- Email: [email protected]
Instructive case report
38 Infectious Diseases Newsletter
4.
5.
6. 7.
8.
Shapiro CD, Wald ER, Single-dose amoxicillin treatment of urinary tract infections. J Pediatr 99:989, 1981. Lohr JA, et al., Three-day therapy of lower urinary tract infections with nitrofurantoin macrocrystals: A randomized clinical trial. J Pediatr 99:980, 1981. Kahn, et al., Three-day antimicrobial therapy of urinary tract infections. J Pediatr 99:992, 1981. Pylkkanen J, et al., The length of antimicrobial therapy in upper versus lower urinary tract infection in childhood. Acta Paediatr Sgand 70:885, 1981. Pitt WR, et al., Single dose trimethoprimTsulfamethoxazole treatment of symptomatic urinary infection. Arch Dis Child 57:229, 1982.
INSTRUCTIVE CASE REPORT Case Report A 16-year-old boy is referred because he has had recurrent pharyngitis. His first episode was 6 weeks ago and consisted of fever, sore throat, and exudative tonsillopharyngitis. A throat culture was not obtained and he was given penicillin G. His symptoms subsided but recurred within 48 hours of his voluntarily stopping penicillin after 3 days of treatment. He was replaced on penicillin and a throat culture obtained and subsequently reported as normal flora. His symptoms and signs subsided but recurred after i0 days of therapy was completed. The throat culture this time was reported to contain 8-hemolytic streptococci. Subsequently, he has had three additional episodes all similar to the first and despite repeated courses of I.M. benzathine penicillin, oral penicillin, erythromycin, and the administration of prophylactic sulfa, has recurred each time therapy was discontinued. On each occasion, a hemolytic streptococcus was isolated. Analysis, Course,
some local or immunologic reason for persistence and recurrence. Such hypotheses as subacute tonsillar abscess, presence of a 8-1actamase producer (staphylococcal or anaerobes) with inhibition of penicillin and failure to develop specific immunity were considered. Examination did not suggest an abscess. No staphylococci, anaerobes, or other 8-1actamase producers were identified and type-specific immunity was not tested. However, our previous experience with persistent or recurrent streptococcal disease suggested that nongroup A organism might be responsible. In fact, of six previous patients with persistent streptococcal isolation, Dr. Ted Mortimer, then in New Mexico, identified six nongroup A organisms for us in his laboratory. We consulted Ken Ryan, our microbiologist, who isolated group C streptococcus from this child on several occasions. Group C streptococci (GCS) are rarely seen in human disease although the organism is prevalent in animals. Besides our patient, GCS has been described in perinatal maternal infection and colonization, in epidemic pharyngitis, in neonatal meningitis, in adult pneumonia, in surgical wound infections, in cervical adenitis, and most recently as a cause of epiglottitis. In an examination of types of streptococci isolated from respiratory specimens obtained from adults, 29% were group A, 10% were group B, 31% group C, 11% group F, 12% group G, and 7% nontypeable. Thus, GCS is apparently prevalent although seldom pathogenic or recognized as such. Our child did well ultimately after his tonsils were removed. Group C streptococci were recovered from the ground tonsillar tissue despite intensive preoperative treatment with effective antibiotics. Vincent A. Fulginiti, M.D. Professor and Head Department of Pediatrics Arizona Health Sciences Center
References
and Comment
This child proved to be a true puzzle for his caretakers. The recurrent clinical syndrome was almost immediately responsive to effective antistreptococcus therapy but recurred with great regularity once treatment was discontinued. Recovery of 8-hemolytic streptococci initially suggested group A disease with
i.
2.
Schwartz R, et al, Acute epiglottitis caused by 8-hemolytic group C streptococci. Amer J Dis Child 136:558, 1982. Fulginiti VA, et al., Recurrent group C streptococcal tonsillitis in an adolescent male requiring tonsillectomy. Clin Pediatr 19:829, 1981.
9 1983 by Elsevier Science Publishing Co., Inc.
39 Infectious Diseases Newsletter
3. 4.
5.
, 6.
7.
8.
9.
10.
Stamm AM, and Cobbs CG, Group C streptococcal pneumonia. Rev Infect Dis 2:889, 1982. Forrer CB and Ellner PD, Distribution of hemolytic streptococci in respiratory specimens. J Clin Microbiol 10:69, 1979. Goldmann DA, and Breton ST, Group C streptococcal surgical wound infections transmitted by an anorectal and nasal carrier. Pediatr 61:235, 1978. Rom S, Beta hemolytic group C streptococcal respiratory infection in infant and horse. J Pe~iatr 91:845, 1977. Krieger PS, and Gotoff SP, Neonatal meningitis due to group C beta hemolytic streptococcus. J Pediatr 90:103, 1977. Benjamin JT, and Perriello VA, Pharyngitis due to group C hemolytic streptococci in children. J Pediatr 89:254, 1976. Kohler W, and Cederberg A, Streptococcus zooepidemicus (group C) as a cause of human infection. Scand J Infect Dis 8:217, 1976. Drusin LM, et al., Group C streptococcal colonization in a newborn nursery. Amer J Dis Child 125:820, 1973.
England: Prospective screening of fecal samples in 451 newborn infants yielded C. difficile colonization rates in three--units ranging from 2 to 52%. Clustering was noted on two wards. A potential common source pattern was identified in one cluster but the source could not be found in the other. Isolation of toxin and nontoxin strains was common. The authors postulate that cross-contamination occurred among the infants and could spread to adults. J Infect Dis 146:727, 1982 Canada: In November 1982, an acute outbreak of ~astroenteritis occurred in a small community north of Montreal. Nausea, vomiting, abdominal cramps with slight or no fever and diarrhea occurred abruptly. Eighty-eight school attendees (of 375) and four teachers were affected in a single day; 50 new cases were reported on the following two days. Careful epidemiologic study did not identify a common source, although carton milk and a surface water source were suspected. Public health authorities suspect person to person Norwalk virus gastroenteritis. Can Dis Wkly Rpt 9-9:34-35, Feb 26, 1983 London: A 23-year-old man developed an episode of meningoencephalitis with urinary retention and an enlarged prostate. Investigation disclosed a rising titer to Chlamydia trachomatis, types D-K (1:256 to 1:102+). Cerebrospinal fluid titer was 1:8 and stable; C. trachomatis was not isolated. Other causes were excluded and the authors believe this episode was due to C. trachomatis and refer to a previous--Swedish report. Brit Med J 286:518, 1983 m
I N T E R N A T I O N A L NOTES Canada: In the past two years, a new syndrome has been described in Inuit and Indian infants in Edmonton. Features include: (i) coastal residence; (2) age 3 months at onset; (3) initial disease of neonatal hepatitis, bronchiolitis, or hemolytic anemia with hepatomegaly; (4) ultimate expression of at least three of the following: hepatitis, hemolytic anemia, respiratory tract infection, rickets, hepatosplenomegaly, failure to thrive, and steatorrhea. Liver biopsy is nonspecific and markers for known viral hepatitides are not present. The etiology is unknown and is currently under intensive study. Can Dis Wkly Rpt 9-9:33-34, Feb 26, 1983 Denmark: An ll-year-old boy suffered acute fatal encephalitis with evidence for simultaneous EBV and measles virus infection. The authors suggest the severity of disease was related to immunosuppression induced by one or both agents. They suggest future patients with severe CNS disease be evaluated for T-cell function and multiple causation. Brit Med J 286:521, 1983
NATIONAL NOTES Campylobacter diarrhea: Nagri and colleagues report that the manifestations of C. jejuni enteritis vary with the age of the patient. Infants less than 3 months of age often have abdominal distention with diarrhea and little fever and no vomiting. From 3 to 6 months, diarrhea and abdominal pain predominate and in the 6- to 12-month-old infant, fever and diarrhea are most common. In contrast, fever, abdominal pain and to a lesser extent, vomiting accompany diarrhea in the child older than 1 year. Clin Pediatr 22:98, 1983 Yersina isolation: In an 8.5 year period from 1974 to 1982, 56 isolates of Y. enterocolitica were studied in Few York City. Bacteremia was caused by serogroups 0:3 and 0:5, 27 and was
9 1983 by ElsevierScience Publi'shin~Co., Inc.
MMWR SUMMARY
Infectious Diseases Newsletter
SUMMARY OF RECENT MORBIDITY AND MORTALITY WEEKLY REPORTS, CDC, USPHS
(MMWR)
Since it became necessary for CDC to charge subscribers who wished to receive MMWR, a great many persons will no longer have access to it. This section will summarize information related to infectious diseases that have appeared in recent MMWR issues. (The abstracts below reflect the Editor's language and are not direct quotes from MMWR.) Vincent A. Fulginiti, M.D. MMWR 32(8):
March 4, 1983
,AIDS: More than 1200 cases of acquired immunodeficiency syndrome (AIDS) have been reported since 1981. High risk groups include male homosexuals, intravenous drug abusers, and Haitians. There have been ii cases in hemophiliacs and one in a child who received transfusions from a donor who developed AIDS later. Female sexual partners of men with AIDS suggests heterosexual transmission. Infants born to mothers in high risk groups have also had an AIDS-like illness. No health care workers or l a b p e r s o n n e l have acquired the syndrome. AIDS probably is caused by a transmissible agent; blood and blood products appear to be involved in many instances. Altered immune function and some findings of the full syndrome have been described in male homosexuals. Thus far, it is uncertain whether these will inevitably evolve into AIDS. Prevention and control of AIDS is problematic until a specific etiology is identified. At present, a variety of national groups have proposed possible safeguards. The Public Health Service recommends: I. 2. 3. 4. 5.
Avoid sexual contact with AIDS patients. Multiple sexual partners in high risk groups enhance risk. Members of high risk groups should refrain from blood donation. Centers for blood collection should inform potential donors of this recommendation. The FDA is developing guidelines. Studies are encouraged to develop screening tests for identifying blood or blood products at risk of transmitting AIDS. Strict adherence to strigent criteria for use of blood and blood products is advised. Safer blood products for hemophilia should be explored.
These are interim recommendations likely to be modified as more becomes known. Influenza - United States: All regions of the United States have continued influenza activity. Excess respiratory mortality continues through the seventh consecutive week. The majority of isolates are A (H3N2); A (HINI) has risen proportionally recently. School outbreaks in Ohio are described; both A (H3N2) and A (HINI) are involved. Nursing home outbreaks more likely involve A (H3N2) and type B influenza viruses. African Trypanosomiasis: A 72-year-old male was bitten by tsetse flies in Tanzania and developed trypanosomiasis in September 1981. He had fever, weakness, a raised nodule on his arm, and ultimately a morbilliform rash and cervical adenopathy. He was treated with suramin after blood smears were positive for trypanosomes. A response was noted in 48 hours and he recovered after doses at 1 g I.V. on days I, 3, 7, 14, and 21. This is the sixth case since 1967 of imported African trypanosomiasis. Suramin is recommended early on with no CNS disease. Melarsoprol is used alone or with suramin if the CNS is involved; it is toxic. Measles in Universities: Eighty-five cases of measles were reported in University of Indiana and Purdue students in January-February 1983. Two students were hospitalized and two others had atypical measles. Voluntary immunization programs were put into effect for more than 200,000 college students in the state among which are susceptibles who are encouraged to receive measles vaccine. Editorial comment re-emphasizes the reservoir of young adults who have either not received measles vaccine or received it as an ineffective preparation (killed vaccine) or at the wrong time (prior to 12.'months of age). At the University of California at Los Angeles (UCLA), the reservoir in 1977 was estimated at 20% of the student body. Active programs are encouraged on a continuing basis among college populations.
9
by Elsevier Science Publishing Co., Inc.
Infectious Diseases Newsletter
MMWR 32(9):
March ii, 1983
Influenza Update: Type A (H3N2) continue to predominate; 93% of 707 isolates. Both Widespread (Iowa, Kentucky, Nebraska, Ohio and Virginia) and regional activity (36 other states) are reported. Tuberculosis - Washington: From a single identification of sputum-positive, fatal tuberculosis in 1980, ll other cases were discovered in a nursing home. Since 1975, 48 residents and 29 employees were found to be PPD-positive. None received INH. After the case in 1980, 65% of 91 residents and 44% of 87 employees were found to be newly infected. All received INH. Sputum cultures were positive as were chest x-rays in ii persons. Rabid Cow - Pennsylvania: In November 1982, a paralyzed cow was diagnosed as ~aving rabies, presumably acquired from a bat two months previously. There were 47 persons exposed to the cow and 32 received rabies prophylaxis. Murine Typhus - Texas: From October 25 to November ii, 1982 five persons developed fever, headache and ~yalgia in various combinations and three had a truncal macular rash whic~ spread to the extremities. Antibody > 1:512 to typhus group antigen, later identified as Rickettsia typhi antibody. R~dents were prevalent in th@~household and four of five cats which died had no known reason for their deaths. Rat control has reduced the occurrence to 60 to 80 cases per year (2000 to 5000 cases of murine typhus per year in the 1950's). Tetracycline or chloramphenicol is effective. MMWR 32(10) :
March 18, 1983
Canada: Hemorrhagic colitis, probably due to E. coli 0:157:47 from contaminated hamburger occurred in 31/353 (8.8%) of residents at a home for the aged in Ottowa. A cytotoxin was identified from the E. coli. This is the third outbreak caused by this organism. Hepatitis B Vaccine (HBVV): An extensive review of the safety of HBVV is provided. Salient features include: (i) more than 200,000 recipients, mostly health case workers; (2) 118 vaccinees have become ill within four weeks of receipt of HBVV; (3) 56 of these were due to provable, other causes or were unrelated; (4) of the 62 remaining, many were "background" illnesses likely to occur in 200,000 persons in any four-week period; (5) the illnesses included 6 neurologic conditions, ii skin or mucus membrane lesions, i0 musculoskeletal ailments, 5 hepatitis-like illnesses and 25 miscellaneous; (6) only 6 persons had serious illnesses (E. multiforme, aseptic meningitis, seizure, transverse myelitis, and two Guillain-Barre syndrome - one of the latter followed a CMV infection; and (7) acquired immunodeficiency syndrome (AIDS) has occurred in HBVV recipients (only in high risk for AIDS groups) and at a frequency lower or comparable to placebo-recipients concurrently followed. The vaccine appears safe. Influenza Update - United States: The first type B outbreak occurred in a nursing home and involved 45% of the residents; 6 had pneumonia and 3 others died with an influenza-like illness. For the ninth consecutive week, excess mortality was reported from 121 sentinel cities. MMWR 32(11):
March 25, 1983
Dengue - 1982: Dengue-like illness occurred in 144 patients in 28 states; 45 were confirmed as dengue. No indigenous transmission was noted despite the presence of the vector, Aedes aegypti, in the South. Types i, 2, and 4 viruses were isolated. Two patients had hemorrhagic signs. Influenza Update: To date, 971 cases have been reported from 44 states; most A (H3N2) but 17 states report A (HINI) isolates. Expanded Program on Immunization (EPI): Success of EPI programs depends on accurate surveillance; many national systems are unreliable in this regard. A study in Washington, D.C. showed that only 35% of notifiable diseases were reported. In Holland, only 3% of measles were recorded. In one country, 858 cases of tetanus were reported but 1880 patients with tetanus were admitted to hospitals. Other examples are given.
9 1983 by Elsevier Science Publishing Co., Inc.
4.
5.
6. 7.
8.
Shapiro CD, Wald ER, Single-dose amoxicillin treatment of urinary tract infections. J Pediatr 99:989, 1981. Lohr JA, et al., Three-day therapy of lower urinary tract infections with nitrofurantoin macrocrystals: A randomized clinical trial. J Pediatr 99:980, 1981. Kahn, et al., Three-day antimicrobial therapy of urinary tract infections. J Pediatr 99:992, 1981. Pylkkanen J, et al., The length of antimicrobial therapy in upper versus lower urinary tract infection in childhood. Acta Paediatr Sgand 70:885, 1981. Pitt WR, et al., Single dose trimethoprimTsulfamethoxazole treatment of symptomatic urinary infection. Arch Dis Child 57:229, 1982.
INSTRUCTIVE CASE REPORT Case Report A 16-year-old boy is referred because he has had recurrent pharyngitis. His first episode was 6 weeks ago and consisted of fever, sore throat, and exudative tonsillopharyngitis. A throat culture was not obtained and he was given penicillin G. His symptoms subsided but recurred within 48 hours of his voluntarily stopping penicillin after 3 days of treatment. He was replaced on penicillin and a throat culture obtained and subsequently reported as normal flora. His symptoms and signs subsided but recurred after i0 days of therapy was completed. The throat culture this time was reported to contain 8-hemolytic streptococci. Subsequently, he has had three additional episodes all similar to the first and despite repeated courses of I.M. benzathine penicillin, oral penicillin, erythromycin, and the administration of prophylactic sulfa, has recurred each time therapy was discontinued. On each occasion, a hemolytic streptococcus was isolated. Analysis, Course,
some local or immunologic reason for persistence and recurrence. Such hypotheses as subacute tonsillar abscess, presence of a 8-1actamase producer (staphylococcal or anaerobes) with inhibition of penicillin and failure to develop specific immunity were considered. Examination did not suggest an abscess. No staphylococci, anaerobes, or other 8-1actamase producers were identified and type-specific immunity was not tested. However, our previous experience with persistent or recurrent streptococcal disease suggested that nongroup A organism might be responsible. In fact, of six previous patients with persistent streptococcal isolation, Dr. Ted Mortimer, then in New Mexico, identified six nongroup A organisms for us in his laboratory. We consulted Ken Ryan, our microbiologist, who isolated group C streptococcus from this child on several occasions. Group C streptococci (GCS) are rarely seen in human disease although the organism is prevalent in animals. Besides our patient, GCS has been described in perinatal maternal infection and colonization, in epidemic pharyngitis, in neonatal meningitis, in adult pneumonia, in surgical wound infections, in cervical adenitis, and most recently as a cause of epiglottitis. In an examination of types of streptococci isolated from respiratory specimens obtained from adults, 29% were group A, 10% were group B, 31% group C, 11% group F, 12% group G, and 7% nontypeable. Thus, GCS is apparently prevalent although seldom pathogenic or recognized as such. Our child did well ultimately after his tonsils were removed. Group C streptococci were recovered from the ground tonsillar tissue despite intensive preoperative treatment with effective antibiotics. Vincent A. Fulginiti, M.D. Professor and Head Department of Pediatrics Arizona Health Sciences Center
References
and Comment
This child proved to be a true puzzle for his caretakers. The recurrent clinical syndrome was almost immediately responsive to effective antistreptococcus therapy but recurred with great regularity once treatment was discontinued. Recovery of 8-hemolytic streptococci initially suggested group A disease with
i.
2.
Schwartz R, et al, Acute epiglottitis caused by 8-hemolytic group C streptococci. Amer J Dis Child 136:558, 1982. Fulginiti VA, et al., Recurrent group C streptococcal tonsillitis in an adolescent male requiring tonsillectomy. Clin Pediatr 19:829, 1981.
9 1983 by Elsevier Science Publishing Co., Inc.
39 Infectious Diseases Newsletter
3. 4.
5.
, 6.
7.
8.
9.
10.
Stamm AM, and Cobbs CG, Group C streptococcal pneumonia. Rev Infect Dis 2:889, 1982. Forrer CB and Ellner PD, Distribution of hemolytic streptococci in respiratory specimens. J Clin Microbiol 10:69, 1979. Goldmann DA, and Breton ST, Group C streptococcal surgical wound infections transmitted by an anorectal and nasal carrier. Pediatr 61:235, 1978. Rom S, Beta hemolytic group C streptococcal respiratory infection in infant and horse. J Pe~iatr 91:845, 1977. Krieger PS, and Gotoff SP, Neonatal meningitis due to group C beta hemolytic streptococcus. J Pediatr 90:103, 1977. Benjamin JT, and Perriello VA, Pharyngitis due to group C hemolytic streptococci in children. J Pediatr 89:254, 1976. Kohler W, and Cederberg A, Streptococcus zooepidemicus (group C) as a cause of human infection. Scand J Infect Dis 8:217, 1976. Drusin LM, et al., Group C streptococcal colonization in a newborn nursery. Amer J Dis Child 125:820, 1973.
England: Prospective screening of fecal samples in 451 newborn infants yielded C. difficile colonization rates in three--units ranging from 2 to 52%. Clustering was noted on two wards. A potential common source pattern was identified in one cluster but the source could not be found in the other. Isolation of toxin and nontoxin strains was common. The authors postulate that cross-contamination occurred among the infants and could spread to adults. J Infect Dis 146:727, 1982 Canada: In November 1982, an acute outbreak of ~astroenteritis occurred in a small community north of Montreal. Nausea, vomiting, abdominal cramps with slight or no fever and diarrhea occurred abruptly. Eighty-eight school attendees (of 375) and four teachers were affected in a single day; 50 new cases were reported on the following two days. Careful epidemiologic study did not identify a common source, although carton milk and a surface water source were suspected. Public health authorities suspect person to person Norwalk virus gastroenteritis. Can Dis Wkly Rpt 9-9:34-35, Feb 26, 1983 London: A 23-year-old man developed an episode of meningoencephalitis with urinary retention and an enlarged prostate. Investigation disclosed a rising titer to Chlamydia trachomatis, types D-K (1:256 to 1:102+). Cerebrospinal fluid titer was 1:8 and stable; C. trachomatis was not isolated. Other causes were excluded and the authors believe this episode was due to C. trachomatis and refer to a previous--Swedish report. Brit Med J 286:518, 1983 m
I N T E R N A T I O N A L NOTES Canada: In the past two years, a new syndrome has been described in Inuit and Indian infants in Edmonton. Features include: (i) coastal residence; (2) age 3 months at onset; (3) initial disease of neonatal hepatitis, bronchiolitis, or hemolytic anemia with hepatomegaly; (4) ultimate expression of at least three of the following: hepatitis, hemolytic anemia, respiratory tract infection, rickets, hepatosplenomegaly, failure to thrive, and steatorrhea. Liver biopsy is nonspecific and markers for known viral hepatitides are not present. The etiology is unknown and is currently under intensive study. Can Dis Wkly Rpt 9-9:33-34, Feb 26, 1983 Denmark: An ll-year-old boy suffered acute fatal encephalitis with evidence for simultaneous EBV and measles virus infection. The authors suggest the severity of disease was related to immunosuppression induced by one or both agents. They suggest future patients with severe CNS disease be evaluated for T-cell function and multiple causation. Brit Med J 286:521, 1983
NATIONAL NOTES Campylobacter diarrhea: Nagri and colleagues report that the manifestations of C. jejuni enteritis vary with the age of the patient. Infants less than 3 months of age often have abdominal distention with diarrhea and little fever and no vomiting. From 3 to 6 months, diarrhea and abdominal pain predominate and in the 6- to 12-month-old infant, fever and diarrhea are most common. In contrast, fever, abdominal pain and to a lesser extent, vomiting accompany diarrhea in the child older than 1 year. Clin Pediatr 22:98, 1983 Yersina isolation: In an 8.5 year period from 1974 to 1982, 56 isolates of Y. enterocolitica were studied in Few York City. Bacteremia was caused by serogroups 0:3 and 0:5, 27 and was
9 1983 by ElsevierScience Publi'shin~Co., Inc.
MMWR SUMMARY
Infectious Diseases Newsletter
SUMMARY OF RECENT MORBIDITY AND MORTALITY WEEKLY REPORTS, CDC, USPHS
(MMWR)
Since it became necessary for CDC to charge subscribers who wished to receive MMWR, a great many persons will no longer have access to it. This section will summarize information related to infectious diseases that have appeared in recent MMWR issues. (The abstracts below reflect the Editor's language and are not direct quotes from MMWR.) Vincent A. Fulginiti, M.D. MMWR 32(8):
March 4, 1983
,AIDS: More than 1200 cases of acquired immunodeficiency syndrome (AIDS) have been reported since 1981. High risk groups include male homosexuals, intravenous drug abusers, and Haitians. There have been ii cases in hemophiliacs and one in a child who received transfusions from a donor who developed AIDS later. Female sexual partners of men with AIDS suggests heterosexual transmission. Infants born to mothers in high risk groups have also had an AIDS-like illness. No health care workers or l a b p e r s o n n e l have acquired the syndrome. AIDS probably is caused by a transmissible agent; blood and blood products appear to be involved in many instances. Altered immune function and some findings of the full syndrome have been described in male homosexuals. Thus far, it is uncertain whether these will inevitably evolve into AIDS. Prevention and control of AIDS is problematic until a specific etiology is identified. At present, a variety of national groups have proposed possible safeguards. The Public Health Service recommends: I. 2. 3. 4. 5.
Avoid sexual contact with AIDS patients. Multiple sexual partners in high risk groups enhance risk. Members of high risk groups should refrain from blood donation. Centers for blood collection should inform potential donors of this recommendation. The FDA is developing guidelines. Studies are encouraged to develop screening tests for identifying blood or blood products at risk of transmitting AIDS. Strict adherence to strigent criteria for use of blood and blood products is advised. Safer blood products for hemophilia should be explored.
These are interim recommendations likely to be modified as more becomes known. Influenza - United States: All regions of the United States have continued influenza activity. Excess respiratory mortality continues through the seventh consecutive week. The majority of isolates are A (H3N2); A (HINI) has risen proportionally recently. School outbreaks in Ohio are described; both A (H3N2) and A (HINI) are involved. Nursing home outbreaks more likely involve A (H3N2) and type B influenza viruses. African Trypanosomiasis: A 72-year-old male was bitten by tsetse flies in Tanzania and developed trypanosomiasis in September 1981. He had fever, weakness, a raised nodule on his arm, and ultimately a morbilliform rash and cervical adenopathy. He was treated with suramin after blood smears were positive for trypanosomes. A response was noted in 48 hours and he recovered after doses at 1 g I.V. on days I, 3, 7, 14, and 21. This is the sixth case since 1967 of imported African trypanosomiasis. Suramin is recommended early on with no CNS disease. Melarsoprol is used alone or with suramin if the CNS is involved; it is toxic. Measles in Universities: Eighty-five cases of measles were reported in University of Indiana and Purdue students in January-February 1983. Two students were hospitalized and two others had atypical measles. Voluntary immunization programs were put into effect for more than 200,000 college students in the state among which are susceptibles who are encouraged to receive measles vaccine. Editorial comment re-emphasizes the reservoir of young adults who have either not received measles vaccine or received it as an ineffective preparation (killed vaccine) or at the wrong time (prior to 12.'months of age). At the University of California at Los Angeles (UCLA), the reservoir in 1977 was estimated at 20% of the student body. Active programs are encouraged on a continuing basis among college populations.
9
by Elsevier Science Publishing Co., Inc.
Infectious Diseases Newsletter
MMWR 32(9):
March ii, 1983
Influenza Update: Type A (H3N2) continue to predominate; 93% of 707 isolates. Both Widespread (Iowa, Kentucky, Nebraska, Ohio and Virginia) and regional activity (36 other states) are reported. Tuberculosis - Washington: From a single identification of sputum-positive, fatal tuberculosis in 1980, ll other cases were discovered in a nursing home. Since 1975, 48 residents and 29 employees were found to be PPD-positive. None received INH. After the case in 1980, 65% of 91 residents and 44% of 87 employees were found to be newly infected. All received INH. Sputum cultures were positive as were chest x-rays in ii persons. Rabid Cow - Pennsylvania: In November 1982, a paralyzed cow was diagnosed as ~aving rabies, presumably acquired from a bat two months previously. There were 47 persons exposed to the cow and 32 received rabies prophylaxis. Murine Typhus - Texas: From October 25 to November ii, 1982 five persons developed fever, headache and ~yalgia in various combinations and three had a truncal macular rash whic~ spread to the extremities. Antibody > 1:512 to typhus group antigen, later identified as Rickettsia typhi antibody. R~dents were prevalent in th@~household and four of five cats which died had no known reason for their deaths. Rat control has reduced the occurrence to 60 to 80 cases per year (2000 to 5000 cases of murine typhus per year in the 1950's). Tetracycline or chloramphenicol is effective. MMWR 32(10) :
March 18, 1983
Canada: Hemorrhagic colitis, probably due to E. coli 0:157:47 from contaminated hamburger occurred in 31/353 (8.8%) of residents at a home for the aged in Ottowa. A cytotoxin was identified from the E. coli. This is the third outbreak caused by this organism. Hepatitis B Vaccine (HBVV): An extensive review of the safety of HBVV is provided. Salient features include: (i) more than 200,000 recipients, mostly health case workers; (2) 118 vaccinees have become ill within four weeks of receipt of HBVV; (3) 56 of these were due to provable, other causes or were unrelated; (4) of the 62 remaining, many were "background" illnesses likely to occur in 200,000 persons in any four-week period; (5) the illnesses included 6 neurologic conditions, ii skin or mucus membrane lesions, i0 musculoskeletal ailments, 5 hepatitis-like illnesses and 25 miscellaneous; (6) only 6 persons had serious illnesses (E. multiforme, aseptic meningitis, seizure, transverse myelitis, and two Guillain-Barre syndrome - one of the latter followed a CMV infection; and (7) acquired immunodeficiency syndrome (AIDS) has occurred in HBVV recipients (only in high risk for AIDS groups) and at a frequency lower or comparable to placebo-recipients concurrently followed. The vaccine appears safe. Influenza Update - United States: The first type B outbreak occurred in a nursing home and involved 45% of the residents; 6 had pneumonia and 3 others died with an influenza-like illness. For the ninth consecutive week, excess mortality was reported from 121 sentinel cities. MMWR 32(11):
March 25, 1983
Dengue - 1982: Dengue-like illness occurred in 144 patients in 28 states; 45 were confirmed as dengue. No indigenous transmission was noted despite the presence of the vector, Aedes aegypti, in the South. Types i, 2, and 4 viruses were isolated. Two patients had hemorrhagic signs. Influenza Update: To date, 971 cases have been reported from 44 states; most A (H3N2) but 17 states report A (HINI) isolates. Expanded Program on Immunization (EPI): Success of EPI programs depends on accurate surveillance; many national systems are unreliable in this regard. A study in Washington, D.C. showed that only 35% of notifiable diseases were reported. In Holland, only 3% of measles were recorded. In one country, 858 cases of tetanus were reported but 1880 patients with tetanus were admitted to hospitals. Other examples are given.
9 1983 by Elsevier Science Publishing Co., Inc.