First Week Of Illness Research Articles

Chikungunya Fever in Travelers: Clinical Presentation and Course

An outbreak of chikungunya virus infection emerged in the southwest Indian Ocean islands in 2005, spread out to India, and resulted in an ongoing outbreak that has involved >1.5 million patients, including travelers who have visited these areas. Our study investigated 69 travelers who developed signs and symptoms compatible with chikungunya fever after returning home from countries involved in the epidemic. Twenty cases of infection that were confirmed by serological analysis, polymerase chain reaction, and/or cell culture were investigated. All patients experienced flulike symptoms with fever and joint pain. No serious complications were observed, but 69% of the patients had persistent arthralgia for >2 months, and 13% had it for >6 months. Viral RNA could be detected in blood samples using reverse-transcriptase polymerase chain reaction in 4 of 4 patients who presented to a health care facility during their first week of illness, and the virus was successfully isolated from blood samples obtained from 2 of these patients. Chikungunya virus-specific immunoglobulin M and/or immunoglobulin G antibodies were detected in all patients. However, initial testing of serum samples yielded negative results for 3 of 5 patients during the first week. Chikungunya fever must be considered in travelers who develop fever and arthritis after traveling to areas affected by an ongoing epidemic. Related arthritis mainly affects smaller joints and often persists for extended periods. Serological testing may have negative results during the first week of the disease; diagnosis using polymerase chain reaction appears to be more reliable during this time. Travelers to areas of epidemicity should be informed of the risk of infection and of adequate preventive measures, such as protection against mosquitos.

Rapid diagnostic tests for dengue and leptospirosis: antibody detection is insensitive at presentation

To determine the performance of rapid diagnostic tests for dengue and leptospirosis that rely on detecting antibodies that may not be produced when patients present for medical treatment. We prospectively enrolled 723 patients with undifferentiated febrile illness presenting to rural hospitals in northern and northeastern Thailand over a 1-year period. We evaluated rapid antibody detection diagnostic tests for dengue and leptospirosis on these patients. Sensitivity of the tests was low at the acute visit (7.6-21.5%). Sensitivity at the convalescent visit ranged from 25.8% to 81.5% and was significantly higher than at the acute visit for all tests (chi(2), P < 0.001). Low sensitivity of the rapid tests at presentation suggests that their utility in the acute phase of dengue and leptospirosis is limited.

Clinical Diagnosis and Treatment of Human Granulocytotropic Anaplasmosis

Tick-borne rickettsiae in the genera Ehrlichia and Anaplasma are intracellular bacteria that infect wild and domestic mammals and, more recently, man. The increased desire of humans for recreational activities outdoors has increased the exposure to potential human pathogens that previously cycled almost exclusively within natural, nonhuman enzootic hosts. Anaplasma phagocytophilum causes an acute, nonspecific febrile illness of humans previously known as human granulocytotropic ehrlichiosis (HGE) and now called human granulocytotropic anaplasmosis (HGA). The first patient to have recognized HGA was hospitalized at St Mary's Hospital in Duluth, Minnesota, USA in 1990. However, the clinical and laboratory presentation of this infection remained undefined until 1994, when Bakken and collaborators published their experience with 12 patients who had HGA. By the end of December 2004, at least 2,871 cases of HGA had been reported from 13 U.S. states to the Centers for Disease Control and Prevention (CDC). A limited number of laboratory-confirmed cases have been reported from countries in Europe, including Austria, Italy, Latvia, the Netherlands, Norway, Poland, Slovenia, Spain, and Sweden. Ixodes persulcatus-complex ticks are the arthropod hosts for Borrelia burgdorferi, the agent of Lyme borreliosis, and are also the arthropod hosts for A. phagocytophilum. Most cases of HGA have been contracted in geographic regions that are endemic for Lyme borreliosis. Male patients outnumber female patients by a factor of 3 to 1 and as many as 75% of patients with HGA have had a tick bite prior to their illness. Seroepidemiologic studies have demonstrated that HGA for the most part is a mild or even asymptomatic illness. However, older individuals and patients who are immunocompromised by natural disease processes or medications may develop an acute, influenza-like illness characterized by high fever, rigors, generalized myalgias, and severe headache. Local skin reactions at the site of the tick bite have not been described, and nonspecific skin rashes have been reported only occasionally. Anaplasmosis is associated with variable but suggestive changes in routine laboratory test parameters. Most patients develop transient reductions in total leukocyte and platelet concentrations. Relative granulocytosis accompanied by a left shift and lymphopenia during the first week of illness has been reported frequently. Serum hepatic transaminase concentrations usually increase two- to fourfold, and inflammatory markers, such as C-reactive protein and the erythrocyte sedimentation rate, rise during the acute phase. Abnormal laboratory findings may return toward normal range for patients who have been ill for more than 7 days, which may obfuscate the clinical decision making. Characteristic clusters of bacteria (morulae) are observed in the cytoplasm of peripheral blood granulocytes in 20% to 80% of infected patients during the acute phase of illness. The clinical diagnosis may be confirmed retrospectively by specific laboratory tests, which include positive polymerase chain reaction (PCR), identification of A. phagocytophilum in culture of acute-phase blood, or the detection of specific antibodies to A. phagocytophilum in convalescent serum. Virtually all patients have developed serum antibodies to A. phagocytophilum after completion of antibiotic therapy, and demonstration of seroconversion by indirect immunofluorescent antibody testing of acute-phase and convalescent-phase serum samples is currently the most sensitive and specific tool for laboratory confirmation of HGA. Treatment with doxycycline usually results in rapid improvement and cure. Most patients with HGA have made an uneventful recovery even without specific antibiotic therapy. However, delayed diagnosis in older and immunocompromised patients may place those individuals at risk for an adverse outcome, including death. Thus, prompt institution of antibiotic therapy is advocated for any patient who is suspected to have HGA and for all patients who have confirmed HGA.

Clinical and Laboratory Findings of SARS in Singapore

Singapore was one of 29 countries worldwide affected by severe acute respiratory syndrome (SARS) in 2003. There were 238 cases identified during the outbreak. We performed a retrospective analysis of the clinical and laboratory data of 234 patients admitted to Tan Tock Seng Hospital and Singapore General Hospital. The mean age of patients was 21 years, 31.6% of patients were males and 41.8% were healthcare workers. At presentation, the common symptoms were fever, myalgia, cough and headache; rhinorrhoea was uncommon. On admission, 21% had leukopenia, 18% had thrombocytopaenia, 29% had hyponatraemia, 31% had hypokalaemia, 21% had transaminitis. Polymerase chain reaction (PCR) testing of respiratory and stool samples provided the best yield at the end of the first week of illness. Thirty-two patients were initially not recognised as probable SARS and were reclassified when the serology test results were available. The chief reasons for not identifying these patients early were persistently normal chest X-rays (68.8%), very mild presentation (43.8%) and the presence of a concomitant illness (12.5%). Overall, 12% of the patients were probable SARS with atypical presentations. Overall mortality was 11.8%. Patients infected with the SARS coronavirus had a wide clinical presentation with non-specific symptoms.

Procalcitonin in Children with Escherichia coli O157:H7 Associated Hemolytic Uremic Syndrome

Shiga toxin producing Escherichia coli (STEC) are noninvasive enteric pathogens that may cause hemorrhagic colitis (HC) and diarrhea-associated hemolytic uremic syndrome (D+ HUS). We hypothesized that development of D+ HUS is associated with increased serum procalcitonin (PCT) levels. PCT was measured by an immunoluminometric assay in 113 patients. Concentrations of PCT were different in normal controls, disease control groups (rotavirus enteritis, HC due to non-STEC pathogens, chronic renal failure), and children with uncomplicated O157:H7 HC or D+ HUS. Children with D+ HUS showed higher PCT levels than those with uncomplicated O157:H7 HC, and increased concentrations were noted in cases requiring peritoneal dialysis. Severely increased concentrations were observed in children with D+ HUS on d 5 or 6 after the onset of enteritis, whereas serial measurements in those with uncomplicated O157:H7 HC remained within the normal range throughout the first week of illness. PCT was correlated with serum concentrations of lipopolysaccharide (LPS)-binding protein and serum levels of alanine aminotransferase. Using two separate sets of real-time PCR primers, we were unable to detect elevated PCT mRNA transcripts in nonadherent undifferentiated (monocytic) or differentiated (macrophage-like) THP-1 cells stimulated with purified Shiga toxin-1 and/or LPS. Our data show that serum levels of PCT are associated with the severity of illness in children with D+ HUS. Further studies are needed to determine the role of PCT in the pathogenesis of thrombotic microangiopathy associated to childhood D+ HUS.

Arterial hypoxia in acute pancreatitis.

Severe arterial hypoxia while breathing ambient air (Pao2 less than 60 mm Hg) was recorded in 38 (45 per cent) of a group of 84 patients with acute pancreatitis when arterial blood gas monitoring was performed during the first week of illness. This contrasted with an incidence of 19 per cent severe hypoxia in a heterogeneous group of 68 patients with acute abdominal pain admitted as surgical emergencies. Clinical evidence of respiratory embarrassment was rarely present in either the patients with acute pancreatitis or the other patients. Arterial hypoxia was related to the prognosis in both groups. It is recommended that all patients with acute pancreatitis have routine arterial blood gas monitoring performed during the first 5 days of illness. Furthermore, all older patients (over 60 years) and younger patients with moderate hypoxia (Pao2 less than 70 mm Hg) should be given supplementary humidified oxygen. An awareness of occult respiratory insufficiency in surgical emergency admissions, and especially in acute pancreatitis, is of importance.

Typhoid Enteric Perforation in Children in Calabar, Nigeria

Typhoid enteric perforation, a severely debilitating illness with a high mortality rate in children was studied in Calabar. The aim of the study was to determine the role that ingestion of herbal preparations, laxatives and enemas has on perforation and whether there is a relationship between the observed perforation and its occurrence within the first week of illness. Fifty-two patients with typhoid enteric perforations were selected from a pool of 178 cases of acute abdomen in children. Clinical, laboratory and radiological assessments were used to diagnose the condition and confirmation obtained intra-operatively. Results showed a male: female ratio of 3:1; with delayed presentation after 6 hours being a common feature in all patients with perforations. Sixty-three percent of the patients who were perforated had either consulted a traditional healer or chemist and had ingested a herbal concoction, a laxative or had an enema administered to them. Mortality was also higher within this group. Early resuscitation and surgical intervention within 24 hours of onset of illness led to a significant reduction in mortality. Seasonal variation was noted in the occurrence of typhoid fever. It was rampant during the dry season but rare during the rainy season. Key words: typhoid perforation, traditional healers, late presentation, seasonal variation Journal of Medical Laboratory Sciences Vol.12(1) 2003: 41-45

Clinical Utility of Commercial Enzyme Immunoassays during the Inaugural Season of West Nile Virus Activity, Alberta, Canada

West Nile virus (WNV) has spread rapidly across North America, creating a need for rapid and accurate laboratory diagnosis on a large scale. Immunoglobulin M (IgM) capture enzyme immunoassays (EIA) became commercially available in the summer of 2003, but limited data are available on their clinical performance. Consolidated human WNV diagnostic testing for the province of Alberta, Canada, at the public health laboratory permitted a large-scale evaluation of the assays, covering a wide clinical spectrum. Two thousand nine hundred sixty-nine sera were tested, from 2,553 Alberta residents, and 266 cases were identified. Sensitivities of the Focus assay and first-generation Panbio IgM capture EIA were 79 and 80%, respectively. During the first week of illness only 53 to 58% of cases were positive, but sensitivity was 96 to 97% after day 8. Sensitivity for neurological cases was 92% overall. Specificity was high for the Focus kit at 98.9%, but only 82.9% for the first Panbio kit. A positive Focus WNV IgG result with a twofold rise in IgG index was a reliable indicator of acute flavivirus infection (67/67 WNV). Agreement between the IgG test and hemagglutinin inhibition titers in paired sera was at least 82%. Commercial IgM and IgG EIA proved useful for WNV diagnosis, provided follow-up sera were collected after 8 days of illness.

Comparative Evaluation of Five Widal Test Kits Used in Kenya for the Serological Diagnosis of Typhoid Fever

Typhoid fever, caused by Salmonella typhi ( S. typhi ), is currently one of the most serious human diseases in Kenya, sometimes occurring in epidemic proportions, particularly in schools. It is essentially an enteric disease, which frequently becomes septicemic and if left untreated can cause death in 10-20% of the infected population. The disease is usually diagnosed by two methods: (1) isolation of the causative bacterium from suitable samples such as blood during the first week of illness and rose spots on the skin, feces and urine during the second to third week of illness, and (2) serologically by demonstrating a four-fold or greater rise in agglutinins to the ‘O' antigen of S typhi in patients, using a standardized, stained S. typhi antigen, in a test commonly referred to as the ‘Widal test'. In Kenya, there are a number of commercial Widal test kits currently in use. However, there is no documentation on their respective sensitivity and specificity in the diagnosis of typhoid fever. This study was therefore designed to compare sensitivity and specificity of the various Widal test kits in the detection of an active typhoid fever infection. This study compared five Widal test kits, using antisera against S typhi and S. typhimurium ‘O' and ‘H' antigens, experimentally produced in rabbits over a four-week period. S. typhimurium antiserum was used to check for the specificity of the Widal test kits for S. typhi agglutinins as well as cross reactivity with agglutinins against other Salmonella serotypes. All the five Widal test kits used in this study showed 100% sensitivity to S. typhi agglutinins, and Widal test kit E was distinctly more sensitive than the other 4, as it was associated with higher titres. The ‘O' antibody titres displayed by all the test kits were significantly less than the ‘H' antibody titres throughout the experimental period. Two test kits, D and E, picked ‘O' and ‘H' antibody titres greater than the standard cut-off titre of 1:160, whereas three test kits, A, B and C, picked the standard cut-off titre at one week post inoculation with respective S. typhi antigens. However, all test kits picked antibody titres greater than the standard cut-off titre at 2 weeks post inoculation, and at 4 weeks post inoculation, all kits picked an antibody titre greater than 1:2560. The Kenya Veterinarian Vol. 29 2005: pp. 94-99

Serial analysis of plasma proteomic signatures in pediatric patients with severe acute respiratory syndrome and correlation with viral load.

An outbreak of severe acute respiratory syndrome (SARS) has affected 33 countries on five continents, with 8098 suspected and probable cases and 774 deaths. During the SARS epidemic, more than 1700 infected cases have been reported in Hong Kong. The disease is infectious, particularly within the healthcare setting. Early diagnosis is essential to control the spread of SARS by identifying and isolating infected patients (1)(2). Diagnostic tests have been developed that detect either antibodies to or reverse transcription-PCR (RT-PCR) products of the SARS coronavirus (SARS-CoV). SARS-CoV antibodies can be reliably detected only around 20 days after disease onset (3)(4). Quantitative real-time RT-PCR assays, on the other hand, allow the detection of SARS-CoV within the first week of illness. Our recent study showed that detection sensitivity could approach 80% for plasma and serum samples from SARS patients (5)(6). Aside from improving the analytical and clinical sensitivity of the RT-PCR assays, it is also possible to develop new types of assays on the basis of other biological variables and/or technologies. In the past few years, surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF MS) has been applied to the discovery of diagnostic proteomic signatures for cancers such as prostate cancer, ovarian cancer, breast cancer, and hepatocellular carcinoma (7)(8). Here we report the presence of plasma proteomic signatures in serial blood samples from eight pediatric patients with SARS and their correlation with SARS-CoV RNA concentrations in plasma (6). The serial plasma samples investigated in this study were those examined for SARS-CoV RNA by real-time RT-PCR in our recently reported study (6). The pediatric patients were admitted to the New Territories East Cluster of Hospital Authority Hospitals in Hong Kong and satisfied the WHO surveillance case definition for SARS (9). These patients were recruited between March …

SARS Transmission and Commercial Aircraft

SARS Transmission and Commercial Aircraft

Magnetic resonance imaging findings and outcome in severe tick-borne encephalitis. Report of four cases and review of the literature.

To describe the magnetic resonance imaging (MRI) findings of four patients with proven tick-borne encephalitis (TBE). These are the most northern cases reported from Scandinavia. Experience of turbo fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) has not previously been published in this context. The MRI findings of four consecutive patients with TBE treated in our hospital during the year 2002 were evaluated. MRI was done during the first week of illness, and follow-up scans were available in three cases. In T2-weighted and turbo FLAIR images, thalamic hyperintensity was equally evident in three of the four patients. One of them also showed hyperintensity in the left putamen and the internal capsule and another patient in the peduncles and the hypothalamus. T1-weighted images without contrast were normal in all patients, and leptomeningeal enhancement was detected in only one patient. The two patients who underwent DW images did not show any restricted diffusion. Follow-up MR images showed no atrophy or necrotic foci, and the signal abnormalities disappeared during 16-34 weeks of follow-up. T2-weighted and turbo FLAIR sequences proved equally effective in detecting and delineating the thalamic, brainstem, and basal ganglia pathologies. According to our results, mechanisms other than cytotoxic edema contribute to the signal pathology. Radiologists should be familiar with the MR findings of TBE even in non-endemic areas.

Quantitative analysis and prognostic implication of SARS coronavirus RNA in the plasma and serum of patients with severe acute respiratory syndrome.

Background: The availability of an early diagnostic tool for severe acute respiratory syndrome (SARS) would have major public health implications. We investigated whether the SARS coronavirus (SARS-CoV) can be detected in serum and plasma samples during the early stages of SARS and studied the potential prognostic implications of such an approach. Methods: We developed two real-time quantitative reverse transcription-PCR (RT-PCR) assays, one for the polymerase and the other for the nucleocapsid region of the virus genome, for measuring the concentration of SARS-CoV RNA in serum/plasma samples from SARS patients. Plasma samples were obtained from 12 confirmed SARS patients on the day of hospital admission, as well as on days 7 and 14 after fever onset. Serum samples were also obtained from 23 confirmed SARS patients on the day of hospital admission, 11 of whom subsequently required intensive care. Viral RNA was extracted from the plasma/serum samples. The extracted RNA was subjected to analysis by the RT-PCR assays. Results: The RT-PCR system for the polymerase region detected SARS-CoV RNA in 50% of plasma and 78% of serum samples from SARS patients during the first week of illness. The detection rates for plasma dropped to 25% at day 14 after fever onset. The median serum SARS-CoV concentrations in patients who required and did not require intensive care unit admission during the course of hospitalization were 5800 and 140 copies/mL, respectively (Mann–Whitney test, P <0.005). These data were confirmed by the RT-PCR system for the nucleocapsid region, which showed an even higher detection rate of 87%. The correlation between the results obtained by the two RT-PCR systems was high (Pearson correlation analysis, r = 0.998; P <0.001). Conclusion: Plasma/serum SARS-CoV quantification represents a potentially useful early diagnostic and prognostic tool for SARS.

Enteric involvement of severe acute respiratory syndrome-associated coronavirus infection

Background & Aims : Severe acute respiratory syndrome (SARS) is a recently emerged infection from a novel coronavirus (CoV). Apart from fever and respiratory complications, gastrointestinal symptoms are frequently observed in patients with SARS but the significance remains undetermined. Herein, we describe the clinical, pathologic, and virologic features of the intestinal involvement of this new viral infection. Methods : A retrospective analysis of the gastrointestinal symptoms and other clinical parameters of the first 138 patients with confirmed SARS admitted for a major outbreak in Hong Kong in March 2003 was performed. Intestinal specimens were obtained by colonoscopy or postmortem examination to detect the presence of coronavirus by electron microscopy, virus culture, and reverse-transcription polymerase chain reaction. Results : Among these 138 patients with SARS, 28 (20.3%) presented with watery diarrhea and up to 38.4% of patients had symptoms of diarrhea during the course of illness. Diarrhea was more frequently observed during the first week of illness. The mean number of days with diarrhea was 3.7 ± 2.7, and most diarrhea was self-limiting. Intestinal biopsy specimens obtained by colonoscopy or autopsy showed minimal architectural disruption but the presence of active viral replication within both the small and large intestine. Coronavirus was also isolated by culture from these specimens, and SARS-CoV RNA can be detected in the stool of patients for more than 10 weeks after symptom onset. Conclusions : Diarrhea is a common presenting symptom of SARS. The intestinal tropism of the SARS-CoV has major implications on clinical presentation and viral transmission.

Enteric involvement of severe acute respiratory syndrome-associated coronavirus infection.

Severe acute respiratory syndrome (SARS) is a recently emerged infection from a novel coronavirus (CoV). Apart from fever and respiratory complications, gastrointestinal symptoms are frequently observed in patients with SARS but the significance remains undetermined. Herein, we describe the clinical, pathologic, and virologic features of the intestinal involvement of this new viral infection. A retrospective analysis of the gastrointestinal symptoms and other clinical parameters of the first 138 patients with confirmed SARS admitted for a major outbreak in Hong Kong in March 2003 was performed. Intestinal specimens were obtained by colonoscopy or postmortem examination to detect the presence of coronavirus by electron microscopy, virus culture, and reverse-transcription polymerase chain reaction. Among these 138 patients with SARS, 28 (20.3%) presented with watery diarrhea and up to 38.4% of patients had symptoms of diarrhea during the course of illness. Diarrhea was more frequently observed during the first week of illness. The mean number of days with diarrhea was 3.7 +/- 2.7, and most diarrhea was self-limiting. Intestinal biopsy specimens obtained by colonoscopy or autopsy showed minimal architectural disruption but the presence of active viral replication within both the small and large intestine. Coronavirus was also isolated by culture from these specimens, and SARS-CoV RNA can be detected in the stool of patients for more than 10 weeks after symptom onset. Diarrhea is a common presenting symptom of SARS. The intestinal tropism of the SARS-CoV has major implications on clinical presentation and viral transmission.

Hemophagocytic syndrome after Kawasaki disease.

Hemophagocytic syndrome (HPS) is a rare and life-threatening disease in which a generalized histiocytic proliferation results in hemophagocytosis and up-regulation of inflammatory cytokines. This syndrome has been associated with infections, malignancy, drugs and immunologic triggers such as Kawasaki disease (KD). We describe the clinical and laboratory features of two children with HPS after KD and review the three previously reported pediatric cases of recrudescence of HD leading to HPS.

Viral hemorrhagic fever

Viral hemorrhagic fever (VHF) is a severe, often fatal disease in humans and nonhuman primates (e.g., monkeys and chimpanzees). The two main causes of VHF are Marburg and Ebola virus infection. Lassa fever and Crimean-Congo hemorrhagic fever occur less commonly. Marburg and Ebola viruses are RNA filoviruses. Filoviruses first emerged as the cause of significant clinical outbreaks of VHF in Marburg, Germany in 1967 and later at multiple sites in Africa in 1976. Pathogenesis appears to involve initial infection of the mononuclear phagocytic system, resulting in a generalized cytopathic effect of other cell types and eventual disruption of the coagulation system, hemorrhage, and shock. The typical fulminant disease course is attributed to an immunosuppressive effect caused by the virus. Viral transmission occurs with close, personal contact and exposure to body fluids, especially in caregivers. The risk for person-to-person transmission of VHF is highest during late-stage disease. Contact with cadavers at the time of funerals is considered an independent risk factor for exposure because of the high levels of viral antigens and particles in skin tissues. The incubation period ranges from 2 to 21 days (average 1 week). Clinical manifestations include an abrupt onset of influenza-like symptoms, sore throat, diarrhea, and abdominal pain. Other common symptoms include high fever, headaches, arthralgias, myalgias, abdominal pain, asthenia, fatigue, and hiccups. A transient morbilliform rash develops and eventually desquamates by the end of the first week of illness. Other physical findings include an exudative pharyngitis and, less commonly, conjunctivitis, jaundice, and edema. Hemorrhagic complications appear as petechiae or frank bleeding from any location, but most commonly the gastrointestinal tract. Within 1 week of infection, symptoms may progress into retrosternal pain, fulminant shock, and death. Diagnosis is based on clinical symptomatology, serologic tests, and virus isolation. Isolation must be performed in a biosafety level four facility. There is no antiviral agent or vaccine for EHF. Supportive therapy is the mainstay of treatment. Case fatality rates range from 50 to 90%.

The vestibulospinal test in unilateral neurolabyrinthitis

In this paper we wanted to assess clinical relevance of two vestibulospinal tests: standing test (derived from Romberg test) and past pointing test. In retrospective and prospective study 42 patients have been tested with standing test and 50 patients with past pointing test. All patients suffered from unilateral neurolabyrinthitis that had started from one day to two years prior to examination. All patients had unilateral areflexion, or hyporeflexion on caloric test using 10 degrees C water. Control group consisted of 32 healthy individuals for both tests. Results show that both tests correctly indicate side of the lesion but only during first week of illness. Moreover, even during that first week sensitivity of both tests was below 50%, which means that more then half results from patients fall within normal findings. We conclude that vestibulospinal tests do not deserve prominent place in assessing patients with vestibular syndrome. Conclusions must be made according to findings obtained from much more precise vestibuloocular tests.

Diagnosis of human granulocytic ehrlichiosis: state of the art.

Human granulocytic ehrlichiosis is an emerging zoonosis caused by Anaplasma phagocytophilum and transmitted through the bite of infected Ixodes scapularis. It is prevalent in the Midwest and Northeast United States and also in Europe, and it presents as a nonspecific febrile illness a few days after a tick bite usually between late spring and fall. Most cases present in adult patients with a mild form of the disease, although it can be severe with multiorgan failure, particularly in the elderly and in the immunocompromised. Routine laboratory abnormalities include leukopenia with a left shift, lymphopenia, and thrombocytopenia. These abnormalities are more frequently present during the first week of illness and then tend to normalize; therefore their absence should not exclude the diagnosis. Specific tests to confirm the diagnosis during the acute phase include microscopic detection of morulae in granulocytes, culture of A. phagocytophilum, and polymerase chain reaction. Of these methods, culture appears to have the greatest sensitivity during the acute phase prior to antimicrobial treatment. Serology has an important role in the confirmation of the diagnosis when used in paired specimens and when high cutoff titers by indirect fluorescence antibody assay (> or = 640) are used to diagnose a recent infection.

Acute central nervous system complications in varicella zoster virus infections

In a previous multicenter study on central nervous system (CNS) viral infections varicella zoster virus (VZV) appeared the most frequent etiologic agent and appeared often without rash. To evaluate the appearance and diagnostics of VZV in CNS more thoroughly, we studied the cases systematically by using sensitive and specific methods to learn the best diagnostic approach in order to start specific therapy. We analyzed all serum and cerebrospinal fluid samples of 174 patients, 88 females and 86 males, with acute CNS symptoms associated with VZV infection diagnosed in the multicenter study on viral CNS infections. About 38 patients (22%) had chickenpox, 59 (34%) had shingles, and 77 (44%) had no cutaneous symptoms at all. The mean age of chickenpox patients was 8.6 years, of the others 46.6 and 41.4 years. VZV-specific nucleic acid was detected in the CSF in one fourth of the patients in all groups, primarily during the first week of illness. In serum specimens, specific IgM was present in two thirds of the patients with chickenpox, whereas in the others in one third of the cases. In CSF, specific IgM was present in 15-17% of patients with skin manifestations, compared with 6% of those without rash. The role of VZV infections in CNS complications seems remarkable, often presenting without rash. Even these cases should be promptly recognized in order to conduct proper antiviral therapy. In children, a combination of PCR and IgM tests is the best approach. In adults, PCR, together with the measurement of intrathecal antibody production yields best results.