RESUMEN

CONTEXT: Patients with cystic fibrosis (CF) are the second largest group of lung transplant recipients in the United States. The survival effect of transplantation on a general CF population has not previously been measured. OBJECTIVE: To determine the impact of bilateral lung transplantation on survival in patients with CF. DESIGN, SETTING, AND PATIENTS: Retrospective observational cohort study of 11 630 CF patients who did not undergo lung transplantation (controls) and 468 transplant recipients with CF from 115 CF centers in the United States, 1992-1998. Patients were stratified into 5 groups based on a 5-year survival prediction model (survival group 1: <30%; survival group 2: 30 to <50%; survival groups 3-5: 50 to <100%.) MAIN OUTCOME MEASURE: Five-year survival from date of transplantation in 1992-1997 in the transplant group and from January 1, 1993, in the control group. RESULTS: Lung transplantation increased 5-year survival of CF patients in survival group 1. Survival group 2 had equivocal survival effects, and groups 3-5 had negative survival effects from transplantation. From 1994-1997, there was a mean annual prevalence of 238 patients in survival group 1 and mean annual incidence of 154 patients entering the group, approximately 1.5 times the number of lung transplantations performed each year in CF patients (mean, 104). Use of the criterion of forced expiratory volume in 1 second of less than 30% resulted in an equivocal survival benefit and identified 1458 potential candidates for transplantation in 1993. CONCLUSIONS: Cystic fibrosis patients in group 1 have improved 5-year survival after lung transplantation. The majority of patients with CF have equivocal or negative survival effects from the procedure. Selection of patients with CF for transplantation based on group 1 survival predictions maximizes survival benefits to individuals and may reduce the demand for scarce donor organs.

Asunto(s)

Fibrosis Quística/cirugía , Trasplante de Pulmón , Adulto , Fibrosis Quística/mortalidad , Femenino , Humanos , Modelos Logísticos , Trasplante de Pulmón/mortalidad , Masculino , Selección de Paciente , Estudios Retrospectivos , Análisis de Supervivencia

RESUMEN

We report a case of recurrent listeriosis for which molecular subtyping by automated ribotyping and pulsed-field gel electrophoresis confirmed either relapse of infection or reinfection due to a common source almost 9 months after initial infection due to a unique Listeria monocytogenes strain in a patient with colorectal cancer. This case report illustrates the potential use of molecular subtyping to further understand the pathogenesis and epidemiology of listeriosis and the potential for relapse of Listeria infections in humans.

Asunto(s)

Listeria monocytogenes/genética , Listeriosis/microbiología , Anciano , Técnicas de Tipificación Bacteriana , Humanos , Listeria monocytogenes/clasificación , Listeria monocytogenes/aislamiento & purificación , Listeriosis/tratamiento farmacológico , Listeriosis/epidemiología , Masculino , New York/epidemiología , Recurrencia

RESUMEN

The objective of this study was to create a 5-year survivorship model to identify key clinical features of cystic fibrosis. Such a model could help researchers and clinicians to evaluate therapies, improve the design of prospective studies, monitor practice patterns, counsel individual patients, and determine the best candidates for lung transplantation. The authors used information from the Cystic Fibrosis Foundation Patient Registry (CFFPR), which has collected longitudinal data on approximately 90% of cystic fibrosis patients diagnosed in the United States since 1986. They developed multivariate logistic regression models by using data on 5,820 patients randomly selected from 11,630 in the CFFPR in 1993. Models were tested for goodness of fit and were validated for the remaining 5,810 patients for 1993. The validated 5-year survivorship model included age, forced expiratory volume in 1 second as a percentage of predicted normal, gender, weight-for-age z score, pancreatic sufficiency, diabetes mellitus, Staphylococcus aureus infection, Burkerholderia cepacia infection, and annual number of acute pulmonary exacerbations. The model provides insights into the complex nature of cystic fibrosis and supplies a rigorous tool for clinical practice and research.

Asunto(s)

Fibrosis Quística/mortalidad , Modelos Logísticos , Análisis de Supervivencia , Adolescente , Adulto , Factores de Edad , Infecciones Bacterianas/complicaciones , Peso Corporal , Niño , Preescolar , Fibrosis Quística/complicaciones , Fibrosis Quística/fisiopatología , Femenino , Volumen Espiratorio Forzado , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Enfermedades Pancreáticas/complicaciones , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Factores Sexuales

RESUMEN

A porcine endogenous retrovirus (PERV) has been shown to infect human embryonic kidney 293 (HEK293) cells in vitro. The PERV proviral sequence exists in the genome of all porcine cells, including hepatocytes used in a bioartificial liver (BAL). We examined the possibility of PERV infection in HEK293 cells during exposure to supernatant from cultured pig hepatocytes. Pig hepatocytes were cultured in media supplemented with serum from patients in fulminant hepatic failure (FHF) to simulate conditions of an extracorporeal BAL. Pig hepatocytes were cultured in serum-free media for 24 hours and then exposed to fresh medium containing serum from a patient with FHF (22 patients tested). Twenty-four hours later, supernatant was collected and analyzed by polymerase chain reaction (PCR), with and without reverse transcriptase. Primers targeting the pol gene of PERV were used for PCR. Products of amplification were detected by an enzyme-linked immunosorbent assay-based technique using an internal capture probe also targeting the pol gene. Levels of PERV sequences were estimated by serial dilution. All positive samples were tested for infectivity in HEK293 cells. Porcine kidney 15 cell supernatant and fresh culture media were studied as positive and negative controls, respectively. Pig hepatocytes were also studied in the absence of FHF sera and in the presence of mitogenic stimulation with phytohemagglutinin (PHA) and phorbol 12-myristate-13-acetate (PMA). PERV DNA and PERV RNA were detected in all supernatants of cultured pig hepatocytes. The level of PERV RNA in the supernatant of pig hepatocytes was not altered by exposure to human FHF serum or stimulation with PHA and PMA. In addition, PERV RNA was undetectable in the supernatant of HEK293 cells for up to 50 days after exposure to pig hepatocyte supernatant (with or without FHF sera). These findings show that production of PERV by cultured pig hepatocytes was unaffected by exposure to growth factors and cytokines present in human FHF sera.

Asunto(s)

Retrovirus Endógenos/crecimiento & desarrollo , Fallo Hepático/sangre , Hígado/citología , Hígado/virología , Animales , Células Cultivadas , Retrovirus Endógenos/aislamiento & purificación , Retrovirus Endógenos/patogenicidad , Ensayo de Inmunoadsorción Enzimática , Humanos , Riñón/citología , Hígado Artificial , Reacción en Cadena de la Polimerasa , ARN Viral/genética , Porcinos

RESUMEN

Polymerase chain reaction (PCR)-based testing of cerebrospinal fluid (CSF) specimens has become standard for confirmatory diagnosis of central nervous system (CNS) infections; however, these tests increase health care costs. We reviewed 3-year data from 974 consecutive CSF specimens submitted for detection of seven pathogens by PCR. In 1997, 237 of 367 specimens (64.6%) were submitted for multiple tests, compared with 203 of 522 (38.9%) in 1996 and 18 of 85 (21.2%) in 1995. In each year the arrival of new house officers coincided with a peak in multiple testing. Among 732 specimens submitted for herpesvirus detection, results were positive for 24 (4.6%) of 523 specimens with increased leukocyte counts or protein levels. None of 209 specimens with normal leukocyte and protein levels were positive for herpesviruses. None of 471 CSF specimens submitted for Borrelia burgdorferi detection were PCR-positive. Use of protein and leukocytes to screen CSF specimens before employing PCR for herpesvirus detection would save almost one-third of costs without reducing sensitivity.

Asunto(s)

Infecciones del Sistema Nervioso Central/diagnóstico , Reacción en Cadena de la Polimerasa , Infecciones del Sistema Nervioso Central/líquido cefalorraquídeo , Infecciones por Herpesviridae/diagnóstico , Humanos , Recuento de Leucocitos , Enfermedad de Lyme/diagnóstico

RESUMEN

BACKGROUND: A porcine endogenous retrovirus (PERV) capable of infecting human cells has been identified. This study was designed to determine whether hollow fiber membranes, such as those used in a bioartificial liver, block the transfer of PERV. METHODS: Three hollow fiber cartridges (HFCs) were studied in duplicate: cellulose fibers with 70 kD nominal molecular weight cut-off (MWCO), polysulfone fibers with 400 kD MWCO, and mixed cellulose fibers with 200 nm porosity. PK15 cells (porcine kidney cell line), known to produce PERV, were grown in the intraluminal compartment of HFCs fiber cartridges. Samples of medium were collected from both intraluminal and extraluminal compartments of the HFCs fiber cartridge during 14 days of culture. Samples were screened for PERV using reverse transcription polymerase chain reaction. All positive samples were tested for PERV infectivity in human 293 cells. RESULTS: PERV was detected in all samples from the intraluminal space and all intraluminal samples seemed to infect 293 cells. All extraluminal samples from the fibers of 200 nm porosity tested positive for PERV. Detection of PERV in the extraluminal space was delayed by fibers of 400 kD MWCO and 70 kD MWCO until at least day 3 and day 7, respectively, after inoculation of PK15 cells. Positive extraluminal samples from fibers of 400 kD MWCO and 70 kD MWCO did not infect 293 cells. CONCLUSION: Pore size, membrane composition, and duration of exposure influenced the transfer of PERV across HFCs. Some HFCs decrease the risk of viral exposure to patients during bioartificial liver therapy.

Asunto(s)

Retrovirus Endógenos , Membranas Artificiales , Porcinos/virología , Animales , Órganos Artificiales , Línea Celular , Celulosa , ADN Viral/análisis , Humanos , Riñón/virología , Polímeros , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Sulfonas

RESUMEN

PURPOSE: To determine the clinical features, causes, and prognostic significance of extreme leukocytosis in adults. PATIENTS AND METHODS: Medical records of 100 consecutive patients who presented at the Minneapolis Veterans Affairs Medical Center between March 1993 and January 1994 with more than 25,000 leukocytes/microL blood and with more than 50% granulocytes were reviewed. Demographic, clinical, and outcome information was recorded, and a cause of extreme leukocytosis was sought in each case. RESULTS: Extreme leukocytosis was attributed to infection in 48 cases, advanced malignancy in 13 cases, hemorrhage in 9 cases, glucocorticoids in 8 cases, and other causes in 22 cases. Four patients had previously diagnosed conditions resulting in chronic leukocytosis. Higher leukocyte counts were associated with malignancy (chi2 for trend=12.5, P <0.002). Fever was more common in patients with infection (weighted rate ratio=3.7, 95% Confidence interval [CI]=2.2 to 6.2). Mortality was high overall (31%), and was greater in patients with noninfectious diagnoses compared with infected patients, an association which persisted after stratification by leukocyte count (weighted rate ratio=2.5, 95% CI=1.2 to 4.9). CONCLUSION: Clinicians should be aware that extreme leukocytosis with a predominance of granulocytes is associated with infection in only 48% of cases. The presence of fever increases the likelihood that infection is the cause. Mortality is high, particularly in patients without infection.

Asunto(s)

Granulocitos , Leucocitosis/diagnóstico , Leucocitosis/etiología , Adulto , Diagnóstico Diferencial , Femenino , Humanos , Recuento de Leucocitos , Leucocitosis/tratamiento farmacológico , Leucocitosis/mortalidad , Masculino , Registros Médicos , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Resultado del Tratamiento

RESUMEN

BACKGROUND: Invasive Aspergillus is an important cause of morbidity and mortality among lung transplant recipients. The diagnosis can be difficult and treatment is often unsuccessful so many centers preemptively treat all Aspergillus airway isolates to prevent invasive disease. This approach is untested as little is known about the relationship between Aspergillus airway colonization and invasive disease. This study was undertaken to evaluate the incidence of Aspergillus airway colonization after lung transplantation and the risk of invasive disease after colonization. DESIGN: All cultures and histologic specimens obtained from a consecutive series of 151 lung transplant cases were reviewed for the presence of Aspergillus and compared with clinical data. RESULTS: Aspergillus was isolated from the airway in 69 (46%) of 151 transplant recipients. Invasive disease occurred in five cases and was uniformly fatal, accounting for 13% of all posttransplant deaths. Results of cytologic examination of BAL fluid were normal in all cases of invasive disease and cultures were positive in only one of five patients prior to invasion. Invasive disease occurred exclusively in patients who died or were colonized with Aspergillus fumigatus within the first 6 months posttransplant. Patients growing A. fumigatus from the airway during the first 6 months were 11 times more likely to develop invasive disease relative to those not colonized. CONCLUSION: Aspergillus airway colonization after lung transplantation is common and in most cases, transient. In contrast, invasive Aspergillus disease is less common, but fatal. Bronchoscopy with cytologic examination and fungal culture are not sensitive or timely predictors of invasive disease. Invasive Aspergillus occurred only in patients initially colonized with A. fumigatus within the first 6 months posttransplant. A trial of empiric anti-Aspergillus therapy limited to the first 6 months posttransplant may be warranted.

Asunto(s)

Aspergilosis/microbiología , Aspergillus fumigatus/crecimiento & desarrollo , Trasplante de Pulmón/efectos adversos , Pulmón/microbiología , Adolescente , Adulto , Aspergilosis/mortalidad , Aspergilosis/patología , Aspergillus fumigatus/patogenicidad , Biopsia , Broncoscopía , Células Cultivadas , Niño , Preescolar , Recuento de Colonia Microbiana , Femenino , Estudios de Seguimiento , Humanos , Pulmón/patología , Trasplante de Pulmón/mortalidad , Trasplante de Pulmón/patología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Tasa de Supervivencia

RESUMEN

Pandemics of human immunodeficiency virus (HIV) type 1 infection and penicillin resistance highlight the urgency of preventing invasive pneumococcal disease with vaccination. We characterized pneumococcal serogroup distribution and the mortality rate among 460 patients with pneumococcal bacteremia from 1984 through 1994 at Denver General Hospital and the prevalence of HIV infection in patients for whom pneumococcal bacteremia was diagnosed from 1989 to 1994. Vaccine-related serogroups accounted for 426 isolates (92.6%), including 48 (92.3%) of 52 isolates from HIV-infected patients. Mortality among patients 15 years of age or older was higher during 1984-1988 (18[12.9%] of 140) than during 1989-1994 (10 [5.2%] of 191: rate ratio, 2.5; 95% confidence interval, 1.2-5.2). Of patients 15-59 years of age from 1989 to 1994, 44 (39.6%) of 111 men and three (7.3%) of 41 women were HIV-infected. Four (8.5%) of 47 HIV-infected patients and four (3.8%) of 105 other patients in this group died (age-weighted rate ratio, 1.8; 95% confidence interval, 0.5-6.2). We recommend routine screening of young adults with pneumococcal bacteremia for HIV infection and immunization of HIV-infected patients with pneumococcal vaccine (which includes most serogroups of infecting strains).

Asunto(s)

Infecciones Oportunistas Relacionadas con el SIDA , Bacteriemia/microbiología , Infecciones por VIH/complicaciones , Infecciones por VIH/epidemiología , VIH-1 , Infecciones Neumocócicas/complicaciones , Infecciones Neumocócicas/epidemiología , Streptococcus pneumoniae/inmunología , Adolescente , Adulto , Anciano , Anticuerpos Antibacterianos/inmunología , Antígenos Bacterianos/análisis , Bacteriemia/complicaciones , Bacteriemia/epidemiología , Niño , Preescolar , Colorado/epidemiología , Femenino , Infecciones por VIH/mortalidad , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Resistencia a las Penicilinas , Infecciones Neumocócicas/prevención & control , Prevalencia , Vacunación

RESUMEN

To study the effectiveness of anaerobic coverage in prevention of postpartum endometritis in women undergoing nonelective cesarean sections, we conducted a randomized prospective double-blind study of women undergoing cesarean sections and requiring antibiotic prophylaxis from April 1, 1989, through December 31, 1990. Ninety-four patients were enrolled in the study. Forty-five patients received ampicillin alone and 46 received ampicillin in conjunction with sulbactam. All patients were evaluated prior to surgery and in the postoperative period. Ninety-one patients completed the study and their records were analyzed. Patients were divided into two groups depending on the presence or absence of ruptured membranes. Seventy-five percent of patients had ruptured membranes. Failure of prophylaxis and subsequent endometritis was documented in 8.8% of patients who received ampicillin and sulbactam and 35.3% of patients who received ampicillin alone. This difference was statistically significant (p < 0.02). In conclusion, single-dose ampicillin and sulbactam provides better prophylaxis than single-dose ampicillin in women undergoing cesarean section with rupture of membranes.

Asunto(s)

Ampicilina/uso terapéutico , Profilaxis Antibiótica , Cesárea , Quimioterapia Combinada/uso terapéutico , Adulto , Método Doble Ciego , Femenino , Humanos , Embarazo , Estudios Prospectivos , Sulbactam/uso terapéutico

RESUMEN

The presence of intracellular bacteria in blood smears is usually associated with overwhelming sepsis and an ominous prognosis. Recently, the hematology laboratory at our institution documented this finding in a group of mostly asymptomatic patients. We studied seven adult patients from a tertiary care university hospital in whom intracellular bacteria were found incidentally on routine manual differential cell counts of 100 white blood cells during a 12-month period. A retrospective review of the clinical and laboratory data was performed. All seven patients were immunosuppressed and had central venous catheters in place. The blood samples positive for intracellular bacteria were all catheter derived. Six patients were asymptomatic at the time of bacteria detection, but they had blood cultures that were positive for coagulase-negative Staphylococcus; five of these patients became symptomatic 1 to 14 days after bacteria detection. Bacteremia persisted in five of these six patients until the eventual removal of the catheters. The one symptomatic patient had Pseudomonas aeruginosa bacteremia and died shortly after admission. The finding of intracellular bacteria in routine differential blood cell counts from a central venous catheter blood specimen most likely indicates active infection. We recommend that central venous catheters be removed in such patients, even if the patient is asymptomatic.

Asunto(s)

Bacteriemia/microbiología , Células Sanguíneas/microbiología , Cateterismo Venoso Central/efectos adversos , Adulto , Bacteriemia/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos

RESUMEN

Patients with aplastic anemia (AA) respond to immunosuppressive therapy, and several lines of laboratory evidence support a role for cell-mediated immunity in the pathogenesis of marrow failure including expansion of cytotoxic T lymphocytes (CTL) in the blood of AA patients, overexpression of inhibitors such as IFN-gamma in the marrow of AA patients, and suppression of hematopoietic cells by CTL in vitro. However, the phenotype of immune effectors in the marrow of AA patients remains unknown. We examined severe (sAA) and moderate AA (mAA) patients and compared them to healthy volunteers and patients with myelodysplastic syndrome (MDS). Our study shows that percentages of HLA-DR+ CD8+ lymphocytes and natural killer (NK) cells, CD56+, were elevated in the marrow of AA patients. Peripheral blood (PB), in all instances, did not reflect changes seen in the bone marrow (BM). Increased percentages of activated CD8+ cells were found in marrow and blood in 43% of AA patients, but in 28% of AA patients, activation of CD8+ cells was only detectable in the marrow. During hematopoietic recovery, activated CD8+ cells and NK cells in marrow declined, but not to normal levels. T cells bearing the gamma delta-phenotype were elevated in the blood of sAA patients (p < 0.05) but were not significantly increased in BM from sAA and MDS patients. Percentages of activated immune effectors are increased in the marrow of AA patients as is consistent with a localized immune response in this disease. Marrow phenotyping may be more sensitive than peripheral blood analysis for detecting an abnormal cellular immune response.

Asunto(s)

Anemia Aplásica/patología , Células de la Médula Ósea , Linfocitos/citología , Síndromes Mielodisplásicos/patología , Relación CD4-CD8 , Linfocitos T CD4-Positivos/citología , Linfocitos T CD8-positivos/citología , Citometría de Flujo , Humanos , Inmunofenotipificación , Células Asesinas Naturales/citología , Activación de Linfocitos , Recuento de Linfocitos , Receptores de Antígenos de Linfocitos T gamma-delta/metabolismo , Subgrupos de Linfocitos T/citología

RESUMEN

BACKGROUND: Homeless people are at high risk for death from many causes, but age-adjusted death rates for well-defined homeless populations have not been determined. METHODS: We identified 6308 homeless persons 15 to 74 years of age who were served by one or both of two agencies for the homeless in Philadelphia between January 1, 1985, and December 31, 1988. Using a data base that contained all deaths in Philadelphia and listings of all Philadelphia residents during the same period, we compared the mortality rate for this homeless population with the rate in the general population of Philadelphia. RESULTS: The age-adjusted mortality rate among the homeless was 3.5 times that of Philadelphia's general population (95 percent confidence interval, 2.8 to 4.5). The age-adjusted number of years of potential life lost before the age of 75 years was 3.6 times higher for the homeless people than for the general population (345 vs. 97 years lost per 1000 person-years of observation). Fifty-one of the 96 deaths of homeless persons (53 percent) occurred during the summer months. Mortality rates were higher among the homeless than in the general population for nonwhites, whites, women, and men. Within the homeless cohort, white men and substance abusers had higher mortality rates than other subgroups, but even homeless people not known to be substance abusers had a threefold higher risk of death than members of the general population. Injuries, heart disease, liver disease, poisoning, and ill-defined conditions accounted for 73 percent of all the deaths among the homeless. CONCLUSIONS: Homeless adults in Philadelphia have an age-adjusted mortality rate nearly four times that of Philadelphia's general population. White men and substance abusers are at particularly high risk. Matching cohorts of homeless people to death records is a useful way to monitor mortality rates over time, evaluate interventions, and identify subgroups with an increased risk of death.

Asunto(s)

Personas con Mala Vivienda/estadística & datos numéricos , Mortalidad , Adolescente , Adulto , Anciano , Causas de Muerte , Intervalos de Confianza , Etnicidad/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Philadelphia/epidemiología , Riesgo

RESUMEN

BACKGROUND: The presence of a specific cellular receptor is thought to be necessary for susceptibility to viral infection. The erythrocyte P antigen is the cellular receptor for parvovirus B19. We hypothesized that the rare persons with the p phenotype, whose erythrocytes do not have this receptor, would be naturally resistant to B19 infection, which causes erythema infectiosum. METHODS: Blood samples were collected from two populations in cross-sectional studies. We determined the P antigen phenotype of the red cells and tested plasma for anti-B19-specific antibodies. Bone marrow from donors of known P antigen phenotype was inoculated with parvovirus B19. Infectivity was measured by assays of erythroid progenitor cells, dot blot analysis, and in situ hybridization for B19 DNA, and an immunofluorescence assay for viral-capsid proteins. RESULTS: Of the 17 subjects with the p red-cell phenotype, who did not have P antigen on their erythrocytes, none (0 of 11 and 0 of 6) had serologic evidence of previous parvovirus B19 infection. In contrast, the seropositivity rates in the two control groups were 71 percent (53 of 75, P < 0.001) and 47 percent (32 of 68, P = 0.03). In vitro, bone marrow from donors with the p phenotype maintained normal erythropoiesis despite very high concentrations of virus, with no evidence of infection of erythroid progenitor cells by parvovirus B19. CONCLUSIONS: People who do not have P antigen, which is the cellular receptor for parvovirus B19, are naturally resistant to infection with this pathogen.

Asunto(s)

Eritema Infeccioso/sangre , Eritema Infeccioso/inmunología , Isoantígenos/inmunología , Sistema del Grupo Sanguíneo P/inmunología , Adolescente , Adulto , Anticuerpos Antivirales/sangre , Células Cultivadas , Estudios Transversales , Susceptibilidad a Enfermedades , Eritema Infeccioso/epidemiología , Eritema Infeccioso/microbiología , Células Precursoras Eritroides/microbiología , Humanos , Parvovirus B19 Humano/inmunología , Fenotipo

RESUMEN

STUDY OBJECTIVE: To identify missed opportunities for syphilis treatment during an outbreak. DESIGN: Prospective prevalence survey. SETTING: Urban hospital emergency department. PARTICIPANTS: Nine hundred sixty-one persons aged 15 to 44 years seeking medical attention in the ED who were not suspected of having any sexually transmitted disease (STD) at the time of their visit. INTERVENTION: Serologic testing for syphilis and public health follow-up as needed. MEASUREMENTS AND MAIN RESULTS: Twenty-one non-STD patients (2%) had untreated early syphilis, and 22 (2%) had positive serology but were lost to follow-up. Among 271 STD patients seen in the ED during the same period, 15 cases (6%) were detected. We estimate that 80 or more additional untreated early syphilis cases would have been identified had all 15- to 44-year-old patients entering the ED been tested. The cost of screening was $251 per case detected. CONCLUSION: Patients not suspected of having any STD account for most early syphilis cases among all ED patients. Screening and on-site treatment for syphilis should be offered to all young adults seeking medical attention in the ED during syphilis outbreaks.

Asunto(s)

Brotes de Enfermedades , Servicio de Urgencia en Hospital , Sífilis/epidemiología , Adolescente , Adulto , Femenino , Humanos , Masculino , Philadelphia , Vigilancia de la Población , Estudios Prospectivos , Sífilis/diagnóstico

RESUMEN

In the spring of 1988, the largest documented US outbreak of cutaneous sporotrichosis to date occurred, with 84 cases among persons from 15 states who were exposed to Wisconsin-grown sphagnum moss used in packing evergreen tree seedlings. In New York State, 13 cases occurred among 109 forestry workers. All 13 cases occurred among 76 workers who had handled evergreen seedlings and moss (attack rate = 17%). For those exposed to evergreens and moss, the risk of infection increased as worktime exposure to moss increased (attack rates: less than 10 hours, 8%; 10-19 hours, 12%; greater than 19 hours, 33%). While environmental samples of moss from the Wisconsin supplier were negative, Sporothrix schenckii was cultured from multiple samples of the sphagnum moss obtained from one of six Pennsylvania tree nurseries, representing the nursery that was identified as the source for 79 (94%) of the moss-associated cases. Differences in tree-handling procedures at this nursery--including the use of 1- to 3-year-old moss to pack seedlings, use of a pond water source to wet the moss, use of an organic polymer gel on the seedling root system, and underground storage and longer storage of moss-packed seedlings before shipping--suggested possible explanations for the association. Efforts to prevent sporotrichosis among persons handling evergreen seedlings should include the use of alternate types of packing material (e.g., cedar wood chips or shredded paper) and protective clothing such as gloves and long-sleeved shirts.

Asunto(s)

Brotes de Enfermedades , Agricultura Forestal , Enfermedades Profesionales/epidemiología , Esporotricosis/epidemiología , Adolescente , Adulto , Anciano , Brotes de Enfermedades/estadística & datos numéricos , Femenino , Humanos , Illinois/epidemiología , Masculino , Persona de Mediana Edad , New York/epidemiología , Enfermedades Profesionales/microbiología , Plantas/microbiología , Sporothrix/aislamiento & purificación , Esporotricosis/microbiología , Estados Unidos/epidemiología

RESUMEN

Aplastic anemia is a rare, life-threatening disease of unknown etiology, with unusually high prevalence in Thailand. It is sometimes associated with non-A, non-B hepatitis (NANBH). The hepatitis C virus (HCV), one of the causes of NANBH, is similar to flaviviridiae, a family of viruses many of whose members cause acute bone marrow suppression. To test the hypothesis that HCV viremia is associated with aplastic anemia among patients in Thailand, we compared 53 untransfused hospitalized aplastic anemia patients and 39 untransfused controls hospitalized for other conditions. We used the polymerase chain reaction to identify HCV viremia in three (5.7%) untransfused patients and two (5.1%) untransfused controls (P = 1.0, by Fisher's two-tailed exact test). Although our data do not exclude the possibility that a small subset of aplastic anemia cases are precipitated by HCV, we conclude that HCV viremia is not generally associated with aplastic anemia in Thailand. Our results also imply that the prevalence of HCV viremia may be unexpectedly high among untransfused persons in Thailand, a hypothesis that should be tested in other populations.

Asunto(s)

Anemia Aplásica/etiología , Hepatitis C/epidemiología , Viremia/epidemiología , Adolescente , Adulto , Secuencia de Bases , Estudios de Casos y Controles , Niño , ADN Viral/química , Electroforesis en Gel de Agar , Femenino , Hepacivirus/genética , Hepacivirus/aislamiento & purificación , Hepatitis C/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Datos de Secuencia Molecular , Reacción en Cadena de la Polimerasa , Prevalencia , ARN Viral/análisis , Tailandia/epidemiología , Viremia/complicaciones

RESUMEN

Haematological syndromes attributed to viruses demonstrate geographical variations in incidence and great dependence on host factors. Severe haematological disease is the exception rather than the rule in dengue virus infection, and probably depends at least in part on the host immune response to the virus. The increased incidence of hepatitis-associated aplasia in east Asia may reflect distribution of an infectious agent, an environmental toxin, or genetic predisposition, but probably represents some combination of these factors. Agents with apparently universal distribution, such as parvovirus B19 and Epstein-Barr virus, are associated with bone marrow failure only in a very narrow range of hosts. These examples teach us that viral causes cannot automatically be excluded from the differential diagnosis of syndromes whose occurrence is rare or apparently sporadic. Further investigation of these syndromes should include more detailed characterization of host factors, particularly immunological characteristics, and possible infectious and toxic cofactors which are associated with morbidity.

Asunto(s)

Enfermedades Hematológicas/microbiología , Virosis/epidemiología , Médula Ósea/patología , Médula Ósea/fisiopatología , Enfermedades Hematológicas/diagnóstico , Enfermedades Hematológicas/epidemiología , Enfermedades Hematológicas/patología , Enfermedades Hematológicas/fisiopatología , Humanos , Virosis/diagnóstico , Virosis/patología , Virosis/fisiopatología , Virosis/transmisión

RESUMEN

OBJECTIVE: To test the hypothesis that the rare, often fatal, syndrome of hepatitis-associated aplasia is associated with hepatitis C virus infection. DESIGN: Case series. SETTING: Tertiary referral centers in the United States, Japan, Italy, and Germany. PATIENTS: Twenty-eight patients with onset of aplastic anemia within 90 days after seeking medical attention for jaundice, or having serum transaminase levels 150% or more of normal (hepatitis-associated aplasia patients) and three patients who developed aplastic anemia following liver transplantation for non-A, non-B hepatitis. OUTCOME MEASURES: Presence of hepatitis C in serum, bone marrow, and liver samples, detected by the polymerase chain reaction; antibody testing; and percentage of activated peripheral cytotoxic T lymphocytes determined by immunophenotyping. RESULTS: Hepatitis ribonucleic acid was present in the serum samples of 10 (36%) patients with hepatitis-associated aplasia. However, hepatitis C virus viremia was associated with transfusions received after the onset of aplasia: seven (58%) of 12 patients with hepatitis-associated aplasia who had received 21 or more units of blood products at the time of serum sampling were viremic, compared with only three (19%) of 16 patients with hepatitis-associated aplasia who had received 20 or less units of blood products (P less than .05). Hepatitis C virus was not found in blood and bone marrow samples of three National Institutes of Health case patients tested at the time of diagnosis. None of three livers from non-A, non-B hepatitis patients who developed aplastic anemia after liver transplantation contained hepatitis C virus ribonucleic acid. Activated CD8+ T lymphocytes were elevated three- to 20-fold early in the course of hepatitis-associated aplasia. CONCLUSIONS: Our results implicate a novel, non-A, non-B, and non-C agent in both hepatitis-associated aplasia and fulminant hepatitis.

Asunto(s)

Anemia Aplásica/microbiología , Hepatitis C/complicaciones , Adolescente , Adulto , Niño , Preescolar , Femenino , Hepacivirus/aislamiento & purificación , Hepatitis C/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa , ARN Viral/análisis

RESUMEN

OBJECTIVE: To investigate the relationship between L-tryptophan (LT) ingestion and eosinophilic fasciitis (EF) occurring prior to the outbreak of eosinophilia-myalgia syndrome in 1989. METHODS: Interviews and record reviews of 45 EF case-patients and 126 polymyositis patients (controls) diagnosed prior to 1988. RESULTS: Nine case-patients (20%) and no controls recalled taking LT before onset of the disease (odds ratio = infinity, 95% confidence interval = 8.3-infinity). Among EF case-patients, LT ingestion was associated with dyspnea. CONCLUSION: LT ingestion was associated with EF prior to the 1989 outbreak of eosinophilia-myalgia syndrome. Lung abnormalities may be a distinguishing feature of LT-mediated illness.

Asunto(s)

Brotes de Enfermedades , Síndrome de Eosinofilia-Mialgia/epidemiología , Eosinofilia/inducido químicamente , Fascitis/inducido químicamente , Triptófano/efectos adversos , Estudios de Casos y Controles , Síndrome de Eosinofilia-Mialgia/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Miositis/diagnóstico , Triptófano/administración & dosificación