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PubMedDate not supplied

[Peripheral lymphadenopathy in childhood--recommendations for diagnostic evaluation].

BACKGROUND: Enlargement of peripheral lymph nodes most commonly caused by a local inflammatory process is frequently seen in childhood. The aim of the present study was to analyze the most common causes of peripheral lymphadenopathy and to develop a simple algorithm for the primary diagnostic evaluation of peripheral lymph node enlargement in this age group. PATIENTS: Between April and September 1999 87 unselected children (median age: 5 1/2 years) with peripheral lymphadenopathy were referred to the Department of Pediatrics, University of Graz, for further investigation. RESULTS: EBV infection was diagnosed in 20 (23.0%) children. 19 (21.8%) patients had acute bacterial lymphadenitis. In 21 (24.1%) patients lymph node enlargement was classified as "post/parainfectious (viral)". Four patients each had toxoplasmosis and cat scratch disease. In 11 (12.6%) patients neither physical nor laboratory examinations revealed pathologic results. Among the remaining 8 children sarcoidosis and Hodgkin disease was diagnosed in one patient each. Small, soft, mobile, nontender, cervical, axillary or inguinal lymph nodes do not require further investigations. In case of enlarged, tender lymph nodes with overlying skin erythema and fever diagnostic evaluation should include complete blood count, erythrocyte sedimentation rate and/or c-reactive protein level, supplemented by appropriate antibody testing (EBV, CMV, Toxoplasma gondii, Bartonella henselae). Firm, enlarged, painless lymph nodes which are matted together and fixed to the skin or underlying tissues necessitate a more detailed diagnostic evaluation in order to exclude malignant or granulomatous diseases. CONCLUSIONS: Our study demonstrated that primary diagnostic evaluation of childhood peripheral lymphadenopathy is mainly based on clinical grounds. In most cases a small number of additionally performed laboratory tests allow to correctly identify the cause of the peripheral lymph node enlargement.

Adolescent↗
PubMed2001

Excessive tumor-elaborated VEGF and its neutralization define a lethal paraneoplastic syndrome.

Vascular endothelial growth factor (VEGF) is a potent endothelial cell mitogen and key regulator of both physiologic and pathologic (e.g., tumor) angiogenesis. In the course of studies designed to assess the ability of constitutive VEGF to block tumor regression in an inducible RAS melanoma model, mice implanted with VEGF-expressing tumors sustained high morbidity and mortality that were out of proportion to the tumor burden. Documented elevated serum levels of VEGF were associated with a lethal hepatic syndrome characterized by massive sinusoidal dilation and endothelial cell proliferation and apoptosis. Systemic levels of VEGF correlated with the severity of liver pathology and overall clinical compromise. A striking reversal of VEGF-induced liver pathology and prolonged survival were achieved by surgical excision of VEGF-secreting tumor or by systemic administration of a potent VEGF antagonist (VEGF-TRAP(R1R2)), thus defining a paraneoplastic syndrome caused by excessive VEGF activity. Moreover, this VEGF-induced syndrome resembles peliosis hepatis, a rare human condition that is encountered in the setting of advanced malignancies, high-dose androgen therapy, and Bartonella henselae infection. Thus, our findings in the mouse have suggested an etiologic role for VEGF in this disease and may lead to diagnostic and therapeutic options for this debilitating condition in humans.

Animals↗
PubMed1998

Lacrimal gland involvement in Kikuchi-Fujimoto disease.

PURPOSE. A 32-year-old Saudi female presented with typical Kikuchi-Fujimoto disease, i.e., fever, cervical lymphadenitis and leukopenia, but there was also painful upper eyelid swelling with pain on upgaze. METHODS. A connective tissue disease and lymphoma workup were unremarkable, as were antibody titers to Apifia felis and Bartonella henselae. RESULTS. Orbital computed tomography showed significant lacrimal gland enlargement. Cervical node biopsy revealed necrotizing lymphadenitis. CONCLUSION. Concomitant lacrimal gland inflammation and cervical lymphadenopathy may be a benign self-limited disease.

Journal Article↗
PubMed2003

Cloning and characterization of an outer membrane protein (Lip18) from Helicobacter bizzozeronii.

A recombinant lambda-Zap II phage was selected by screening a genomic library of Helicobacter bizzozeronii (Hb) using antibodies from a naturally infected cat. DNA sequencing resulted an open reading frame containing 172 codons with a predicted molecular mass of 18 kDa (Lip18). The amino acid sequence showed 22.1, 55.2, 56.7 and 57.1% identity to peptidoglycan-associated lipoprotein of Helicobacter pylori, Agrobacterium tumefaciens, Bartonella bacilliformis, respectively. A peptidoglycan associating alpha-helical motif (LALGQRRSVAVRDYLVS) was located in the C-terminal region. H. bizzozeronii contains a potential lipoprotein signal peptide cleavage site (Val-Val-Gly-Cys), and yields a predicted mature protein with 148 amino acids. The Lip18 was localized into the outer membrane of the bacteria. Immunoblot analysis of serum samples from a dog and cat naturally infected with Helicobacter spp was able to recognize the purified recombinant Lip18.

Amino Acid Motifs↗
PubMedDate not supplied

Joint and bone infections due to anaerobic bacteria in children.

The current review describes the microbiology, diagnosis and management of septic arthritis and osteomyelitis due to anaerobic bacteria in children. Staphylococcus aureus, Haemophilus influenzae type-b, and Group A streptococcus, Streptococcus pneumoniae, Kingela kingae, Neisseria meningiditis and Salmonella spp are the predominant aerobic bacteria that cause arthritis in children. Gonococcal arthritis can occur in sexually active adolescents. The predominant aerobes causing osteomyelitis in children are S. aureus, H. influenzae type-b, Gram-negative enteric bacteria, beta-hemolytic streptococci, S. pneumoniae, K. kingae, Bartonella henselae and Borrelia burgdorferi. Anaerobes have rarely been reported as a cause of these infections in children. The main anaerobes in arthritis include anaerobic Gram negative bacilli including Bacteroides fragilis group, Fusobacterium spp., Clostridium spp. and Peptostreptococcus spp. Most of the cases of anaerobic arthritis, in contrast to anaerobic osteomyelitis, involved a single isolate. Most of the cases of anaerobic arthritis are secondary to hematogenous spread. Many patients with osteomyelitis due to anaerobic bacteria have evidence of anaerobic infection elsewhere in the body, which is the source of the organisms involved in osteomyelitis. Treatment of arthritis and osteomyelitis involving anaerobic bacteria includes symptomatic therapy, immobilization in some cases, adequate drainage of purulent material and antibiotic therapy effective to these organisms.

Arthritis, Infectious↗
PubMed2000

Detection of selected fastidious bacteria.

The intent of this article is to describe the optimal methods for culture recovery of 7 fastidious bacteria: Legionella species, Brucella species, Francisella tularensis, Leptospira species, Borrelia burgdorferi, Bartonella species, and Bordetella species. These organisms share much in common beyond the fact that their genus names all end in the letter "a." Culture recovery of these organisms, even from adequate clinical specimens, is logistically demanding, often costly, and lacking in both timeliness and sensitivity. In addition, there is generally no need to recover culture isolates on which to perform antimicrobial susceptibility tests because these 7 bacteria are nearly uniformly susceptible to specific, clinically useful antimicrobial agents and because, for some of them, susceptibility tests of proven reliability have not yet been devised. Perhaps for these reasons, alternative, more rapid, direct diagnostic approaches have been developed that are based on either immunochemical or nucleic-acid detection methods. These methods have generally served to supplant culture as a primary diagnostic modality. Situations exist, however, in which culture may be desirable, if not necessary, to establish a definitive diagnosis of infection with these 7 organisms. This review attempts to summarize how best to proceed in those cases.

Bacteriological Techniques↗
PubMed2003

In search of encephalitis etiologies: diagnostic challenges in the California Encephalitis Project, 1998-2000.

The California Encephalitis Project was initiated in June 1998 to identify the causes and characterize the clinical and epidemiologic features of encephalitis in California. Testing for >or=13 agents, including herpesviruses, enteroviruses, arboviruses, Bartonella species, Chlamydia species, and Mycoplasma pneumoniae, was performed at the Viral and Rickettsial Disease Laboratory (Richmond, California). Epidemiologic and clinical information collected for each case guided further testing. From June 1998 through December 2000, 334 patients who met our case definition of encephalitis were enrolled. A confirmed or probable viral agent of encephalitis was found in 31 cases (9%), a bacterial agent was found in 9 cases (3%), and a parasitic agent was found in 2 cases (1%). A possible etiology was identified in 41 cases (12%). A noninfectious etiology was identified in 32 cases (10%), and a nonencephalitis infection was identified in 11 (3%). Despite extensive testing and evaluation, the etiology of 208 cases (62%) remained unexplained.

California↗
PubMed1999

Survey of three bacterial louse-associated diseases among rural Andean communities in Peru: prevalence of epidemic typhus, trench fever, and relapsing fever.

Typhus and other louse-transmitted bacterial infections in Peruvian sierra communities are known to occur but have not recently been assessed. In this study, 194 of 1,280 inhabitants of four villages in Calca Province in the Urubamba Valley were included. Thirty-nine (20%) of the 194 volunteers had antibodies to Rickettsia prowazekii, whereas 24 (12%) had antibodies to Bartonella quintana and 2 against Borrelia recurrentis. There was a significant correlation between the presence of infesting ectoparasites and antibodies to R. prowazekii, as well as between antibodies to R. prowazekii and ectoparasite infestation and fever in the previous 6 months. The proportion of inhabitants infested with ectoparasites was significantly higher in the highest-altitude village than in the other three villages. Two volunteers' antibody levels suggested a recent typhus infection, but only B. quintana DNA was amplified from lice. Epidemic typhus remains extant in the area, and B. quintana infections were encountered and documented for the first time in South America.

Adult↗
PubMed1999

The body louse as a vector of reemerging human diseases.

The body louse, Pediculus humanus humanus, is a strict human parasite, living and multiplying in clothing. Louse infestation is associated with cold weather and a lack of hygiene. Three pathogenic bacteria are transmitted by the body louse. Borrelia recurrentis is a spirochete, the agent of relapsing fever, recently cultured on axenic medium. Historically, massive outbreaks have occurred in Eurasia and Africa, but currently the disease is found only in Ethiopia and neighboring countries. Bartonella quintana is now recognized as an agent of bacillary angiomatosis bacteremia, trench fever, endocarditis, and chronic lymphadenopathy among the homeless. Rickettsia prowazekii is the agent of epidemic typhus. The most recent outbreak (and the largest since World War II) was observed in Burundi. A small outbreak was also reported in Russia in 1997. Louse infestation appears to become more prevalent worldwide, associated with a decline in social and hygienic conditions provoked by civil unrest and economic instability.

Animals↗
PubMed1999

Changing epidemiology of infections in patients with neutropenia and cancer: emphasis on gram-positive and resistant bacteria.

Over the past 3 decades, considerable changes have occurred in the types of bacteria causing infection in febrile patients with neutropenia and cancer. Twenty years ago, gram-negative bacteria caused approximately 70% of bloodstream infections. As a probable consequence of long-dwelling intravascular devices, fluoroquinolone prophylaxis, and high-dose chemotherapy-induced mucositis, there has been a shift toward gram-positive coccal bacteremia. In most centers today, approximately 70% of bacteremic isolates are gram-positive cocci. Of potential concern is that antimicrobial-resistant gram-positive organisms are becoming increasingly frequent in patients with neutropenia. Fluoroquinolone-resistant Escherichia coli are being isolated from several cancer centers. Several "new" organisms, such as Stomatococcus mucilaginosus, Bacillus cereus, Leuconostoc species, Corynebacterium jeikeium, Rhodococcus species, Stenotrophomonas maltophilia, Moraxella catarrhalis, Burkholderia cepacia, and Bartonella species, now cause infections in these patients. Careful application of infection-control principles, judicious prophylaxis, appropriate evaluation of new antibiotics, and prompt effective therapy will maximize benefits for these patients.

Anti-Bacterial Agents↗
PubMed2003

Characterization of the ftsZ gene from Ehrlichia chaffeensis, Anaplasma phagocytophilum, and Rickettsia rickettsii, and use as a differential PCR target.

Degenerate primers corresponding to highly conserved regions of previously characterized ftsZ genes were used to PCR amplify a portion of the ftsZ gene from the genomic DNA of Ehrlichia chaffeensis (ftsZ(Ech)), Anaplasma phagocytophilum (ftsZ(Ap)), and Rickettsia rickettsii (ftsZ(Rr)). Genome walking was then used to amplify the 5' and 3' termini of the genes. The DNA sequences of the resulting amplification products yielded open reading frames coding for proteins with molecular masses of 42.0, 45.7, and 48.3 kDa for A. phagocytophilum, E. chaffeensis, and R. rickettsii, respectively. These homologs are 20 to 70 amino acids longer than the FtsZ proteins characterized in bacteria such as Escherichia coli and Bacillus subtilis, but do not possess the large extended carboxyl-termini found in the FtsZ proteins of Bartonella, Rhizobium, and Agrobacterium species. The functional domains important for FtsZ activity are conserved within the ehrlichial and rickettsial FtsZ protein sequences. The R. rickettsii FtsZ sequence is highly homologous to the FtsZ protein previously described for Rickettsia prowazekii (89% identity), and identical to the FtsZ protein of Rickettsia conorii. The percent identity observed between the A. phagocytophilum and E. chaffeensis FtsZ proteins is only 79% and is particularly low in the carboxyl-terminal region (15.8% identity). Primers were designed to PCR amplify a portion of the variable carboxyl-terminal region of the ftsZ gene, and used to differentiate each agent based on the size of the amplicons: A. phagocytophilum, 278 bp; E. chaffeensis, 341 bp; and Rickettsia spp., 425 bp.

Amino Acid Sequence↗
PubMed2002

Epidemiology and impact of coinfections acquired from Ixodes ticks.

Ixodes scapularis and other ticks in the Ixodes ricinus complex may transmit multiple pathogens, but research on coinfections has been limited. Coinfections occur with varying frequency in ticks, but single infections are more common than dual infections. The proportion of I. scapularis or I. ricinus ticks coinfected with both Borrelia burgdorferi sensu lato and Anaplasma phagocytophila is generally low, ranging from < 1% to 6% in six geographic areas. A higher prevalence of tick coinfection (26%) has been reported in Westchester County, New York. Genetic variants of the human disease-causing strain of A. phagocytophila are present in some tick populations, and they may affect the risk of coinfection or clinical illness. The proportion of Ixodes ticks coinfected with B. burgdorferi and Babesia microti has ranged from 2% in New Jersey to 19% on Nantucket Island, Massachusetts. In humans, cross-sectional seroprevalence studies have found markers of dual infection in 9-26% of patients with a tick-borne infection, but such studies often fail to distinguish simultaneous coinfection from sequential infections. Several studies have prospectively assessed the occurrence of acute coinfection. Among patients with a confirmed tick-borne infection, coinfection rates as high as 39% have been reported. The most commonly recognized coinfection in most of the eastern United States is Lyme borreliosis (LB) and babesiosis, accounting for approximately 80% of coinfections. LB and human granulocytic ehrlichiosis coinfections are less common, occurring in 3-15% of patients with a tick-borne infection in Connecticut or Wisconsin. Studies of clinical outcomes suggest that patients with acute Babesia coinfection have more severe symptoms and a longer duration of illness than patients with LB alone, but the risk of spirochete dissemination is similar. Coinfections can modify the immune response and alter the severity of arthritis in animal models. Future coinfection research should focus on long-term clinical outcomes, the role of genetic variants, immunologic effects, and the potential role of Bartonella species as tick-borne pathogens.

Animals↗
PubMed2002

Comparative genomics of microbial pathogens and symbionts.

We are interested in quantifying the contribution of gene acquisition, loss, expansion and rearrangements to the evolution of microbial genomes. Here, we discuss factors influencing microbial genome divergence based on pair-wise genome comparisons of closely related strains and species with different lifestyles. A particular focus is on intracellular pathogens and symbionts of the genera Rickettsia, Bartonella and BUCHNERA: Extensive gene loss and restricted access to phage and plasmid pools may provide an explanation for why single host pathogens are normally less successful than multihost pathogens. We note that species-specific genes tend to be shorter than orthologous genes, suggesting that a fraction of these may represent fossil-orfs, as also supported by multiple sequence alignments among species. The results of our genome comparisons are placed in the context of phylogenomic analyses of alpha and gamma proteobacteria. We highlight artefacts caused by different rates and patterns of mutations, suggesting that atypical phylogenetic placements can not a priori be taken as evidence for horizontal gene transfer events. The flexibility in genome structure among free-living microbes contrasts with the extreme stability observed for the small genomes of aphid endosymbionts, in which no rearrangements or inflow of genetic material have occurred during the past 50 millions years (1). Taken together, the results suggest that genomic stability correlate with the content of repeated sequences and mobile genetic elements, and thereby indirectly with bacterial lifestyles.

Alphaproteobacteria↗
PubMed2004

Guidelines for the antibiotic treatment of endocarditis in adults: report of the Working Party of the British Society for Antimicrobial Chemotherapy.

The BSAC Guidelines on Endocarditis were last published in 1998. The Guidelines presented here have been updated and extended to reflect changes in both the antibiotic resistance characteristics of causative organisms and the availability of new antibiotics. Randomized, controlled trials suitable for the development of evidenced-based guidelines in this area are still lacking, and therefore a consensus approach has again been adopted. The Guidelines cover diagnosis and laboratory testing, suitable antibiotic regimens and causative organisms. Special emphasis is placed on common causes of endocarditis, such as streptococci and staphylococci, however, other bacterial causes (such as enterococci, HACEK organisms, Coxiella and Bartonella) and fungi are considered. The special circumstances of prosthetic endocarditis are discussed.

Anti-Bacterial Agents↗
PubMed1999

Cat-scratch disease causing status epilepticus in children.

Status epilepticus from cat-scratch encephalopathy is often recalcitrant to usual therapies, causing treatment to focus on critical care management of the patient that may require aggressive interventions, such as continuous pentobarbital administration. We describe two children whose initial clinical presentation of cat-scratch disease was status epilepticus with normal cerebrospinal fluid studies. A history of cat exposure (specifically, kitten and/or fleas), regional lymphadenopathy, and a papule or inoculation site should be sought, but are not essential for diagnosis. The presumptive diagnosis of cat-scratch disease can be made by serology alone even in the absence of classic diagnostic criteria. Our two cases and other reports in the literature show a favorable prognosis in most cases, despite the occurrence of status epilepticus. The diagnosis of cat-scratch disease should be strongly considered in all children with unexplained status epilepticus or encephalopathy and serologic testing for Bartonella henselae should be done.

Cat-Scratch Disease↗
PubMed2005

Epidemiology of cat-scratch disease hospitalizations among children in the United States.

BACKGROUND: Cat-scratch disease (CSD), caused by infection with Bartonella henselae, affects both children and adults but is principally a pediatric disease. Typical CSD is generally benign and self-limited and is characterized by regional lymphadenopathy with fever. Infections can, however, be accompanied by focal or diffuse inflammatory responses (atypical CSD) involving neurologic, organ (liver/spleen), lymphatic or skeletal systems. METHODS: Pediatric hospitalizations with CSD listed as a diagnosis were examined using the Kids' Inpatient Database for the year 2000. National estimates of CSD-associated hospitalizations, hospitalization rates and various hospitalization statistics were examined for patients younger than 18 years of age. RESULTS: During 2000, an estimated 437 (SE 43) pediatric hospitalizations associated with CSD occurred among children younger than 18 years of age in the United States. The national CSD-associated hospitalization rate was 0.60/100,000 children younger than 18 years of age (95% confidence interval, 0.49-0.72) and 0.86/100,000 children younger than 5 years of age (95% CI 0.64-1.07). Accompanying diagnoses included neurologic complications (12%), organ (liver/spleen) involvement (7%) and "other" (5%). Atypical CSD accounted for approximately 24% of the CSD-associated hospitalizations. The median charge for a CSD-associated hospitalization was 6140 dollars with total annual hospital charges of approximately 3.5 million dollars among children in the United States. CONCLUSIONS: The CSD-associated hospitalization rate among children during 2000 appeared similar to those estimated for the 1980s in the United States, despite significant increases in cat ownership in the intervening time. Early serologic and molecular testing for CSD in children is suggested to minimize unnecessary interventions and promote optimally effective care when supportive measures are required.

Adolescent↗
PubMed2003

The X-linked hyper-IgM syndrome: clinical and immunologic features of 79 patients.

The X-linked hyper-IgM (XHIGM) syndrome is an uncommon primary immunodeficiency disease caused by mutations in the gene for CD40 ligand and characterized by normal or elevated serum IgM, reduced levels of IgG and IgA, and defective T-cell function. Because of its rarity, it has been difficult for any single investigator or institution to develop a comprehensive clinical picture of this disorder. Accordingly, a national registry was developed in the United States to provide demographic, genetic, immunologic, and clinical information on a relatively large number of patients with the XHIGM syndrome.A total of 79 patients from 60 unrelated families were registered between January 1997 and July 2002. The estimated minimal incidence was approximately 1/1,030,000 live births. All of the patients had significant IgG deficiency and most had IgA deficiency, but only one-half had elevated IgM levels. Most patients presented initially with a history of an increased susceptibility to infection including Pneumocystis carinii pneumonia. The average age of diagnosis was significantly earlier in patients born into a family with a previously affected individual. However, only one-third of the patients born into a family with a previously affected individual were diagnosed exclusively because of the presence of the positive family history before any clinical symptoms developed. Over half the patients developed symptoms of immunodeficiency and were diagnosed by 1 year of age, and over 90% by 4 years of age. The most prominent clinical infections were pneumonia (81% of patients), upper respiratory infections (49%) including sinusitis (43%) and recurrent otitis (43%), recurrent/protracted diarrhea (34%), central nervous system infections (14%), sepsis (13%), cellulitis (13%), hepatitis (9%), and osteomyelitis (1%). In addition to infections caused by encapsulated bacteria, opportunistic infections were relatively common and were caused by P. carinii, members of the herpes virus family (including cytomegalovirus), Cryptosporidium, Cryptococcus, Candida, Histoplasma, and Bartonella. Sclerosing cholangitis occurred in 5 patients and in 4 of these was associated with Cryptosporidium infection. Eight patients had died at the time of their entry into the Registry; 2 of pneumonia (1 P. carinii and 1 cytomegalovirus), 2 of encephalitis (1 ECHO virus and 1 cytomegalovirus), 2 of malignancy (both hepatocellular carcinoma), 1 of sclerosing cholangitis caused by Cryptosporidium, and 1 of hemolytic uremic syndrome.

Adolescent↗
PubMed2003

Etiologic diagnosis of 204 pericardial effusions.

The etiologic evaluation of pericardial effusion is frequently unsuccessful when noninvasive methods are used. To determine the cause of the current episode, all patients with echographically identified pericardial effusion from May 1998 to December 2002 underwent noninvasive diagnostic testing of blood, throat, and stool samples. Patients with postpericardiotomy syndrome were excluded. To analyze the value of our tests, we tested randomly selected blood donors as negative controls. Among 204 included patients, 107 (52.4%) had a final etiologic diagnosis: the etiology of 52 was highly suspected at first examination and later confirmed (thyroid deficiency, 5 cases; systemic lupus erythematous, 7; rheumatoid arthritis, 7; scleroderma, 3; cancer, 25; and renal insufficiency, 5). A definite etiologic diagnosis was made in 11 patients from pericardial fluid analysis (cancer, 5 cases; tuberculosis, 3; Streptococcus pneumoniae, Citrobacter freundii, and Actinomyces, 1 case each). Among 141 patients considered to have idiopathic pericarditis, 44 (32.1%) gained an etiologic diagnosis by our systematic testing strategy. This included serologic evaluation of serum (Coxiella burnetii, 10 cases; Bartonella quintana, 1; Legionella pneumophila, 1; Mycoplasma pneumoniae, 4; influenza virus, 1), viral culture of throat swabs (enterovirus, 8 cases; and adenovirus, 1), high-level antinuclear antibodies (>1/400, 3 cases), and thyroid-stimulating hormone (15 abnormal results). Antibodies to Toxoplasma and cytomegalovirus, enterovirus recovered from rectal swabs, and low-level antinuclear antibodies were seen with equal frequency in patients and controls. Using our evaluation strategy, the number of pericardial effusions classified as idiopathic was less than in other series. Systematic testing for Q fever, Mycoplasma pneumoniae, thyroid abnormalities, and antinuclear antibodies, accompanied by viral throat cultures, frequently enabled us to diagnose diseases not initially suspected in patients with pericardial effusion.

Adolescent↗