Norman J. Waecker

Mycobacterium bovis infections in San Diego: a clinicoepidemiologic study of 73 patients and a historical review of a forgotten pathogen.

We have presented 73 patients (48 adults and 25 children) with microbiologically documented M. bovis infections identified over the 12-year period from 1980 through 1991. Epidemiologic investigation of these patients revealed that the majority (80%) were of Hispanic origin. The non-Hispanic patients either had traveled extensively outside the United States, were born in the United States during its endemic period or in other countries with endemic bovine tuberculosis, or were exposed to a close relative with a positive PPD and known exposure to M. bovis. For Hispanic patients, the presence of reactivation disease in adults and primary disease in children indicate that this mycobacterium remains endemic in Mexican beef and dairy herds, a position supported by United States monitoring of Mexican cattle transferred across the border. Our review of the historical and contemporary efforts to eradicate this animal and human pathogen from the livestock industry in the United States and abroad shows that the implementation of similar methods could be effective in Mexico. The detailed presentations of selected patients and summaries of the clinical manifestations in the remainder of our 73 patients reveal striking similarities to historical accounts and to more contemporary studies of reactivated disease in England. Although M. bovis infections are still expressed predominantly in extrapulmonary sites (cervical and mesenteric nodes, the peritoneum, and the GU tract), as many as 50% of adult patients will present only with pulmonary disease. Underlying immunosuppressive disorders were particularly prominent in adults with extrapulmonary disease. For example, HIV positive patients accounted for 12 of 48 adults and 1 adolescent patient in our series. Overall, M. bovis infections accounted for almost 3% of all tuberculous disease reported in San Diego County during the study period. The intrinsic resistance of M. bovis to PZA could threaten the response of patients with bovine tuberculosis to the short-course chemotherapeutic regimens now recommended by the CDC and the American Thoracic Society. We strongly recommend continued surveillance for this forgotten pathogen because the importation of Mexican cattle, the migration of Hispanic immigrants from border areas to the United States interior, and the persistence of extrapulmonary disease in immunocompetent and HIV-infected United States citizens assure its persistence in this country.

Diagnosis of enteroviral central nervous system infection by polymerase chain reaction during a large community outbreak.

Enteroviruses are common causes of localized and systemic infection in patients of all ages and are the most frequent cause of epidemic aseptic meningitis in the United States. We have developed a polymerase chain reaction (PCR) assay of cerebrospinal fluid (CSF) for rapid diagnosis of enteroviral meningitis. This assay was applied to 257 CSF specimens during a large community outbreak of enterovirus disease; 109 (97%) of 112 enterovirus culture-positive CSF samples contained enterovirus RNA. In addition 35 (66%) of 53 samples from patients with suspected central nervous system disease with negative or no CSF viral cultures were positive by enterovirus PCR. The enterovirus PCR detected 13 different enterovirus serotypes. PCR results are available within 24 hours compared with a mean of 6.8 days for enterovirus culture. The clinical characteristics of 141 patients with enterovirus central nervous system disease are presented. This study demonstrates the usefulness of enterovirus PCR for the rapid diagnosis of enterovirus central nervous system disease and the potential for PCR tests to shorten hospitalization.

Central nervous system tuberculosis in children: a review of 30 cases.

The medical records of 30 children with central nervous system tuberculosis (CNS tuberculosis) who were treated between March, 1976, and February, 1989, were reviewed. All had cranial computerized tomography scans at presentation. The mean cerebrospinal fluid leukocyte count was 200/mm3, protein 239 mg/dl, glucose 25 mg/dl and CSF/serum glucose ratio 21%. Mantoux skin tests with 5 tuberculin units were ≥10 mm induration in 50%, and chest radiographs were positive in 40% of patients. Hydrocephalus was demonstrated by cranial computerized tomography in all 30 patients (100%). Cranial computerized tomography scan demonstrating hydrocephalus is a sensitive radiographic finding in children with central nervous system tuberculosis and should be part of the early evaluation of children with suspected central nervous system tuberculosis.

Streptococcus pneumoniae-induced hemolytic uremic syndrome: a case for early diagnosis

Hemolytic uremic syndrome associated with infection by neuraminidase-producingStreptococcus pneumoniae usually presents with fulminant pneumonia and has a high mortality rate. Post-pneumococcal hemolytic uremic syndrome may occur earlier in life than classical hemolytic uremic syndrome. We describe an 18-month-old male with hemolytic uremic syndrome,S. pneumoniae pneumonia, and T-antigen activation characteristic of neuraminidase activity. We have summarized the features of this case and 11 previously reported children. As the use of blood products containing IgM may aggravate this disorder, early recognition of hemolytic uremic syndrome associated withS. pneumoniae neuraminidase production may lead to improved patient outcome through the judicious use of blood products.

Cat Scratch Disease Associated with Neuroretinitis in a 6-Year-old Girl

Cat scratch disease is a subacute regional lymphadenitis usually preceded by a history of being scratched by a cat or young kitten. The spectrum of illness ranges from mild self-limited adenopathy to severe systemic disease, including hepatosplenomegaly, encephalopathy, osteolytic lesions, splenic abscesses, mediastinal masses, and neuroretinitis. Vision loss is a rare complication of the disease. The authors report a patient with cat scratch disease associated with acute febrile illness, lymphocytic meningitis, and acute vision loss secondary to neuroretinitis. To their knowledge, this is the first ophthalmic case reported in which the diagnosis is supported by both a positive skin test and positive histopathology.

Comparison of fluconazole and nystatin oral suspensions for treatment of oral candidiasis in infants

Oral thrush is a common condition in young infants. Nystatin treatment is associated with frequent recurrences and difficulty in administration. Fluconazole was compared with nystatin for the treatment of oral candidiasis in infants. Thirty-four infants were randomized to either nystatin oral suspension four times a day for 10 days or fluconazole suspension 3 mg/kg in a single daily dose for 7 days. Clinical cures for nystatin were 6 of 19 (32%), and those for fluconazole were 15 of 15 (100%), P < 0.0001. In this small pilot study fluconazole was shown to be superior to nystatin suspension for the treatment of oral thrush in otherwise healthy infants.

Moraxella (Branhamella) Catarrhalis Bacteremia in Children A Report of Two Patients and Review of the Literature

We report two cases of Moraxella catarrhalis (M. catarrhalis ) bacteremia in apparently healthy children. One patient had bilateral otitis media and the other had pharyngitis and sinusitis; both patients had uncomplicated clinical courses. A literature review revealed 22 reported cases of M. catarrhalis bacteremia in children, 14 (63%) of which occurred in patients who had no identified underlying condition. Eight (36%) cases were seen in children who were immunocompromised. Nine (40%) patients presented with either purpura, petechia, or a maculopapular rash. M. catarrhalis is well known as a respiratory pathogen, but it has not been recognized as a common cause of unsuspected bacteremia in children.

Nosocomial Transmission of Mycobacterium bovis Bacille Calmette-Guerin to Children Receiving Cancer Therapy and to Their Health Care Providers

A previous report of nosocomial infection due to Mycobacterium bovis bacille Calmette-Guerin (BCG) implicated contamination of chemotherapy solutions reconstituted under the same biosafety hood as BCG vaccine used for bladder cancer therapy. We report 3 similar BCG infections in children and describe evidence of respiratory transmission to health care workers (HCWs) from 1 patient. These children were receiving chemotherapy for leukemia when they presented with active tuberculosis. Each isolate was identified biochemically and by both gas-liquid chromatography and major polymorphic tandem repeat-polymerase chain reaction. Pulsed-field gel electrophoresis showed that 2 isolates were identical strains and identical to the Tice and Connaught strains licensed in the United States for bladder chemotherapy. The third isolate differed by a single fragment after DraI restriction. One patient with heavily positive sputum exposed numerous HCWs. Of 41 HCWs, 2 (5%) converted their purified protein derivatives (PPD) skin test. These data underscore the risk of nosocomial BCG transmission by contamination of chemotherapy solutions and demonstrate the potential for transmission to HCWs from patients with active pulmonary disease.

Prediction of neurologic sequelae in childhood tuberculous meningitis: A review of 20 cases and proposal of a novel scoring system

Background: Despite effective antituberculous medications, the mortality and morbidity remain high in children with tuberculous meningitis (TBM). The traditional clinical staging for TBM developed by Lincoln et al in 1960 has been widely used to predict long term neurologic sequelae (NS). In the current era of critical care medicine and corticosteroid therapy, a new scoring system is needed to predict NS more accurately in children with TBM. Methods: We reviewed all available cases of TBM in San Diego, CA, during 1991–2001 retrospectively, and we developed a novel scoring system to predict NS in children with TBM. We assessed a tuberculous meningitis acute neurologic (TBAN) score at day 0 and on day 3 of hospitalization, to compare children who subsequently developed severe NS with those who did not. Results: Among 20 children with TBM, 7 children developed severe NS and 1 child died during hospitalization. The TBAN score was higher on day 0 in those with severe NS (5.5 versus 2.0, P = 0.09), and the difference became statistically significant by day 3 of hospitalization (5.5 versus 0.0, P = 0.02). Sensitivity and specificity of the TBAN score (≥4) on day 0 (75 and 92%) and day 3 (88 and 100%) to predict severe NS were superior to the traditional clinical staging system on day 0 (63 and 58%). Conclusions: The TBAN score is an objective marker for predicting severe NS in children with TBM.

The Rhino-Probe nasal curette for detecting respiratory syncytial virus in children.

During two outbreaks of respiratory syncytial virus (RSV) infection, 68 children with acute respiratory illnesses were cultured for RSV using a Rhino-Probe (RP) nasal curette and either a nasopharyngeal (NP) swab or a nasal wash (NW). In the first outbreak isolations of RSV by the RP nasal curette and NP swab methods were compared. RSV was cultured from 25 of 42 (60%) subjects using the RP nasal curette and from 20 of 42 (48%) subjects using the NP swab. In the second outbreak the RP nasal curette and the NW collection techniques were compared. RSV was isolated from 15 of 26 (58%) children evaluated. RSV was cultured from 14 of 15 (93%) patients by RP and 13 of 15 (87%) when using NW. In the group of culture-positive subjects, the TESTPACK RSV rapid antigen test was positive in 10 of 15 (67%) using the RP and in 6 of 15 (40%) using the NW. Like the NP swab the RP nasal curette was simple, noninvasive and relatively inexpensive, yet it was as sensitive as the NW for detection of RSV.