CORRELATION OF GENITO-URINARY AND GENERAL TUBERCULOSIS

Genito-urinary tuberculosis is considered to be a local manifestation of a generalized tuberculous infection which, for all practical purposes, has gained entrance to the body through the respiratory tract. Even though clinical or roentgenographic evidence of the pulmonary infection is found in only a small percentage of cases, the problem must be attacked as a whole.Indolent or inactive disease in other parts of the body may become reactivated as the result of surgical intervention or severe complicating infection.The importance of thorough general antituberculosis treatment in every case cannot be overemphasized.     

Evaluation of a Direct Agglutination Test for Detection of Antibodies Against Toxoplasma gondii in Cat,Pig and Sheep Sera

The protozoan parasite Toxoplasma gondii is the causative agent of the zoonosis toxoplasmosis. In sheep and goats, it is one of the most prevalent causes of infectious abortion. Also in pregnant women, a primary infection can result in miscarriage. Humans acquire the infection either by ingestion of oocysts excreted by cats, the definitive host of the parasite, or by eating raw or undercooked meat from latently infected animals (Dubey & Beattie 1988). In Sweden, toxoplasmosis is a notifiable disease, and cases of clinical disease in humans as well as animals must be reported. In both veterinary and human medicine serological assays based on detecting the humoral antibody response of the host against the parasite are used as diagnostic tools. So far, solid phase assays, such as the indirect fluorescent antibody test (IFAT) and the enzyme-linked immunosorbent assay (ELISA), have been widely used to diagnose T. gondii infection in many species including cats, pigs and sheep (Dubey & Beattie 1988). However, both IFAT and ELISA require appropriate anti-species specific immunoglobulins (Ig) that must be carefully evaluated for each species prior to use. This makes these assays complicated and time consuming. Consequently, alternative, simpler methods that do not require specific antisera would be of great value. The direct agglutination test (DA), which is based on the principle that formalin-treated organisms agglutinate in the presence of specific IgG antibodies, is such an assay (Fulton & Turk 1959). The DA-test is widely used in human medicine as a screening test for T gondii infection but it has not yet been thoroughly evaluated for use in veterinary medicine (Uggla & Buxton 1990).     

Pasteurella Pseudotuberculosis Infection in Man

Pasteurella pseudotuberculosis has been considered a widespread animal pathogen for many years, but only within the last decade has its capacity to cause human disease been recognized. Two forms of human disease have been established—acute septicemia and mesenteric lymphadenitis. Because mesenteric adenitis is frequently indistinguishable from acute appendicitis, blood serum was obtained from 66 consecutive patients who underwent operation for appendicitis and was examined for agglutinins to seven serotype strains of P. pseudotuberculosis. Agglutinins were obtained in 21.2% of this series. Titres of over 1/100 were found in three of three cases of mesenteric lymphadenitis, one of 11 with no apparent disease, and one of 46 with appendicitis. P. pseudotuberculosis was isolated from a lymph node in the latter case. Two to four follow-up samples of sera in each of these five cases had increasing and then decreasing titres, indicative of active disease. Titres of 1/15 or less were found in five of the cases of appendicitis, in one case of salpingitis, and in three with no apparent disease. The occurrence of these nine cases with low titres may be indicative of previous contact with the organism.Human infection with P. pseudotuberculosis is not unusual in the Edmonton region and is responsible for at least some cases of mesenteric lymphadenitis.     

Chronic pulmonary sporotrichosis

We report a case of chronic human pulmonary sporotrichosis which was not associated with superficial manifestations involving the skin or lymph nodes. As it is difficult to verify an etiology, it is possible that some undiagnosed pulmonary granulomas could represent pulmonary sporotrichosis of the chronic type. These may have been treated for other diseases, such as a mycobacterial infection as in this case. Since the immunodiffusion test is a simple procedure and is almost always positive in chronic disease, its greater utilization should help in defining this disease more frequently. The skin test, agglutination test and culture are variably useful as documented in the literature.Sporotrichosis is a common mycotic infection which is usually confined to the skin and superficial lymph nodes. In disseminated disease, the lung is very rarely involved. Pulmonary sporotrichosis then represents a second form of primary infection though less common than the lymphocutaneous disease. Scott et al. (18) reported two cases of pulmonary sporotrichosis. Ridgeway et al. (15) at about the same time reviewed the previously reported cases up to 1962 and concluded that 12 of the cases could be accepted as sporotrichosis and added two cases of their own. Subsequently, Siegrist & Ferrington (20) and Trevathan & Phillips (23) each reported a case. Presently, approximately 50 cases have been reported in the United States (1–10, 12, 13, 16). Chronic and acute involvement have been delineated by Ridgeway et al. (15) It is believed that the following case represents one of primary pulmonary sporotrichosis of the chronic type without manifest involvement of other organs.     

The dynamics of simultaneous infections with altered susceptibilities

We describe a model in which individuals can be infected simultaneously by multiple diseases or parasites, taking into account the fact that individuals already infected by a subset of n co-circulating diseases may see their susceptibility to concurrent infection by another disease from the pool either enhanced or reduced. We propose an n-dimensional approximation to the 2n dimensional model required to describe the dynamics of each possible subset of the pool of n co-circulating diseases, using as state variables the overall prevalence of each infection. Analysis of the two disease case shows that the reduced model provides a very good approximation throughout the full dynamics for small alterations of susceptibility, and, after a transient error, a good approximation to the complete model when susceptibilities are highly enhanced. As the number of diseases becomes large, the approximation remains close for small alterations of susceptibility.     

NONCARDIAC SURGERY COMBINED WITH CORONARY ARTERY BYPASS

The coexistence of coronary artery disease with noncardiac disease often leads to a dilemma in planning therapeutic procedures. This problem is especially difficult in the presence of accelerated angina or left coronary artery stenosis. A series of 17 patients is presented in which coronary artery bypass grafts were combined with noncardiac operations without mortality or significant morbidity. An illustrative case report shows the interrelated nature of the coexisting disorders. The conclusion of this study is that, at times, various surgical procedures should be combined with coronary artery bypass grafting for a smoother, less complicated recovery. However, there are no hard and fast rules dictating combined procedures; each operation must be planned according to the existing conditions and needs of the individual patient.     

Spectrum of tuberculosis in patients with HIV infection in British Columbia: report of 40 cases.

OBJECTIVE: To review the clinical features, treatment and outcome of all known cases of tuberculosis in patients with human immunodeficiency virus (HIV) infection in British Columbia between 1984 and 1990. DESIGN: Retrospective case review. SETTING: Provincial tuberculosis registry and university-affiliated HIV clinic. PATIENTS: All people with HIV infection in whom active tuberculosis was diagnosed during the study period. RESULTS: All 40 patients identified were men; their mean age was 38 years. Of the subjects 30 (75%) were homosexual, 6 (15%) were homosexual and used intravenous drugs, 2 (5%) just used intravenous drugs, and 1 (2%) had had heterosexual contact with prostitutes; for the remaining subject the risk factor for HIV infection was not established. In all cases cultures of specimens from 15 body sources yielded Mycobacterium tuberculosis. Thirty-five of the patients had acquired immunodeficiency syndrome (AIDS), and five had HIV infection uncomplicated except for tuberculosis. In 28 (70%) of the cases no AIDS-defining disease had previously been diagnosed, and in 23 (58%) extrapulmonary tuberculosis represented the AIDS-defining disease. Symptoms at presentation included weight loss (in 80% of the cases), fever (in 75%), cough (in 70%) and night sweats (in 55%). The mean CD4 lymphocyte count was 0.2 x 10(9)/L (in 15 cases). Tuberculin skin test results were positive in 8 of 16 cases. The most striking radiologic finding was intrathoracic adenopathy. All except one of the 36 patients who received appropriate treatment responded favourably at first. Adverse reactions necessitating changes in treatment occurred in 12 (33%) of the cases. Relapse occurred after completion of therapy in two cases (one at 3 weeks and the other at 9 months after treatment was stopped). Tuberculosis was the cause of death in five cases. CONCLUSIONS: Tuberculosis in people with HIV infection commonly presents as extrapulmonary disease and precedes or coincides with other AIDS-defining opportunistic infections. In most cases tuberculosis is the AIDS-defining disease. Even though radiologic findings are often unusual physicians should suspect tuberculosis. A careful examination for evidence of disease at multiple sites should be done. The duration and choice of therapy must be adequate to avoid relapse.     

Human cytomegalovirus end-organ disease is associated with high or low systemic viral load in preemptively treated solid-organ transplant recipients

Human cytomegalovirus (HCMV) end-organ disease in solid-organ transplant recipients (SOTR) may be associated with either high or low HCMV load in blood. In transplantation Centers where the preemptive therapy approach is adopted, antiviral therapy of systemic HCMV infections is initiated upon reaching pre-determined cut-off levels of viral DNA in blood, whereas no guidelines are provided for local end-organ infection/disease. In the latter case, clinicians often start antiviral treatment without defining the etiology of local symptoms. Here, we describe 14 cases of SOTR, in which a documented HCMV end-organ disease was observed. Nine patients had a systemic viral load lower than the cut-off for preemptive therapy and were treated based on viral load of local HCMV disease. The remaining five patients had a systemic viral load greater than the preemptive therapy cut-off and were efficiently treated for both the systemic and the local HCMV disease. Thus, HCMV infection in the post-transplant period must be monitored virologically both in blood and locally. End-organ disease in preemptively treated patients, seems to be associated with lack of development (primary HCMV infection) or reconstitution (reactivated infection) of HCMV-specific CD4+ and CD8+ T-cell immunity or with its functional impairment.     

Variant CJD

It is now 18 years since the first identification of a case of vCJD in the UK. Since that time, there has been much speculation over how vCJD might impact human health. To date there have been 177 case reports in the UK and a further 51 cases worldwide in 11 different countries. Since establishing that BSE and vCJD are of the same strain of agent, we have also shown that there is broad similarity between UK and non-UK vCJD cases on first passage to mice. Transgenic mouse studies have indicated that all codon 129 genotypes are susceptible to vCJD and that genotype may influence whether disease appears in a clinical or asymptomatic form, supported by the appearance of the first case of potential asymptomatic vCJD infection in a PRNP 129MV patient. Following evidence of blood transfusion as a route of transmission, we have ascertained that all blood components and leucoreduced blood in a sheep model of vCJD have the ability to transmit disease. Importantly, we recently established that a PRNP 129MV patient blood recipient with an asymptomatic infection and limited PrP^Sc deposition in the spleen could readily transmit disease into mice, demonstrating the potential for peripheral infection in the absence of clinical disease. This, along with the recent appendix survey which identified 16 positive appendices in a study of 32 441 cases, underlines the importance of continued CJD surveillance and maintaining control measures already in place to protect human health.     

Blood Loss During Pediatric Operations

The gravimetric method of measuring blood loss was used during all types of pediatric operations at The Montreal Children''s Hospital. Results of 1787 such measurements indicated that the method is of value in the management of transfusion. Grading blood loss as minor, moderate or severe, in terms of its relation to total blood volume or body weight is a procedure of practical value. Operations were grouped into those that usually led to a loss of less than 10% of the blood volume (7.5 ml./kg.), those with a loss usually between 10% and 14% and those with blood loss usually over 14% (10.5 ml./kg.), in order that appropriate plans for transfusion could be made to reduce the incidence of serious hypovolemia without fear of cardiovascular overloading. Blood loss at operation (adenotonsillectomy) was noted to vary considerably among surgeons but was fairly constant for each surgeon and seemed to be independent of the surgeon''s experience. Two alleged hemostatic agents, adrenochrome carbazone (Statimo) and estrogenic substances (Premarin), were not effective in reducing the amount of blood lost during adenotonsillectomy. The importance of calculation of approximate equivalent amounts of blood at various ages of childhood is emphasized.     

Classification of Rhinoentomophthoromycosis into Atypical,Early, Intermediate,and Late Disease: A Proposal

Background

Rhinoentomophthoromycosis, or rhino-facial conidiobolomycosis, is a rare, grossly disfiguring disease due to an infection with entomophthoralean fungi. We report a case of rhinoentomophthoromycosis from Gabon and suggest a staging system, which provides information on the prognosis and duration of antifungal therapy.

Methods

We present a case of rhinoentomophthoromycosis including the histopathology, mycology, and course of disease. For the suggested staging system, all cases on confirmed rhinoentomophthoromycosis published in the literature without language restriction were eligible. Exclusion criteria were missing data on (i) duration of disease before correct diagnosis, (ii) outcome, and (iii) confirmation of entomophthoralean fungus infection by histopathology and/or mycology. We classified cases into atypical (orbital cellulitis, severe pain, fever, dissemination), early, intermediate, and late disease based on the duration of symptoms before diagnosis. The outcome was evaluated for each stage of disease.

Findings

The literature search of the Medpilot database was conducted on January 13, 2014, (updated on January 18, 2015). The search yielded 8,333 results including 198 cases from 117 papers; of these, 145 met our inclusion criteria and were included in the final analysis. Median duration of treatment was 4, 3, 4, and 5 months in atypical, early, intermediate, and late disease, respectively. Cure rates were clearly associated with stage of disease and were 57%, 100%, 82%, and 43% in atypical, early, intermediate, and late disease, respectively.

Conclusion

We suggest a clinical staging system that underlines the benefit of early case detection and may guide the duration of antifungal treatment. The scientific value of this classification is its capacity to structure and harmonize the clinical and research approach towards rhinoentomophthoromycosis.     

THE SIGNIFICANCE OF INFECTION IN ALLERGIC DISEASE—Its Influence on Diagnosis and Management

The presence of infection in allergic disease produces a confused picture in which two different causative factors must be clearly separated by the physician if he is to treat the patient successfully. The effects of infection are not consistent. There are situations, as seen in infectious diseases, where symptoms of allergic disease are temporarily relieved and others where the infection may intensify or precipitate the allergic condition. It is likewise important to recognize the complications superimposed upon allergic disease by infection. In such cases, control of the infection is as dependent upon control of the allergy as it is upon antibiotics.     

THE SIGNIFICANCE OF INFECTION IN ALLERGIC DISEASE-Its Influence on Diagnosis and Management

The presence of infection in allergic disease produces a confused picture in which two different causative factors must be clearly separated by the physician if he is to treat the patient successfully. The effects of infection are not consistent. There are situations, as seen in infectious diseases, where symptoms of allergic disease are temporarily relieved and others where the infection may intensify or precipitate the allergic condition. It is likewise important to recognize the complications superimposed upon allergic disease by infection. In such cases, control of the infection is as dependent upon control of the allergy as it is upon antibiotics.     

Mandibular herpes zoster; with report on the use of cortisone in a case with geniculate ganglion symptoms

Herpes zoster, an acute specific viral infection, occurs more commonly than is generally supposed. It should be differentiated from other diseases involving the ear and skin; it must be considered as a possible etiologic agent in some palsies of the facial, glossopharyngeal or vagal nerves. The type of cephalic herpes zoster should be carefully differentiated; cases involving the "geniculate zone" may be other than "Ramsay Hunt's syndrome." This syndrome is now defined as a herpes zoster eruption of the external ear at the "geniculate zone" with involvement of the seventh or seventh and eighth nerves. The "topognostic" method is the best for determining the level at which the facial nerve has been affected. It is questioned whether there is a single outstanding therapeutic agent for this disease. Cortisone had no apparent therapeutic effect in a case reported herein.     

Family Rubella Study in Los Angeles

A prospective study was initiated before the expected rubella epidemics in 1964 and 1965 in Los Angeles. Seventy-six families were evaluated by means of rubella complement fixing (cf) antibodies. The cf test, which has notable limitations, was chosen as a serologic test because it was possible to secure repeated samples of sera from all members of the families if venipuncture could be avoided.Definite evidence of clinical or serological rubella occurred in 13 of 399 persons enrolled in 1964, an attack rate of 3.3 percent. Four persons had clinical rubella only, five had clinical disease with seroconversion and four had seroconversion only. The ratio of apparent to unapparent disease was nine to four.There were four key families, each of which had more than one individual with definite clinical or serological evidence of rubella, suggesting that clustering of rubella cases does occur in families having an index case. In these families three types of intra-family spread were demonstrated: (1) all affected members had clinical disease, (2) all those affected had only inapparent disease, and (3) both apparent and inapparent disease in the same family.     

TETANUS—Prophylaxis and Treatment of the Disease

Cleansing and debridement is paramount in dealing with tetanus-prone wounds (severe crushing injuries, piercing wounds, blisters and burns are outstanding examples, particularly if contaminated with dirt, grass or other debris).Prophylaxis then is relatively easy in persons who have been actively immunized by toxoid injections. For them, a “booster” injection is indicated.Use of antitoxin, however, is hazardous, whether for prophylaxis or for treatment of the disease. Since it may in itself cause severe disease, including anaphylactic reaction and serum sickness, decision to use it must be weighed against the possibility of the development of tetanus in each case.To prepare for use of it, careful history should be taken, with particular reference to sensitivity to horse dander. Dermal tests, and perhaps ophthalmic tests, for sensitivity to the serum should be carried out. Even the tests may be hazardous and precautions should be taken accordingly.If it is decided that the use of antitoxin is necessary even though the patient is sensitive to the material, desensitization must be carried out promptly, with adequate preparation for severe reaction.There is experimental evidence that antibiotics of the tetracycline group, given soon after injury, may have prophylactic effect against tetanus.     

Primary postpartum hemorrhage

Postpartum hemorrhage is the outstanding cause of maternal mortality, and a redoubtable contributor to puerperal death from other causes, notably infection and renal failure. The clinical situations in which hemorrhage is liable to occur must be better known, so that anticipatory and preventive measures can be taken. Recent knowledge about defibrinated blood in women with degenerative changes at the placental site must be incorporated in the thinking and practice of physicians dealing with obstetrical cases. The indications, limitations, and hazards of the various anesthetic methods available for parturient women should be carefully considered in the circumstances of each case.     

PRIMARY POSTPARTUM HEMORRHAGE

Postpartum hemorrhage is the outstanding cause of maternal mortality, and a redoubtable contributor to puerperal death from other causes, notably infection and renal failure. The clinical situations in which hemorrhage is liable to occur must be better known, so that anticipatory and preventive measures can be taken. Recent knowledge about defibrinated blood in women with degenerative changes at the placental site must be incorporated in the thinking and practice of physicians dealing with obstetrical cases. The indications, limitations, and hazards of the various anesthetic methods available for parturient women should be carefully considered in the circumstances of each case.     

Neurological effects of American trypanosomyiasis: clinical aspects

Trypanosoma cruzi, causative agent of Chagas disease, affects not only cardiac and intestinal structures but also neurological structures. A high prevalence of T. cruzi infection occurs in Colombia, prompting the present study. First, a qualitative metaanalysis was undertaken using the PubMed database, the electronic internet engine Altavista, Colombian journals indexed by Colciencias, and three relevant textbooks. The following key words were used: Trypanosoma, Chagas disease, nervous system, spinal cord, central nervous system, peripheral nervous system, neuromuscular junction, autonomic nervous system, muscle, muscle disorders, neuromuscular disease, neuromuscular disorders, synapticopathies and dysautonomia. The documents analyzed numbered 116 and included original papers, reviews, case reports, editorials, brief communications, conferences and book chapters. At minimum, each document included data involving ELISA testing, indirect immunofluorescense, or parasitemia levels in the clinical, serological or histopathological studies. Polymerase chain reaction (PCR) studies were not included because of the recent introduction of PCR as a confirmatory technique for Chagas disease in Colombia. Chagas disease affects the central, the peripheral and the autonomic nervous system in humans, although its effects on the antonomic system is most commonly investigated in Colombia. Neurological lesions must be evaluated carefully, because patients may be misdiagnosed and treated as carriers of 'idiopathic' diseases. Neurological pathologies poses a serious threat in Colombia due to the prevalence of Chagas disease.     

Complications of tonsillectomy and adenoidectomy in 9409 children observed overnight.

In attempts to minimize the cost of health care, physicians are reducing the duration of hospital stay. Traditionally, at the Hospital for Sick Children, Toronto, otherwise healthy children undergoing adenoidectomy, tonsillectomy or adenotonsillectomy have been admitted the morning of surgery and discharged from hospital at 7 am the next day. The nursing records of 9409 patients aged 17 years or less who were managed in this way between 1980 and 1984 were reviewed to determine the occurrence of complications during the observation period. A total of 202 patients (2.15%) bled during the observation period. Of the 202, 6 (0.06% of all the patients) required a second general anesthetic for hemostasis; 1 of these 6 patients and 5 others required blood transfusions. Discharge was delayed for 42 patients (0.45% of all the patients) because of postoperative bleeding and for 57 patients (0.6%) for a variety of other reasons. Delayed discharge for reasons other than hemorrhage was more frequent among children less than 2 years of age and those over 12 years of age. The authors concluded that children undergoing adenoidectomy could safely be discharged the same day after 6 hours of observation following surgery. However, as a substantial number of children bled from the tonsillar fossa more than 6 hours after surgery, the efficacy of periodic examination of the oral cavity during the observation period in reducing the rate of hemorrhage after 6 hours must be evaluated before a same-day discharge program is established for children undergoing adenotonsillectomy.