- Email: [email protected]
Instructive case report
46 Infectious Diseases Newsletter
Antibiotics in Laboratory Medicine, V. Lorian (ed). Baltimore, MD: Williams and Wilkins Company, 114, 1980. 3. Bourgault, A, Harkness, JL, and Rosenblatt, JE, Clinical usefulness of susceptibility testing of anaerobes. Arch Intern Med 138:1825, 1978. INSTRUCTIVE CASE REPORT The patient was a previously well 7~year-old Spanish American female with a 1 1/2 week history of low grade fever, intermittent frontal and posterior auricular headaches, vomiting,.decreased appetite, and paleness. ~he was also noted to have increasingly uncoordinated gait and a questionable history of one seizure. Two weeks prior to onset of symptoms the patient had a flu-like illness with fever, headache, vomiting, diarrhea, and myalgias. The family owned a pet dog which was killed two months prior to the patient's hospitalization because of "tick fever". Admission physical examination was normal except for abnormal cerebellar function (right finger to nose with past pointing). Spinal fluid obtained on admission showed a white blood count of 522 with 88% monos, 12% segs, and 1 red blood cell, glucose was 53mg% (serum glucose = i00), protein was 161 mg/dl. Gram stain was negative for organisms. Blood WBC was 10,600/mm3 with 74% polys, 5 bands, 15 lymphs, 4 monos, and 2 eos. Hematocrit wQs 40.3 and platelets = 387,000/mm3. Blood chemistries were normal except for a CO2 content of 21.3mmol/L. SGOT, Alk. phosphatase, and bilirubin were normal. Bacterial, viral, fungal, and TB cultures w e r e obtained. In addition the patient was evaluated for parasites. Serological evaluation included studies for Brucella, Toxoplasma, Hepatitis B, Cryptococcus, cysticercosis, toxocarra, monospot, leptospira, lymphocytic choriomeningitis, and mycoplasma. Convalescent serologies were also obtained. An immunologic evaluation was essentially normal. Despite courses of antimicrobial, antifungal, and antituberculous therapy, the patient's neurologic status deteriorated over a 2 week period before slowly improving. After discharge, the CDC reported an acute leptospira titer (by IHA) of 1:50 and a convalescent titer (2 weeks later) of 1:400. Discussion: Leptospirosis
is
frequently
among differential diagnostic possibilities because of the diversity and nonspecificity of its clinical presentation; it is rarely proved. Nevertheless two distinct patterns of infection can be identified. Anicteric disease accounts for at least 90% of documented leptospirosis. Our patient fits into this category. Icteric disease (also known as Weil's Syndrome) is rare and associated with a high mortality rate. Leptospira is usually transmitted from animal to man and dogs have become increasingly common vectors. Anicteric leptospirosis is usually a biphasic illness. After 7 to 12 days of incubation, the leptospiremia occurs and lasts about one week. Fever, myalgias, headache, malaise, and prostration are characteristic during this phase. These "flu-like" symptoms are not unlike those this child exhibited several weeks prior to admission. Abdominal pain and vomiting can also occur during this stage and rarely circulatory collapse and death may ensue. In the untreated patient organisms may be recovered from both blood and CSF during this stage. After an asymptomatic interval, most patients enter the immune stage which is characterized by meningoencephalitis, uveitis, rash, and fever. The hallmark of this stage is the CNS involvement characterized by CSF pleocytosis (initially polymorphonuclear and subseqnently mononuclear). The CSF protein concentration is normal or elevated and the glucose level is usually normal. Encephalitic symptoms may predominate during or after the immune stage. Despite the inflammatory response, CSF cultures during this stage are usually negative. Laboratory diagnosis is made by appropriate cultures prior to antibiotic therapy and by serology. While the value of antimicrobial therapy is controversial, therapy should be instituted as early in the course of disease as possible. Penicillin or tetracycline are the drugs of choice. The spectrum of disease due to leptospira is broad and probably the diagnosis is frequently missed. This child points out the need to consider leptospirosis in patients with CNS disease not identified as viral or bacterial. A previous "flu-like" illness followed by the development of meningoencephalitis should suggest leptospirosis as one possibility. Allan D. Friedman, M.D. Assistant Professor ' Department of Pediatrics Arizona Health Sciences Center
included
9
by Elsevier Science Publishing Co., Inc.
47
Infectious Diseases Newsletter
Suggested Reading: I.
2. 3.
Feigin RD and Anderson DC, Leptospirosis, in Textbook of Pediatric Infectious Diseases, Feigin and Cherry (ed). Saunders, pp. 895-911, 1981. Edwards GA and Domm BM, Human leptospirosis. Medicine (BAH) 39:117-156, 1960. Heath CW et al, Leptospirosis in the United States. N Engl J Med 273:857-922, 1965.
INTERNATIONAL NOTES Denmark and Finland: Acyclovir (acycloguanosine) is an antiviral for which a herpes ~Irus enzyme (thymidine kinase) specifies its phosphorylation, converting it into a potent antiviral DNA inhibitor. An editorial and two reports in Lancet (ii:827, 845, and 875, 1981) review the drug and its effects in herpes simplex and herpes zoster (varicella) patients. In a 21-year-old woman with severe herpetic oral lesions and systemic and CNS signs following renal transplant and immunosuppression, acyclovir given for seven days reversed all of her finaings. A double blind study of acyclovir (27 patients) and placebo (29 patients) in consecutive patients with zoster who were older than 30 years, did not have malignant disease, and were not receiving steroids demonstrated a shortened period of pain and more rapid healing in those receiving acyclovir. Manitoba: Lignt and his colleagues investigated the use of trimethoprim alone i_nn urinary tract infections in 20 women. Sulfa hypersensitivity precluded the use of sulfas or the combination of trimethoprim with sulfamethoxazole. Acute, recurrent and systematic chronic infections were included. Of the i0 with acute infections, 5 had antibody coated bacteria (ABC) in urine and only 2 were cured (2 removed from Rx because of drug reaction, 1 failure). Of the 5 without ABC, 2 were cured, 2 failed, and 1 was removed. Symptomatic relief but not bacteruria was noted in two chronic infections secondary to staghorn calculi. In the 8 patients with recurrent infection, a significant decrease in frequency was noted. The authors believe that trimethoprim alone is a potentially effective agent for acute UTI and possibly in chronic and recurrent "disease. They observe that the high incidence of adverse effects (20% GI and 25% allergic) may limit usefulness. Arch Intern Med 141:1809, 1981 Worldwide: Influenza A (H3N2) was iso-
lated in Guam and two influenza B viruses in the Phillipines; all in United States airmen. In Asia, outbreaks of influenza B were documented in children and influenza A (HINI) in adults. Italy reports an A (HINI) and several A (H3N2) isolates and B strains were recovered in France and Switzerland. No single pattern emerges predictive of our anticipated influenzal disease. MMWR 30:634, 1982 Asia: A slightly different Influenza A (H3N2) virus given the label A/Shanghai/31/80 has appeared in the Far East. This agent has drifted to a greater degree than more recent strains of Influenza A. As of January, it had not reached the continental United States but had been isolated from U.S. airmen in Japan and Guam. Let's hope it avoids our shores this season. Multiple sources Birmingham: Continuous positive airway pressure (CPAP) has been successfully used in the management of bronchiolitis associated with respiratory insufficency. Delivered by nasal cannula or endotracheal tube in 23 infants over a five-year period, CPAP resulted in marked clinical and laboratory improvement. Particularly impressive was the recovery of 7 infants with PCO 2 levels in excess of 60 mmHg. Beasley, MJ and Jones, SE, Brit Med J 283:1506, 1981 London: Cubitt and McSwiggan studied 592 cases of gastroenteritis in Northwestern London and found 6.6% to be shedding calciviruses. The patients ranged in age from 3 weeks to 13 years, peaking at 1-6 months. Calciviruses are widespread in animals and man; it is believed three distinct types exist and can only be identified by electron microscopy at present. Lancet ii:975, 1981 Finland: Killed mumps virus vaccine was abandoned years ago in the United States and other places but it left behind residual unanswered questions. One such was why protection after immunization was so short-lived. These investigators studied specific immune responses to mumps in infected men who had received killed vaccine 4-18 years previously in the Armed Forces. They all failed to develop specific IgM-antimumps antibody suggesting a long-lasting suppression of this acute antibody in vaccine recipients. J Infect Dis 144:496, 1981 Sweden: Ahlfors, et al investigated the risk of acquisition o_ff cytomegalovirus infection in nurses and potential effect on their fetuses in 292 women ,working in pediatric clinics and day care centers. Younger women (25-years-old) who had tended children in these settings had a higher seropositivity rate when
9 1982 by Elsevier Science Publishing: Co.. Inc.
Antibiotics in Laboratory Medicine, V. Lorian (ed). Baltimore, MD: Williams and Wilkins Company, 114, 1980. 3. Bourgault, A, Harkness, JL, and Rosenblatt, JE, Clinical usefulness of susceptibility testing of anaerobes. Arch Intern Med 138:1825, 1978. INSTRUCTIVE CASE REPORT The patient was a previously well 7~year-old Spanish American female with a 1 1/2 week history of low grade fever, intermittent frontal and posterior auricular headaches, vomiting,.decreased appetite, and paleness. ~he was also noted to have increasingly uncoordinated gait and a questionable history of one seizure. Two weeks prior to onset of symptoms the patient had a flu-like illness with fever, headache, vomiting, diarrhea, and myalgias. The family owned a pet dog which was killed two months prior to the patient's hospitalization because of "tick fever". Admission physical examination was normal except for abnormal cerebellar function (right finger to nose with past pointing). Spinal fluid obtained on admission showed a white blood count of 522 with 88% monos, 12% segs, and 1 red blood cell, glucose was 53mg% (serum glucose = i00), protein was 161 mg/dl. Gram stain was negative for organisms. Blood WBC was 10,600/mm3 with 74% polys, 5 bands, 15 lymphs, 4 monos, and 2 eos. Hematocrit wQs 40.3 and platelets = 387,000/mm3. Blood chemistries were normal except for a CO2 content of 21.3mmol/L. SGOT, Alk. phosphatase, and bilirubin were normal. Bacterial, viral, fungal, and TB cultures w e r e obtained. In addition the patient was evaluated for parasites. Serological evaluation included studies for Brucella, Toxoplasma, Hepatitis B, Cryptococcus, cysticercosis, toxocarra, monospot, leptospira, lymphocytic choriomeningitis, and mycoplasma. Convalescent serologies were also obtained. An immunologic evaluation was essentially normal. Despite courses of antimicrobial, antifungal, and antituberculous therapy, the patient's neurologic status deteriorated over a 2 week period before slowly improving. After discharge, the CDC reported an acute leptospira titer (by IHA) of 1:50 and a convalescent titer (2 weeks later) of 1:400. Discussion: Leptospirosis
is
frequently
among differential diagnostic possibilities because of the diversity and nonspecificity of its clinical presentation; it is rarely proved. Nevertheless two distinct patterns of infection can be identified. Anicteric disease accounts for at least 90% of documented leptospirosis. Our patient fits into this category. Icteric disease (also known as Weil's Syndrome) is rare and associated with a high mortality rate. Leptospira is usually transmitted from animal to man and dogs have become increasingly common vectors. Anicteric leptospirosis is usually a biphasic illness. After 7 to 12 days of incubation, the leptospiremia occurs and lasts about one week. Fever, myalgias, headache, malaise, and prostration are characteristic during this phase. These "flu-like" symptoms are not unlike those this child exhibited several weeks prior to admission. Abdominal pain and vomiting can also occur during this stage and rarely circulatory collapse and death may ensue. In the untreated patient organisms may be recovered from both blood and CSF during this stage. After an asymptomatic interval, most patients enter the immune stage which is characterized by meningoencephalitis, uveitis, rash, and fever. The hallmark of this stage is the CNS involvement characterized by CSF pleocytosis (initially polymorphonuclear and subseqnently mononuclear). The CSF protein concentration is normal or elevated and the glucose level is usually normal. Encephalitic symptoms may predominate during or after the immune stage. Despite the inflammatory response, CSF cultures during this stage are usually negative. Laboratory diagnosis is made by appropriate cultures prior to antibiotic therapy and by serology. While the value of antimicrobial therapy is controversial, therapy should be instituted as early in the course of disease as possible. Penicillin or tetracycline are the drugs of choice. The spectrum of disease due to leptospira is broad and probably the diagnosis is frequently missed. This child points out the need to consider leptospirosis in patients with CNS disease not identified as viral or bacterial. A previous "flu-like" illness followed by the development of meningoencephalitis should suggest leptospirosis as one possibility. Allan D. Friedman, M.D. Assistant Professor ' Department of Pediatrics Arizona Health Sciences Center
included
9
by Elsevier Science Publishing Co., Inc.
47
Infectious Diseases Newsletter
Suggested Reading: I.
2. 3.
Feigin RD and Anderson DC, Leptospirosis, in Textbook of Pediatric Infectious Diseases, Feigin and Cherry (ed). Saunders, pp. 895-911, 1981. Edwards GA and Domm BM, Human leptospirosis. Medicine (BAH) 39:117-156, 1960. Heath CW et al, Leptospirosis in the United States. N Engl J Med 273:857-922, 1965.
INTERNATIONAL NOTES Denmark and Finland: Acyclovir (acycloguanosine) is an antiviral for which a herpes ~Irus enzyme (thymidine kinase) specifies its phosphorylation, converting it into a potent antiviral DNA inhibitor. An editorial and two reports in Lancet (ii:827, 845, and 875, 1981) review the drug and its effects in herpes simplex and herpes zoster (varicella) patients. In a 21-year-old woman with severe herpetic oral lesions and systemic and CNS signs following renal transplant and immunosuppression, acyclovir given for seven days reversed all of her finaings. A double blind study of acyclovir (27 patients) and placebo (29 patients) in consecutive patients with zoster who were older than 30 years, did not have malignant disease, and were not receiving steroids demonstrated a shortened period of pain and more rapid healing in those receiving acyclovir. Manitoba: Lignt and his colleagues investigated the use of trimethoprim alone i_nn urinary tract infections in 20 women. Sulfa hypersensitivity precluded the use of sulfas or the combination of trimethoprim with sulfamethoxazole. Acute, recurrent and systematic chronic infections were included. Of the i0 with acute infections, 5 had antibody coated bacteria (ABC) in urine and only 2 were cured (2 removed from Rx because of drug reaction, 1 failure). Of the 5 without ABC, 2 were cured, 2 failed, and 1 was removed. Symptomatic relief but not bacteruria was noted in two chronic infections secondary to staghorn calculi. In the 8 patients with recurrent infection, a significant decrease in frequency was noted. The authors believe that trimethoprim alone is a potentially effective agent for acute UTI and possibly in chronic and recurrent "disease. They observe that the high incidence of adverse effects (20% GI and 25% allergic) may limit usefulness. Arch Intern Med 141:1809, 1981 Worldwide: Influenza A (H3N2) was iso-
lated in Guam and two influenza B viruses in the Phillipines; all in United States airmen. In Asia, outbreaks of influenza B were documented in children and influenza A (HINI) in adults. Italy reports an A (HINI) and several A (H3N2) isolates and B strains were recovered in France and Switzerland. No single pattern emerges predictive of our anticipated influenzal disease. MMWR 30:634, 1982 Asia: A slightly different Influenza A (H3N2) virus given the label A/Shanghai/31/80 has appeared in the Far East. This agent has drifted to a greater degree than more recent strains of Influenza A. As of January, it had not reached the continental United States but had been isolated from U.S. airmen in Japan and Guam. Let's hope it avoids our shores this season. Multiple sources Birmingham: Continuous positive airway pressure (CPAP) has been successfully used in the management of bronchiolitis associated with respiratory insufficency. Delivered by nasal cannula or endotracheal tube in 23 infants over a five-year period, CPAP resulted in marked clinical and laboratory improvement. Particularly impressive was the recovery of 7 infants with PCO 2 levels in excess of 60 mmHg. Beasley, MJ and Jones, SE, Brit Med J 283:1506, 1981 London: Cubitt and McSwiggan studied 592 cases of gastroenteritis in Northwestern London and found 6.6% to be shedding calciviruses. The patients ranged in age from 3 weeks to 13 years, peaking at 1-6 months. Calciviruses are widespread in animals and man; it is believed three distinct types exist and can only be identified by electron microscopy at present. Lancet ii:975, 1981 Finland: Killed mumps virus vaccine was abandoned years ago in the United States and other places but it left behind residual unanswered questions. One such was why protection after immunization was so short-lived. These investigators studied specific immune responses to mumps in infected men who had received killed vaccine 4-18 years previously in the Armed Forces. They all failed to develop specific IgM-antimumps antibody suggesting a long-lasting suppression of this acute antibody in vaccine recipients. J Infect Dis 144:496, 1981 Sweden: Ahlfors, et al investigated the risk of acquisition o_ff cytomegalovirus infection in nurses and potential effect on their fetuses in 292 women ,working in pediatric clinics and day care centers. Younger women (25-years-old) who had tended children in these settings had a higher seropositivity rate when
9 1982 by Elsevier Science Publishing: Co.. Inc.