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Dengue fever and dengue haemorrhagic fever--a diagnostic challenge.

The number of cases of dengue fever in returning travellers is increasing worldwide. In Australia, two mosquito vectors exist and the Aedes aegypti mosquito has already been responsible for local transmission within Queensland. For these reasons, general practitioners need to be able to recognise dengue fever and its complications: dengue haemorrhagic fever (DHF) and dengue shock syndrome. Infections can vary from severe to asymptomatic. The incubation period, duration of fevers, presence of rash and relative bradycardia can assist in the diagnosis of dengue. Dengue haemorrhagic fever is a severe form of dengue fever associated with plasma leakage and specific risk factors. The risk of DHF to most travellers previously infected with dengue is probably low. Serology and reverse transcriptase polymerase chain reaction are useful tests for diagnosing infection, although both have limitations. Vaccine design is a promising strategy to prevent infection.

Adult↗

Studies on infection and immunity in experimental typhoid fever. I. Typhoid fever in chimpanzees orally infected with Salmonella typhosa.

A disease resembling human typhoid fever has been induced by feeding live cultures of Salmonella typhosa to young chimpanzees, thus confirming the classical reports of Grünbaum and of Metchnikoff and Besredka. Detailed clinical observations, results of stool and blood cultures, and serological studies have confirmed the impression that the disease produced in chimpanzees closely resembles the mild form of human typhoid fever frequently seen in childhood. Gross and histologic examination of intestines, mesenteric lymph nodes, liver, spleen, and other organs of orally infected chimpanzees has demonstrated that the pathological findings are essentially indistinguishable from those seen in mild typhoid fever in man. The clinical spectrum of disease seen in chimpanzees ranged from moderately severe illness, through transitory illness, to afebrile infection with or without bacteriemia (but invariably with an antibody response), occasionally leading to the development of persisting biliary infection and the carrier state. Thus the range of illness observed in chimpanzees resembled that seen in man, except that the severe and complicated forms of typhoid fever were not observed in the chimpanzee. A reason for this difference is proposed and discussed. In contrast to the limitations imposed upon the interpretation of human epidemiologic observations, it has been possible to demonstrate in the chimpanzee that clinical variation in disease pattern from animal to animal may occur despite the administration of the same dose of the same bacterial strain simultaneously to an entire group of animals under study; in other words, variation in clinical pattern is dependent on inherent, non-specific host factors as well as on dose, strain or preceding state of immunity. Variation in dose and in challenge strain of S. typhosa employed also appeared to have an effect upon the likelihood of producing febrile as against afebrile infection in chimpanzees. The dose required to produce clinical disease, even with the more virulent strain, was excessively large compared to what is believed to be the dose required to produce illness in man; the limitations of this assumption, and suggested explanations for the findings, are discussed. The production of the spectrum of typhoid fever in the chimpanzee has made possible the study of basic problems in this disease which are not amenable to definitive study through the use of prevailing laboratory techniques.

Animals↗

Bartonella henselae as a cause of prolonged fever and fever of unknown origin in children.

A prospective evaluation of 146 children with fever of unknown origin (FUO) and prolonged fever was performed from 1990 to 1996. FUO was defined as a documented daily temperature of > or = 38 degrees C for at least 14 days without diagnostic signs or symptoms. Prolonged fever was defined as fever for at least 14 days and no diagnosis at the time of referral for evaluation. An established diagnosis was made for 84 (57.5%) of 146 patients. The most common infectious disease diagnoses were Epstein-Barr virus infection (22 [15.1%] of 146), osteomyelitis (14 [9.6%] of 146), bartonellosis (7 [4.8%] of 146), and urinary tract infection (6 [4.1%] of 146). Three of seven patients with confirmed Bartonella henselae infection presented with FUO and no ultrasonographic findings compatible with hepatosplenic involvement; two patients presented with FUO and hepatosplenic involvement. The relatively common finding of acute bartonellosis in this population suggests that FUO and prolonged fever in children are other presentations of infection with B. henselae.

Adolescent↗

Rat bite fever misdiagnosed as Rocky Mountain spotted fever.

A patient who had been exposed to ticks and who had also been bitten by a laboratory rat developed fever, headache, and a rash. He was treated with chloramphenicol for Rocky Mountain spotted fever, and recovered. Blood cultures, however, grew Streptobacillus moniliformis, a causative agent of rat bite fever. The case report illustrates the clinical similarities between rat bite fever and Rocky Mountain spotted fever.

Adult↗

Familial Mediterranean fever and the other autoinflammatory syndromes: evaluation of the patient with recurrent fever.

PURPOSE OF REVIEW: The aim of this article is to summarize recent clinical, genetic and pathophysiologic findings of familial Mediterranean fever and several of the other systemic autoinflammatory diseases, a recently recognized group of disorders characterized by seemingly unprovoked inflammation but lacking high-titer autoantibodies. Genetic and clinical tools are improving the ability of the clinician to better approach patients with periodic fever and inflammation. RECENT FINDINGS: The spectrum of reported genetic mutations and susceptible ethnicities for the hereditary periodic fever subset of the autoinflammatory diseases has continued to expand. At the same time, the pathogeneses of many of these diseases are now understood to involve different aspects of a common pathway, largely affecting inflammatory cascades related to IL-1 or tumor necrosis factor-alpha. Three of these diseases which have been grouped as the cryopyrin-associated periodic syndromes result from defects in the same gene, and all three appear to respond well to anti-IL-1 therapy although controlled trials are still in progress. In addition, cytokine-based therapies are also now under investigation for hyperimmunoglobulinemia D with periodic fever syndrome and pyogenic sterile arthritis, pyoderma gangrenosum, and acne syndrome. SUMMARY: The identification of the genes and proteins mutated in many of the autoinflammatory diseases has broadened our understanding of the regulation of inflammation and the immune system, and provided the basis for the use of targeted therapies in these syndromes. We propose an algorithm for the evaluation of a patient with periodic fever, taking into account the patient's age, ethnicity, symptoms and signs, and results from laboratory and genetic testing.

Acne Vulgaris↗

[A case report--typhoid fever complicated with liver and gallbladder abscess, treated for long-time as fever of unknown origin].

A 25-year-old male admitted to Kawasaki municipal hospital with the diagnosis of typhoid fever. He had noticed high fever since one month ago, and had been treated with prednisolone with the diagnosis of fever of unknown origin in a hospital. Then he had admitted to St. Marianna University Hospital, and Salmonella Typhi had been detected from his blood and stool. On admission, multiple liver abscess were detected by abdominal ultrasonography. S. Typhi in bile was not eliminated with CP and AMPC, but he was successfully treated with cholecystectomy and the chemotherapy of LVFX. Abscess formation was found in the resected gall bladder wall. Typhoid nodule in the lymph node, liver or other organs is a well known pathological change in the typhoid fever. But abscess formation in the liver or other organs is rare. In this case, multiple abscess is characteristic and this cause is thought to be induced by the factors that the period from onset of typhoid fever to beginning of effective therapy was too long, and that steroid therapy was done without antibiotic therapy.

Abscess↗

Exclusion of the familial Mediterranean fever locus as a susceptibility region for autosomal dominant familial Hibernian fever.

Autosomal dominant periodic fevers constitute a range of syndromes characterised by recurrent attacks of fever and abdominal pain. Familial Hibernian fever (FHF) has been described in only one United Kingdom based family, but two other Irish families have been found with similar clinical features. FHF resembles familial Mediterranean fever (FMF) in several clinical features, but the mode of inheritance of FHF is dominant whereas FMF is recessive. We have investigated whether autosomal dominant periodic fevers, in particular FHF, map to the FMF susceptibility locus (MEFV) on chromosome 16p13.3. We have used informative microsatellite markers flanking this locus to genotype members of the three families mentioned above. Two point and multipoint lod scores definitively excluded linkage to MEFV in the two larger families. A haplotype study confirmed these findings, indicating that FHF is genotypically as well as phenotypically distinct from FMF.

Chromosomes, Human, Pair 16↗

Persistent fever as the only symptom of familial Mediterranean fever.

We describe a 54-year-old man who suffered from familial Mediterranean fever, but the fever has been the only symptom during a 10-year period. During this period, results of laboratory tests and roentgenographic studies were negative. On the basis of these findings we propose that familial Mediterranean fever can be included in the causes of persistent fever in patients with long periods of fever.

Familial Mediterranean Fever↗

[Monosymptomatic familial Mediterranean fever as the cause of fever of unknown origin].

A previously healthy 2 year old female child developed fever of unknown origin recurring in monthly cycles. The periodic fever attacks, family history and ethnologic criteria were in agreement with familial mediterranean fever, although further more major symptoms were missing. It was highly unusual to find repeatedly raised levels of angiotensin I converting enzyme, a finding previously not described in literature. Excluding any other differential diagnosis by intensive investigations, together with a positive metaraminol provocation test, the diagnosis of a rare, monosymptomatic variant of familial mediterranean fever was proposed. Amyloidosis was excluded by rectal biopsy. Monosymptomatic familial mediterranean fever is very seldom. We suggest to measure routinely angiotensin I converting enzyme for further evaluation of our findings.

Child, Preschool↗

Arboviral causes of non-specific fever and myalgia in a fever hospital patient population in Cairo, Egypt.

Fever and myalgia are non-specific clinical manifestations of illness which commonly occur in patients with arboviral disease. In Egypt, such illness is often mis-diagnosed as "influenza". To determine arboviral aetiology in patients admitted with fever and myalgia, acute and convalescent sera samples were obtained from 55 patients admitted with these clinical manifestations to the Imbaba Fever Hospital, Giza, Egypt, during October and November 1984. Based on viral isolation, and a comparison of acute and convalescent sera, 4 patients (7%) had acute arboviral infections. Haemagglutination inhibition and indirect immunofluorescence tests showed that one had West Nile virus (WNV) infection, 2 had sandfly fever virus-Naples (SFN), and 1 had sandfly fever virus-Sicilian (SFS) infection. SFN was isolated from the acute serum sample of 1 of the 2 patients with SFN infection.

Adolescent↗

[A group fever: safari's fever].

INTRODUCTION: Acute schistosomiasis, called safari's fever in Africa and Katayama fever in Japan, is an immunoallergic reaction due to transcutaneous penetration of infective cercaria. We report the collective case of seven young adults spending holidays in Mali. EXEGESIS: An eighteen years-old girl presents fever, headache, diarrhoea and abdominal pains at return from Dogon country (south of Mali). After turned down malaria and with the notion of bathing in fresh water followed by pruritus, we think to safari's fever. So we alarm all other members of the group. All can be treated to avoid chronic schistosomiasis. CONCLUSION: These observations recall that acute schistosomiasis is a real danger for tourists when bathing in fresh water in endemic areas of Africa. Education of travellers is necessary. Occurrence of safari's fever should alert physicians to prevent chronic schistosomiasis.

Adolescent↗

Risk factors for recurrent fever after the discontinuation of empiric antibiotic therapy for fever and neutropenia in pediatric patients with a malignancy or hematologic condition.

We studied episodes of fever and neutropenia in children and adolescents without documented infections to determine the risk of recurrent fever after early discontinuation of empiric antibiotic therapy; 213 episodes occurred in 106 patients. All patients received empiric antibiotic therapy after cultures were obtained. Antibiotic therapy was discontinued if no infection was found, culture results were negative for 48 hours, and the patient was afebrile for 24 hours. In 83 episodes without documented infection, antibiotic therapy was stopped with absolute neutrophil counts < 0.5 x 10(9)/L (< 500/mm3); 50 episodes occurred in patients with solid tumors, leukemia in remission, and other hematologic conditions (group 1), and 33 in patients with active leukemia (group 2). Fever recurred before neutropenia resolved in 6% of group 1 and 45% of group 2 episodes; five patients in group 2 had documented infection. Recurrent fever risk correlated with absolute neutrophil count and monocyte count at the time antibiotic therapy was stopped, in both groups, as did increasing absolute neutrophil count and increasing leukocyte count in group 2. We conclude that discontinuing antibiotic therapy is safe in febrile episodes without documented infections before neutropenia resolves in patients with high potential for bone marrow recovery. The risk of recurrent fever and infection is significant for patients with neutropenia and poor marrow recovery potential.

Adolescent↗

Serosurvey among Mediterranean spotted fever patients of a new spotted fever group rickettsial strain (Bar29).

Mediterranean spotted fever is an endemic disease in Catalonia, Spain. A new spotted fever group (SFG) rickettsial strain (Bar29) of unknown pathogenicity for humans was isolated by our group, in 1996, from the dog brown tick, Rhipicephalus sanguineus. Interestingly, Rickettsia conorii was not isolated in this study. The aim of the present study was to assess the possible pathogenic role of the Bar29 strain. To this purpose, serum samples from 15 patients with Mediterranean spotted fever were obtained and tested by immunofluorescence for antibodies against four related rickettsial strains (R. conorii, R. africae, R. massiliae, and Bar29). Eight of the studied sera reacted at high titers with only R. conorii and Bar29 antigens. For five of the eight sera, the titers against Bar29 were clearly higher than for R. conorii. Four of these sera were also studied by Western blot immunoassay to confirm a specific response. Two of these sera reacted with the high-molecular-mass specific proteins of Bar29 as well as with the low-molecular-mass region (LPS antigen) whereas their reactions with R. conorii were located only on bands of the LPS. This specific response would support the possible pathogenic role of the Bar29 strain for humans. According to this finding, spotted fever caused by R. conorii and rickettsial strain Bar29 may be present in our area. The epidemiological implications of spotted fever caused by R. conorii and by rickettsial strain Bar29 in the Catalonia deserve further studies with isolation and characterization of more rickettsial strains.

Adolescent↗

Variation in immune response genes and chronic Q fever. Concepts: preliminary test with post-Q fever fatigue syndrome.

Acute primary Q fever is followed by various chronic sequelae. These include subacute Q fever endocarditis, granulomatous reactions in various organs or a prolonged debilitating post-infection fatigue syndrome (QFS). The causative organism, Coxiella burnetii, persists after an initial infection. The differing chronic outcomes may reflect variations within cytokine and accessory immune control genes which affect regulation of the level of persistence. As a preliminary test of the concept we have genotyped QFS patients and controls for gene variants spanning 15 genes and also examined HLA-B and DR frequencies. QFS patients exhibited a significantly increased frequency of HLA-DR-11 compared with controls and also significant differences in allelic variant frequencies within the NRAMP, and IFNgamma genes. These results indicate a possible genetic role in the expression of overt chronic Q fever. Further studies will be undertaken to increase sample sizes, to survey other forms of chronic Q fever and to examine Q fever patients who have recovered without sequelae.

Cation Transport Proteins↗

Studies on the pathogenesis of fever. VIII. Fever-producing substances in the serum of dogs.

Intravenous administration of bacterial endotoxins in dogs is followed within 2 hours by the appearance of a fever-producing substance in the blood. This endogenous pyrogen differs from the endotoxins originally administered by its ability to produce fever in tolerant recipients and failure to promote tolerance after repeated daily injections. Endogenous serum pyrogen is destroyed by heating at 90 degrees C. for 30 minutes, and is also inactivated to some degree by incubation at 37 degrees C. for 24 hours. Suppression of fever by aminopyrine does not affect appearance of the endogenous factor. Animals made febrile with dinitrophenol, kaolin, or lysergic acid do not elaborate a fever-promoting substance in the blood. Sterile abscesses, accompanied by elevations in body temperature of the host, are unassociated with detectable amounts of secondary pyrogen in the serum. The absence of endogenous pyrogen in the blood of febrile dogs made leukopenic with nitrogen mustard favors the idea that polymorphonuclear leukocytes injured by endotoxins release the endogenous factor. On the other hand, the finding that the granulocytopenic animals are febrile when no circulating endogenous pyrogen is present, casts doubt upon the essential role of this substance in endotoxin fever.

Animals↗

An economic evaluation of increased uptake in Q fever vaccination among meat and agricultural industry workers following implementation of the National Q Fever Management Program.

INTRODUCTION: Q fever is a serious but vaccine-preventable infectious disease that predominantly affects those working in the meat and agricultural industries. In October 2000, the Commonwealth Government introduced the National Q Fever Management Program. This economic evaluation assesses the cost-effectiveness and cost-utility of improved vaccine uptake among meat and agricultural industry workers. METHODS: Separate analyses were conducted for meat and agricultural industry workers. Clinical and epidemiological data used to create the models were obtained from published sources. Markov modelling was used to estimate the impact of Q fever vaccination uptake on the direct costs and outcomes of Q fever over a 20-year period. RESULTS: Increasing vaccine uptake from 65% to 100% among meat industry workers results in an incremental cost per life year gained of $20,002, and a cost per QALY of $6,294. Increasing vaccine uptake from zero to 20% among agricultural industry workers results in an incremental cost per life year gained of $24,950, and a cost per QALY of $7,984. Including some indirect costs in the form of Workcover payments results in cost savings for both industry groups. CONCLUSION: The results of this evaluation indicate that public health strategies to enhance the uptake of Q fever vaccine among high-risk workers potentially provides excellent value for the money invested.

Adult↗

Increases in the levels of Coxiella burnetii-specific immunoglobulin G1 and G3 antibodies in acute Q fever and chronic Q fever.

A detailed analysis of the humoral response to Coxiella burnetii may provide insight into the pathogenesis of Q fever, a zoonosis caused by C. burnetii. The subclasses of C. burnetii-specific antibodies were determined by immunofluorescence in 20 patients with acute Q fever and 20 patients with chronic Q fever. Although immunoglobulin G1 (IgG1) and IgG3 antibodies were found in acute and chronic Q fever, neither IgG2 nor IgG4 was detected. The detection of IgG1 and IgG3 antibodies was not due to an increase of the IgG1 and IgG3 subclasses. Moreover, IgG1 and IgG3 antibodies were not correlated, suggesting that they may play different roles in Q fever.

Acute Disease↗

Role of fever in infection: has induced fever any therapeutic potential in HIV infection?

Ancient societies had no rational understanding of fever. The Greeks were the first to recognise that it may be part of nature's method of effecting cure in some diseases. How best to assist nature went through many trials and errors. Appreciation of the prognostic value of fever and how it may be controlled was slow to appear. That there was a place in the therapeutic arsenal for induced fever came only with the 20th century. Finding a suitable, safe, and satisfactory means came slowly. The curative power of well controlled and reproducible levels of fever was proved by the arrest of one deadly and incurable complication of a sexually transmitted disease in the first half of this century. The purpose of this review is to promote discussion and, hopefully, well ordered laboratory and clinical trials aimed at learning whether or not induced fevers have a place in the care of patients with HIV/AIDS.

Animals↗