Mary J. Spencer

Adenovirus infection in the immunocompromised patient

Illness associated adenovirus infection is described in 15 immunocompromised patients. Patients were immunocompromised by severe underlying disease, immunosuppressive or corticosteroid therapy or by age (prematurity). Evidence of adenovirus infection was obtained by either viral isolation or, in two cases, characteristic adenovirus inclusion bodies at postmortem study. All clinical illness was associated with high fever (temperature greater than 39 degrees C). Eighty per cent of the patients had severe systemic complaints including malaise, lethargy, fatigue and night sweats; a similar number of gastrointestinal symptoms. Pulmonary complaints were described in 11 of 15 cases and included cough (67 per cent) and tachypnea (53 per cent). Roentgenologic evidence of pneumonia was demonstrated in 12 of 15 patients (80 per cent). Elevation of serum hepatic enzyme levels (serum glutamic pyruvic transaminase (SGPT)) occurred in eight of 11 patients (73 per cent) and was moderate to severe (serum glutamic pyruvic transaminase greater than 450 IU/liter) in five of 11 (45 per cent). Nine patients died; seven after a rapid downhill course and two after a prolonged illness. Evidence of adenovirus infection microscopically by autopsy in the lung, liver or both is demonstrated in four patients with fulminant systemic illness. Adenovirus infection should be considered in the etiology of severe overwhelming illness in the immunocompromised host.

HL-A antigens and antibody response after influenza A vaccination. Decreased response associated with HL-A type W16.

We investigated possible associations of HL-A types and antibody-response patterns during clinical trials with a live, attenuated intranasal influenza A vaccine. After vaccination, subjects with HL-A type W16 had, as a group, a mean convalescent-phase hemagglutination-inhibiting antibody titer of 14, which was significantly lower (P less than 0.001) than the mean titer of 36 in subjects without Type W16. Of 25 subjects with a poor antibody response, 32 per cent had HL-A type W16, whereas only 5 per cent with a good response had Type W16. The mean titers in nasal secretions of five W16 subjects at 13 and 30 days were less than 3; in contrast, similar titers of 22 subjects without W16 were 8 and 9 respectively. The results suggest that the lower antibody response in W16 subjects is due to increased cellular resistance to infection rather than to a suppressed immune response because other subjects with W16 had normal antibody responses after vaccination with killed influenza vaccine.

Epidemic Measles in Young Adults: Clinical, Epidemiologic, and Serologic Studies

An outbreak of measles at the University of California at Los Angeles provided the opportunity to study clinical, epidemiologic, and serologic characteristics of the disease in young adults in the present vaccine era. Of the 34 cases studied, 18 occurred in persons who thought they were immune. Fifteen of 19 seronegative students vaccinated during the epidemic responded with a secondary (IgG) antibody response. Antibody prevalence studies indicated that 91% of the student population had measles antibody at the onset of the outbreak, and history relating to measles correlated poorly with antibody prevalence. Of 212 adults vaccinated, 58% complained of one or more symptoms. Seventeen percent were confined to bed, and in three women vaccine-associated illness was notably severe. That measles will continue to be a problem in adults with our present national approach to immunization is predicted.

Antibody responses following rubella immunization analyzed by HLA and ABO types

HLA typing was performed on 232 rubella seronegative (HAI antibody titer <8) children immunized with RA 27/3 vaccine. High convalescentphase geometric mean antibody titers were noted in children one to five years of age, in girls one to 12 years of age, in subjects with AB blood type and in vaccinees with HLA types B14 and BW22. Of nine children with rubella titers≧512, 44 percent had HLA type A28; in contrast, only eight percent of the total group had A28 HLA type. HLA-A2 was present in four, and HLA types B12 and BW17 were present in three of the six children in whom seroconversion did not occur. Fifteen of 37 sibling pairs had identical antibody responses; in contrast, only 18 percent of randomly paired children had titers identical to each other. Vaccine-related symptomatology could not be associated with any HLA type. The results of this study suggest that infection with and antibody response to RA 27/3 rubella vaccine is influenced by genetic factors, which include cellular membrane determinants.

Fever in infants less than two months of age: spectrum of disease and predictors of outcome.

Four hundred thirty-four febrile infants two months of age or younger were evaluated in the emergency departments of five major teaching hospitals over a one year period. A culture-proven bacterial infection was present in 3.5% of the infants; bacteremia was detected in 3.3%. Bacterial meningitis was present in 2.4%, and aseptic meningitis was noted in 13.4%. Twenty-one percent had clinically apparent serious disease including pneumonia, otitis media, and gastroenteritis with dehydration. Six variables (age < 1 month, lethargy, no contact with an ill individual, breast-feeding, total polymorphonuclear ≥ 10,000/mm3 and band count ≥ 500/ mm3) were correlated with bacterial infection by stepwise discriminant analysis. However, these findings were neither sensitive nor specific enough to be clinically useful. Management varied, and 62% of the infants were hospitalized. Fifty-four percent, some of whom were managed as outpatients, received antibiotics. Febrile infants two months of age or younger require a comprehensive emergency department assessment, including appropriate laboratory studies (CBC, differential, urinalysis and culture, lumbar puncture, and blood culture), since 3.5% have bacterial infection that may be life-threatening. Hospitalization is warranted if the infant appears ill, laboratory studies indicate serious infection, or follow-up care is uncertain.

Dientamoeba fragilis, a protozoan parasite in adult members of a semicommunal group

Dientamoeba fragilis is an intestinal protozoan parasite associated with gastrointestinal symptoms. This study was undertaken in a semicommunal group reported to have a high prevalence of this parasite. Stools were collected from 81 adult group members. Intestinal parasites were observed in stool specimens of 45 (56%) of the 81 adults;D. fragilis was found in 33 (41%) subjects. This paper describes the clinical findings and treatment of 26 adults withD. fragilis alone or with a commensal. Gastrointestinal symptoms were observed in 22 (85%) of infected subjects; abdominal pain and excessive flatus were significantly more common in this group. Diiohydroxyquin 650 mg three times a day for 20 days eliminated the parasite in 10 (83%) of the 12 treated, although three subjects required a second course of therapy. Parasitic infection should be considered in patients with vague gastrointestinal symptoms, especially those living in endemic areas, in close proximity, or with a history of foreign travel.

Parasitic infections in a pediatric population.

We studied the frequency of parasitic infection and associated clinical symptoms in children who attended general pediatric and dental clinics at UCLA. Parasites were detected in stool specimens of 40 (38%) of the 104 children completing the study. Protozoan parasites were recovered in 39 (38%); one child had whipworm eggs. Parasites included Dientamoeba fragilis in 22 (21%) children and Giardia lamblia in 18 (17%) children; commensals were observed in 15 (14%) children. Parasitic infection was more frequent in younger children, those with a history of immigration or foreign travel and those attending a day care center. A significant proportion of children with parasites had vague gastrointestinal complaints; however, parasites had not been considered as the etiologic agent by the parent or childs physician. Anorexia, irritability and gas were frequent in children with G. lamblia; abdominal pain was more frequent in those with D. fragilis. Intestinal parasitic infection should be considered in children with vague gastrointestinal complaints, particularly those in endemic areas, with a history of foreign travel or immigration or attending a day care center. Siblings of infected children should have stool examination even if asymptomatic.

A clinical trial with Alice/R-75 strain, live attenuated serum inhibitor-resistant intranasal bivalent influenza A/B vaccine.

A clinical trial was conducted with Alice/R-75 strain live attenuated intranasal influenza A/B vaccine. With double blind control 88 adult volunteers were administered 2 doses of Alice/R-75 vaccine, 93 volunteers received one dose of Alice/R-75 vaccine and one dose placebo solution and 94 subjects were administered 2 doses of placebo solution. Twenty-three other subjects received Alice strain monovalent influenza A vaccine. For comparison, data from 21 subjects who received monovalent intranasal R-75 strain influenza B in two doses is included. The vaccine was generally well tolerated. Four-fold serum hemagglutination-inhibiting (HAI) antibody titer rises to A/England/42/72 occurred in 39% of the monovalent Alice strain vaccinees; in contrast 18% of those given 2 doses of bivalent Alice/R-75 vaccine and 11% of those given 1 dose of bivalent vaccine had similar four-fold HAI antibody titer rises. HAI antibody titer rises to influenza B/Hong Kong/72 occurred in 38% of R-75 strain monovalent vaccinees, 14% of Alice/R-75 2-dose vaccinees and 11% of Alice/R-75 one dose vaccinees. An epidemic of influenza at the onset of the study made evaluation of the efficacy of the vaccine impossible.

Grassheads in the Tracheobronchial Tree: Two Different Outcomes

Many vegetable foreign bodies can produce serious pulmonary complications because of chemical irritation to the airway. Barley grass, a type of grasshead, does not induce such a reaction because of its resistance to organic decay. Complications which may occur are illustrated by the clinical course of two patients with aspiration of this foreign body. In the first patient the grasshead entered the trachea with the flowering unit first and the stem following. In the second patient the stem entered the trachea first. Recurrent pneumonias were noted in the first patient. Despite its presence in the right stem bronchus for three years, no further episodes of pneumonia followed its removal. In the second patient the grassheads could not be removed endoscopically. They migrated into the right lower lobe producing pneumonia and ultimately resulting in a brain abscess. The difference of entry of the same foreign body into the trachea, stem first versus flowering unit first, is an essential factor in altering the clinical outcome.

483 ENDEMIC INTESTINAL PROTOZOAN INFECTION IN A CALIFORNIA SEMI-COMMUNAL GROUP

Recently we had the opportunity to study intestinal protozoan infection in children in a semi-communal religious group in Los Angeles. The community is predominantly white, lower middle class, each family lives in a separate apartment, but daily activities are communal. Children ages 2 to 5 attend a group day care facility & older children are divided into small closed-school settings.This prospective study was conducted from February to June 1980 to determine the frequency & distribution of parasites in the communes children & their adult contacts. After completing a demographic, travel & medical questionnaire, the parent was requested to collect three stool specimens for ova & parasites in polyvinyl alcohol (PVA) preservative. Stools were processed utilizing formalin-ether sedimentation concentration technique & trichrome-stained smear. Of 273 enrolled subjects, 220 completed the study (136 children & 84 adults). One hundred fifty-three (69%) of the group (74% of children, 51% of adults) had parasites recovered which included Giardia lamblia, Dientamoeba fragilis & Entamoeba histolytica. Six of 7 infants under two years had no parasite recovered. G.lamblia occurred in preschool children; D.fragilis was more frequent in schoolage children. Most infected adults had D.fragilis (72%) recovered. In 30 (60%) of the 50 infected families, two or more members had similar pathogens. Pathogenic intestinal protozoan infection was common in this communal group & may well present a public health problem.