W.M.V. Dolmans

Review: Infectious Diseases and Coagulation Disorders

Infection, both bacterial and nonbacterial, may be associated with coagulation disorders, resulting in disseminated intravascular coagulation and multiorgan failure. In the last few decades a series of in vivo and in vitro studies has provided more insight into the pathogenetic mechanisms and the role of cytokines in these processes. Because of the growing interest in this field, the complexity of the subject, and the fact that many physicians must deal with a variety of infections, current data are reviewed on the association between infectious diseases and the coagulation system. Novel therapeutic intervention strategies that will probably become available in the near future are mentioned, along with those of special interest for infectious disorders for which only supportive care can be given.

Poor food hygiene and housing as risk factors for typhoid fever in Semarang, Indonesia

To identify risk factors for typhoid fever in Semarang city and its surroundings, 75 culture‐proven typhoid fever patients discharged 2u2003weeks earlier from hospital and 75 controls were studied. Control subjects were neighbours of cases with no history of typhoid fever, not family members, randomly selected and matched for gender and age. Both cases and controls were interviewed at home by the same trained interviewer using a standardized questionnaire. A structured observation of their living environment inside and outside the house was performed during the visit and home drinking water samples were tested bacteriologically. Univariate analysis showed the following risk factors for typhoid fever: never or rarely washing hands before eating (OR=3.28; 95% CI=1.41–7.65); eating outdoors at least once a week (OR=3.00; 95% CI=1.09–8.25); eating outdoors at a street food stall or mobile food vendor (OR=3.86; 95% CI=1.30–11.48); consuming ice cubes in beverage in the 2‐week period before getting ill (OR=3.00, 95% CI=1.09–8.25) and buying ice cubes from a street vendor (OR=5.82; 95% CI=1.69–20.12). Water quality and living environment of cases were worse than that of controls, e.g. cases less often used clean water for taking a bath (OR=6.50; 95% CI= 1.47–28.80), for brushing teeth (OR=4.33; 95% CI=1.25–15.20) and for drinking (OR=3.67; 95% CI=1.02–13.14). Cases tended to live in houses without water supply from the municipal network (OR=11.00; 95% CI=1.42–85.2), with open sewers (OR=2.80; 95% CI=1.0–7.77) and without tiles in the kitchen (OR=2.67; 95% CI=1.04–6.81). Multivariate analysis showed that living in a house without water supply from the municipal network (OR=29.18; 95% CI=2.12–400.8) and with open sewers (OR=7.19; 95% CI=1.33–38.82) was associated with typhoid fever. Never or rarely washing hands before eating (OR=3.97; 95% CI=1.22–12.93) and being unemployed or having a part‐time job (OR=31.3; 95% CI=3.08–317.4) also were risk factors. In this population typhoid fever was associated with poor housing and inadequate food and personal hygiene.

The toll-like receptor 4 Asp299Gly variant and tuberculosis susceptibility in HIV-infected patients in Tanzania

Toll-like receptor 4 (TLR4) plays an important role in the pattern recognition of Mycobacterium tuberculosis, and polymorphisms in the TLR4 gene influence the function of the receptor. We therefore investigated in a cohort of HIV-infected Tanzanian patients whether the Asp299Gly TLR4 polymorphism is associated with the development of active tuberculosis. We found a greater risk of developing active tuberculosis as well as a reduction in CD4 T-cell counts in patients with the Asp299Gly TLR4 polymorphism.

M. tuberculosis genotypic diversity and drug susceptibility pattern in HIV- infected and non-HIV-infected patients in northern Tanzania

BackgroundTuberculosis (TB) is a major health problem and HIV is the major cause of the increase in TB. Sub-Saharan Africa is endemic for both TB and HIV infection. Determination of the prevalence of M. tuberculosis strains and their drug susceptibility is important for TB control.TB positive culture, BAL fluid or sputum samples from 130 patients were collected and genotyped. The spoligotypes were correlated with anti-tuberculous drug susceptibility in HIV-infected and non-HIV patients from Tanzania.ResultsOne-third of patients were TB/HIV co-infected. Forty-seven spoligotypes were identified.Fourteen isolates (10.8%) had new and unique spoligotypes while 116 isolates (89.2%) belonged to 33 known spoligotypes. The major spoligotypes contained nine clusters: CAS1-Kili 30.0%, LAM11- ZWE 14.6%, ND 9.2%, EAI 6.2%, Beijing 5.4%, T-undefined 4.6%, CAS1-Delhi 3.8%, T1 3.8% and LAM9 3.8%. Twelve (10.8%) of the 111 phenotypically tested strains were resistant to anti-TB drugs. Eight (7.2%) were monoresistant strains: 7 to isoniazid (INH) and one to streptomycin. Four strains (3.5%) were resistant to multiple drugs: one (0.9%) was resistant to INH and streptomycin and the other three (2.7%) were MDR strains: one was resistant to INH, rifampicin and ethambutol and two were resistant to all four anti-TB drugs. Mutation in the kat G gene codon 315 and the rpo B hotspot region showed a low and high sensitivity, respectively, as predictor of phenotypic drug resistance.ConclusionCAS1-Kili and LAM11-ZWE were the most common families. Strains of the Beijing family and CAS1-Kili were not or least often associated with resistance, respectively. HIV status was not associated with spoligotypes, resistance or previous TB treatment.

Changes in the Plasma Lipid Profile as a Potential Predictor of Clinical Outcome in Dengue Hemorrhagic Fever

In 50 consecutive children admitted to the intensive care unit with the clinical diagnosis of dengue hemorrhagic fever (DHF)/dengue shock syndrome (grade III or IV), 20 patients with mild DHF (grade I or II), and 20 healthy control patients, the plasma lipid profile was measured. Levels of total plasma cholesterol, high-density lipoprotein, and low-density lipoprotein were significantly decreased in patients with the severest cases, compared with patients with mild DHF and healthy controls. Changes in the plasma lipid profile differentiate between patients with different stages of DHF disease severity and could be used as a potential predictor for clinical outcome.

Injection practices in Mwanza region, Tanzania: prescriptions, patient demand and sterility

This paper describes prescription and sterilization practices in Mwanza Region, Tanzania, before the introduction of interventions aiming at reducing HIV transmission by injections. Sixty‐six health facilities from Mwanza Region were included in the study. Data were collected in interviews and questionnaires, through structured observation, bacteriological culture and record analysis. Criteria for avoidable injections were based on recommendations of the Essential Drugs Programme and on a regional consensus workshop. One in 4 out‐patients received an injection 70% of which were avoidable. Most were given for acute respiratory infections, skin diseases and urinary tract infections. Forty per cent of cultures taken from sterilized needles and syringes yielded growth of microorganisms. Of 120 patients interviewed most preferred to be treated with injections for almost any complaint. Patient demand for injections was felt to be a problem in 85% of the health facilities and may have contributed to overprescription of injectables. Consensus treatment and sterilization guidelines as well as a health education programme were developed and introduced to all health workers through seminars.

Laboratory diagnosis of pulmonary tuberculosis in TB and HIV endemic settings and the contribution of real time PCR for M. tuberculosis in bronchoalveolar lavage fluid

Backgroundu2002 Tuberculosis (TB) in Africa is increasing because of the human immunodeficiency virus (HIV) epidemic, and in HIV/AIDS patients it presents atypically. Pulmonary tuberculosis (PTB) in Africa is mainly diagnosed clinically, by chest radiograph or by sputum smear for acid fast bacilli (AFB).

Persistence of Salmonellae in Blood and Bone Marrow: Randomized Controlled Trial Comparing Ciprofloxacin and Chloramphenicol Treatments against Enteric Fever

ABSTRACT We performed a randomized controlled trial involving 55 adult patients with enteric fever to compare ciprofloxacin and chloramphenicol. Blood and bone marrow cultures and cytokine profiles during therapy were done to compare the clinical and bacteriological efficacies of these drugs. All patients were randomly assigned to receive chloramphenicol (500 mg four times a day orally) for 14 days or ciprofloxacin (500 mg twice a day orally) for 7 days. In each treatment group, patients were subsequently randomized to have blood and bone marrow cultured after either 3 or 5 days of treatment. Twenty-seven patients received chloramphenicol, and 28 received ciprofloxacin. The two groups were similar in terms of baseline characteristics. No significant differences in clinical cure and time to defervescence were found. All strains isolated were susceptible to both antibiotics. Although ciprofloxacin was more effective in the elimination of Salmonellaenterica serovars Typhi and Paratyphi A from bone marrow than chloramphenicol, there was still an impressive persistence of Salmonella in the bone marrow culture (67%). In the ciprofloxacin-treated patients the suppressed cytokine production capacity showed a trend to normalize earlier than in patients treated with chloramphenicol.

Improved injection practices after the introduction of treatment and sterility guidelines in Tanzania

Summaryobjectiveu2002To evaluate the effect of introduction of treatment and sterilization guidelines on the number of avoidable injections and on the sterility of needles and syringes.

Zinc and vitamin A supplementation fails to reduce sputum conversion time in severely malnourished pulmonary tuberculosis patients in Indonesia

BackgroundA previous study showed that combination of zinc and vitamin A reduced sputum conversion time in pulmonary tuberculosis (TB) patients.ObjectiveWe studied the efficacy of which single micronutrient contributed more to the sputum conversion time.MethodsIn a double-blind randomized community trial, newly sputum smear positive pulmonary TB patients were assigned randomly to receive zinc, vitamin A, zinc + vitamin A or placebo on top of TB treatment. Patients were asked to deliver their sputum on weekly basis to measure positivity of the bacteria. Nutritional status, chest x-ray, hemoglobin, C-reactive protein (CRP), retinol and zinc level were examined prior to, after 2 and 6 months of treatment.ResultsInitially, 300 patients were enrolled, and 255 finished the treatment. Most patients were severely malnourished (mean BMI 16.5 ± 2.2 Kg/m2). Patients in the zinc + vitamin A group showed earlier sputum conversion time (mean 1.9 weeks) compared with that in the other groups; however the difference was not significant. Also, no benefit could be demonstrated of any of the used supplementations on clinical, nutritional, chest x-ray, or laboratory findings.ConclusionsThis study among severely malnourished TB patients, did not confirm that single or combined supplementation of zinc and vitamin A significantly reduced sputum conversion time or had other significant benefit.