[A patient with bilateral lesion in the striatum and slowly progressive dystonia secondary to T14487C mutation in the ND6 gene of complex I of the mitochondrial respiratory chain]

INTRODUCTION

A large number of diseases present as bilateral striatal lesion syndrome (BSLS). Clinical manifestations, course and prognosis of these diseases are extremely variable. On the basis of their evolutive course, they can be separated into two major groups: acute, which include toxic, infectious or parainfectious causes, and subacute or chronic, in which inborn errors of metabolism, especially mitochondrial disorders, are the main causes.

CASE REPORT

We report a detailed clinical follow-up of a 18 years old Caucasian male who, at the age of four, presented with BSLS. A respiratory chain defect was suspected on the basis of slowly progressive dystonia and cognitive impairment, changes in serial MRI studies, and the finding of 'trabecular fibers' as well as a 50% decrease of the complex I activity in striated-skeletal muscle specimen. Blood, urine and CSF markers classically associated with respiratory chain diseases were normal. Molecular studies identified a new pathogenetic mutation (T14487C) in the mitochondrial ND6 gene of the respiratory chain complex I.

CONCLUSION

Mitochondrial metabolism disorders should be ruled out in patients presenting with a subacute or chronic form of BSLS even in the absence of other common mitochondrial disease markers.

[Familiar chronic progressive external ophthalmoplegia of mitochondrial origin]

INTRODUCTION

The syndrome of chronic progressive external ophthalmoplegia (CPEO) is a mitochondrial disease characterized by ptosis and ophthalmoplegia has that has been associated to the presence of large deletion, single or multiple, in the mitochondrial DNA of skeletal muscle.

CASE REPORT

We report a familiar case of chronic progressive external ophthalmoplegia of maternal inheritance that began at birth, and developed with slow progression but with no multisystemic involvement. Non of the affected individuals had ragged-red fibers in skeletal muscle. Genetic analysis of mitochondrial DNA revealed the presence of a single deletion of 4,977 bp that encompasses the nucleotide positions 8,482 to 13,460, flanked by a direct repeat sequence.

CONCLUSIONS

The amount of deleted mitochondrial DNA (15%) in this patient's muscle suggests, even if the percentage of the mutation is low, that this deletion is the molecular cause of the phenotypic presentation of this patient. This is one of the few cases described in the literature of CPEO maternally inherited.

[A single deletion of mitochondrial DNA in a Brazilian patient with chronic progressive external ophthalmoplegia]

INTRODUCTION

The syndrome of chronic progressive external ophthalmoplegia (CPEO) has been associated to the presence of large deletion, single or multiple, in the mitochondrial DNA of skeletal muscle.

CASE REPORT

We report a sporadic case of chronic progressive external ophthalmoplegia that began at age 19 years and was associated with ragged red fibers in skeletal muscle. Genetic analysis of mitochondrial DNA revealed the presence of a single deletion of 4237 bp that encompasses the nucleotide positions 9486 to 13722, a location that has not been described before, and flanked by a direct repeat sequence. The deletion is flanked by a direct repeat.

CONCLUSIONS

The amount of deleted mitochondrial DNA (55%) in this patient's muscle suggests that this deletion is the molecular cause of the phenotypic presentation of this patient.

[Evolution of perinatal Escherichia coli disease in the era of group B Streptococcus prophylaxis]

BACKGROUND

The aim of this study was to characterize perinatal Escherichia coli disease, and to analyze its possible correlation with the employment of prophylaxis for group B streptococcal (GBS)disease.

PATIENTS AND METHOD

Between 1994 and 2000, 24 neonates born in our hospital were diagnosed of early-onset E. coli disease: 12 born to mothers who received prenatal care in our center and 12 born to mothers who were referred from other hospitals shortly before labor. Three further neonates born in other centers were also referred with the same diagnosis.

RESULTS

The annual rate did not change significantly (RR:1.065; confidence interval [CI] 95% -0.873-1.301; p = 0.533):from 0.6 per 1,000 live births in 1994 to 1.7 per 1,000 in 1997 and 0.5 in 2000. Among mothers, 92% presented obstetric risk factors including 68% with prematurity (mean 32.9 gestation weeks, median 32), 64% with prolonged rupture of membranes (mean 184 hours,median 44), and 56% with intrapartum fever. Twelve percent of mothers received intrapartum ampicillin as prophylaxis against GBS and 80% received antibiotics: prophylaxis for rupture of membranes in 6 cases, treatment of urinary tract infection in 6 cases and treatment of probable chorioamnionitis in 8 cases. Ampicillin-resistant E. coli was isolated in 81% of neonates. No significant correlation was found between ampicillin resistance and prematurity(p = 0.57), rupture of membranes (p = 0.63), intrapartum fever(p = 0.24) or death (p = 0.53).

CONCLUSIONS

Our results suggest that perinatal E. coli disease is not related with the employment of prophylaxis against GBS disease. Instead, it seems to be related with prematurity, prolonged gestation in premature rupture of membranes and exposure to antibiotics.

[Role of Lactobacillus as protector against vaginal candidiasis]

BACKGROUND

To evaluate the possible protector role of Lactobacillus against vaginal candidiasis.

PATIENTS AND METHOD

In vitro studies performed to assess the capacity of 15 Lactobacillus strains to block the adhesion of two Candida albicans and one C. glabrata strain to vaginal epithelial cells and to inhibit the growth of these yeasts. Moreover, the presence of Lactobacillus was analyzed in 115 vaginal exudates from women with vaginal candidiasis.

RESULTS

Only 8 of the 15 lactobacilli studied significantly blocked the adhesion of C. albicans Y18 to vaginal cells. Lactobacilli from group III showed the greatest blocking capacity (62.9%), followed by group II (50.6%) and group I (26.1%). In solid assays, none of the 15 Lactobacillus strains studied was able to inhibit growth of the 3 yeasts. However, in liquid assays some lactobacilli evidenced a certain degree of inhibitory power against C. albicans Y17 (35.7%, 41.7% and 38.1% of light transmittance for Lactobacillus groups I, II and III, respectively). Lactobacillus was detected in 89.6% of women with vaginal candidiasis (by microscopy in 87.8% and by culture in 72.2%).

CONCLUSIONS

These results lead us to suggest that probably Lactobacillus provides protection against vaginal candidiasis.

Assessment of the capacity of Lactobacillus to inhibit the growth of uropathogens and block their adhesion to vaginal epithelial cells

To gain insight into the mechanisms by which Lactobacillus blocks the adherence of uropathogens to vaginal epithelial cells and inhibits their growth, 15 Lactobacillus strains and 22 uropathogens were studied. Lactobacilli from hemagglutination group III, identified as Lactobacillus crispatus, showed greater capacity to block uropathogen adherence than those from hemagglutination groups II and I (61.9%, 49.5%, and 52.6% of blockage, respectively). Pseudomonas aeruginosa PA5 and Klebsiella pneumoniae KP7 were the uropathogens most susceptible to blockage, and Staphylococcus aureus SA11 and Proteus mirabilis PM1 were the most resistant. Lactobacillus inhibited uropathogen growth better in liquid assays; the 3 Lactobacillus groups showed similar inhibitory power (72.3%, 71.9%, and 74.2% of light transmittance). P. aeruginosa PA5 was the most inhibited, and Enterococcus species E15 was the least inhibited. There is considerable variation among Lactobacillus strains regarding their adherence to uroepithelium, blockage of uropathogen attachment, and inhibition of uropathogen growth. Although these properties are independent, they may coincide and therefore allow for these strains to balance the vaginal ecosystem and to make them useful as probiotics.

[Microorganisms isolated in cases of pertussis-like syndrome]

OBJECTIVE

To describe the etiologic study of the pertussis-like syndrome, not only as far as Bordetella genus is concerned but also regarding the causative role of other microorganisms for a 11-year period (1988-1998).

METHODS

In all specimens from patients suffering from pertussis-like cough the presence of Bordetella spp., other bacteria, viruses, and mycoplasma was investigated. The analysed data included microbiological findings and epidemiologic issues (age, sex, hospital admission area, yearly distribution and seasonal period).

RESULTS

A total of 1,063 specimens were investigated, most of them nasopharyngeal aspirates (910), corresponding to 905 patients; a positive culture was obtained form 56.9 of these patients. B. pertussis was isolated from 10.5% of patients. As for other bacteria, Haemophilus influenzae and Streptococcus pneumoniae were also isolated, in 16.9% and 15.8% of occasions, respectively. The respiratory syncitial virus was isolated from 10.7% of patients and other viruses in 9.4%. Among mycoplasma, Ureaplasma urealyticum predominated, with a recovery rate of 2.9%. The male/female ratio was 495/410; the ages of 67.2% of patients ranged from 0 to 6 months; a total of 689 (76.1%) required hospital admission. The recovery of B. pertussis and adenoviruses predominated during spring and summer months. In contrast, H. influenzae, S. pneumoniae and respiratory syncitial virus were recovered more frequently during winter months.

CONCLUSIONS

Most patients with pertussis-like syndrome are children aged less than 6 months. The recovery percentages of B. pertussis and respiratory syncitial virus are identical and therefore we think that the investigation of their presence in this syndrome is fully warranted as well as the search for other microorganisms, since clinical symptoms are commonly non-specific among infants.

[Changes in emergency visits of patients infected by human immunodeficiency virus since the widespread use of protease inhibitors]

OBJECTIVE

To evaluate the changes in the urgent visits made by HIV+ patients after generalisation of the protease inhibitors.

PATIENTS AND METHODS

Comparison on the visits made during a period prior to and after use of protease inhibitor.

RESULTS

After the generalisation of the protease inhibitors the visits rate decreased, the motives for consulting with the physician and complementary examinations changed, invasive therapeutic procedures, admissions from urgencies and death rates decreased.

CONCLUSIONS

The protease inhibitors have changed the urgent visits profile of HIV+ patients.

[Molecular studies in Cuban patients with progressive external ophthalmoplegia]

INTRODUCTION

The mitochondria, subcellular organelles which possess their own DNA (mtDNA), produce most of the energy, in the form of ATP, which is necessary for life. This mtDNA may have diverse molecular defects which have been associated with a great variety of clinical syndromes. Deletions in mtDNA are one of the common mutations in patients with mitochondrial myopathies, which in the great majority present with the common symptom of progressive external ophthalmoplegia. In this study we report our findings in eight Cuban families with suspected mitochondrial disease.

OBJECTIVES

To characterize these patients from the molecular point of view, which would allow a preliminary understanding of the behavior of these deletions in Cuban patients.

PATIENTS AND METHODS

We studied nine patients from eight Cuban families in whom mitochondrial encephalomyopathy was suspected. We analyzed the presence of ragged red fibres, the enzymatic activity of the mitochondrial respiratory chain and detection of mtDNA mutations. We used the technique of restriction length polymorphism analysis for detection of deletions.

RESULTS

Histochemical studies showed the presence of COX negative ragged red fibres in seven of the patients studied. The enzymatic activity of the mitochondrial respiratory chain was normal in all the patients. We detected four patients with single deletions of mtDNA, and one with multiple deletions and of the patients had the A3243G mutation.

CONCLUSIONS

With the methods used we were able to determine the presence of a mitochondrial disorder in seven of the eight families studied and deletions of mtDNA were detected as the cause of the illness in five. The disorder was always associated with progressive external ophthalmoplegia and COX negative ragged red fibres.

Prevalence of bacterial vaginosis and correlation of clinical to Gram stain diagnostic criteria in low risk pregnant women

The present study aimed to evaluate the prevalence of bacterial vaginosis, and the correlation of clinical Amsel criteria with Gram Nugent criteria for the diagnosis of bacterial vaginosis in a low risk population of pregnant women. Pregnant women under 28 weeks of gestation who were followed in the low risk clinics at two centers were evaluated for the presence of bacterial vaginosis using the Amsel clinical criteria, and underwent vaginal samples for Gram staining. Gram smears were examined for the diagnosis of bacterial vaginosis on the basis of Nugent's criteria. A total of 492 women were included in the study. Bacterial vaginosis was diagnosed in 1.6% (8/492) women on the basis of clinical criteria, and in 4.5% (22/492) according to Gram stain. The sensitivity and specificity of Amsel criteria compared with Gram stain were 35% and 99%, respectively. In accordance with other recent reports, the prevalence of bacterial vaginosis appears to be much lower in certain areas than figures previously suggested. In these populations, the correlation of composite clinical criteria defined in groups with high prevalence of bacterial vaginosis appears to be also poor.

Use of Granada medium to detect group B streptococcal colonization in pregnant women

Direct inoculation onto Granada medium (GM) in plates and tubes was compared to inoculation into a selective Todd-Hewitt broth (with 8 microg of gentamicin per ml and 15 microg of nalidixic acid per ml) for detection of group B streptococci (GBS) in pregnant women with 800 vaginal and 450 vaginoanorectal samples. Comparatively, GM was found to be as sensitive as the selective broth for the detection of GBS in vaginal specimens and more sensitive than selective broth for the detection of GBS in vaginoanorectal samples (96 versus 82%). The use of GM improved the time to reporting of a GBS-positive result by at least 24 h and reduced the direct cost of screening. We have also found that the inconvenience of anaerobic incubation of GM plates can be avoided when a cover slide is placed upon the inoculum, because aerobic incubation in GM plates with cover slides causes GBS to develop the same pigmentation that it develops with incubation under anaerobic conditions. These data support the routine use of GM plates or tubes as a more accurate, easier, and cheaper method of identification of GBS-colonized women compared to the enrichment broth technique.

Evaluation of the Granada agar plate for detection of vaginal and rectal group B streptococci in pregnant women

Granada medium was evaluated for the detection of group B streptococci (GBS) in vaginal and rectal swabs compared with selective Columbia blood agar and selective Lim broth. From May 1996 to March 1998, 702 pregnant women (35 to 37 weeks of gestation) participated in this three-phase study; 103 (14.7%) of these women carried GBS. In the first phase of the experiment (n = 273 women), vaginorectal specimens were collected on the same swab; the sensitivities of Granada tube, selective Columbia blood agar, and Lim broth were 31.4, 94.3, and 74.3%, respectively. In the second and third phases (n = 429 women), vaginal and rectal specimens were collected separately; the sensitivities of Granada plate, selective Columbia blood agar, and Lim broth (subcultured at 4 h on selective Columbia agar in the second phase and at 18 to 24 h in Granada plate in the third phase) were 91.1, 83.9, and 75%, respectively, in the second phase and 88.5, 90.4, and 63.5%, respectively, in the third phase. There were no statistically significant differences in GBS recovery between the Granada agar plate and selective Columbia blood agar, but the Granada plate provided a clear advantage; the characteristic red-orange colonies produced overnight by GBS can be identified by the naked eye and is so specific that further identification is unnecessary. The use of the Granada tube and Lim broth did not result in increased isolation of GBS. In conclusion, the Granada agar plate is highly sensitive for detecting GBS in vaginal and rectal swabs from pregnant women and can provide results in 18 to 24 h.

[Neonatal infection by Streptococcus agalactiae. Multicenter study in the area of Barcelona, Spain]

BACKGROUND

Streptococcus agalactiae or streptococcus group B (SGB) is the main etiologic agent of early neonatal sepsis. A multicenter study was performed with the aim of determining the incidence and characteristics of this disease in our medium and contribute the design of an adequate prevention protocol.

METHODS

Ten hospitals and two primary health care centers were implicated in the study; 103 microbiology confirmed episodes of SGB neonatal sepsis (blood and/or LCR positive) were reported from 1994 to 1996.

RESULTS

The incidence of early SGB neonatal sepsis was 1.48/1,000 live births with a mortality of 8.7%. The cultures, for detecting the state of the SGB carrier were performed in only 26 (25%) of the patients. At least one of the factors described for risk of perinatal SGB infection was observed in 46% of the mothers, with the most frequent being prolonged amniorrhea (26%), intrapartum fever (17%), and early delivery (14%). At the time of delivery only 10.7% of the mothers received endovenous antibiotherapy.

CONCLUSIONS

From these results the following recommendations have been made: a) detection of SGB carriers by the systematic practice of blood cultures in the last weeks of gestation and b) the administration of intrapartum antibiotic prophylaxis in both early births (< 37 weeks) and in all the SGB carriers should be undertaken. With these measures we aim to decrease the neonatal infections by streptococcus group B.

Urovirulence determinants in Escherichia coli strains causing prostatitis

To define the urovirulence properties of Escherichia coli strains producing prostatitis, E. coli strains isolated from men with acute (7 strains) or chronic (23) prostatitis were compared with E. coli isolates from women with pyelonephritis (30), acute cystitis (60), or complicated urinary tract infection (UTI; 30). Strains from prostatitis patients were significantly more likely to express hemolysin than were strains causing complicated UTI (73% vs. 43%; P = .02) and more often demonstrated hybridization with the cytotoxic necrotizing factor-1 (CNF-1) probe (63%) than did strains from women (44%-48%). P fimbrial expression was highest among pyelonephritis (73%) and prostatitis strains (53%) and lowest among E. coli from women with complicated UTI (23%) and cystitis (30%; P < .05, prostatitis strains vs. either of the latter 2 groups). Results suggest that E. coli strains producing prostatitis generally possess urovirulence profiles similar to those of strains from women with acute uncomplicated pyelonephritis and that hemolysin and CNF-1 are especially prevalent in prostatitis strains.

[Maternal-fetal vertical transmission of Haemophilus influenzae and Haemophilus parainfluenzae]

BACKGROUND

Maternal-fetal transmission of Haemophilus influenzae (HI) and Haemophilus parainfluenzae (HPI) as well as characteristics of the infection in the neonate have been poorly described.

METHODS AND RESULTS

From 1982 to 1994 18 HI and 12 HPI from vaginal secretion of 30 women obtained intrapartum or immediately post partum were isolated. The following was observed in the 18 patients in whom HI was isolated: 1 abortion, 2 antepartum death, 1 post partum death, and 14 live neonates from whom 10 were suspect a infection with 5 cases being confirmed with isolation of HI in blood culture. Mortality was 40%. The rate of vertical transmission of HI was 80% (8/10) and neonatal sepsis 50% (5/10) (71.4% of the infants whose mothers did not receive intrapartum antibiotics and 0% in those who did). Twenty-seven point seven percent of the strains of HI were beta-lactamase producers with II and III being the most frequent biotypes observed. Of the 12 patients from whom HPI was isolated the following was reported: 1 antepartum death, and 12 live neonates of whom 10 were suspect a infection, but no case was confirmed because HPI was not isolated from blood culture. The vertical transmission of HPI was 20% (2/10).

CONCLUSIONS

The isolation of HI in the vagina of pregnant women should be considered as being potentially very virulent since despite a low prevalence, the rate of vertical transmission and, overall, neonatal sepsis, is high.

Prophylactic administration of amoxicillin and clavulanic acid in pregnant women with premature rupture of the membranes

Seventy-five pregnant women (mean gestational age 32.26 weeks, range 20-36 weeks) with premature rupture of the membranes (PROM) were admitted in our department during 1989 and the first 6 months of 1990. Amoxicillin and clavulanic acid was initially administered at a dose of 1.2 g i.v. every 8 hours for 3-4 days and was followed by oral administration of 625 mg every 8 hours until labor. Sixty-one patients (mean gestational age 32.6 +/- 2.3 weeks, range 26-36 weeks) achieved an uncomplicated course of their pregnancies with a mean time of 11.4 +/- 5.7 days (range 3-27 days), from rupture to delivery. Fourteen women (mean gestational age 30.8 +/- 5 weeks, range 20-36 weeks) developed chorioamnionitis 3.5 +/- 0.9 days (range 1.4-5.6 days) after the rupture with several degrees of leukocyte infiltration of the membranes, placenta and the umbilical cord. Five women (mean gestational age 23.8 +/- 2.3 weeks, range 20-26 weeks) had complications resulting in fetal/infant death, three of them because of fetal sepsis (Escherichia coli, Pseudomonas aeroginosa, Staphylococcus aureus). The newborns were followed up 6 months from delivery and had no signs of drug influence. Few side effects were observed with the chief complaints involving the gastrointestinal tract (4%). No one discontinued the drug. It seems therefore, that the prophylactic administration of amoxicillin and cluvalanic acid in women with PROM is associated with a significant prolongation of pregnancy and with a reduction in the incidence of fetal/maternal infections.

Candida glabrata: in vitro susceptibility of 84 isolates to eight antifungal agents

The in vitro susceptibility of 84 isolates of Candida glabrata from patients treated at the University Hospital of the Canary islands to eight antifungal agents (amphotericin B, itraconazole, fluconazole, miconazole, clotrimazole, tioconazole and econazole) has been studied using the broth dilution micro-method. Among the eight antifungal agents tested, the smaller geometric mean corresponded to tioconazole, econazole, clotrimazole and miconazole. In contrast with fluconazole, a greater geometric mean has been achieved. All the C. glabrata isolates tested were sensitive to concentrations of 3.125 micrograms/ml of clotrimazole and miconazole, 6.25 micrograms/ml of amphotericin and ketoconazole. Concentrations of 12.5 micrograms/ml were needed to obtain 100% inhibition of isolates for econazole and tioconazole and concentrations of 25 and 50 micrograms/ml, respectively for itraconazole and fluconazole. Among our C. glabrata isolates, 2.4% were found to be resistant to amphotericin B. For fluconazole and itraconazole, 19.1% and 7.9% of isolates, respectively, were resistant. With reference to imidazoles, we obtained 2.4% and 3.6% resistance for tioconazole and econazole, respectively. No isolates were found to be resistant to ketoconazole, miconazole and clotrimazole. The results have shown a high activity of amphotericin B and itraconazole, observing a similar response with the five imidazole antifungals tested. The highest rate of resistance was found when fluconazole was used.

Hemagglutination, adherence, and surface properties of vaginal Lactobacillus species

To address the poorly understood mechanisms through which lactobacilli adhere to vaginal epithelial cells (VECs), 65 wild type lactobacilli isolated from the vaginal flora of young women and 3 American Type Culture Collection Lactobacillus strains were studied. Group I isolates (n = 56) hemagglutinated sheep, rabbit, and human red blood cells (RBCs) and adhered poorly to VECs. In contrast, all 4 group II strains hemagglutinated sheep and human but not rabbit RBCs, adhered in large numbers to VECs, and were identical in five phenotypic tests and DNA-DNA hybridization. Eight other strains (group III) hemagglutinated all RBC types studied, adhered avidly to VECs, and had identical protein and hybridization patterns but showed heterogeneous enzyme activities. Although most wild type lactobacilli from the vaginal flora of young women adhered poorly to VECs, selected isolates (groups II and III) adhered in large numbers, demonstrated specific and reproducible hemagglutination patterns, and may have specific mechanisms of attachment to VECs.

Protein synthesis in specific tissues during sepsis

BACKGROUND

The hypothesis that fractional protein synthesis rates (Ks) are tissue-specific and bidirectional during sepsis was tested in an animal model.

MATERIAL AND METHODS

Ks in liver, triceps muscle, and diaphragm were measured in septic (n = 27) and control rats (n = 26). Sepsis was induced by a reproducible model established in our laboratory (intraperitoneal injection of sterile NaOH 0.75 N at 0.075 ml/100 g of body weight). Ks were measured using the flooding-dose method in tissue obtained from the diaphragm, liver, and from the triceps muscle.

RESULTS

In hepatic and diaphragmatic tissue, Ks were significantly higher in the septic animals (Ks: 112.2 +/- 8 and 5.4 +/- 1.9, respectively) than in control animals (Ks: 78.5 +/- 13 and 2.9 +/- 1.7, respectively). In the triceps, Ks were significantly lower in septic animals (Ks: 2.9 +/- 1.4) than in control animals (Ks: 5 +/- 1.8).

CONCLUSION

The results suggest that in septic animals the rate of protein synthesis is enhanced in tissues of priority, such as the liver, and varies in response to differences in muscle activity.