Rickettsial infections of the central nervous system.
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Central Nervous System Diseases↗
Biomedical subjects
T J Marrie
Publications and source records attributed to T J Marrie.
Normal resolution of community-acquired pneumonia.
Resolution of pneumonia has to be considered as two different phases: resolution of the acute illness and resolution of radiographic opacities. Age, comorbidities, immunosuppression, and etiological agent(s) are all important in determining whether the acute illness resolves; there is a considerable mortality rate from pneumonia requiring hospitalization. The major concern when there is slow radiographic resolution of pneumonia is the possibility of an underlying malignancy. In 96% of patients whose pneumonia has not resolved in 30 days, an underlying disease is found; emphysema, chronic bronchitis, or bronchogenic carcinoma are the most common. Normal resolution of community-acquired pneumonia has to be defined in terms of the severity of the illness, comorbidity (ies), and infecting pathogen(s).
Adult↗
Mycobacterium avium-intracellulare endocarditis causing rupture: replacement and repair with aortic homograft.
Aortic valve endocarditis with extension to the tricuspid annulus and ventricular septum in an intravenous drug abuser - with Mycobacterium avium-intracellulare identified as the offending organism - forms the basis of this report. The aortic root and ventricular septal defect were successfully repaired using an aortic cryopreserved homograft. This case is of particular interest because M avium-intracellulare has not been recognized as a cause of endocarditis. The incidence of atypical organisms as a cause of endocarditis may increase in the future because of the rise of drug abuse and the acquired immune deficiency syndrome in North America.
Adult↗
Pneumonia.
Pneumonia is one of the most serious infections in elderly persons. For example, individuals with nursing-home acquired pneumonia requiring hospitalization have a mortality rate of approximately 40%. In the frail, elderly patient, the clinical manifestations may be very nonspecific and consist only of confusion and falls; these individuals often may not present with either fever or cough. Sputum is frequently not available for culture in this population, and chest radiography for pneumonia may be confounded by underlying pulmonary or cardiac disease. Antibiotic therapy for pneumonia in older patients must often be empirical.
Aged↗
Nosocomial legionnaires' disease: lessons from a four-year prospective study.
We studied all cases of nosocomial pneumonia at our 800-bed tertiary care hospital from September 1983 to September 1987. Of the 813 cases of nosocomial pneumonia, 31 (3.8%) were definite (isolation of organism or fourfold rise in titer) and 21 (2.5%) were possible cases (single or stable antibody titer of greater than or equal to 1:256) of legionnaires' disease. The definite cases involved a more severe form of pneumonia and a significantly higher mortality rate--64% versus 14% (p less than 0.0009) compared with the possible cases. Despite attempted comprehensive surveillance, only four (13%) of the definite cases of legionnaires' disease were found that would not have been diagnosed if the study were not ongoing. The yield from adequate (4- to 6-week convalescent serum samples) serologic testing was 5%, whereas the yield from sputum culture was 11%. We conclude that targeted surveillance of immunosuppressed patients with nosocomial pneumonia by culture of respiratory tract secretions for Legionella pneumophila is adequate for monitoring for the presence of legionnaires' disease in a hospital.
Cross Infection↗
Control of endemic nosocomial legionnaires' disease by using sterile potable water for high risk patients.
In a setting where potable water is contaminated with Legionella pneumophila serogroup 1, we performed two case control studies. The first case control study consisted of 17 cases of nosocomial Legionnaires' disease (LD) and 33 control (the patients who were admitted to the ward where the case was admitted immediately before and after the case) subjects. Cases had a higher mortality rate 65% vs 12% (P less than 0.004); were more likely to have received assisted ventilation (P less than 0.00001); to have nasogastric tubes (P less than 0.0004) and to be receiving corticosteroids or other immunosuppressive therapy (P less than 0.0001). Based on the results of this study, sterile water was used to flush nasogastric tubes and to dilute nasogastric feeds. Only 3 cases of nosocomial LD occurred during the next year compared with 12 the previous year (P less than 0.0001). Nine cases subsequently occurred and formed the basis for the second case-control study. Eighteen control subjects were those patients admitted to the same unit where the case developed LD, immediately before and after the case. The mortality rate for the cases was 89% vs 6% for controls (P less than 0.00003). The only other significant difference was that cases were more likely to be receiving corticosteroids or other immunosuppressive therapy 89% vs 39% (less than 0.01). We hypothesized that microaspiration of contaminated potable water by immunocompromised patients was a risk factor for nosocomial Legionnaires' disease. From 17 March 1989 onwards such patients were given only sterile potable water. Only two cases of nosocomial LD occurred from June 1989 to September 1990 and both occurred on units where the sterile water policy was not in effect. We conclude that aspiration of contaminated potable water is a possible route for acquisition of nosocomial LD in our hospital and that provision of sterile potable water to high risk patients (those who are receiving corticosteroids or other immunosuppressive drugs; organ transplant recipients or hospitalized in an intensive care unit) should be mandatory.
Case-Control Studies↗
Culture-negative endocarditis probably due to Chlamydia pneumoniae.
A 59-year-old man had culture-negative endocarditis (clinical evidence compatible with endocarditis and histopathologic evidence of a recent episode of endocarditis) and serology compatible with a recent episode of Chlamydia pneumoniae infection. The conclusion was that this episode of culture-negative endocarditis was probably due to C. pneumoniae.
Antibodies, Bacterial↗
A comparison of Q fever endocarditis with native valve endocarditis.
We compared 10 episodes (8 patients) of Q fever endocarditis with 27 episodes (27 patients) of native valve endocarditis. Patients with Q fever endocarditis were more likely to have weight loss (p less than 0.003), experience fatigue (p less than 0.07), have clubbing of the fingers (p less than 0.005), have a diastolic murmur at the time of admission (p less than 0.03), be anemic (p less than 0.05), have a normal white blood cell count (p less than 0.005), and have a higher serum globulin concentration (p less than 0.007). While valve replacement was required for 50% of the episodes in both groups of patients, it was required later--mean 107 days following the onset of treatment--for the Q fever patients than for the native valve patients--mean 27 days. The mortality rates for these two diseases were not significantly different (30% for native endocarditis vs. 12.5% for Q fever endocarditis), but the Q fever patients experienced significantly fewer complications.
Endocarditis↗
The immune response to phase I and phase II Coxiella burnetii antigens as measured by western immunoblotting.
To determine the utility of Western immunoblotting in distinguishing chronic Q fever from acute Q fever, we first examined serum samples from individuals who had no antibodies to Coxiella burnetii by either the indirect immunofluorescence antibody test or by the enzyme-linked immunosorbent assay. In these subjects, the IgG fraction in low dilutions of serum (1:8, 1:16) reacted with as many as 10 proteins in phase I and phase II antigens. This number of reacting bands seen in Western blots was reduced by using serum in a dilution of 1:1024. In contrast, IgA antibodies were uncommon even at low dilutions. Likewise, IgA antibodies were infrequently observed in patients with acute Q fever. However, in chronic Q fever there were many IgA antibodies to phase I and phase II proteins. Antibodies to phase I proteins were more common than those to phase II proteins. Several antigenic protein bands were recognized only by serum from chronic Q fever patients. Three of these antigens had molecular masses of, respectively, 50 kDa, 80 kDa, and 160 kDa. Serial serum samples from patients with chronic Q fever revealed that the number of antigens recognized by the IgA fraction decreased after the initiation of antibiotic therapy. The decline was faster for antibodies to phase II proteins. We conclude that immunoblotting is useful in the diagnosis of chronic Q fever.
Acute Disease↗
Q fever in octogenarians.
Two of the 186 persons (1%) with acute Q fever examined in this study were 80 years of age or older. Both were males and both had Coxiella burnetti pneumonia. Q fever was not suspected during their hospital stay and would not have been diagnosed if these patients had not been part of a prospective study of community-acquired pneumonia.
Age Factors↗
Seroepidemiology of Q fever among cats in New Brunswick and Prince Edward Island.
The indirect microimmunofluorescence test was used to determine the presence of antibodies to phase I and phase II Coxiella burnetii antigens in New Brunswick and Prince Edward Island cats. Twenty of 104 (19.2%) New Brunswick cats tested had antibodies to phase II antigen; five of these (4.8%) also had antibodies to phase I antigen. Six of 97 (6.2%) Prince Edward Island cats tested had antibodies to phase I and phase II antigens. Our data suggest that cats may be important in the epidemiology of Q fever in these provinces.
Animals↗
Incidence of Q fever: pilot studies in two areas in Nova Scotia.
We carried out two pilot studies to determine the incidence of Q fever in Nova Scotia. The first study involved 199 people from the Annapolis Valley region. The first set of blood samples was collected between May and September and the second three to five months later. Two subjects had titers greater than or equal to 1:256 (by the indirect immunofluorescence test), suggesting recent infection. The second group studied consisted of 95 residents of Baddeck. Nova Scotia. Their first serum samples were collected between March and October 1987 and their second samples 18 months later. Two (2%) had fourfold rises in titer and one had a high stable titer. We conclude that the incidence of Q fever in these two areas of Nova Scotia is high.
Aged↗
The immune response in a cat-related outbreak of Q fever as measured by the indirect immunofluorescence test and the enzyme-linked immunosorbent assay.
The isotypic immune response of 16 individuals who developed Q fever pneumonia following exposure to an infected parturient cat was studied. The enzyme-linked immunosorbent (ELISA) test was used to detect IgM, IgA, and IgG antibodies to phase I and phase II Coxiella burnetii whole-cell antigens and to the phase I lipopolysaccharide. The indirect immunofluorescent antibody (IFA) test was also used to detect antibodies to phase I and phase II whole cells. None of the 16 subjects developed antibodies to the phase I lipopolysaccharide. The ELISA was more sensitive than the IFA test. IgM antibodies to phase II antigen were detectable by ELISA in 80% of the subjects at the time of onset of symptoms and were still present in 7 of the 8 tested at 32 weeks following the onset of symptoms. In all instances (ELISA: IgG, IgM; IFA: IgG, IgM) phase II antibodies developed earlier and reached higher levels than did phase I antibodies. The absence of antibodies to phase I lipopolysaccharide in acute Q fever combined with our unpublished findings of antibodies to phase I lipopolysaccharide in chronic Q fever suggests that this test may be used to distinguish acute from chronic Q fever.
Adult↗
Streptococcus bovis meningitis: report of 2 cases.
We describe 2 cases of Streptococcus bovis meningitis and review the 9 cases previously reported. This microorganism is a rare cause of meningitis in which there are no distinctive clinical or laboratory features. The Gram stain of the CSF is usually negative. Ten of the 11 cases had some underlying disease or comorbid condition that predisposed to S bovis infection: gastrointestinal disorder, endocarditis, CSF leak, polymyalgia rheumatica, and mandibular block. Treatment with high-dose penicillin is usually adequate.
Adult↗
Epidemiology of community-acquired pneumonia in the elderly.
The attack rate for pneumonia increases with increasing age and with residence in a nursing home. The rate of hospitalization of Halifax County, Nova Scotia, Canada, residents with pneumonia was 1 in 1,000, while for nursing home residents it was 33 in 1,000. The overall mortality rate for community-acquired pneumonia requiring hospitalization was 21.9%. Mortality was age-related: Seven percent of those 30 years of age or younger died, while 38% of those in the 81 to 90 year age group died. Comorbidities increased with increasing age from 0.73 +/- 0.81 for those 30 years old or younger to 2.75 +/- 1.47 for those 71 to 80 years of age. The most common comorbidities were chronic obstructive pulmonary disease, ischemic heart disease, hypertension, diabetes mellitus, malignancy, alcoholism, and neurological disease. The acquired immunodeficiency syndrome was a significant comorbidity among those 50 years of age or younger. Age-dependent trends were observed in the use of antimicrobial therapy: Cefamandole and aminoglycosides were prescribed more frequently with increasing age, whereas after the age of 61 years, the use of erythromycin declined. Penicillin usage was not age-dependent. Resource (hemograms, chest radiographs, blood chemistry, blood gases, and sputum culture) use peaked at the 50 to 60 year age group.
Adolescent↗
Truckin' pneumonia--an outbreak of Q fever in a truck repair plant probably due to aerosols from clothing contaminated by contact with newborn kittens.
We describe an outbreak of Q fever affecting 16 of 32 employees at a truck repair plant. None of the cases were exposed to cattle, sheep or goats, the traditional reservoirs of Q fever. The cases did not work, live on, or visit farms or attend livestock auctions. One of the employees had a cat which gave birth to kittens 2 weeks prior to the first case of Q fever in the plant. The cat owner fed the kittens every day before coming to work as the cat would not let the kittens suckle. Serum from the cat had high antibody titres to phase I and phase II Coxiella burnetii antigens. The attack rate among the employees where the cat owner worked, 13 of 19 (68%), was higher than that of employees elsewhere, 3 of 13 (28%) [P less than 0.01]. The cat owner's wife and son also developed Q fever. None of the family members of the other employees with Q fever was so affected. We conclude that this outbreak of Q fever probably resulted from exposure to the contaminated clothing of the cat owner.
Adult↗
Cardiac function at rest and with exercise in the chronic fatigue syndrome.
To evaluate a possible cardiac pathophysiology of the chronic fatigue syndrome, we compared the resting cardiac function and exercise performance of 41 patients to those of an age-matched and sex-matched normal control group. Persistent fatigue following an acute apparently viral illness was the major complaint of all patients; none had specific cardiac symptoms nor abnormal physical findings. Electrocardiographic spatial patterns were normal in the patients, and there were no differences in the body surface sum of positive T-wave integrals between the patients (240 microV.x 10(2) +/- 107 microV.s x10(2)) and control (244 microV.x 10(2) +/- 108 microV.s x 10(2) subjects. Twenty-four hour ambulatory ECGs revealed no differences in sinus rates and incidences of ventricular dysrhythmias in the two populations. Left ventricular dimensions and systolic fractional shortening values were also similar in both groups; moreover none of the patients had segmental wall motion abnormalities. On graded exercise testing, 20 of 32 normal subjects achieved target (85 percent of age-maximum) heart rates, compared to four of 31 patients (p less than 0.001). The duration of exercise averaged 12 +/- 4 minutes for the normal subjects and 9+/- 4 minutes for the patients (p less than 0.01). The temporal profile of exercise heart rates was dissimilar in the two groups, with patients' rates consistently and progressively less than those of normal subjects. Peak heart rate averaged 152 +/- 16 beats per minute for the normal group vs 124 +/- 19 beats per minute for the patients (p less than 0.0001); in age-related terms, respectively, 82 +/- 6 percent of the maximum heart rate vs 66 +/- 10 percent (p less than 0.0001). Thus, patients with chronic fatigue syndrome have normal resting cardiac function but a markedly abbreviated exercise capacity characterized by slow acceleration of heart rate and fatigue of exercising muscles long before peak heart rate is achieved.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Q fever pneumonia.
Pneumonia is one of several clinical syndromes that results from inhalation of Coxiella burnetii. This microorganism, the etiologic agent of "Q" (query) fever, infects a wide range of animals and insects. Cattle, sheep, goats, and cats are the reservoirs whereby this agent is spread to humans. High concentrations of C burnetii are present in the placenta and at parturition, the organism is shed into the environment to be inhaled by humans. Following an incubation period that ranges from four to 30 days (mean 14 days), fever, headache, malaise, and cough ensue. The clinical presentation of pneumonia may range from a mild to a severe illness--the latter with the clinical picture of rapidly progressive pneumonia. There are no characteristic features of Q fever pneumonia but the severe headache and the epidemiological history should serve as clues. Treatment with tetracycline or rifampin for two weeks usually results in cure. Many cases of Q fever pneumonia remit without antibiotic therapy. The diagnosis is usually confirmed serologically using a complement fixation or microimmunofluorescence test.
Animals↗