Tomislav Maretić

Asymptomatic pharyngeal carriage of beta-haemolytic streptococci and streptococcal pharyngitis among patients at an urban hospital in Croatia

In a one-year study at the University Hospital of Infectious Diseases in Zagreb, Croatia the rate of asymptomatic throat carriage of beta-haemolytic streptococci was investigated. Throat carriage was investigated in 1796 patients, none of whom had a sore throat nor signs and/or symptoms of a respiratory tract infection. The carrier rate of beta-haemolytic streptococci was 8.3%, for group A streptococci 6%, group B 1.3%, group C 0.3% and group F 0.1%. The highest rate was observed in the 6 to 14 year age group: 13.8% for all streptococcal groups, 11.7% for group A alone. The proportion of non-A streptococci was higher in older age groups. Tonsillectomised individuals were less frequently carriers. No sex or season-dependent variations were observed. In a four-month study of 629 patients with pharyngitis the throat cultures yielded: group A streptococci in 44.7%, group B in 1.7%, group C in 0.8%, and group G in 0.6% of the patients. Group A streptococcal rates in carriers compared to rates in patients with pharyngitis suggest that approximately one fourth of the schoolchildren with culture-positive pharyngitis actually are not truly infected, but only carriers currently having a sore throat of non-streptococcal etiology.Antibiotics were administrated to 605 (96.2%) patients with pharyngitis; in 571 (94.4%) of the cases before culture results became available. After culture-negative results were obtained the therapy was discontinued in only 28.5% of the cases. The throat culture is the standard for laboratory testing of group A streptococcal infection and should have more influence on the management of patients with pharyngitis at our hospital.

Meningitis and radiculomyelitis caused by Angiostrongylus cantonensis.

To the Editor: Angiostrongylus cantonensis infection is endemic in regions such as Southeast Asia, China, the Pacific Basin, and the Caribbean, but international travel has spread the disease elsewhere, including Europe (1–10). Dissemination of the parasite to many regions has also occurred because of the ship-borne international migration of rats and the diversity of potential intermediate hosts. The target organ in humans is the central nervous system in which an eosinophilic reaction develops in response to dying larvae. We report a case of eosinophilic meningitis and lumbosacral myeloradiculopathy caused by A. cantonensis and present a review of cases of A. cantonensis infections from Europe. A 47-year-old merchant seaman was admitted to the University Hospital of Infectious Diseases, Zagreb, Croatia, in March, 2006 on the 17th day of illness because of fever, headache, vomiting, and constipation. At the end of the first week of illness, paresthesias developed in his feet; on the 10th day of illness, he also noticed difficulties with urination. He had returned from a 1-month trip to Southeast Asia (Malaysia and Singapore) 35 days before the onset of symptoms and recalled eating vegetables and salads. He also consumed shrimp, but he believed that they were from salt water. On physical examination, we noticed increased muscle tone, tremor of the tongue and upper limbs, and decreased deep tendon reflexes of the lower limbs. He experienced urinary retention, and catheterization was required. Saddle anesthesia was observed. There was no neck stiffness, and the results of the rest of the physical examination were normal. His blood leukocyte count was 11.5 × 109/L with 80% neutrophils, 12% lymphocytes, 4% monocytes, 2% basophils, and 2% eosinophils. Cerebrospinal fluid (CSF) analysis showed 320 cells/μL with 6.5% eosinophils (21 eosinophils/μL). Results of CSF testing by PCR for herpes simplex virus 1 (HSV-1) and HSV-2 DNA were negative, as were cultures for bacteria, mycobacteria, and fungi. Results of serum and CSF antibody tests for Borrelia burgdorferi, Treponema pallidum, HSV-1, HSV-2, tick-borne encephalitis virus, Toxoplasma gondii, Taenia solium, Toxocara spp., and Trichinella spp. were also negative. Results of stool examination for Ascaris lumbricoides, Trichuris trichiura, Taenia spp., Giardia intestinalis, Strongyloides spp., and Entamoeba histolytica were negative. The patient was also negative for HIV by ELISA. Magnetic resonance imaging scans of the brain and spine were unremarkable. A. cantonensis infection was diagnosed by immunoblot testing at the Department of Helminthology, Faculty of Tropical Medicine, Mahidol University, Bangkok. Antibodies against A. cantonensis 31-kDa antigen were detected in serum and CSF of the patient; antibodies against Gnathostoma spinigerum were not detected. Treatment was symptomatic; to lessen the headache, 4 lumbar punctures were performed. After 1 month, the patient’s general condition was greatly improved; however, minor symptoms such as diminished concentration, slow thinking, and mild headache persisted. Urinary retention lasted for 38 days, and the patient had occasional mild headaches and paresthesia in his feet for the next 5 months. Because large numbers of persons from Europe travel to destinations where angiostrongyliasis is endemic, it is somewhat surprising that the infection has been rarely described in Europe. In a Google and Medline Internet literature search, we identified 9 additional case reports and 1 report on a cluster of 5 A. cantonensis infections. The first report was in a 14-month-old child born in Tahiti who became ill in France in 1988 (1). Eight cases, as did our case, involved travelers returning to Europe after a visit to disease-endemic areas (2–9) (Table). Not all cases were serologically confirmed, most likely because antibody tests for A. cantonensis infection have not been widely available. In a retrospective cohort study, 5 French policemen, who returned from French Polynesia with severe headache and blood eosinophilia, were believed to have eosinophilic meningitis caused by A. cantonensis (10). However, CSF examination was performed in only 1 patient, and none of the cases were serologically confirmed. Table Epidemiologic and clinical findings from 11 reported case-patients with Angiostrongylus cantonensis infection, Europe* Definitive diagnosis of angiostrongyliasis would require identification of larvae or young adults in human tissue, such as the brain, CSF, and eye chamber, which is rarely achieved. Thus, the diagnosis is usually made on the basis of serologic test results. Specific A. cantonensis antigens (29 kDa, 31 kDa, and 32 kDa) were identified; antibodies against these antigens can be detected by ELISA, dot-blot ELISA, or Western blot. In most patients, A. cantonensis causes a benign and self-limiting disease; treatment is usually symptomatic. Data are limited, but mostly favorable, on the use of steroids, albendazole, and mebendazole. However, the administration of antihelmintics without steroids is not recommended because such treatment might elicit deleterious inflammatory responses to dying worms within the nervous system or ocular structures. In summary, the presence of headache, fever, and paresthesias in travelers returning from disease-endemic areas should alert clinicians to the possibility of eosinophilic meningitis caused by A. cantonensis. With growing international travel, physicians may encounter A. cantonensis infection more frequently.

Acute promyelocytic leukemia after whole brain irradiation of primary brain lymphomainan HIV-infected patient

The occurrence of acute promyelocytic leukemia (APL) in HIV-infected patients has been reported in only five cases. Due to a very small number of reported HIV/APL patients who have been treated with different therapies with the variable outcome, the prognosis of APL in the setting of the HIV-infection is unclear. Here, we report a case of an HIV-patient who developed APL and upon treatment entered a complete remission. A 25-years old male patient was diagnosed with HIV-infection in 1996, but remained untreated. In 2004, the patient was diagnosed with primary central nervous system lymphoma. We treated the patient with antiretroviral therapy and whole-brain irradiation, resulting in complete remission of the lymphoma. In 2006, prompted by a sudden neutropenia, we carried out a set of diagnostic procedures, revealing APL. Induction therapy consisted of standard treatment with all-trans-retinoic-acid (ATRA) and idarubicin. Subsequent cytological and molecular analysis of bone marrow demonstrated complete hematological and molecular remission. Due to the poor general condition, consolidation treatment with ATRA was given in March and April 2007. The last follow-up 14 months later, showed sustained molecular APL remission. In conclusion, we demonstrated that a complete molecular APL remission in an HIV-patient was achieved by using reduced-intensity treatment.