Mario Midulla

Multi-system Coxsackievirus B-6 infection with findings suggestive of diabetes mellitus

A fatal case of Coxsackievirus B-6 (CBV-6) infection in a 4 1/2-year-old girl is reported. The disease was initially characterized by a severe meningoencephalitis and, successively, by the appearance of hyperglycaemia and glycosuria, concomitantly with complement-fixingislet cell antibodies (CF-ICA) and ICA, diarrhoea, electrolyte disorders, arrhythmia and decrease of the IgG levels, suggesting a multi-system involvement.CBV-6 was identified by isolation from stool and cerebrospinal fluid and by detection of specific IgM antibodies.

Ciguatera Fish Poisoning: An Emerging Syndrome in Italian Travelers

Ciguatera is an acute or chronic intoxication syndrome associated with the consumption of marine tropical reef fish. The illness has a short incubation period, and the symptoms typically affect the gastrointestinal and nervous systems. Ciguatera poisoning has been extensively reviewed. 1‐5 It is endemic in many tropical and subtropical regions, also in the United States, 5,6 and Mexico, 7 where it accounts for more than half of all outbreaks related to ingestion of fish. In the Caribbean and Indo-Pacific islands, regions where coral reefs are present, the disease is the most common seafood-borne illness.Ciguatera poisoning can occur after the consumption of a wide variety of predatory tropical fish including barracuda,surgeon fish,red-snapper,amber-jack,red-grouper, and king-mackerel. These fish contain heat resistant and acid-stable toxins, mainly ciguatoxin, a lipid-soluble toxin, and maitotoxin, a water-soluble toxin. Both poisons belong to a newly described class of toxins, chemically polycyclic ether compounds, produced by tropical marine microalgae that become attached to the epiphytes of macroalgae, which herbivorous fish consume while foraging. Many small fish succumb to ciguatoxin and are eaten by other fish. Hence ciguatera toxin becomes more bioconcentrated as it passes up through the food chain from large carnivorous fish to larger predatory reef fish and ultimately to humans. Whereas the toxins are harmless in the host fish, in humans they produce illness. The earliest and commonest symptoms to appear are watery diarrhea, nausea and vomiting, abdominal pain, typically lasting about 12 hours. Usually, 24‐48 hours after ingesting the toxic fish, neurologic symptoms follow, including numbness, lip, tongue, and limb paresthesias, severe itching, and cold-to-hot temperature reversal (considered a pathognomonic sign). The illness generally subsides within a week. Neurologic symptoms may last for months or subside and then recur. Prompted by the growing number of Italian travelers returning from the Caribbean who present to our unit after experiencing symptoms of ciguatera poisoning, we designed this clinical study to assess the clinical outcome in our patients.We also sought to know whether they had received information before departure on the potential risks of ciguatera fish poisoning. Methods

Chlamydia trachomatis in neonatal respiratory distress of very preterm babies: biphasic clinical picture

We observed 12 very preterm infants (10 males) with a peculiar respiratory syndrome characterized by early onset soon after birth and by a biphasic course. The severe first phase was characterized by a clinical pattern mimicking the idiopathic respiratory distress syndrome of prematurity. Gradually, respiratory symptoms decreased and assisted ventilation with oxygen therapy was reduced. In the second phase, a significant worsening of respiratory signs and the appearance of apneic spells were observed. Chest X‐ray showed hypoexpansion of the lungs and the prevalence of a fine reticular pattern. Chlamydia trachomatis was identified in this second phase in conjunctival and pharyngeal swabs and/or on tracheal aspirates. Our data suggest that in the very preterm infants, chlamydial infection shows different clinical and laboratory features if compared with Chlamydia trachomatis pneumonia of infants born at term.

Simultaneous detection of specific serum IgM and IgA antibodies for rapid serodiagnosis of congenital or acquired cytomegalovirus infection

Abstract Three hundred and seventy-one serum samples from 170 children with congenital or natally or post-natally acquired cytomegalovirus (CMV) infections, demonstrated by virus isolation from urine and/or saliva, were tested for specific IgM and IgA antibodies by an indirect enzyme immunoassay. Among infants with congenital CMV infection, IgM was detected more frequently than IgA ( P P P > 0·05) than IgM. Among 53 children with recurrent or chronic cytomegaloviral diseases, IgA was detected in 11 (20·7%) and IgM in two (3·8%) patients ( P The simultaneous detection of specific IgM and IgA antibodies is better than only IgM for rapid serological diagnosis of both congenital, and post-natally acquired CMV infections.

SOME EFFECTS OF RUBELLA VACCINATION ON IMMUNOLOGIC RESPONSIVENESS1

Some viral diseases such as measles, chicken pox and rubella, are known to depress cutaneous delayed hypersensitivity to tuberculin (2, 5, 14) and the same effect has been observed after administration of live viral vaccines (3, 7, 8). Recently it was also demonstrated that during measles, viral hepatitis, and after vaccination against measles, there occurs a depression of blast transformation of lymphocytes cultivated in vitro in the presence of phytohaemagglutinin (PHA). Such lymphocytes cannot be activated by tuberculin (6, 7, 9). It would appear that these effects depend on a temporary impairment of lymphocyte functions, possibly triggered by the virus (1 1). Lymphocytes from infants with congenital rubella were demonstrated to lack the property of being activated by PHA (11, 12). During a trial with rubelha vaccine (4), we have studied its effect, on the tuberculin reaction, on the peripheral leukocytes, and on the blast tran5formation of lymphocytes of the vaccinees.

Viral infections in transfusion-dependent patients with beta- thalassemia major: the predominant role of cytomegalovirus

For 9 months, 38 transfusion‐dependent patients with beta‐thalassemia, ranging in age from 3.4 to 19.1 years, were observed for serologic evidence of viral infections, by the collection of serial serum samples. Seventy‐six age‐matched healthy subjects, two for each patient, were followed as controls. Samples taken at the beginning, middle, and end of the study were tested against 18 viral antigens by complement fixation (CF). In addition, tests for antibodies to HIV, Epstein‐Barr virus, hepatitis A virus, and markers for hepatitis B virus were performed. When changes in the antibody titer on CF tests (greater than or equal to 2‐fold increase or decrease) or persistently high titers (greater than or equal to 64) were revealed, specific enzyme immunoassays (EIAs) for IgM and IgA antibodies were performed concomitant with CF tests in all sera. When symptomatic infections occurred, viral cultures and/or direct detection of antigens were carried out by immunofluorescence methods, EIA, or latex agglutination tests. Thalassemic patients and controls had similar (p greater than 0.05) overall rates of serologically confirmed viral infections (53 versus 132), but the former group had a higher (p less than 0.01) incidence of cytomegalovirus (CMV) infections (9 versus 4). CMV infections were associated in the thalassemic patients with hepatitis (2 cases), lymphadenitis (2 cases), and upper respiratory tract infection (1 case), while the remaining cases of CMV had a subclinical course. Moreover, the thalassemic patients had a lower (p less than 0.01) incidence of symptomatic infections (27 versus 110) than controls. Therefore, this study showed that both symptomatic and subclinical CMV infections may occur often in thalassemic patients, who otherwise have subclinical viral infections at an overall rate similar to that in healthy subjects.

Determination of vaccine-induced and naturally acquired class-specific mumps antibodies by two indirect enzyme-linked immunosorbent assays.

Paired sera from 46 vaccinees and 22 patients with clinically typical or atypical parotitis were tested for class-specific mumps antibodies by two different indirect enzyme-linked immunosorbent assay (ELISA) procedures. Both ELISAs appeared suitable, specific and more sensitive than neutralization (NT) and complement-fixation (CF). However, the macro-ELISA (M-ELISA) method, using beads as antigen-coated solid phase, showed a higher sensitivity than micro-ELISA (m-ELISA), performed on microplates. Diagnostic rises in mumps IgG antibodies and mumps IgA antibodies were detected more frequently by M-ELISA, mostly in post-vaccination sera. In addition, higher mean OD values of mumps IgG, IgA and IgM antibodies were generally found by M-ELISA. Nevertheless, m-ELISA appeared more convenient for evaluating class-specific mumps antibodies in large-scale studies, since the procedure is simpler, more rapid and less expensive than that of M-ELISA. Conversely, M-ELISA may be considered the test of choice for detecting low class-specific antibody levels. However, the determination of class-specific mumps antibodies appeared as an essential tool for evaluating vaccine-induced or naturally acquired mumps immunity.

Arrhythmia or myocarditis: a novel clinical form of Legionella pneumophila infection in children without pneumonia.

The possibility that L. pneumophila causes cardiac disorders without respiratory or pulmonary symptoms in childhood was investigated. Out of 20 children with cardiac troubles of unknown aetiology, three showed a four-fold antibody increase or fall in titre against L. pneumophila antigens by the IFA test. Two children, aged 7 months and 2.5 years, had self-limiting arrhythmia and a third, 10-year-old, was suffering from a severe myocarditis. There was no serologic evidence of concurrent infection by respiratory or coxsackie B viruses nor by M. pneumoniae. It is suggested that Legionella infection should be considered in cardiac diseases in childhood, even if pneumonia is lacking.

Clostridium difficile Isolation in Leukemic Children on Maintenance Cancer Chemotherapy: A Preliminary Study

Between December 1982 and November 1983, stool specimens from 15 children with acute lymphoblastic leukemia, who were on maintenance cancer chemotherapy, were examined weekly for the presence of Clostridium difficile and its toxin. Four out of 15 patients were positive for C. difficile: three patients had stool specimens that did not contain toxin, but cultures yielded growth of toxigenic C. difficile on only one occasion. The fourth patient, who had a recent history of hospitalization, particularly aggressive cancer chemotherapy, neutropenia, and antibiotic therapy, excreted both C. difficile and its toxin for at least 1 month. All children were asymptomatic at the time of positive cultures. This preliminary study reveals a low rate of C. difficile colonization in leukemic children on maintenance cancer chemotherapy.

Acute Cerebellar Ataxia Associated with Echo Type 6 Infection in Two Children

It is known that ataxic symptoms may occur in the course of drug intoxications [12] and of some infectious diseases such as malaria [9], whooping cough, scarlet fever, poliomyelitis, chicken pox, rubella, mumps, influenza and infectious mononucleosis [l, 2, 7, 8, 11, 15, 20, 211. Therefore ataxia must sometimes be considered only as a cerebellar symptom of an underlying disease. However, there are some cases presenting a rather well defined clinical picture in which ataxia is not accompanied by other apparent pathological changes. This has been termed “Acute Cerebellar Ataxia” (A.C.A.). According to Curnen et al. [6] as well as Berg et al. [2] the clinical picture consists of sudden onset of symmetrical cerebellar signs in the absence of prodromal symptoms, fever, nuchal rigidity, abnormalities of the cerebral spinal fluid and signs of drug intoxications. The syndrome has been generally observed in children under five years of age, who frequently also present alterations in mus-