- Email: [email protected]
International and national notes
13 Infectious Diseases N e w s l e t t e r
therapy can be a d m i n i s t e r e d on an a m b u l a tory basis. Some a d v o c a t e a n t i b i o t i c t h e r a p y if the b i t e is b r o u g h t to y o u r a t t e n t i o n p r i o r to o b v i o u s i n f l a m m a t i o n , b e c a u s e of the h e a v y c o n t a m i n a t i o n and the i n e v i t a b i l i t y of infection. V i n c e n t A. Fulginiti, M.D. P r o f e s s o r and H e a d D e p a r t m e n t of P e d i a t r i c s A r i z o n a H e a l t h Sciences C e n t e r Suggested i. P l a s t 2. J Bone
Reading Reconstr Joint
Surg
28:394,
Surg 59A:416,- 1977.
3. J T r a u m a
19(9):655,
1979.
4. J T r a u m a
20;~):383,
1980.
INTERNATIONAL
1961.
NOTES
Y u g o s l a v i a - in 1979 an e p i d e m i c of hepatitis A virus (HAV) o c c u r r e d in a b o a r d ing s c h o o l at U m k a among 165 residents. Seventy-nine individuals were investigated as c o n t a c t s of the four c l i n i c a l cases; 45 contacts w e r e immune w h e n the e p i d e m i c began, of the 34 s u s c e p t i b l e , e i g h t cases of overt h e p a t i t i s , five of s u b c l i n i c a l d i s e a s e (abnormal FLT's) and 13 of i n a p p a r e n t i n f e c t i o n ensued. The ratio of s i l e n t / o v e r t i n f e c t i o n s was 2.3/ i. N o t e the h i g h attack rate; 76% of s u s c e p t i b l e s w e r e infected. In the same interval, only one case of H B V i n f e c t i o n o c c u r r e d (Amer J E p i d e m i o l 114:260, 1981). L o n d o n - A s t r i k i n g i n c i d e n c e of m u l t i p l y d r u g r e s i s t a n t S h i @ e l l a sepsis was r e p o r ted by Grass and colleagues. Of 2370 strains of S. d y s e n t e r i a e , S. flexneri, and S. boyd~i, 80% were r e s i s t a n t to one or m o r e o f 12 drugs, i n c l u d i n g those comm o n l y used. A m p i c i l l i n r e s i s t a n c e inc r e a s e d f r o m 2% in 1974 to 23.7% in 1978 and m u l t i p l e drug r e s i s t a n c e f r o m 13% to 49%. The authors note t h a t m a n y of these i s o l a t e s w e r e a c q u i r e d o u t s i d e of E n g l a n d a n d in both tourists and immigrants - a f r i g h t e n i n g i m p o r t (Brit M e d J 283:575, 1981). B a n g l a d e s h - M o r e than 2000 c h i l d r e n in the s e c o n d y e a r of life w e r e s t u d i e d to d e t e r m i n e the risk of d i a r r h e a l d i s e a s e s by n u t r i t i o n a l status. No correlation b e t w e e n i n i t i a l n u t r i t i o n and ~ t t a c k rates w e r e n o t e d (Amer J E p i d e m i o l 114: -284, 1981). N e w f o u n d l a n d - Six cases w e r e r e p o r t e d of t r a n s f e r of v a c c i n i a virus f r o m an 18 y e a r old female r e c r u i t to c o n t a c t s 1540 y e a r s old. The r e c r u i t w a s v a c c i n a t e d in the m i l i t a r y and in e a c h i n s t a n c e , t r a n s f e r o c c u r r e d b e c a u s e of close con-
tact (kissing, touching) w i t h h e r or one of the s e c o n d a r y cases. This is a disease we t h o u g h t h a d d i s a p p e a r e d b u t reports still occur, o f t e n from armed forces p e r s o n n e l w h o are v a c c i n a t e d (In the U.S. m o r e than one m i l l i o n s m a l l p o x v a c c i n a t i o n s are g i v e n to m i l i t a r y personnel e a c h year.). (MMWR 30:453, 1981). L o n d o n - A s i x - m o n t h study by E n s m o n and c o l l e a g u e s led to the c o n c l u s i o n that G r o u p B s t r e p t o c o c c i could be t r a n s m i t t e d f r o m p e r s o n s o t h e r than the n e o n a t e ' s mother. Other mothers who were culture positive, o t h e r babies, and a staff m e m b e r w e r e the sources of i n f e c t i o n for 14 of 21 infants in the n o r m a l n u r s e r y and one e p i s o d e in the h i g h - r i s k unit. The group also found t h a t o r d i n a r y h y g i e n e (i.e., handwashing) could prevent transmission (Brit M e d J 283: 459, 1981). L a t i n A m e r i c a - A c u t e h e m o r r h a g i c conj u n c t i v i t i s (AHC), m o s t often caused by e n t e r o v i r u s 70 (also by a d e n o v i r u s 1 and C o x s a c t i n e A-24), has b e e n r e p o r t e d from South, Central, and C a r i b b e a n ~erica. This is a severe illness w i t h a b r u p t onset, p r o f u s e w a t e r y discharge, intense i n f l a m m a t i o n , p a i n and itching, and s u b c o n j u n c t i v a l h e m o r r h a g e in i0100% (I~;R 30:450, 1981). A H C has b e e n r e p o r t e d only in F l o r i d a in the U.S. (~I~IR30:465, 1981). T a i w a n - B e a s l e y a n d his c o l l e a g u e s r e p o r t an i m p o r t a n t t h e r a p e u t i c trial of-Hepatitis B Immune g l o b u l i n (HBIG) in i n f a n t s b o r n to HB A g p o s i t i v e mothers. The c a r r l e r r a t e in w o m e n is 15-20% in Tai~r and the risk of carriage in the b a b i e s varies f r o m 40-95%. A d o u b l e - b l i n d p l a c e b o trial of H B I G compared: 9
i. 2. 3.
S
-
9
placebo H B I G at birth alone, and H B I G plus ISG at birth, three six months.
and
The r e s u l t s d e m o n s t r a t e a 91% c a r r i e r rate for placebo, 45% for a single dose of HBIG and o n l y 23% for H B I G given three times. Thus, the c a r r i e r rate was r e d u c e d 75% by the latter (Lancet ii:388, 1981). W o r l d w i d e - A n e d i t o r i a l in A r c h I n t e r n M e d 141:1123, 1981, by Q u i n n reminds u s o f the r e s u r g e n c e of malaria. We w e r e r e m i n d e d m o r e f o r c i b l y as two c h i l d r e n and one a d u l t w e r e a d m i t t e d r e c e n t l y to our s e r v i c e s w i t h m a l a r i a - i m p o r t e d f r o m M e x i c o and the F a r East. Quinn points out that the d i s e a s e has i n c r e a s e d 100fold in some areas of the w o r l d l e a v i n g more than 150 m i l l i o n i n f e c t e d p e r s o n s in Africa, Asia, and L a t i n America. The
9 1981 by Elsevier North-Holland, Inc.
14 Infectious Diseases N e w s l e t t e r
m o r t a l i t y is an a s t o n i s h i n g 1 , 0 0 0 , 0 0 0 p e r year! Poverty, p o o r sanitation, P l a s m o d i u m drug r e s i s t a n c e and m o s q u i t o i n s e c t i cide r e s i s t a n c e are c o n t r i b u t i n g to the increase. He e s t i m a t e s that m o r e than 4000 cases are o c c u r r i n g in the U.S. for 1980 and 1981. Q u i n n details the d i a g n o s tic and t h e r a p e u t i c d i f f i c u l t i e s U.S. p h y s i c i a n s h a v e w i t h the disease. NATIONAL
NOTES
T e x a & - H e m o p h i l u s i n f l u e n z a e type (HIB) has done it again. Following w i d e - s p r e a d use of r i f a m p i n p r o p h y l a x i s for c o n t a c t s of p a t i e n t s w i t h s e r i o u s HIB i n f e c t i o n in Dallas, a 16 m o n t ~ old boy w a s t r e a t e d for HIB m e n i n g i t i s and his family m e m b e r s w.e,re t r e a t e d w i t h rifampin. A two a n ~ ~ n e h a l f y e a r old s i b l i n g w a s still culture p o s i t i v e ten days and six w e e k s after treatment. The HIB r e c o v e r e d h a d i n c r e a s e d its MIC f r o m 0.312 m c g / m l to 25 ug/ml. Mother became colonized subsequently with a similar HIB isolate. We h o p e this is n o t a h a r b i n g e r of things to come, b u t are fearful t h a t it is (J P e d i a t r 99:406, 1981). O k l a h o m a a n d Texas - N o n - g o n o c o c c a l urethritis w a s e v a l u a t e d in p r e p u b e r t a l children; n o n e w e r e i n f e c t e d w i t h C h l a m ~ dia t r a c h o m a t i s . However, of 33 e p i s o d e s of u r o g e n i t a l gonorrhea, nine w e r e a s s o c i ated w i t h c h l a m y d i a l i n f e c t i o n concurr e n t l y or s u b s e q u e n t l y . This 27% incidence in p r e p u b e K t a l c h i l d r e n is c o m p a r able to rates in adult m e n and women. The a u t h o r s p o i n t o u t that p o s t - G C discharge in m a l e s may w e l l be due to chlam y d i a l i n f e c t i o n b u t that s y m p t o m s m a y be l a c k i n g in the female (J P e d i a t r 99:206, 1981) . W i s c o n s i n - C h e s n e y reports on the clinical m a n i f e s t a t i o n s of toxic shock syndrome (TSS) in 2 2 w o m e n aged 13-44 years. V u l v a r c e l l u l i t i s , d e c r e a s e s in calcium, p h o s p h a t e , cholesterol, sodium, lymphocytes, and iron, late loss of h a i r and nails, s u b s e q u e n t vocal cord p a r a l y s i s and i m p a i r e d s e n s a t i o n in the fingers are n e w f e a t u r e s of TSS d e s c r i b e d ( J ~ 246:741, 1981). N e w A n t i b i o t i c s - The A u g u s t 21 issue of M e d i c a l L e t t e r r e v i e w s the use of cefotaxime and m o x a l a c t a m in the h i g h - m o r tality g r a m n e g a t i v e m e n i n g i t i s in adults. T h e y p o i n t out that the s p e c t r u m and p h a r m a c o k i n e t i c s of these n e w cephalosporins argue for p o s s i b l e success w h e n c o m p a r e d to c o n v e n t i o n a l c h l o r a m p h e n i c o l or a m i n o g l y c o s i d e therapy. CSF levels are h i g h for both new drugs and w e l l above cidal levels for m a n y of the
e n t e r i c pathogens. Anectdotal evidence suggests this is i m p o r t a n t clinically, as some p a t i e n t s h a v e b e e n cured a f t e r failure of t r a d i t i o n a l therapy. U n i t e d States - More than 1000 cases of Rocky M o u n t a i n S p o t t e d F e v e r (RMSF) have b e e n r e p o r t e d in e a c h of the last four years. M o s t o c c u r in the South A t l a n t i c states. A l m o s t all p a t i e n t s became ill b e t w e e n A p r i l and S e p t e n ~ e r w i t h peaks in M a y and June. Case-fatality rates vary b e t w e e n 3-8%. Mortality can o n l y be r e d u c e d by p r o m p t recognition (fever, headache, rash, myalgia, and tick exposure) and a d e q u a t e t r e a t m e n t (~[MWR 30:318, 1981). U n i t e d S t a t e s - T u b e r c u l o s i s is not a disease of the past. It has b e e n on the i n c r e a s e in nine states across the c o u n t r y (see map, pagel5, from CDC) over 1978 and 1 9 7 9 , ' a n d in ten a d d i t i o n a l states o v e r 1979 rates. In 1980, more than 27,000 cases w e r e reported. So w h e r e v e r y o u are in the U.S., this d i a g n o s i s m u s t be considered; the S o u t h e r n states have a c o n s t a n t prevalence and the N o r t h e r n t i e r is on the increase ( ~ ; R 30:325, 1981). F r o m the C D C - T w o n e w sets of recomm e n d a t i o n s have r e c e n t l y b e c o m e a v a i l a b l e from the A d v i s o r y C o m m i t t e e on I m m u n i z a tion P r a c t i c e (ACIP) ; for p n e u m o c o c c a l v a c c i n e (PPV) and DTP. We cannot r e p o r t the e n t i r e r e c o m m e n d a t i o n s , b u t here are some h i g h l i g h t s : i.
2. 3.
4.
O n e - h a l f given P P V d e v e l o p m i l d i n f l a m m a t i o n and p a i n locally. Serious side e f f e c t s are rare (5/1 million doses). S e c o n d doses to adults h a v e r e s u l t e d in severe r e a c t i o n (? A r t h u s - t y p e ) . I n d i c a t i o n s for P P V include: a. f u n c t i o n a l or a n a t o m i c a s p l e n i a in p e r s o n s >2 y e a r s old; b. c h r o n i c i l l n e s s e s w i t h risk of serious p n e u m o c o c c a l disease (>2 years old); c. r e s t r i c t e d p o p u l a t i o n s at h i g h risk. A l m o s t e v e r y t h i n g y o u e v e r w a n t e d to k n o w about DTP singly and in c o m b i n a tion ( ~ ; R 30:392 and 410, 1981).
U n i t e d States - S y p h i l i s is i n c r e a s i n g in the p a s t three years, 33+% m o r e positive since 1977. Large u r b a n areas pred o m i n a t e a n d the b i g g e s t cities w i t h only 25~ of the p o p u l a t i o n r e p o r t 63% of cases. C o n g e n i t a l syphilis is r e s u r g e n t w i t h 129 cases in 1979 and iii cases in 1980, ref l e c t i n g the i n c r e a s e s in w o m e n (MMWR 30: 441, 1981).
9 1~81 by Elsevier North Holland, Ins._
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15 Infectious Diseases Newsletter INTERNATIONAL
NOTES
(continued)
W a s h i n g t o n , D.C. - B r o o k c o n t i n u e s his series of @eports w h i c h d e t a i l the role of a n a e r o b e s in p e d i a t r i c infections. His last e f f o r t c o n c e r n e d c h r o n i c s i n u s i tis in w h i c h he reports c u l t u r e r e s u l t s of "aspirated s p e c i m e n s from m a x i l l a r y e t h m o i d and frontal sinuses in 40 children w i t h c h r o n i c infection. Anaerobes w e r e r e c o v e r e d in all 37 i n s t a n c e s of b a c t e r i a l r e c o v e r y and w e r e the sole organisms in 23. B a c t e r o i d e s sp, p e D r o s t r e p t o c o c c i , and F u s o b a c t e r i u m spp predominated (J~ 246:967, 1981). T a c o m a and Seattle, W a s h i n g t o n - A l l of us b e l i e v e that o c u l a r 9 o n o c o c c a l i n f e c tion is easy to r e c o g n i z e by its m a r k e d i n f l a m m a t o r y exudate. P o d g o r e and H o l m e s r e m i n d us that on occasion, little or no i n f l a m m a t i o n m a y be present. They report two cases w i t h GC o p h t h a l m i a in w h i c h the o r g a n i s m was i s o l a t e d d e s p i t e little or no p u r u l e n c e . A 14 day o l d female infant was c h e c k e d b e c a u s e GC h a d b e e n cultured f r o m the a m n i o t i c fluid. Positive A g N O ~ p r o p h y l a x i s was e m p l o y e d , and w i t h no c I i n i c a l signs the i n f a n t was discharged, b u t r e t u r n e d at 14 days of age still w i t h o u t clinical signs, b u t y i e l d e d a p o s i t i v e culture. A 32 y e a r old lab t e c h n i c i a n w o r k i n g in a VD lab h a d m i n i mal m u c o i d c o n j u n c t i v i t i s and b e c a u s e of
h e r h a n d l i n g of N. 9onorrheae, was cultured; the o r g a n i s m was i s o l a t e d from the c o n j u n c t i v a e . Both p a t i e n t s r e s p o n d e d to p e n i c i l l i n ( J ~ A 246:242, 1981). Rabies V a c c i n e - E l i L i l l y and C o m p a n y p l a n to d i s c o n t i n u e d o m e s t i c m a r k e t i n g of rabies v a c c i n e on N o v e m b e r 30, 1981 and i n t e r n a t i o n a l m a r k e t i n g in 1982. No reasons w e r e stated, b u t the l i c e n s u r e and u t i l i z a t i o n of h u m a n d i p l o i d v a c c i n e c e r t a i n l y has had its impact. Stateswithanincreaseintu~rculosJscaserates,
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9 1981 by ElsevierNorth Holland, Inc.
UnitedStates, 1980
L~ EXCEEDED IgTg CASE RATE 9 EXCEEOEO i978 A~01~TS CASE RATs
therapy can be a d m i n i s t e r e d on an a m b u l a tory basis. Some a d v o c a t e a n t i b i o t i c t h e r a p y if the b i t e is b r o u g h t to y o u r a t t e n t i o n p r i o r to o b v i o u s i n f l a m m a t i o n , b e c a u s e of the h e a v y c o n t a m i n a t i o n and the i n e v i t a b i l i t y of infection. V i n c e n t A. Fulginiti, M.D. P r o f e s s o r and H e a d D e p a r t m e n t of P e d i a t r i c s A r i z o n a H e a l t h Sciences C e n t e r Suggested i. P l a s t 2. J Bone
Reading Reconstr Joint
Surg
28:394,
Surg 59A:416,- 1977.
3. J T r a u m a
19(9):655,
1979.
4. J T r a u m a
20;~):383,
1980.
INTERNATIONAL
1961.
NOTES
Y u g o s l a v i a - in 1979 an e p i d e m i c of hepatitis A virus (HAV) o c c u r r e d in a b o a r d ing s c h o o l at U m k a among 165 residents. Seventy-nine individuals were investigated as c o n t a c t s of the four c l i n i c a l cases; 45 contacts w e r e immune w h e n the e p i d e m i c began, of the 34 s u s c e p t i b l e , e i g h t cases of overt h e p a t i t i s , five of s u b c l i n i c a l d i s e a s e (abnormal FLT's) and 13 of i n a p p a r e n t i n f e c t i o n ensued. The ratio of s i l e n t / o v e r t i n f e c t i o n s was 2.3/ i. N o t e the h i g h attack rate; 76% of s u s c e p t i b l e s w e r e infected. In the same interval, only one case of H B V i n f e c t i o n o c c u r r e d (Amer J E p i d e m i o l 114:260, 1981). L o n d o n - A s t r i k i n g i n c i d e n c e of m u l t i p l y d r u g r e s i s t a n t S h i @ e l l a sepsis was r e p o r ted by Grass and colleagues. Of 2370 strains of S. d y s e n t e r i a e , S. flexneri, and S. boyd~i, 80% were r e s i s t a n t to one or m o r e o f 12 drugs, i n c l u d i n g those comm o n l y used. A m p i c i l l i n r e s i s t a n c e inc r e a s e d f r o m 2% in 1974 to 23.7% in 1978 and m u l t i p l e drug r e s i s t a n c e f r o m 13% to 49%. The authors note t h a t m a n y of these i s o l a t e s w e r e a c q u i r e d o u t s i d e of E n g l a n d a n d in both tourists and immigrants - a f r i g h t e n i n g i m p o r t (Brit M e d J 283:575, 1981). B a n g l a d e s h - M o r e than 2000 c h i l d r e n in the s e c o n d y e a r of life w e r e s t u d i e d to d e t e r m i n e the risk of d i a r r h e a l d i s e a s e s by n u t r i t i o n a l status. No correlation b e t w e e n i n i t i a l n u t r i t i o n and ~ t t a c k rates w e r e n o t e d (Amer J E p i d e m i o l 114: -284, 1981). N e w f o u n d l a n d - Six cases w e r e r e p o r t e d of t r a n s f e r of v a c c i n i a virus f r o m an 18 y e a r old female r e c r u i t to c o n t a c t s 1540 y e a r s old. The r e c r u i t w a s v a c c i n a t e d in the m i l i t a r y and in e a c h i n s t a n c e , t r a n s f e r o c c u r r e d b e c a u s e of close con-
tact (kissing, touching) w i t h h e r or one of the s e c o n d a r y cases. This is a disease we t h o u g h t h a d d i s a p p e a r e d b u t reports still occur, o f t e n from armed forces p e r s o n n e l w h o are v a c c i n a t e d (In the U.S. m o r e than one m i l l i o n s m a l l p o x v a c c i n a t i o n s are g i v e n to m i l i t a r y personnel e a c h year.). (MMWR 30:453, 1981). L o n d o n - A s i x - m o n t h study by E n s m o n and c o l l e a g u e s led to the c o n c l u s i o n that G r o u p B s t r e p t o c o c c i could be t r a n s m i t t e d f r o m p e r s o n s o t h e r than the n e o n a t e ' s mother. Other mothers who were culture positive, o t h e r babies, and a staff m e m b e r w e r e the sources of i n f e c t i o n for 14 of 21 infants in the n o r m a l n u r s e r y and one e p i s o d e in the h i g h - r i s k unit. The group also found t h a t o r d i n a r y h y g i e n e (i.e., handwashing) could prevent transmission (Brit M e d J 283: 459, 1981). L a t i n A m e r i c a - A c u t e h e m o r r h a g i c conj u n c t i v i t i s (AHC), m o s t often caused by e n t e r o v i r u s 70 (also by a d e n o v i r u s 1 and C o x s a c t i n e A-24), has b e e n r e p o r t e d from South, Central, and C a r i b b e a n ~erica. This is a severe illness w i t h a b r u p t onset, p r o f u s e w a t e r y discharge, intense i n f l a m m a t i o n , p a i n and itching, and s u b c o n j u n c t i v a l h e m o r r h a g e in i0100% (I~;R 30:450, 1981). A H C has b e e n r e p o r t e d only in F l o r i d a in the U.S. (~I~IR30:465, 1981). T a i w a n - B e a s l e y a n d his c o l l e a g u e s r e p o r t an i m p o r t a n t t h e r a p e u t i c trial of-Hepatitis B Immune g l o b u l i n (HBIG) in i n f a n t s b o r n to HB A g p o s i t i v e mothers. The c a r r l e r r a t e in w o m e n is 15-20% in Tai~r and the risk of carriage in the b a b i e s varies f r o m 40-95%. A d o u b l e - b l i n d p l a c e b o trial of H B I G compared: 9
i. 2. 3.
S
-
9
placebo H B I G at birth alone, and H B I G plus ISG at birth, three six months.
and
The r e s u l t s d e m o n s t r a t e a 91% c a r r i e r rate for placebo, 45% for a single dose of HBIG and o n l y 23% for H B I G given three times. Thus, the c a r r i e r rate was r e d u c e d 75% by the latter (Lancet ii:388, 1981). W o r l d w i d e - A n e d i t o r i a l in A r c h I n t e r n M e d 141:1123, 1981, by Q u i n n reminds u s o f the r e s u r g e n c e of malaria. We w e r e r e m i n d e d m o r e f o r c i b l y as two c h i l d r e n and one a d u l t w e r e a d m i t t e d r e c e n t l y to our s e r v i c e s w i t h m a l a r i a - i m p o r t e d f r o m M e x i c o and the F a r East. Quinn points out that the d i s e a s e has i n c r e a s e d 100fold in some areas of the w o r l d l e a v i n g more than 150 m i l l i o n i n f e c t e d p e r s o n s in Africa, Asia, and L a t i n America. The
9 1981 by Elsevier North-Holland, Inc.
14 Infectious Diseases N e w s l e t t e r
m o r t a l i t y is an a s t o n i s h i n g 1 , 0 0 0 , 0 0 0 p e r year! Poverty, p o o r sanitation, P l a s m o d i u m drug r e s i s t a n c e and m o s q u i t o i n s e c t i cide r e s i s t a n c e are c o n t r i b u t i n g to the increase. He e s t i m a t e s that m o r e than 4000 cases are o c c u r r i n g in the U.S. for 1980 and 1981. Q u i n n details the d i a g n o s tic and t h e r a p e u t i c d i f f i c u l t i e s U.S. p h y s i c i a n s h a v e w i t h the disease. NATIONAL
NOTES
T e x a & - H e m o p h i l u s i n f l u e n z a e type (HIB) has done it again. Following w i d e - s p r e a d use of r i f a m p i n p r o p h y l a x i s for c o n t a c t s of p a t i e n t s w i t h s e r i o u s HIB i n f e c t i o n in Dallas, a 16 m o n t ~ old boy w a s t r e a t e d for HIB m e n i n g i t i s and his family m e m b e r s w.e,re t r e a t e d w i t h rifampin. A two a n ~ ~ n e h a l f y e a r old s i b l i n g w a s still culture p o s i t i v e ten days and six w e e k s after treatment. The HIB r e c o v e r e d h a d i n c r e a s e d its MIC f r o m 0.312 m c g / m l to 25 ug/ml. Mother became colonized subsequently with a similar HIB isolate. We h o p e this is n o t a h a r b i n g e r of things to come, b u t are fearful t h a t it is (J P e d i a t r 99:406, 1981). O k l a h o m a a n d Texas - N o n - g o n o c o c c a l urethritis w a s e v a l u a t e d in p r e p u b e r t a l children; n o n e w e r e i n f e c t e d w i t h C h l a m ~ dia t r a c h o m a t i s . However, of 33 e p i s o d e s of u r o g e n i t a l gonorrhea, nine w e r e a s s o c i ated w i t h c h l a m y d i a l i n f e c t i o n concurr e n t l y or s u b s e q u e n t l y . This 27% incidence in p r e p u b e K t a l c h i l d r e n is c o m p a r able to rates in adult m e n and women. The a u t h o r s p o i n t o u t that p o s t - G C discharge in m a l e s may w e l l be due to chlam y d i a l i n f e c t i o n b u t that s y m p t o m s m a y be l a c k i n g in the female (J P e d i a t r 99:206, 1981) . W i s c o n s i n - C h e s n e y reports on the clinical m a n i f e s t a t i o n s of toxic shock syndrome (TSS) in 2 2 w o m e n aged 13-44 years. V u l v a r c e l l u l i t i s , d e c r e a s e s in calcium, p h o s p h a t e , cholesterol, sodium, lymphocytes, and iron, late loss of h a i r and nails, s u b s e q u e n t vocal cord p a r a l y s i s and i m p a i r e d s e n s a t i o n in the fingers are n e w f e a t u r e s of TSS d e s c r i b e d ( J ~ 246:741, 1981). N e w A n t i b i o t i c s - The A u g u s t 21 issue of M e d i c a l L e t t e r r e v i e w s the use of cefotaxime and m o x a l a c t a m in the h i g h - m o r tality g r a m n e g a t i v e m e n i n g i t i s in adults. T h e y p o i n t out that the s p e c t r u m and p h a r m a c o k i n e t i c s of these n e w cephalosporins argue for p o s s i b l e success w h e n c o m p a r e d to c o n v e n t i o n a l c h l o r a m p h e n i c o l or a m i n o g l y c o s i d e therapy. CSF levels are h i g h for both new drugs and w e l l above cidal levels for m a n y of the
e n t e r i c pathogens. Anectdotal evidence suggests this is i m p o r t a n t clinically, as some p a t i e n t s h a v e b e e n cured a f t e r failure of t r a d i t i o n a l therapy. U n i t e d States - More than 1000 cases of Rocky M o u n t a i n S p o t t e d F e v e r (RMSF) have b e e n r e p o r t e d in e a c h of the last four years. M o s t o c c u r in the South A t l a n t i c states. A l m o s t all p a t i e n t s became ill b e t w e e n A p r i l and S e p t e n ~ e r w i t h peaks in M a y and June. Case-fatality rates vary b e t w e e n 3-8%. Mortality can o n l y be r e d u c e d by p r o m p t recognition (fever, headache, rash, myalgia, and tick exposure) and a d e q u a t e t r e a t m e n t (~[MWR 30:318, 1981). U n i t e d S t a t e s - T u b e r c u l o s i s is not a disease of the past. It has b e e n on the i n c r e a s e in nine states across the c o u n t r y (see map, pagel5, from CDC) over 1978 and 1 9 7 9 , ' a n d in ten a d d i t i o n a l states o v e r 1979 rates. In 1980, more than 27,000 cases w e r e reported. So w h e r e v e r y o u are in the U.S., this d i a g n o s i s m u s t be considered; the S o u t h e r n states have a c o n s t a n t prevalence and the N o r t h e r n t i e r is on the increase ( ~ ; R 30:325, 1981). F r o m the C D C - T w o n e w sets of recomm e n d a t i o n s have r e c e n t l y b e c o m e a v a i l a b l e from the A d v i s o r y C o m m i t t e e on I m m u n i z a tion P r a c t i c e (ACIP) ; for p n e u m o c o c c a l v a c c i n e (PPV) and DTP. We cannot r e p o r t the e n t i r e r e c o m m e n d a t i o n s , b u t here are some h i g h l i g h t s : i.
2. 3.
4.
O n e - h a l f given P P V d e v e l o p m i l d i n f l a m m a t i o n and p a i n locally. Serious side e f f e c t s are rare (5/1 million doses). S e c o n d doses to adults h a v e r e s u l t e d in severe r e a c t i o n (? A r t h u s - t y p e ) . I n d i c a t i o n s for P P V include: a. f u n c t i o n a l or a n a t o m i c a s p l e n i a in p e r s o n s >2 y e a r s old; b. c h r o n i c i l l n e s s e s w i t h risk of serious p n e u m o c o c c a l disease (>2 years old); c. r e s t r i c t e d p o p u l a t i o n s at h i g h risk. A l m o s t e v e r y t h i n g y o u e v e r w a n t e d to k n o w about DTP singly and in c o m b i n a tion ( ~ ; R 30:392 and 410, 1981).
U n i t e d States - S y p h i l i s is i n c r e a s i n g in the p a s t three years, 33+% m o r e positive since 1977. Large u r b a n areas pred o m i n a t e a n d the b i g g e s t cities w i t h only 25~ of the p o p u l a t i o n r e p o r t 63% of cases. C o n g e n i t a l syphilis is r e s u r g e n t w i t h 129 cases in 1979 and iii cases in 1980, ref l e c t i n g the i n c r e a s e s in w o m e n (MMWR 30: 441, 1981).
9 1~81 by Elsevier North Holland, Ins._
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15 Infectious Diseases Newsletter INTERNATIONAL
NOTES
(continued)
W a s h i n g t o n , D.C. - B r o o k c o n t i n u e s his series of @eports w h i c h d e t a i l the role of a n a e r o b e s in p e d i a t r i c infections. His last e f f o r t c o n c e r n e d c h r o n i c s i n u s i tis in w h i c h he reports c u l t u r e r e s u l t s of "aspirated s p e c i m e n s from m a x i l l a r y e t h m o i d and frontal sinuses in 40 children w i t h c h r o n i c infection. Anaerobes w e r e r e c o v e r e d in all 37 i n s t a n c e s of b a c t e r i a l r e c o v e r y and w e r e the sole organisms in 23. B a c t e r o i d e s sp, p e D r o s t r e p t o c o c c i , and F u s o b a c t e r i u m spp predominated (J~ 246:967, 1981). T a c o m a and Seattle, W a s h i n g t o n - A l l of us b e l i e v e that o c u l a r 9 o n o c o c c a l i n f e c tion is easy to r e c o g n i z e by its m a r k e d i n f l a m m a t o r y exudate. P o d g o r e and H o l m e s r e m i n d us that on occasion, little or no i n f l a m m a t i o n m a y be present. They report two cases w i t h GC o p h t h a l m i a in w h i c h the o r g a n i s m was i s o l a t e d d e s p i t e little or no p u r u l e n c e . A 14 day o l d female infant was c h e c k e d b e c a u s e GC h a d b e e n cultured f r o m the a m n i o t i c fluid. Positive A g N O ~ p r o p h y l a x i s was e m p l o y e d , and w i t h no c I i n i c a l signs the i n f a n t was discharged, b u t r e t u r n e d at 14 days of age still w i t h o u t clinical signs, b u t y i e l d e d a p o s i t i v e culture. A 32 y e a r old lab t e c h n i c i a n w o r k i n g in a VD lab h a d m i n i mal m u c o i d c o n j u n c t i v i t i s and b e c a u s e of
h e r h a n d l i n g of N. 9onorrheae, was cultured; the o r g a n i s m was i s o l a t e d from the c o n j u n c t i v a e . Both p a t i e n t s r e s p o n d e d to p e n i c i l l i n ( J ~ A 246:242, 1981). Rabies V a c c i n e - E l i L i l l y and C o m p a n y p l a n to d i s c o n t i n u e d o m e s t i c m a r k e t i n g of rabies v a c c i n e on N o v e m b e r 30, 1981 and i n t e r n a t i o n a l m a r k e t i n g in 1982. No reasons w e r e stated, b u t the l i c e n s u r e and u t i l i z a t i o n of h u m a n d i p l o i d v a c c i n e c e r t a i n l y has had its impact. Stateswithanincreaseintu~rculosJscaserates,
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9 1981 by ElsevierNorth Holland, Inc.
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