Kawasaki disease,or mucocutaneous lymph node syndrome: report of seven cases in North America.

The clinical and laboratory findings in seven children with Kawasaki disease are reviewed. Four of the patients had the more complicated course that has characterized the cases diagnosed in North America. This suggests that the benign forms are often mistaken for other febrile illnesses. The patients were two girls and five boys ranging in age from 4 months to 7 years; six were Caucasian and one was a North American Indian. Fever, redness of the oral mucosa, an erythematous or scarlatiniform rash and cervical adenopathy were seen in all; six patients had the characteristic fingertip desquamation and nonexudative conjunctivitis. Cardiac involvement occurred in four patients, two of whom had coronary artery aneurysm or thrombosis. Arthritis or arthralgia was seen in six patients, and aseptic meningitis occurred in four. Of the three patients with jaundice two underwent laparotomy and excision of a hydropic gallbladder; one of them died from Klebsiella pneumoniae sepsis and disseminated intravascular coagulopathy.     

Listeriosis at Vancouver General Hospital, 1965-79.

The records were reviewed of all patients treated at the Vancouver General Hospital over the 15 years from 1965 through 1979 for infections proved by culture to have been caused by Listeria monocytogenes. Although listeriosis is not common in humans, certain groups seem to be susceptible - immunocompromised patients, pregnant women, neonates and the elderly. All these groups were represented among the 22 cases reviewed. There were 17 adults, 3 of whom were pregnant women who had only a mild influenza-like illness. Of the remaining 14 adults 9 were immunocompromised and 5 apparently immunocompetent; 7 presented with meningitis and 7 with bacteremia only. Of the five infants with neonatal listeriosis, two had early-onset disease (bacteremia) and three had the late-onset form (meningitis). Seven patients were treated with penicillin alone, seven with ampicillin alone and eight with penicillin or ampicillin combined with kanamycin, gentamicin or chloramphenicol. There were eight deaths: several were directly attributable to the listeriosis, but in others the severity of the underlying illness was an important factor. Serotypes 1 and 4b were equally common among the 16 specimens of L. monocytogenes that were typed.     

BACTERIAL MENINGITIS AND OTHER DISEASES AFFECTING THE MENINGES—A Review of 349 Cases

Three hundred and forty-nine cases of disease affecting the meninges were observed at the San Bernardino County Charity Hospital in an eight year period.A total of 29 patients with meningococcal, H. influenzae and pneumococcal meningitis were treated. There were four deaths, of which three occurred during the first 24 hours in the hospital.Of 22 cases of unclassified meningitis, four probably were tuberculous, four probably were meningococcal and two probably were of virus origin.Under present treatment programs the differentiation between viral and bacterial meningitides is difficult and it is possible, therefore, that the reported incidence of the two groups may not represent the facts.Of 22 cases of unclassified meningitis, 12 had no specific characteristics which would permit a clinical diagnosis. One of the patients died.Of 70 cases of clinical meningitis, the infecting organism was identified in 69 per cent.Meningococcal meningitis made up only 17 per cent of 70 cases of purulent meningitis observed between July 1, 1945, and July 1, 1948.     

Bacterial meningitis and other diseases affecting the meninges; a review of 349 cases

Three hundred and forty-nine cases of disease affecting the meninges were observed at the San Bernardino County Charity Hospital in an eight year period.A total of 29 patients with meningococcal, H. influenzae and pneumococcal meningitis were treated. There were four deaths, of which three occurred during the first 24 hours in the hospital. Of 22 cases of unclassified meningitis, four probably were tuberculous, four probably were meningococcal and two probably were of virus origin. Under present treatment programs the differentiation between viral and bacterial meningitides is difficult and it is possible, therefore, that the reported incidence of the two groups may not represent the facts. Of 22 cases of unclassified meningitis, 12 had no specific characteristics which would permit a clinical diagnosis. One of the patients died. Of 70 cases of clinical meningitis, the infecting organism was identified in 69 per cent. Meningococcal meningitis made up only 17 per cent of 70 cases of purulent meningitis observed between July 1, 1945, and July 1, 1948.     

Staphylococcus aureus meningitis: 26 years' experience at Vancouver General Hospital.

The records of all patients with Staphylococcus aureus meningitis admitted to Vancouver General Hospital between 1956 and 1981 were reviewed. All the patients had clinical and laboratory features of meningitis, and in all cases S. aureus was isolated from the cerebrospinal fluid. S. aureus was responsible for 21 (3%) of the 710 cases of acute bacterial meningitis. Therapy with cloxacillin or methicillin, or both, with or without other agents, was successful in 14 of the 21 patients. Three of the 14 patients without ventricular shunts died, 2 with fulminating septicemia and 1 with a postoperative brain abscess treated with cloxacillin. Following shunt removal and antibiotic therapy all seven patients with ventricular shunts survived the infection. Shunt removal may therefore be essential in appropriate cases.     

Treatment of Nelson's syndrome by pituitary implantation of yttrium-90 or gold-198.

Eight patients with Nelson''s syndrome were treated with a pituitary implant of yttrium-90 or gold-198 four to 16 years after adrenal surgery. All had considerable pigmentation. One already had cranial nerve abnormalities and visual field defects and had had both a craniotomy and deep x-ray treatment. Radiographs showed that the pituitary fossa was abnormal in seven patients. A biopsy performed in six cases showed mucoid (or basophil) adenoma in all. In the four specimens examined ACTH was identified by electron microscopy or immunofluorescence, or both. Patients were followed up after pituitary implantation for three months to 12 years. All showed decreased pigmentation, and six became normal. Four patients regained normal ACTH levels and the other two studied had decreased levels. In no case did new cranial nerve disease or further sellar expansion develop since operation, and two patients showed remodelling of the sella. Complications were temporary leakage of cerebrospinal fluid and diabetes insipidus in one patient and gonadotrophin deficiency in another.     

Plague Meningitis—A Retrospective Analysis of Cases Reported in the United States, 1970-1979

Meningitis caused by Yersinia pestis developed in 6 (6%) of a total of 105 patients with plague reported to the Centers for Disease Control from 1970 to 1979. Five of the six cases occurred in children aged 10 to 15 years. All six patients received antibiotic therapy before meningitis developed, which appeared between the 9th and 14th days after the onset of acute illness in five of the six patients. There were no neurologic sequelae. The antigenic and biochemical profiles of the Y pestis strains isolated from cerebrospinal fluid in the meningitis cases did not differ from those of the Y pestis strains obtained from blood and bubo aspirates in the other 99 patients, and neither did in vitro studies suggest antibiotic resistance. While plague meningitis is an uncommon complication of acute plague infection, physicians in the western United States should be aware that it may develop as much as 14 days after antibiotic therapy for the acute plague infection has been initiated.     

Meningitis in diabetic patients

Community acquired bacterial (CBM) meningitis in diabetic patients was analyzed for risk factors and outcome in a cohort of 201 cases of meningitis within last 17 years: 15 patients with diabetes mellitus and meningitis were identified and compared for etiology and mortality as well as for neurologic sequellae with all CBM cases.     

A clinical trial of chronic care diabetic clinics in general practice in the United Arab Emirates: a preliminary analysis

Control of diabetes mellitus is a high priority for primary health care systems. One innovative method of diabetes care delivery is the use of structured diabetes care in primary care. This includes the use of chronic care diabetes clinics or mini-clinics operated by general practitioners in primary care. There is limited experience with this model in non-Western settings. This study sought to evaluate a multi-component structured approach to diabetes care in primary care including chronic care diabetes clinics in a newly developed country in the Arabian Gulf. The study design used was a controlled before-after methodology. Three primary health centers were chosen for the intervention with six of the remaining clinics in a Health District being used as controls. A multifaceted intervention was initiated in the intervention clinics composed of chronic care diabetes clinics, a diabetic flow chart, and educational programs for clinic nurses and doctors and patients. The study intervention took place over a period of 18 months with three diabetic outcomes (fasting blood glucose, blood pressure and cholesterol) and adherence to seven diabetes guidelines being compared for the year prior to the intervention and during the last 12 months of the intervention period. Knowledge and satisfaction questionnaires were also administered to intervention and control subjects at the end of the study. In this study, 219 subjects were enrolled (130 males and 89 females). They had a mean age of 51.6 years and a mean of 3.1 years of formal education. Of these 109 were enrolled in one of three clinics that had a chronic care diabetes clinic and 110 were enrolled in one of the six control clinics. Subjects had diabetes for a mean of 7.8 +/- 4.8 years and the majority was treated with pharmacological therapy. Baseline characteristics in the intervention and the control clinics were similar with the exception of younger age (p = 0.01) and a trend for more males (p = 0.06) in the intervention clinics. There was a statistically insignificant change noted with the intervention in the three clinical outcomes studied (fasting blood glucose, blood pressure and cholesterol) both in comparison to the control group before and after and within the intervention group. However most changes noted were in the expected direction of improvement; six of the seven guidelines were statistically improved in the intervention group when compared with the control group. Within the intervention group, adherence with five of seven guidelines was also statistically significantly increased with the remaining guidelines showing a trend in favor of improvement (fasting blood glucose measurements (p = 0.07) and urine determinations for protein (p = 0.07)). Knowledge questionnaire scores were similar between the intervention and control groups on completion of the study but 2 of 4 items on a satisfaction scale were statistically significantly higher in the intervention group. The intervention described in this setting was successful in improving adherence to diabetes guidelines and increased some aspects of satisfaction with diabetes care. The intervention did not result in a statistically significant improvement in clinical outcomes but changes noted were in the expected direction of improvement. The significant improvement in adherence to diabetes guidelines suggests that this intervention is a promising model for diabetes care for newly developed countries.     

Meningitis in the central Arctic: a 4-year experience.

There were 37 cases of meningitis during a 4-year period among the native and white populations served by the Churchill Health Centre in northern Manitoba, an annual incidence of 128 per 100 000 in the overall population and of 202 per 100 000 among the Inuit. Bacterial meningitis predominated; Neisseria meningitidis and Haemophilus influenzae each accounted for one third of the cases. There were five deaths, and 14 of the survivors had severe sequelae. Therefore, although the doctors and nurses involved in the study had improved access to telecommunication and air transportation services in caring for patients in isolated northern settlements, and despite their efforts to be vigilant for possible cases of meningitis and to begin vigorous treatment early, the incidence, morbidity and mortality of this disease remained relatively high, particularly among the Inuit.     

Myocardial Infarction and Carbohydrate Metabolism Relating to Diabetes Mellitus

Fifteen non-obese males with acute myocardial infarction and no diabetic history were evaluated for diabetes. During infarction, results of oral glucose tolerance tests were “diabetic” or “probably diabetic” in 10 of the 15 patients (67 percent). The plasma immuno-reactive insulin response in 12 patients (80 percent) was of a pattern observed in patients with maturity-onset diabetes. Six months after infarction, follow-up glucose tolerance tests in 12 surviving patients were diabetic or probably diabetic in three cases (25 percent). In seven of twelve patients (58 percent) had delay in the peaking of the plasma insulin response to an oral glucose tolerance test, a phenomenon that is observed in patients with maturity-onset diabetes.Glucose tolerance tests were abnormal in one of fourteen control subjects (7 percent). There was a delayed plasma insulin response to an oral glucose test in two of fourteen controls (14 percent).Patients with myocardial infarction have an increased incidence of diabetes mellitus.     

Cardiac Manifestations During a Coxsackie B5 Epidemic

During a widespread Coxsackie B5 epidemic which occurred in Finland in the autumn of 1965 18 patients with acute myopericarditis were admitted to Kuopio Central Hospital (530 beds, representing a hospital district with 270,000 inhabitants) within a period of three months.The mean age of these patients was 28 years. Twelve were males and six were females.In 12 cases Coxsackie B5 virus and in one case Coxsackie A9 virus were isolated from the faeces. A significant increase in neutralizing antibodies or high antibody titres (≥1:128) were noted in 16 cases against Coxsackie B5 and in one case against Coxsackie A9. In two cases the cause of the myopericarditis remained obscure.All the patients had fever. Six showed all classical criteria of pericarditis: chest pain, pericardial rub, E.C.G. changes, and radiologically observable enlargement of the heart. As regards the various criteria, E.C.G. changes were found in all cases. Signs of cardiac tamponade were observed in one patient. Five, in addition, showed aseptic meningitis.All the patients recovered. Twelve were re-examined at an average of seven months after discharge from hospital. All were symptom-free except one, who still showed E.C.G. changes.     

Mumps and Enteroviral Meningitis in Toronto, 1966

Of 52 children admitted to hospital for apparently typical mumps meningitis in 1966, 50 had their cerebrospinal fluid (CSF) examined. In only 17 was the mumps virus isolated from the CSF. Mumps antihemagglutinin conversions or increments were detected in 32 subjects including 10 whose CSF yielded virus. Antibody conversions were found in 16 patients and fourfold increments in another nine whose serum pairs were collected only one to four days apart. Initial sera from 20 patients were obtained three days or less after the onset of meningitis. Antibody increments were frequently noted about one day after defervescence and clinical improvement. Interferon was detected in CSF from two of eight patients, both of whom yielded virus. Enteroviruses were isolated from CSF and/or feces in seven of 15 cases of aseptic meningitis which occurred between July and October. Six patients including three virus excretors showed enteroviral neutralizing antibody increments during convalescence. The dominant enteroviral serotype was coxsackievirus A9.     

Predictors of inferior outcome in community acquired bacterial meningitis

The aim of this study was to assess mortality and sequellae within cases from Nationwide survey of community acquired meningitis and identify risk factors for inferior outcome. Risk factors such as underlying disease (diabetes mellitus, cancer, trauma, neonatal age, splenectomy, alcoholism, sepsis, other infections), etiology, clinical symptoms and outcome (death, improvement and cured after modifications of ATB therapy, cured without change of therapy, cured with neurologic sequellae) were recorded and analysed with univariate analysis (chi2 or t test for trends, CDC Atlanta 2004). Analysing risk factors for inferior outcome (death or cured with neurologic sequellae), we compared patients who died or survived with neurologic sequellae to all patients with community acquired bacterial meningitis. Univariate analysis showed that trauma (p<0.05), alcohol abuse (p<0.05), diabetes, S. aureus (p<0.05) and gram-negative etiology (A. baumannii, Ps. aeruginosa or Enterobacteriaceae) (36% vs. 11,9%, p<0.05) were predicting inferior outcome. Analysing risk factors for treatment failure (death or failed but cured after change of antibiotic treatment) prior sepsis (34.1% vs. 13.9%, p<0.01) and gram-negative etiology (25% vs. 11.9%, p<0.02) were statistically significant predictors of treatment failure. Neisseria meningitis had less failures (p<0.05). Concerning infection associated mortality again diabetes mellitus (p<0.05), alcoholism (p<0.05) staphylococcal and gram-negative etiology (p<0.05) were significant predictors of death. N. meningitis had surprisingly less treatment failures (appropriate and rapid initial therapy). Neurologic sequellae were more common in patients with alcohol abuse (p<0.05), craniocerbral trauma (p<0.05) and less common in meningitis with pneumococcal etiology (p<0.05).     

结核性脑膜炎与化脓性脑膜炎脑脊液与血浆生化指标比值的比较研究

目的:比较结核性脑膜炎与化脓性脑膜炎脑脊液与血浆生化指标比值。方法:选择2010年2月~2014年12月我院结核性脑膜炎患者82例,化脓性脑膜炎98例,检测脑脊液与血浆中的蛋白、糖及氯化物含量,并计算比值。结果:两组患者脑脊液蛋白、糖含量的差异无统计学意义(P0.05),化脓性脑膜炎组的氯化物含量高于结核性脑膜炎组(P0.05);两组血浆糖含量的差异无统计学意义(P0.05),化脓性脑膜炎组蛋白和氯化物含量明显高于结核性脑膜炎组(P0.05);化脓性脑膜炎组蛋白比值低于结核性脑膜炎组,氯化物比值则高于化脓性脑膜炎组,差异均有统计学意义(P0.05);两组间糖比值比较,差异无统计学意义(P0.05)。结论:脑脊液与血浆生化指标比值对鉴别诊断结核性脑膜炎与化脓性脑膜炎有重要意义。     

Interferon in the Cerebrospinal Fluid of Children with Central Nervous System Disorders

Interferon was detected in the cerebrospinal fluid (CSF) of 26 of 51 children with aseptic meningitis, two of 44 with bacterial meningitis, and four of 118 with miscellaneous conditions including encephalitis, convulsive disorders and leukemia with neurological involvement. The geometric mean titre of interferon in mumps meningitis was seven to eight times higher than that in enteroviral meningitis; however, levels of interferon were not related to the concentration of leukocytes in CSF from these patients. Interferon titres were relatively greater at the height of the febrile response in children with mumps meningitis or enteroviral meningitis. There was no association between the presence of interferon in the CSF and the isolation of mumps virus or an enterovirus from the same specimen. Patients frequently developed homologous antibody one to three days after signs of aseptic meningitis, obscuring the relationship of interferon production to clinical improvement.     

Scrub Typhus Meningitis in South India — A Retrospective Study

Background

Scrub typhus is prevalent in India although definite statistics are not available. There has been only one study on scrub typhus meningitis 20 years ago. Most reports of meningitis/meningoencephalitis in scrub typhus are case reports

Methods

A retrospective study done in Pondicherry to extract cases of scrub typhus admitted to hospital between February 2011 and January 2012. Diagnosis was by a combination of any one of the following in a patient with an acute febrile illness- a positive scrub IgM ELISA, Weil-Felix test, and an eschar. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits.

Results

Sixty five cases of scrub typhus were found, and 17 (17/65) had meningitis. There were 33 males and 32 females. Thirteen had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 54 cells/µL, 98%, 88 mg/dL, 0.622 and 3.5 U/mL respectively. Computed tomography was normal in patients with altered sensorium and cranial nerve deficits. Patients with meningitis had lesser respiratory symptoms and signs and higher urea levels. All patients had received doxycycline except one who additionally received chloramphenicol.

Conclusion

Meningitis in scrub typhus is mild with quick and complete recovery. Clinical features and CSF findings can mimic tuberculous meningitis, except for ADA levels. In the Indian context where both scrub typhus and tuberculosis are endemic, ADA and scrub IgM may be helpful in identifying patients with scrub meningitis and in avoiding prolonged empirical antituberculous therapy in cases of lymphocytic meningitis.     

Risk Factors for Invasive Cryptococcus neoformans Diseases: A Case-Control Study

Background

Cryptococcus neoformans is a ubiquitous environmental fungus that can cause life-threatening meningitis and fungemia, often in the presence of acquired immunodeficiency syndrome (AIDS), liver cirrhosis, diabetes mellitus, or other medical conditions. To distinguish risk factors from comorbidities, we performed a hospital-based, density-sampled, matched case-control study.

Methods

All new-onset cryptococcal meningitis cases and cryptococcemia cases at a university hospital in Taiwan from 2002–2010 were retrospectively identified from the computerized inpatient registry and were included in this study. Controls were selected from those hospitalized patients not experiencing cryptococcal meningitis or cryptococcemia. Controls and cases were matched by admission date, age, and gender. Conditional logistic regression was used to analyze the risk factors.

Results

A total of 101 patients with cryptococcal meningitis (266 controls) and 47 patients with cryptococcemia (188 controls), of whom 32 patients had both cryptococcal meningitis and cryptococcemia, were included in this study. Multivariate regression analysis showed that AIDS (adjusted odds ratio [aOR] = 181.4; p < 0.001), decompensated liver cirrhosis (aOR = 8.5; p = 0.008), and cell-mediated immunity (CMI)-suppressive regimens without calcineurin inhibitors (CAs) (aOR = 15.9; p < 0.001) were independent risk factors for cryptococcal meningitis. Moreover, AIDS (aOR = 216.3, p < 0.001), decompensated liver cirrhosis (aOR = 23.8; p < 0.001), CMI-suppressive regimens without CAs (aOR = 7.3; p = 0.034), and autoimmune diseases (aOR = 9.3; p = 0.038) were independent risk factors for developing cryptococcemia. On the other hand, diabetes mellitus and other medical conditions were not found to be risk factors for cryptococcal meningitis or cryptococcemia.

Conclusions

The findings confirm AIDS, decompensated liver cirrhosis, CMI-suppressive regimens without CAs, and autoimmune diseases are risk factors for invasive C. neoformans diseases.     

Type I (insulin dependent) diabetes: a disease of slow clinical onset?

Type I (insulin dependent) diabetes is usually believed to present acutely and it is assumed that metabolic decompensation is sudden. In a prospective family study, however, 10 of 13 subjects developing the disease showed progressive or intermittent development of hyperglycaemia over many months and the others had non-specific symptoms over a long period. All were first degree relatives of a child with type I diabetes; 10 were siblings (aged 5-24) and three were parents (aged 45-58). All possessed HLA-DR4 or DR3, or both, and all but two had been positive for islet cell antibodies for six to 86 months before diagnosis. Ten had non-specific symptoms for two to 14 months before the onset of thirst and polyuria; one remained asymptomatic even when insulin became necessary. Six subjects had an oral glucose tolerance test before clinical onset, of whom five were diabetic by World Health Organisation criteria four, four, six, seven, and 21 months before insulin was needed. Nine showed random blood glucose concentrations above the 97.5th centile (6.3 mmol/l) six to 34 months (median 12) before diagnosis. Two others had a glucose tolerance test result compatible with diabetes but had not reached the stage of needing insulin. Hyperglycaemia is often of insidious onset in type I diabetes, even in children and young adults. Diagnosis will inevitably be late if considered only when acute symptoms of thirst and polyuria develop.     

Diabetes in tropical Africa: a prospective study, 1981-7. I. Characteristics of newly presenting patients in Dar es Salaam,Tanzania, 1981-7.

OBJECTIVE--To study the clinical characteristics of newly diagnosed diabetic patients in tropical Africa. DESIGN--Prospective study of all newly diagnosed diabetic patients registered at a major urban hospital between 1 June 1981 and 31 May 1987. SETTING--Muhimbili Medical Centre, Dar es Salaam, Tanzania. PATIENTS--1250 Patients: 874 men, 376 women. RESULTS--272 (21.8%) Patients had diabetes requiring insulin, 825 (66.0%) had diabetes not requiring insulin, and 153 (12.2%) had diabetes of uncertain type. Most patients (1103, 88.2%) presented with the classic symptoms of diabetes. The peak time of presentation of diabetic patients requiring insulin was at age 15 to 19 years. Male manual workers and peasant farmers with diabetes not requiring insulin presented at a significantly older age and had a lower body mass index than sedentary office workers. Forty six (18.1%) of the patients requiring insulin diabetes and 111 (14.4%) not requiring insulin had first degree relative with diabetes. Twenty seven per cent of patients were underweight (body mass index less than 20 kg/m2) and 14.6% were obese (body mass index greater than 30 kg/m2). Hypertension was diagnosed in 211 (26.7%) of 791 patients not requiring insulin. Nine (3.3%) of those requiring insulin may have had the protein deficient type of diabetes related to malnutrition. The fibrocalculous variety of diabetes related to malnutrition was not observed. CONCLUSIONS--Newly presenting diabetic patients in Tanzania with diabetes requiring insulin are older at presentation than those in Britain; most diabetic patients present with diabetes not requiring insulin and a smaller proportion of Tanzanian patients are obese. Most have a lower socioeconomic state than diabetic patients in Britain. There are often delays in diagnosis in Tanzania, and there is a higher incidence of death shortly after presentation.