fimbriated strains (31/36, 86%) compared to patients without such underlying factors (p less than 0.01). There was no significant difference in clinical parameters or in frequency of P-fimbriated strains between patients with one positive blood culture and those with two or more positive cultures. The high incidence of P-fimbriated Escherichia coli strains in these patients is thought to depend on the ability of such bacteria to cause acute pyelonephritis, which in many cases precedes Escherichia coli bacteremia.

Unfavourable prognostic factors in Staphylococcus aureus septicemia and endocarditis

Factors predictive of a fatal outcome were retrospectively studied in 248 patients admitted with Staphylococcus aureus septicemia during 1965-1982, 78 of whom had endocarditis. 77 patients were intravenous drug addicts and 47 of them had endocarditis. 48 patients (19.4%) died. The fatality rate in addicts and non-addicts from septicemia was 0% and 17.9% and from endocarditis 8.5% and 61.3%, respectively. After analyzing clinical and laboratory data available early in the course of the disease 4 risk factors were found both in septicemia and endocarditis: age greater than or equal to 60 yr, pre-existing cardiovascular disease, prior hospitalization within 30 days of onset of illness, and neurological symptoms and/or signs. In addition, in endocarditis a platelet count before therapy less than 100 X 10(9)/l and left-sided involvement were unfavourable prognostic factors.