Elevated Hepatic Transaminase Levels Research Articles

Human case of Anaplasma phagocytophilum infection in Eastern Taiwan

Human granulocytic anaplasmosis (HGA) is a tick-borne infection caused by the bacterium Anaplasma phagocytophilum. In this study, we report an indigenous case of clinically diagnosed HGA. The patient was a 41-year-old man who experienced a tick bite and later developed fever, chills, myalgia, malaise, thrombocytopenia, leukocytosis with a left shift, elevated hepatic transaminase levels, and splenomegaly upon admission to the hospital. Immunofluorescence assays detected seroconversion against A. phagocytophilum, whereas tests for spotted fever group rickettsiae, murine typhus, scrub typhus, Q fever, and ehrlichiosis were negative. ELISA and Western blot analysis using recombinant MSP2 protein confirmed the exposure to A. phagocytophilum. Oral doxycycline and intravenous ceftriaxone were prescribed, and the patient made a full recovery. Our findings indicate the presence of HGA on the main island of Taiwan. Precautions against tick bites should be taken when engaging in outdoor activities, and HGA should be considered by physicians in the differential diagnosis.

Ceftriaxone Therapy of Bacterial Meningitis in Children

Twenty-nine children, age 3 months to 11 years, admitted with the clinical diagnosis of bacterial meningitis to the Department of Child Health, were included in a prospective treatment study of ceftriaxone (RocephinHoffmann- La Roche AG Bas/e, Switzerland). Ceftriaxone was used as the only antibiotic agent in single daily dose of 100 mg/kg body weight given intravenously for a minimum of 10 days. Of these 29 patients, 25 (86.2%) recovered, 3 (10.3%) died and 1 (3.4%) no respond to treatment. Among fatal cases, two patients had subdural empyema and one had a cerebral abscess. The microorganisms isolated from cerebrospinal fluid were: Streptococcus pneumoniae (5), Pseudomonas sp. (4), Proteus sp. (2), Salmonella typhi (1), Escherichia coli (1), Clostridium sp. (1), Pseudomonas aeruginosa (1), Staphylococcus aureus {1), and Streptococcus haemolyticus (1). In 12 patients (41,4%), organisms were not identified. The diagnosis was made based on clinical symptoms, Gram staining, cell count. ~!·tease, and protein in the CSF. In all patients, repeated spinal fluid cultures had no bacterial growth at 24 hours after initation of intravenous therapy. No evidence of clinical important drug toxicity was observed. Three p'Oiients, however, had lightly elevated hepatic transaminase levels, and one patient had rnild neutropenia. These clinical and bacteriological results suggested that ceftriaxone is reasonably safe and effective in the treatment of bacterial meningitis caused by the most common pediatric pathogens in Indonesian children over one month of age.

Relevant pericardial effusion caused by cytomegalovirus infection in an immunocompetent patient: a case report

BackgroundCytomegalovirus infection is known to cause symptomatic disease in immunocompromised patients, while an infection in immunocompetent individuals normally causes few or no symptoms. We present the case of an immunocompetent adult patient with unexpected severe evolution.Case presentationAn otherwise healthy, 72-year-old Caucasian woman presented with complaints of progressive shoulder pain and dyspnoea on exertion. The blood test results showed elevated inflammation parameters and elevated hepatic transaminase levels. Radiologic examinations were carried out, and the computed tomography scan revealed a hepatomegaly and a chest X-ray showed evidence of a unilateral pleural effusion. A transthoracic echocardiography detected pericardial effusion with consecutive hemodynamic changes. Since it was considered that using ultrasound-guided pericardiocentesis could significantly increase the risk of liver injury due to hepatomegaly, a pericardial window was performed instead. Further investigation showed that our patient tested positive for an acute cytomegalovirus infection in the serologic tests. Laboratory findings included new evidence of immunoglobulin M seroconversion and high immunoglobulin G avidity, so we considered the possibility that a former cytomegalovirus infection may be coexisting with a new cytomegalovirus reinfection.ConclusionsIn immunocompetent individuals, a symptomatic cytomegalovirus primary infection or reinfection should be considered in patients presenting with pericardial effusion and serositis.

Molecular detection of Coxiella burnetii from the formalin-fixed tissues of Q fever patients with acute hepatitis.

BackgroundSerologic diagnosis is one of the most widely used diagnostic methods for Q fever, but the window period in antibody response of 2 to 3 weeks after symptom onset results in significant diagnostic delay. We investigated the diagnostic utility of Q fever PCR from formalin-fixed liver tissues in Q fever patients with acute hepatitis.MethodsWe reviewed the clinical and laboratory data in patients with Q fever hepatitis who underwent liver biopsy during a 17-year period, and whose biopsied tissues were available. We also selected patients who revealed granuloma in liver biopsy and with no Q fever diagnosis within the last 3 years as control. Acute Q fever hepatitis was diagnosed if two or more of the following clinical, serologic, or histopathologic criteria were met: (1) an infectious hepatitis-like clinical feature such as fever (≥ 38°C) with elevated hepatic transaminase levels; (2) exhibition of a phase II immunoglobulin G (IgG) antibodies titer by IFA of ≥ 1:128 in single determination, or a four-fold or greater rise between two separate samples obtained two or more weeks apart; (3) histologic finding of biopsy tissue showing characteristic fibrin ring granuloma.ResultsA total of 11 patients with acute Q fever hepatitis were selected and analyzed. Of the 11 patients, 3 (27%) had exposure to zoonotic risk factors and 7 (63%) met the serologic criteria. Granulomas with either circumferential or radiating fibrin deposition were observed in 10 cases on liver biopsy and in 1 case on bone marrow biopsy. 8 (73%) revealed positive Coxiella burnetii PCR from their formalin-fixed liver tissues. In contrast, none of 10 patients with alternative diagnosis who had hepatic granuloma revealed positive C. burnetii PCR from their formalin-fixed liver tissues.ConclusionsQ fever PCR from formalin-fixed liver tissues appears to be a useful adjunct for diagnosing Q fever hepatitis.

Results From Screening Immigrants of Low‐Income Countries: Data From a Public Primary Health Care

A total of 3,132 immigrants from low- and middle-income countries were involved in a cross-sectional observational study to screen for infectious diseases among immigrants attending public primary health care (PHC) centers. The study was conducted to clarify the degree of demographic differences and risk predictors of these diseases. Demographic and clinical variables, screening for infectious diseases [hepatitis B and C, human immunodeficiency virus infection, syphilis, and tuberculosis (TB)], and analytical data (anemia, hematuria, and liver function) were recorded from immigrants attending a public PHC unit in Barcelona. Global hepatitis B, including chronic and previous, reached 18.1%; Morocco as the country of origin [odds ratio (OR) 2.1, 95% confidence interval (CI) 1.07-4.14] and gastrointestinal symptoms (OR 1.9, CI 1.18-3.02) were risk factors. Hepatitis C prevalence was 3.3% with elevated hepatic transaminase levels as a risk factor (OR 26.1, CI 8.68-78.37). Positive syphilis was 3.1%; latent and active TB rates were 28.1 and 5.8%, respectively. Concerning TB, we found remarkable differences both among WHO regions of origin (the Eastern Mediterranean region showed the highest rate of active TB, 8%) and the three categories of years of residence in Spain (6.5% for <1 year, 12.8% for 1-5 years, and 10% for >5 years). The data allowed recommendation of a minimal screening of TB in immigrants from low-income countries regardless of the years of residence in Spain, hepatitis C in patients with altered transaminase levels, and hepatitis B in patients with gastrointestinal symptoms and/or from Morocco.

A Phase I/II Study of Bortezomib in Combination with Doxorubicin and Intermediate-Dose Dexamethasone (iPAD therapy) for Relapsed or Refractory Multiple Myeloma

Abstract 5137 [Background]Bortezomib and doxorubicin have synergistic activity against myeloma cells. However, the combination of bortezomib and cytotoxic agents has not long been permitted in Japan because the safety of the combination therapy has not been determined in Japanese patients. We, therefore, decided to undergo a phase I/II study of bortezomib, doxorubicin and intermediate-dose dexamethasone (iPAD) combination therapy in Japanese patients with relapsed or refractory myeloma. [Methods]In a phase I study, the maximally tolerated dose of bortezomib was determined when given in combination with a fixed dose of doxorubicin and dexamethasone. Bortezomib was administered iv on days 1, 4, 8 and 11 at a dose of 1.0 mg/m2 in cohort 1 and 1.3 mg/m2 in cohort 2. Doxorubicin 9 mg/m2 was given iv on days 1–4, and dexamethasone 20 mg po on days 1–2, 4–5, 8–9 and 11–12. After a recommended dose of bortezomib was determined, a phase II study was undertaken to examine overall response rate, survival time and toxicity profiles. [Results]The dose-limiting toxicity (DLT), defined as grade 4 hematological toxicity lasting more than 5 days and/or grade 3 or higher non-hematological toxicity, was observed in 2 of 6 patients in cohort 1, indicating this dose was considered tolerable. In cohort 2, 3 of 5 patients developed DLTs including grade 4 thrombocytopenia lasting more than 5 days, grade 3 elevated hepatic transaminase levels and grade 3 ileus in one of each patient, indicating this dose was intolerable. Thus, 1.0 mg/m2 of bortezomib is a recommended dose in iPAD therapy. In a phase II study, 27 patients, aged 40 to 78 (median 63), were enrolled to receive iPAD therapy by using 1.0 mg/m2 dose of bortezomib. Overall response (CR+PR) was achieved in 89% (95% CI, 76–100%), and complete response (CR+nCR) in 30% (95% CI, 11–48%). The median overall survival time was not reached and progression-free survival time was 12.3 months (95% CI, 6.1–18.5 months). One patient died of pneumonia. Grade 3/4 thrombocytopenia, neutropenia and anemia developed in 67%, 41% and 19%, respectively, and febrile neutropenia in 11%. Sensory neuropathy was observed in 78% with grade 3/4 in 22% of the patients. Grade 3/4 hypokalemia developed in 15%, hyponatremia in 11%, and fatigue, nausea and diarrhea in 4%. [Conclusion]The iPAD therapy is feasible and effective to treat relapsed or refractory myeloma in Japanese population.(This clinical study was registered in University hospital Medical Information Network (UMIN) (registration number; UMIN000001210)) Disclosures:No relevant conflicts of interest to declare.

Association between Celiac Disease and Chronic Hepatitis C Virus Infection

Celiac disease affects the proximal small intestine and is caused by a local immune response to dietary gluten. Celiac disease usually presents with chronic diarrhea; however, presentations with elevated hepatic transaminase levels in blood or with iron-deficiency anemia have been described. Celiac disease has been reported to be associated with autoimmune liver diseases. Hepatitis C virus (HCV) can also initiate autoimmune disease process. Therefore, HCV infection and celiac disease may occur together. Here, we describe 4 cases of celiac disease associated with chronic hepatitis C. This small case series indicates that chronic HCV infection and celiac disease are not causally associated.

Spontaneous Rectus Sheath Hematoma Pregnancy: Case Report and Review of the Literature

Rectus sheath hematoma (RSH) is a rare, but important potential cause of acute upper abdominal pain in pregnancy. We report a patient with history of hemolysis, elevated liver enzymes, low platelets syndrome who presented with upper abdominal pain, hypotension, elevated hepatic transaminase levels, and a visibly enlarging right costal margin mass at 33 weeks' gestation. She underwent emergent cesarean delivery and upper abdominal exploration with findings of a large hematoma involving the entire right rectus sheath. The current case illustrates that the diagnosis of an RSH in pregnancy can be difficult as its presentation can mimic many common causes of abdominal pain seen outside of pregnancy, as well as many specific to pregnancy. Review of the published cases from the past 20 years shows that correct diagnosis remains difficult in pregnancy despite advances in diagnostic imaging. Although management of an RSH outside of pregnancy is frequently conservative, it is very often treated surgically in pregnant patients and often leads to preterm delivery.

A review of STRIDE‐2 and STRIDE‐2X: the case for selective endothelin receptor blockade

Pulmonary arterial hypertension remains incurable and has previously required difficult parenteral therapy. Endothelin-1(ET-1) is an important mediator of pulmonary arterial hypertension. The recent availability of oral therapies, including endothelin receptor antagonists, has improved ease of use for patients, but most patients remain symptomatic to a significant degree. Two classes of ET-1 receptors have been described, ET(A) and ET(B). It has previously been unclear whether both receptors must be blocked in pulmonary arterial hypertension, or only the ET(A) receptor. The Sitaxsentan To Relieve ImpaireD Exercise-2 (STRIDE-2) study followed by STRIDE-2X exposed patients with pulmonary arterial hypertension to the highly selective ET(A) antagonist sitaxsentan (n = 145), or to bosentan (n = 84), a nonselective ET(A) and ET(B) antagonist. The total exposure duration and follow-up period was 1 year. Pre-specified comparisons included time to discontinuation of monotherapy, time to clinical worsening, incidence of elevated hepatic transaminase levels > 3 x upper limit of normal and survival. Sitaxsentan therapy showed significant benefit over bosentan with respect to discontinuation of monotherapy at 1 year (24% vs. 43%, P = 0.002), clinical worsening at 1 year (28% vs. 39%, P = 0.0425), elevated hepatic transaminases at 1 year (4% vs. 14%, P = 0.014) and 1-year survival (96% vs. 88%, P = 0.028). STRIDE-2 and its extension, STRIDE-2X, suggest significant benefit of sitaxsentan compared with bosentan, in terms of efficacy and reduced hepatotoxicity. The former may be related to the high ET(A) receptor selectivity of sitaxsentan.

Elevated hepatic transaminases associated with the use of interferon alfacon-1 and ribavirin

The case of a patient with hepatitis C who developed elevated hepatic transaminase levels associated with the use of interferon alfacon-1 and ribavirin is described. A 55-year-old Caucasian man arrived at a hepatitis C clinic to discuss alternative treatment options for his hepatitis C virus (genotype 1a) infection, which did not respond to a 48-week course of peginterferon and ribavirin therapy. He was subsequently treated with interferon alfacon-1 9 microg subcutaneously daily plus ribavirin 200 mg orally twice daily. During treatment with interferon alfacon-1, he developed elevated hepatic transaminase levels despite a decrease in viral load. His hepatic transaminase levels returned to baseline when interferon alfacon-1 was discontinued and rose again upon rechallenge. Ribavirin was not the likely cause of the increase in transaminases since the patient previously tolerated it in combination with peginterferon. While activation of autoimmune hepatitis is a potential cause of acute decompensation in patients treated with interferons, it was not believed to be the case in this patient. Interferon alfacon-1 was determined to be the probable cause of the rise in hepatic transaminase levels in this patient, since his levels declined when therapy was discontinued and rose dramatically once it was restarted. This case illustrates the importance of monitoring both viral loads and hepatic transaminase levels in patients with hepatitis C being treated with interferon therapy. A patient with hepatitis C developed elevated hepatic transaminase levels despite showing an improvement in viral load after receiving interferon alfacon-1 and ribavirin.

Rhabdomyolysis and Acute Renal Failure Associated With Human Granulocytic Anaplasmosis

To the Editor: Rhabdomyolysis and renal failure have rarely been reported in patients with human granulocytic anaplasmosis (HGA) (formerly called ehrlichiosis). We report an unusual case in which a patient with HGA presented with severe myositis, rhabdomyolysis, and acute renal failure. Report of a Case. A 69-year-old woman was admitted to the hospital with a 3-day history of high fever with chills, general fatigue, and diarrhea followed by generalized arthralgia, profound thigh pain, and dark-colored urine. She lived alone in a wooded suburb in the northeastern United States and recalled removing numerous ticks from her body in the preceding month. The patient's temperature was 39.5°C, pulse rate was 110/min, and initial blood pressure was 100/60 mm Hg. She was exquisitely tender on both thighs and was unable to bear weight or transfer from the lying to the sitting position without assistance. The conjunctivas were clear, and no rash or petechiae was noted. Results from examination of all her other systems were within normal limits. Initial blood studies showed mild anemia, severe thrombocytopenia, leukopenia, elevated hepatic transaminase levels, and an elevated creatinine value (Table 1). A peripheral blood smear showed the presence of typical morulae in the neutrophils. Negative serologic titers were obtained for Lyme disease, West Nile virus, and Babesia microti. Blood and urine cultures yielded no growth. Renal ultrasound revealed normal-sized kidneys with normal renal cortical echogenicity and no hydronephrosis. Imaging studies excluded any pelvic, hip, or femur fractures.TABLE 1Selected Laboratory Data From a Patient With HGA*ALT = alanine aminotransferase; AST = aspartate aminotransferase; HGA = human granulocytic anaplasmosis; ND = not done.VariableDay 1Day 2Day 5White blood cell count (× 109/L)4.63.39.1Hematocrit (%)1.026.230.8Platelet count (× 109/L)382992Serum urea nitrogen (mg/dL)708566Creatinine (mg/dL)4.05.23.0Creatine kinase (U/L)15,03913,276733Creatine kinase-MB fraction (U/L)11871NDAST (U/L)520457149ALT (U/L)153137126* ALT = alanine aminotransferase; AST = aspartate aminotransferase; HGA = human granulocytic anaplasmosis; ND = not done. Open table in a new tab The patient was hydrated with normal saline, and intravenous doxycycline was administered. Defervescence occurred within 24 hours. Her laboratory abnormalities slowly improved (Table 1), and she was discharged to a rehabilitation facility on the 5th day of hospitalization. Three months later, her primary care physician reported complete normalization of her renal function and resumption of her active life. Discussion. This case is unusual because of the prominence of the myositis, the presence of rhabdomyolysis, and the severity of the renal dysfunction. Rhabdomyolysis and acute renal failure have rarely been reported in patients with HGA.1Heller HM Telford III, SR Branda JA Case records of the Massachusetts General Hospital: a 73-year old man with weakness and pain in the legs.N Engl J Med. 2005; 352 (Case 10-2005.): 1358-1364Crossref PubMed Scopus (10) Google Scholar, 2Javed MZ Srivastava M Zhang S Kandathil M Concurrent babesiosis and ehrlichiosis in an elderly host.Mayo Clin Proc. 2001; 76: 563-565Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar No cases of renal failure were noted in a review of 546 confirmed cases of anaplasmosis from the Connecticut surveillance data from 1995 through 2005.3Ertel S Esponda B Nelson R Human granulocytic anaplasmosis (HGA) — Connecticut, 2005.Conn Epidemiologist. September 2006; 26: 15-16Google Scholar Given the potential for severe and fatal disease, a therapeutic trial is indicated once the disease is suspected. As our case illustrates, early institution of appropriate therapy can lead to rapid resolution of symptoms. Tetracycline remains the drug of choice. Currently, no clear therapeutic alternatives are available. On the basis of in vitro studies, levofloxacin activity is only marginal.

Tenofovir Disoproxil Fumarate and an Optimized Background Regimen of Antiretroviral Agents as Salvage Therapy for Pediatric HIV Infection

Highly active antiretroviral therapy has altered the course of HIV infection among children, but new antiretroviral agents are needed for treatment-experienced children with drug-resistant virus. Tenofovir disoproxil fumarate (DF) is a promising agent for use in pediatric salvage therapy, because of its tolerability, efficacy, and resistance profile. We designed this study to provide preliminary pediatric safety and dosing information on tenofovir DF, while also providing potentially efficacious salvage therapy for heavily treatment-experienced, HIV-infected children. Tenofovir DF, alone and in combination with optimized background antiretroviral regimens, was studied among 18 HIV-infected children (age range: 8.3-16.2 years) who had progressive disease with > or = 2 prior antiretroviral regimens, in a single-center, open-label trial. Tenofovir DF monotherapy for 6 days was followed by the addition of individualized antiretroviral regimens. Subjects were monitored with HIV RNA reverse transcription-polymerase chain reaction, flow cytometry, and routine laboratory studies; monitoring for bone toxicity included measurement of lumbar spine bone mineral density (BMD) with dual-energy x-ray absorptiometry. Subjects were monitored through 48 weeks. Two subjects developed grade 3 elevated hepatic transaminase levels during monotherapy and were removed from the study. The remaining 16 subjects had a median of 4 antiretroviral agents (range: 3-5 agents) added to tenofovir DF. HIV plasma RNA levels decreased from a median pretreatment level of 5.4 log10 copies per mL (range: 4.1-5.9 log10 copies per mL) to 4.21 log10 copies per mL at week 48 (n = 15), with 6 subjects having < 400 copies per mL, including 4 with < 50 copies per mL. The overall median increases in CD4+ T cell counts were 58 cells per mm3 (range: -64 to 589 cells per mm3) at week 24 and 0 cells per mm3 (range: -274 to 768 cells per mm3) at week 48. The CD4+ cell responses among the virologic responders were high and sustained. The major toxicity attributed to tenofovir DF was a >6% decrease in BMD for 5 of 15 subjects evaluated at week 48, necessitating the discontinuation of tenofovir DF therapy for 2; all 5 subjects experienced >2 log10 copies per mL decreases in HIV plasma RNA levels. Tenofovir DF-containing, individualized, highly active antiretroviral therapy regimens were well tolerated and effective among heavily treatment-experienced, HIV-infected children. Loss of BMD may limit tenofovir DF use among prepubertal patients.

Safety and efficacy of gemtuzumab ozogamicin in pediatric patients with advanced CD33+ acute myeloid leukemia

AbstractThis open-label, dose-escalation study evaluated the safety and efficacy of single-agent gemtuzumab ozogamicin, a humanized anti-CD33 antibody–targeted chemotherapeutic agent, for pediatric patients with multiple relapsed or primary refractory acute myeloid leukemia (AML). Twenty-nine children 1 to 16 years of age (relapsed disease, 19; refractory disease, 10) received gemtuzumab ozogamicin ranging from 6 to 9 mg/m2 per dose for 2 doses (separated by 2 weeks) infused over 2 hours. All patients had anticipated myelosuppression. Other toxicities included grade 3/4 hyperbilirubinemia (7%) and elevated hepatic transaminase levels (21%); the incidence of grade 3/4 mucositis (3%) or sepsis (24%) was relatively low. One patient treated at 9 mg/m2 developed veno-occlusive disease (VOD) of the liver and defined the dose-limiting toxicity. Thirteen patients underwent hematopoietic stem-cell transplantation less than 3.5 months after the last dose of gemtuzumab ozogamicin; 6 (40%) developed VOD. Eight of 29 (28%) patients achieved overall remission. Remissions were comparable in patients with refractory (30%) and relapsed (26%) disease. Mean multidrug resistance-protein–mediated drug efflux was significantly lower in the leukemic blasts of patients achieving remission (P < .005). Gemtuzumab ozogamicin was relatively well tolerated at 6 mg/m2 for 2 doses and was equally effective in patients with refractory and relapsed disease. Further studies in combination with standard induction therapy for childhood AML are warranted.

A Case of Sweet Syndrome Associated With Human Granulocytic Anaplasmosis

Acute febrile neutrophilic dermatosis, or Sweet syndrome (SS), is a condition that is presumed to be triggered by infectious disease agents. We report a case of SS associated with human granulocytic anaplasmosis (HGA), which is of interest because Anaplasma phagocytophilum infects, multiplies in, and disrupts the function of neutrophils, the key infiltrating cell in SS. A patient with initial dermatologic manifestations of SS who did not respond to standard SS treatment was suspected to have concurrent HGA with the demonstration of leukopenia, thrombocytopenia, and elevated hepatic transaminase levels. The HGA diagnosis was established when morulae in neutrophils were observed on a peripheral blood smear, a finding confirmed by both serologic examination and polymerase chain reaction on the skin biopsy specimen used to establish the SS diagnosis. The significant involvement of neutrophils with both SS and HGA warrants a broader search for additional cases that may further define whether pathogenetic linkages could exist.

Antibiotic susceptibility of the newly cultivated agent of human granulocytic ehrlichiosis: promising activity of quinolones and rifamycins.

Human granulocytic ehrlichiosis (HGE) is a rapidly emerging tick-borne infection which presents as an acute febrile illness and is associated with hematologic abnormalities, elevated hepatic transaminase levels, and characteristic intracellular organisms in peripheral blood granulocytes. Although HGE has been successfully treated with tetracyclines, its susceptibility to other antibiotics remains unknown. No clear treatment alternative exist for young children, pregnant women, or allergic individuals, in whom tetracyclines are contra-indicated. We performed in vitro antibiotic susceptibility tests with this recently isolated agent grown in the human promyelocytic leukemia cell line HL-60. Doxycycline (MIC, 0.25 micrograms/ml), rifampin (MIC, 0.5 micrograms/ml), rifabutin (MIC, < or = 0.125 micrograms/ml), ciprofloxacin and ofloxacin (both with MICs of 2 micrograms/ml), and trovafloxacin (MIC, < or = 0.125 micrograms/ml) ciprofloxacin and ofloxacin (both with MICs of 2 micrograms/ml), and trovafloxacin (MIC, < or = 0.125 micrograms/ml) demonstrated significant activity against the HGE agent. These agents were also bactericidal. The HGE agent was resistant to clindamycin, trimethoprim-sulfamethoxazole, and imipenem-cilastatin, as well as to ampicillin, ceftriaxone, erythromycin, and azithromycin, antibiotics commonly used to treat Lyme disease. Both chloramphenicol and gentamicin had weak inhibitory activities but were not bactericidal. Our findings confirm the observed clinical efficacy of doxycycline and further suggest that the rifamycins and quinolones, particularly trovafloxacin, hold promise as alternative agents for treating this new infection.

Emergence of the ehrlichioses as human health problems.

Ehrlichiae are small, gram-negative, obligately intracellular bacteria that reside within a phagosome. The first human ehrlichial infection was recognized in the United States in 1987. It was later shown to be caused by a new species, Ehrlichia chaffeensis. In 1994, an ehrlichial pathogen within neutrophils that is closely related to the known veterinary pathogens E. equi and E. phagocytophila was found to infect humans. Molecular methods were required to detect, characterize, and identify these fastidious and uncultivated bacteria. Subsequently, E. chaffeensis infection was documented in more than 400 patients in 30 states, Europe, and Africa. Likewise, approximately 170 cases of human granulocytic ehrlichiosis have been diagnosed, most since 1994, predominantly in the upper midwestern and northeastern states, but also in northern California. The disease caused by ehrlichiae is generally undifferentiated but is often associated with leukopenia, thrombocytopenia, and elevated serum hepatic transaminase levels in tick-exposed patients. Infection ranges from subclinical to fatal; tetracycline appears to be an effective therapy. The emergence of these two newly recognized tickborne infections as threats to human health is probably due to increased clinical cognizance, but as in other emerging tickborne infections, it is likely that the rapid increase in identified cases signals a true emergence of disease associated with a changing vector-host ecology.

Health screening of international adoptees. Evaluation of a hospital based clinic.

To report the findings of health screening of 100 international adoptees. Retrospective case review. The first 100 children to attend the Outpatient Inter-Country Adoption Clinic at the Royal Children's Hospital, Melbourne. A medical history was taken and a thorough physical examination and series of screening investigations were performed on all children. The children ranged in age from two months to 16 years (median, five months; mean, 2.8 years). The countries most represented were Korea, with 36 children, and India, with 21. Thirty children fell below the third Australian centile for both height and weight. Abnormalities on physical examination included hepatosplenomegaly (13 children), scabies (six) and severe dental caries (six). Parasitic infestation of the stools was found in 23 children, a positive Mantoux test result in nine (three had active tuberculosis), anaemia in 12, elevated hepatic transaminase levels in nine and positive hepatitis B surface antigen and e antigen in two. One child had acquired syphilis. Screening for human immunodeficiency virus antibody gave negative results in all children. International adoptees constitute a special paediatric subgroup requiring assessment and screening investigations as soon as possible after arrival in their adoptive country.