P 39

A RARE CLINICAL MANIFESTATION OF MURINE TYPHUS

S. Doukakis, I. Bompolaki, E. Vittorakis, S. Kastanakis
First Medical Department, “Saint George” General Hospital, Chania, Greece

A man aged 56 years, farmer, presented at our hospital and gave a two-day history of high fever accompanied with chills, headache and malaise. He referred dogs and rats contact. On admission his temperature was 38.6°C, the pulse 100 beats/min, and his systolic blood pressure was 95 mmHg. On physical examination he had a diffuse macular rash on the trunk. On abdominal palpation he had moderate hepatomegaly. The peripheral white blood cells count was 7.6 x 103/ml and the sedimentation rate was 11 mm in the first hour. There was a mild elevation of AST (47 U/L) and ALT (61 U/L). Chest radiograph was negative. A new chest x-ray was performed 3 days later and showed the presence of bilateral pleural effusion. Serological evidence of acute infection with Rickettsia typhi was found using the indirect immunofluorescence antibody technique (IFAT). The patient was treated with ciprofloxacin i.v. and doxycyclin per os. Fever disappeared in 6 days after the onset of treatment and the patient was discharged after a period of eleven days of hospitalization in good general status. The clinical course of murine typhus is usually uncomplicated and the mortality rate is low (< 1 percent). Pleuritis as a clinical manifestation of murine typhus is considered extremely rare but may be happen in undiagnosed for long period patients. The early administration of antirickettsial therapy is imperative.

P 40

BACTERIAL ENDOCARDITIS AFTER URINARY TRACT INFECTIONS AT VALVULAR PATIENTS

S. Iacob, I. Rebedea, L. Benea, M. Pana
Matei Bals Infectious Disease Institute, Bucharest; “Cantacuzino” Institute, Bucharest, Romania

Introduction: Urinary tract infections (UTI) are important risc factors for valvular patients and must be always precocious treated.

Objective: In a retrospective study we investigated bacteriuria as a possible source of infection at 70 patients with bacterial endocarditis (EB) diagnosis, hospitalized in Matei Bals Institute between 2000-2002.

Results: The endocarditis diagnosis criteria were: clinical major criteria (persistent fever, heart murmurs) and vegetations on echocardiography for all patients, associated with positive hemoculture in 33/70 patients. UTI were suspected as possible portal of entry in 13/70 patients and were confirmed in 7/70 patients (the same microorganism isolated from hemoculture and uroculture). UTI bacteriological confirmed ethiologic agents were E. coli (1 patient), Enterobacter (1 patient), Enterococcus faecalis (4 patients), E. coli + Enterococcus faecalis (1 patient with indwelling catheter). The interval between UTI clinical symptoms and the onset of BE was between 4-6 weeks and most of patients were pretreated with fluorochinolones. BE evolution was mild in 6/13 patients and complicated in 7/13 patients: 3 with major embolic manifestation, 3 with cardiac failure, 1 with renal intrainfections failure. The response to antimicrobial therapy was slow and 2 patients (2/13) necessited changing and prolonged therapy because of high resistant microorganisms (1 ampicillin resistant Enterococcus, 1 multiple resistant Enterobacter).

Conclusion: Some microorganisms, Enterococcus especially, may express resistance and a high virulence potential to invade the kidneys and to colonize the heart tissue producing subacute BE. The therapy must be according with antibiograms in valvular patients bacteriuria for preventing BE.

P 41

IN-HOSPITAL COLONIZATION OF PSEUDOMONAS DURING OXYGENTHERAPY IN PATIENTS WITH ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

T.K. Galeas, V. Galea, E. Tselepatiotis, V. Zambetas, V. Ippa, M. Lemoni
B’ Internal Medicine Clinic, Microbiology Laboratory, General Hospital of Trikala, Greece

Introduction: We refer to a work that began 7 years ago and has recently been completed with new data.
The purpose of this study is to show that the respirator moisturizers could be responsible for colonization of Pseudomonas in the respiratory system.
Material of the study were 3 patients, 2 male and 1 female aged 55, 66 and 84 respectively. They were hospitalized in the clinic in a period of three months with exacerbation of COPD caused by infection of the upper respiratory system. Three days later they all had deterioration of respiratory function both in clinic and laboratory findings and afluent sputum purulence. Sputum culture revealed Pseudomonas aeruginosa. The fact that they had been under oxygentherapy from the day of admission led to the thought that the moisturizers could possibly be the source of colonization. 10 samples of the moisturizers content were randomly taken from the clinics and 3 of them (30%) were found positive for Pseudomonas.
The above mentioned data led to preventive measures such as washing before use. The same test was recently repeated and following the same steps we found no trail of Pseudomonas or any other pathogenic factor.

Conclusion:
1. The possibility of respiratory system infections, especially Pseudomonas, during the use of oxygentherapy calls for the special attention of the hospital infection committee and the careful cleaning of the oxygenequipment.
2. The appropriate health measures ensure the limitation of Pseudomonas infection and other pathogenic factors.

P 42

ACUTE ASEPTIC MENINGITIS: CASE REVIEW FROM 1997 TO 2002

J. Velez, H. Alves, J. Oliveira, I. Ramos, S. da Cunha, R. Côrte-Real, A.A. Meliço-Silvestre
Department of Infectious Diseases, University Hospital of Coimbra, Portugal

Introduction: Acute aseptic meningitis (AAM) is a benign clinical entity, however it can be confused with other CNS infections requiring prompt antibiotic therapy.

Material and methods: Retrospective review of the clinical records with the diagnosis of AAM, from 1997 to 2002.

Results: 87 patients were reviewed, 60 (69.7%) were male, with an average age of 26.8 +- 15.4 [11 - 74]; the mean cases/year ratio was 14.3, with 2 incidence peaks (one from May to August, another from December to January); the mean hospitalisation time was 8 days +- 4.2 [2 - 22].
The most frequent symptoms were headaches (97.7%), fever (65.1%), vomiting (60.5%), neck stiffness (50.0%) and photophobia (18.6%).
The spinal tap showed pleocytosis in all patients (7-100 cells/mm³ in 27 patients, 101-500 cells/mm³ in 51 patients and > 500 cells/mm³ in 8 patients); 80% showed lymphocytic pleocytosis, 17.4% showed neutrophilic pleocytosis, and 2.4% showed no predominance.
Spinal tap glucose was diminished in 1 case (6 mg/dl); proteins were mildly elevated (60-100 mg/dl) in 37.2% of the patients and, in 19%, > 100 mg/dl.
52 patients were submitted to symptomatic therapies, the remainder were treated with different antibacterial/antiviral therapies.
All patients were discharged without sequelae.
Etiologic agents were isolated in 32 (37.2%) of the patients (Enteroviruses - 17; Parotiditis virus - 8; Influenza viruses - 3; HSV - 1; EBV - 1; Leptospira spp. - 1; Rickettsia conorii - 1).

Conclusion: The AA verify that AAM is a benign condition, all the patients recovering without sequelae. Etiologic agents were identified in 37.2% of the patients, Enteroviruses and Parotiditis virus being the most frequent.

P 43

RENAL FUNCTION IN MURINE TYPHUS: A STUDY OF 101 CASES

S. Kastanakis, S. Doukakis, F. Axioti, C. Daskalaki, I. Bompolaki, A. Evaggelopoulos, A. Goggou, A. Galis, A. Xini, G. Polimili
First Medical Department, “Saint George” General Hospital, Chania, Greece

101 patients with compatible clinical status of murine typhus and high serological titers of antibodies against Rickettsia typhi were studied between January 1993 and December 1998. Three blood samples were obtained from each patient for the study of their renal function. The first sample was obtained on admission, approximately 9 days after the onset of the disease. The second sample approximately two weeks after the first. The third sample, taken from about the half of the patients, was obtained one month after the second.
On admission 4/101 patients (4.0%) presented acute renal failure. The median value of urea and creatinine was 28.0 mg/dl (range 15-265 mg/dl) and 1.0 mg/dl (range 0.7-9.9 mg/dl) respectively. Two weeks later renal failure was presented in 2/101 patients (2.0%). The median value of urea and creatinine was 26.0 mg/dl (range 11-101 mg/dl) and 0.9 mg/dl (range 0.6-6.4 mg/dl) respectively. One month later no patient presented an increase of urea or creatinine and their median value was 35.0 mg/dl (range 14-76 mg/dl) and 0.9 mg/dl (range 0.6-1.3 mg/dl) respectively. The outcome of murine typhus was favorable for all 101 patients (100%). The four patients who presented acute renal failure reversed after the administration of anti-rickettsial treatment and careful administration of fluids.

P 44

HYPONATREMIA IN MURINE TYPHUS: A STUDY OF 101 CASES

S. Kastanakis, S. Doukakis, I. Bompolaki, E. Vittorakis, C. Daskalaki, A. Xini, F. Axioti, K. Palla
First Medical Department, “Saint George” General Hospital, Chania, Greece

Hyponatremia is an electrolyte abnormality in murine typhus. A hundred and one patients with compatible clinical status of murine typhus and high serological titers of antibodies against Rickettsia typhi were studied from our team during a period of time between January 1993 and December 1998. For the study of hyponatremia, three serum samples were obtained from each patient. The first sample was obtained on admission, approximately 9 days after the onset of the disease. The second sample approximately two weeks after the first. The third sample, taken from about the half of the patients, was obtained one month after the second.
On admission (first sample) 46/101 patients (45.5%) presented a serum sodium decrease while the median value of sodium was 136.0 mEq/L. Two weeks later (second sample) 23/101 patients (22.7%) presented a serum sodium decrease while the median value of sodium was 138.0 mEq/L. One month later (third sample) 3/46 patients (6.5%) presented a serum sodium decrease and the median value of sodium was 140.5 mEq/L. In our study hyponatremia occurred in 45.5% of our patients on admission, while in other retrospectives studies was higher. This study showed that hyponatremia (as other manifestations) in rickettsial diseases can be absent or minimal in patients with mild cases or in those who are given specific treatment early.

P 45

VISCERAL LEISHMANIASIS IN ASSOCIATION WITH PYOMYOSITIS

A. Kaloterakis, A. Filiotou, S. Kastanakis, E. Papakonstantinou, S.J. Hadziyannis
2nd Academic Department of Medicine, Hippokration General Hospital,
University of Athens, Greece, “Saint George” General Hospital, Chania, Greece

Background: A unique case of visceral leishmaniasis associated with pyomyositis is described in a 59 years old Greek female.

Methods: Visceral leishmaniasis was diagnosed by bone marrow intracellular and extracellular Leishmanias identification (Leishman-Donovan bodies) and by high titer of serum anti-leishmanial antibodies. Pyomyositis was documented by fever, painful woody edema of the right thigh and pus aspirated from muscles with Staphylococcus aureus and Leishmania donovani in culture. Treatment of visceral leishmaniasis with liposomal amphotericin B and of pyomyositis with antibiotic therapy plus surgical incision and drainage, were satisfactory.

Results: The patient has been followed for 18 months without recurrence of visceral leishmaniasis or pyomyositis.

Conclusion: We note that our unique case may support an etiopathogenetic implication of visceral leishmaniasis in the development of pyomyositis.

P 46

RAPID DIAGNOSTIC METHOD FOR INVASIVE CANDIDIASIS

M. Hui, S.W. Cheung, M.L. Chin, K.C. Chu, A.F.B. Cheng
Department of Microbiology, the Chinese University of Hong Kong, The Prince of Wales Hospital, Hong Kong SAR

Invasive fungal infections had taken a great toll in the immunocompromised patients, with the various Candida species accounting for the majority of the invasive diseases. Diagnosis based on blood cultures, tissue cultures and/or histopathological evidences are time consuming, technically demanding and of low sensitivity. Therefore, we explored an alternative rapid non-culture diagnostic method. D-arabinitol is a chemical metabolite produced by Candida species, whereas mammalian cells can produce both D- and L-arabinitols. The enantiomers-ratios detection from urine and serum was made possible by the use of gas chromatography coupled with mass spectrometry (GC/MS). The mean D-/L-arabinitol ratios +/- standard deviation (range) in urine (n = 40) and serum (n = 20) were 2.08 +/- 0.78 (0.57 to 3.55) and 1.79 +/- 0.75 (0.74 to 3.54) respectively from patients without evidence of fungal infection or colonization; 9.91 +/- 3.04 (7.24 to 16.27) and 13.58 +/- 7.31 (5.57 to 25.88) in urine and serum respectively in patients (n = 7) with culture proven invasive candida infections. The difference in D-/L-arabinitol ratios between the candidaemic patients and the non-candidaemic patients were statistically significant (P < 0.01, t-test) in both serum and urine samples. The D-/L-arabinitol ratios were not significantly affected in patients with oral or vaginal candidiasis and candiduria. The sample preparation and GC/MS analysis could be completed within one working day. These results suggested that gas chromatography/mass spectrometry detection of D-/L-arabinitol ratios could be employed as a rapid diagnostic method in the detection of invasive Candida infection in high-risk patients.

P 47

EFFECT OF INTERLEUKIN-2 ON EXPERIMENTAL ACUTE TOXOPLASMOSIS

I.H. Hegazy, N.A. Hammouda, I.A. Rashwan, S.M. Ali
Department of Parasitology, Faculty of Medicine, Alexandria University, Egypt;
Department of Immunology, Medical Research Institute, Alexandria, Egypt

The traditional treatment of toxoplasmosis involves the use of pyrimethamine and sulphadiazine. This combination has a teratogenic effect and its use is limited especially in immunosuppressed cases. Spiramycin used safely during pregnancy is also not effective because it is toxoplamistatic only. The potential efficiency of alternative immunotherapy was assessed. The present study was undertaken to evaluate the effect of exogenously supplied Interleukin-2 (IL-2 ) on Toxoplasma gondii infected mice.
IL-2 was administered after infection (on days +2, +4, +6 ), before and after infection (on days -3, -1, +2, +4, +6 ) and before infection (on days -8, -6, -4, -2 ). The date of infection was considered zero. Assessment of its effect was through:
a) Parasitological study which included parasite count, differentiation between living and dead tachyzoites and death rate of infected mice.
b) Immunological study which included detection of circulating antigen on the 3rd, 5th, 7th, and 9th day post infection. The results showed that IL-2 was most effective when administered before and after infection in the form of significant reduction in parasite count, least number of living tachyzoites, significant reduction in the death rate of infected mice and delayed appearance of circulating antigen with reduction in its level.

P 48

CONJUNCTIVITIS IN MURINE TYPHUS: A STUDY OF 101 CASES

S. Doukakis, M. Kastanakis, I. Bompolaki, E. Vittorakis, A. Galis, F. Axioti, K. Bambili, K. Palla, S. Kastanakis
First Medical Department, “Saint George” General Hospital, Chania, Greece

Conjunctivitis usually accompanies rickettsial diseases such as Rocky Mountain spotted fever, epidemic typhus and murine typhus. One hundred and one patients with compatible clinical status of murine typhus and high serological titers of antibodies against Rickettsia typhi were studied from our team during a period of time between January 1993 and December 1998. The clinical examination of these patients revealed the presence of conjunctivitis in 33/101 patients (32.7%). In the same time these patients referred retroocular pain and mild photophobia. This study showed that in murine typhus the injection of conjunctivae is rather common. Almost one third of the patients presented conjunctivitis despite the fact that this ocular manifestation is less severe than in other typhus and spotted fevers.

P 49

LYME BORRELIOSIS IN LUXEMBOURG: CLINICAL AND SEROLOGICAL FOLLOW-UP OF THE CASE REVIEWS FROM 1990 - 1997

M. Opp, J. Reiffers-Mettelock
Luxembourg

In 1986, we described the first two cases of Lyme borreliosis: erythema migrans and lymphadenosis cutis (1). Borreliosis should be diagnosed clinically. Since then, efforts have been made to confirm the clinical diagnosis by serology. Between 1990-1997 the dermatologist consultation recorded 107 cases of tick bites resulting clinically into borreliosis in children and adults. The diagnosis was only partially confirmed by a positive serology. Clinical symptoms were ECM (31), lymphadenosis (3), scerodermia (7), joint pain (4), pain (4), fatigue (9), headache (4), heart pain (2), ACA (2), meningitis (1), neurological troubles (1), multiple sclerosis (2), arrhythmias (2), prurigo (1), adenopathy (1), parkinson (1), urticaria (2), muscular pain (1), flue-like symptoms (2), impetigo (1), epilepsy (1), generalised eruption (1), fever (1), purple lesions (1). The diversity of symptoms accompanying borreliosis highlights the multiple systemic nature of this infection.
The serologic diagnosis of borreliosis can be hindered by test insensitivies of ELISA screening tests where most manufacturers are focussed on near 100% specificity with poor sensitivies as result. This may lead to omission of further investigations with the more sensitive western blot. The western blot should be introduced in the medical confirmation scheme of borreliosis and medical insurance companies should therefore reimburse it.
The western blot is also needed for the follow-up by medical practitioners in a phase of infection where the antibody response is often not fully established or in cases where appropirately treatment serological negativation has failed. Efforts should be undertaken to establish a serological diagnosis protocol respecting the heterogeneous spectrum of Borrelia found in Europe.