Outcomes of febrile children presumed to be immunocompetent who present with leukopenia or neutropenia to an ambulatory setting

To determine significant medical outcomes in febrile children presenting to an ambulatory setting with neutropenia and/or leukopenia.

METHODS

Retrospective medical record review conducted on febrile patients who had a blood culture drawn, with white blood cell counts less than 5,000/mm3 and/or an absolute neutrophil count less than 1000/mm3. Ninety-one patients were identified; 5 with positive blood culture results, 13 with significant non-oncologic disease, and 3 patients with leukemia who had involvement of 2 or more cell lines.

CONCLUSIONS

In the majority of patients, clinical judgment, physical findings, and review of all cell lines of the complete blood cell count identified those with significant disease.

Ticks associated with wild mammals in Ghana

The host ranges of a collection of 21 tick species found on wild mammals in the savanna, forests and coastal zone of Ghana suggested that most species were adapted to feeding mainly on host species within a single mammalian order, i.e. on artiodactyls (bovids/suids), carnivores, rodents or pholidotes (pangolins). Only a few species were dispersed evenly across a range of orders. Seven out of ten of the most common ticks on forest mammals were significantly associated with a particular host species or a group of closely related host species, which could be viewed as their major host or hosts, but they were also recorded much less frequently on a wide range of host species. Two other species were confined to their major hosts. Only one species appeared to be widely dispersed on forest mammals and to lack a particular major host. The majority of tick species therefore occurred on hosts with very distinctive biological, behavioural and ecological characteristics. The study provided no evidence to support the view that host specificity is an artefact of sampling. Finding that the tick species on Ghanaian wild mammals occurred on particular hosts, as well as in distinct habitats, indicated that tick-host associations are important for tick survival and confirmed the importance of climate and vegetation in tick distribution.

Incidence and prevalence of tick-borne haemoparasites in domestic ruminants in Ghana

Giemsa-stained thin blood smears prepared monthly from cattle, sheep and goats in the Greater Accra region of Ghana between May 1994 and December 1996 were examined for presence of tick-borne haemoparasites. The majority of animals were less than 2 months old at the start of the survey. Monthly and cumulative incidences are presented of Anaplasma sp., Babesia bigemina, Borrelia sp., Eperythrozoon sp., Theileria mutans and Theileria velifera in cattle, Anaplasma sp., Borrelia sp., and Theileria sp. in sheep, and Anaplasma sp. in goats. T. mutans was the commonest parasite in cattle, with 100% incidence in calves by 10 months of age, and Anaplasma was commonest in small ruminants. The relative prevalence of these haemoparasites in blood smears from cattle, sheep and goats sampled on a single occasion at sites in all 10 regions of Ghana was found to be similar, though actual infection rates were lower. Packed cell volume (PCV) measurements from the sampled animals are also presented; no seasonal trends were evident in the PCV of the cattle, sheep and goats sampled monthly. In animals sampled on a single occasion, mean PCV was significantly higher in cattle and sheep without detectable haemoparasite infection, and in cattle was lowest in animals positive for both Babesia and Anaplasma, while there was no difference in mean PCV levels between parasitised and non-parasitised goats.

Ehrlichia ruminantium seroprevalence in domestic ruminants in Ghana. II. Point prevalence survey

Serum samples collected on a single occasion from cattle, sheep and goats at sites in all 10 regions of Ghana were tested for antibodies to Ehrlichia (previously Cowdria) ruminantium, the causative agent of heartwater, by polyclonal competitive ELISA (PC-ELISA). The survey revealed the presence of heartwater-exposed ruminants throughout the country, with local seroprevalence up to 100%. Seronegative, and therefore presumably susceptible, animals were also present in all regions, in some areas in numbers high enough to indicate local endemic instability. Overall seroprevalences in cattle, sheep and goats were 61, 51 and 28% respectively, and were generally higher in the northern part of the country and lower in the forest zone. Amongst animals over 1 year old, two thirds of cattle and sheep, and around one third of goats throughout the country had been exposed to E. ruminantium. In the north, seroprevalence in sheep sampled with and without cattle was similar, whereas in the south seroconversion rates in sheep were significantly higher in areas where cattle were present.

Ehrlichia ruminantium seroprevalence in domestic ruminants in Ghana; I. Longitudinal survey in the Greater Accra Region

Serum samples collected monthly over a 34-month period from cattle, sheep and goats in the Greater Accra Region of Ghana were tested for antibodies to Ehrlichia (previously Cowdria) ruminantium, the causative agent of heartwater, by polyclonal competitive ELISA (PC-ELISA). Maternal antibodies, detected in about half of animals followed from under 1 month old, declined to negative levels within 2-4 months. Amblyomma variegatum tick vectors were present on livestock in rural areas throughout the year, and first seroconversion occurred at any age, although the majority of calves seroconverted between 1 and 10 months old, sheep by 11 months, and goats by 7 months. All the cattle in the study became seropositive by 20 months of age, except one animal which subsequently died of heartwater. Following seroconversion, 25% of bovine sera tested negative in the PC-ELISA. Just over half the sheep in the survey seroconverted before or during the study period; following seroconversion, less than 3% of ovine sera became PC-ELISA negative. About a quarter of the goats seroconverted, and 34% of their post-seroconversion sera tested negative in the PC-ELISA. Overall, the serology indicated that virtually all cattle on the survey farms were exposed to E. ruminantium without suffering disease, but that a substantial proportion of sheep and goats escaped exposure and thus formed a susceptible population. E. ruminantium was detected in brains of 14, 36 and 4% of cattle, sheep and goats submitted for post mortem at the Accra Veterinary Laboratory, indicating that sheep were most at risk from heartwater disease.

An updated list of the ticks of Ghana and an assessment of the distribution of the ticks of Ghanaian wild mammals in different vegetation zones

Twenty one species of ticks belonging to five genera of the family Ixodidae (Order Acari, sub-order Ixodida) - Amblyomma, Haemaphysalis, Hyalomma, Ixodes and Rhipicephalus (including the sub-genus Rhipicephalus (Boophilus)) - were collected from 1260 mammals, representing 29 species, 14 families and 6 orders, in four vegetation zones in Ghana during the period 1971-1978. Four other species were collected from humans in 1977. In all, eight species appeared to be new records for Ghana: Amblyomma tholloni Neumann; Dermacentor circumguttatus Neumann; Haemaphysalis houyi Nuttall & Warburton; Ixodes loveridgei Arthur; Ixodes oldi Nuttall; Ixodes vanidicus Schultze; Rhipicephalus complanatus Neumann; Rhipicephalus cuspidatus Neumann. The updated list of tick species in Ghana given here includes 41 species of ixodid ticks and four species of argasid ticks. Most species have been found in neighbouring regions of West Africa but 56 of the 121 different combinations of ixodid tick species and host species found in the collection described here have not apparently been reported before. The new combinations recorded here bring the total number of different combinations of ixodid tick species and mammalian host species now reported in Ghana to 151. The tick species found on wild mammals in Ghana mostly differed from those reported from domestic stock by other authors. The data showed that different tick species occurred in different vegetation zones and that most species displayed a pronounced preference for certain groups of related host species. Some tick species were found in the savanna feeding mainly on large bovids and/or suids; others were found in forests feeding mainly on small bovids, large rodents or small carnivores.

Some puzzling situations in the onset, occurrence and future of coronary heart disease in developed and developing populations, particularly such in sub-Saharan Africa

Coronary heart disease (CHD) was rare in developed populations until the early 1900s; this prevailed even among the small segments who were prosperous and who, in measure, had most of the currently recognised risk factors. However, in the 1930s, with improved circumstances from general rises in socio-economic state, there were major increases in the occurrence and mortality rate from the disease, the latter reaching a third of the total mortality in some countries, as in the United Kingdom (UK). Puzzlingly, the inter-population diversity of the increases in CHD has been such that there are as much as five fold differences in CHD mortality rates, as, for example, between Poland and Spain. Within recent years, with appropriate treatments, the mortality rate has halved in some countries, again, as in the UK. However, the incidence rate of the disease has diminished little or hardly at all. Risk factors include a familial component and, nutritionally, over-eating, a high fat intake, relatively low intakes of plant foods, especially of vegetables and fruit and, non-nutritionally, smoking, excessive alcohol consumption and a low level of everyday physical activity. On the one hand, known risk factors, broadly, are considered to be capable of explaining only about half of the variation in the occurrence of the disease. Even at present, known risk factors far from fully explain the epidemiological differences in mortality rates. Yet, on the other hand, there is abundant evidence that in population groups, among whom risk factors are low or have been reduced, CHD incidence and mortality rates are lower. Notwithstanding this knowledge, broadly, there is very little interest in the general public in taking avoiding measures. As to the situation in developing populations, in sub-Saharan Africa, in urban Africans, as in Johannesburg, South Africa, despite considerable westernisation of life style and with rises in risk factors, CHD remains of very low occurrence, the situation thereby resembling, historically, its relatively slow emergence in developed populations. In most eastern countries, mortality rates remain relatively low, as in Russia and Japan. However, in major contrast, in India, rates have risen considerably in urban dwellers. Indeed, in Indian immigrants, as in those in the UK, their rate actually exceeds that in the country's white population. In brief, much remains to be explained in the epidemiology of the disease.

The feeding behaviour and Plasmodium infection of Anopheles mosquitoes in southern Ethiopia in relation to use of insecticide-treated livestock for malaria control

Anopheles arabiensis and An. quadriannulatus species B mosquitoes were collected at sites of human and livestock housing and analysed for blood feeding patterns and infection with malaria sporozoites. A low percentage of human blood meals at some sites suggested that zooprophylaxis could be effective in reducing challenge from Plasmodium falciparum.

World pandemic of obesity: the situation in Southern African populations

Among sub-Saharan Africans in general, a generation or so ago, there was very little gain in weight, or in blood pressure, with age. Even at present, in most populations, especially in the indigent masses, obesity prevalence remains very low, at 1-5%. However, in South Africa and some neighbouring countries, Botswana, Namibia and Zimbabwe, with rise in socio-economic status, urbanization, and diminishing physical activity, the proportion affected has increased. Rises, as noted in Cape Town, have been only slight in men, to 8%; but in women much more so, to 34%, ie to a level similar to that of African-American women. Dietarily, energy intake has increased slightly, that from fat from 15-20% to 25-30%. However, there have been falls in dietary fibre intake, to 20-25 g and 15-20 g daily, in rural and urban areas, respectively. Evidence suggests that the health disadvantage of obesity in African women is less than that in white women, and would seem to have little influence on their proneness to hypertension, coronary heart disease and breast cancer. Traditionally, and even currently, sociologically, the disorder carries little opprobrium. As to the future, the prevalence in women may well increase still further. Regarding treatment, unfortunately among African women desirous of losing weight, sustained reducing measures are near impossible; moreover, pharmacological treatment is too costly to implement.

A novel plastid-targeted J-domain protein in Arabidopsis thaliana

Arabidopsis cDNAs encoding ATJ11, the smallest known J-domain protein, have been isolated and characterized. The precursor protein of 161 amino acid residues was synthesized in vitro and imported by isolated pea chloroplasts where it was localized to the stroma and cleaved to a mature protein of 125 amino acid residues. The mature protein consists of an 80 amino acid J-domain, and N- and C-terminal extensions of 24 and 21 amino acid residues, respectively, which show no similarity to regions in other DnaJ-related proteins. ATJ11 produced in Escherichia coli stimulated the weak ATPase activity of E. coli DnaK, but was unable to stimulate refolding of firefly luciferase by DnaK, and inhibited refolding by DnaK, DnaJ and GrpE. ATJ11 is encoded by a single-copy gene on chromosome 4, and is expressed in all plant organs examined. A paralogue of ATJ11, showing 72% identity, is encoded in a 4.5 Mb duplication of chromosome 4 on chromosome 2. These proteins represent a novel class of J-domain proteins.

Changes in public health in South Africa from 1876

The present population in South Africa, roughly 43 million inhabitants, is made up of Africans (77.2%), whites (10.5%), Coloureds (mixed race) (8.8%) and Indians (2.5%). In 1900 the infant mortality rate (IMR) among Africans was 330 per 1,000 live births; this has now fallen to 50-60. In Soweto, a primarily African city, IMR averages 20-25. Life expectancy in the past was only 25-30 years; by 1995, this reached 63 years. However, this could fall again due to the rapidly spreading HIV/AIDS epidemic. Life expectancy could fall to 40-45 years by 2010 with the AIDS epidemic being the cause of half of all deaths--a disastrous change from the previous relatively commendable public health situation. Formerly, the most common causes of deaths in young people were infections, diseases associated with malnutrition and gastroenteritis. Adults died almost solely from infections, including typhoid, dysentery, malaria and tuberculosis (TB). Even though diseases associated with malnutrition are less common today, many infections still remain a major problem, particularly TB, which is increasing. As late as 1970, Africans who reached 50 years had longer life expectancy than whites due to the low prevalences of the chronic diseases of lifestyle. This is no longer so, due to the recent rises in non-communicable disorders/diseases, principally obesity in women, hypertension, diabetes, stroke and the cancers of prosperity. In the not so distant future, the level of control of HIV/AIDS related diseases will be the major health/disease regulating factor among Africans. Among white, Coloured and Indian populations, there have been falls in the mortality rates of the young and, despite rises in lifestyle diseases, increases in life expectancy are continuing. For all populations other important public health regulatory factors include water supply, sanitation, clinic/hospital services and personal environmental factors, employment, dietary pattern and intake, smoking practices and alcohol consumption and physical activity, particularly in urban dwellers. Unfortunately, public health expenditure, also a highly regulating factor, has fallen from 8.2% of the gross domestic product in 1994 to 4.1% in 2000.

Acute hemorrhagic complication of diagnostic lumbar puncture

OBJECTIVE

To present a case of an epidural hematoma after lumbar puncture in a pediatric patient without known risk factors for such a complication and to review the literature regarding this complication.

DESIGN

Case report, review of the literature, and discussion.

DATA SOURCES

A review of MEDLINE (1966-1998) for keywords "lumbar puncture" and "hemorrhage" or "hematoma" was conducted, and each bibliography was reviewed for other sources extending to 1911. Articles describing a case of spinal hematoma after a lumbar puncture for any procedure were included.

RESULTS

A 5-year-old boy underwent a lumbar puncture for evaluation of lethargy and fever, and subsequently developed marked back pain and severe pain on flexion of his legs. Magnetic resonance imaging revealed an epidural blood collection. The patient's symptoms resolved over the next few days in association with steroid administration. Multiple reports of epidural and subdural hematomas were found on literature review, most occurring in the setting of coagulation abnormalities. These reports involve lumbar puncture in anesthetic, interventional, and diagnostic settings.

CONCLUSION

Lumbar puncture is a frequently employed procedure. Known complications include epidural, subdural, and subarachnoid hemorrhage, usually in the setting of abnormal coagulation. The case presented is unusual in that the patient is a child and lacks any known risk factors for a hemorrhagic complication. Such a complication appears to be rare; only five of the 64 cases discovered in the literature review occurred following this diagnostic procedure in patients without known risk factors.

Risk factors in habitats of the tick Ixodes ricinus influencing human exposure to Ehrlichia phagocytophila bacteria

Ixodes ricinus L. (Acari: Ixodida) were sampled during 1996-99 in southern Scotland, on vegetation using cloth drags, on humans by removal from clothing and on roe deer (Capreolus capreolus L.) by searching legs of culled deer. Developmental microclimate was recorded by automatic recorders and questing microclimate by portable instruments during tick collections. Ticks and deer were examined for infection with Ehrlichia phagocytophila bacteria (Rickettsiales) using microscopy and polymerase chain reaction. This pathogen causes tick-borne fever of sheep in Europe and human granulocytic ehrlichiosis in North America, but in Europe human clinical ehrlichiosis due to E. phagocytophila has not been recorded despite serological evidence of exposure. Among three types of habitat, coniferous woodland was most infested with questing ticks (560 ticks/km of drag; mean numbers collected on long trousers: 24.3 larvae, 13.5 nymphs and 0.8 adult ticks/km walked), deciduous woodland had slightly lower infestation (426 ticks/km drag) and upland sheep pasture had much lower infestation (220 ticks/km drag). Of the three main vegetation types, bracken was least infested (360 ticks/km drag), ericas most (430 ticks/km drag) and grassland had intermediate infestation density (413 ticks/km drag). Questing and developmental microclimates were poor predictors of exposure within these habitats, except lower infestation of pastures was attributed to greater illumination there. Collectors who walked a total of 300 km through all habitats (taking 360 h in all seasons), wearing cotton trousers hanging outside rubber boots, were bitten by only four nymphs and 11 larvae of I. ricinus (but no adult ticks). There was a negative correlation between densities of deer and ticks collected, although presence of deer remains a major indicator of exposure. The proportion of infected ticks was fairly uniform at four sites studied. Overall prevalence of E. phagocytophila in I. ricinus was 3.3% in nymphs (40/1203) but only approximately 1.5% in adults of both sexes (although males do not bite). It was estimated that nymphs of I. ricinus gave 4.4% probability of one infected bite/person/year (for occupational exposure during this research) due to presence in all seasons and habitats, their human biting rate of 0.011 nymphs/h or 0.013 nymphs/km and widespread infection with E. phagocytophila. The frequency distribution of intensity of infection in ticks was approximately normal (mean 98 morulae/nymph infected), thus there is a high risk of receiving a high dose from any one infected tick bite.

With increasing ageing in Western populations, what are the prospects for lowering the incidence of coronary heart disease?

Coronary heart disease (CHD), rare in the early 1900s, in the 1970s was responsible for almost a third of deaths in Western populations. Although its mortality rate has fallen in the last 20 years, considerably in certain populations, it remains the leading cause of death, and there is little evidence of any fall in its incidence rate. The primary risk factors, which include pattern of diet, smoking practice, and level of physical activity, are well known, but explain only approximately 50% of variation in its occurrence. Despite the numerous health improvement recommendations made, alterations in diet have been relatively slight. Although smoking practice has halved in some populations, its prevalence is now rising in the young. The extent of physical activity is low, compared with that in the past, and may even be decreasing in the young. With the general ageing of populations, the near absence of strong encouragement from the state, and individuals' general failure to reduce risk factors significantly, the chances of decreases in the incidence of CHD appear remote.

Tick-Theileria interactions in response to immune activation of the vector

Watt, D. M., Walker, A. R., Lamza, K. A., and Ambrose, N. C. 2001. Tick-Theileria interactions in response to immune activation of the vector. Experimental Parasitology 97, 89-94. Immune mechanisms towards the haemoprotozoan parasite Theileria parva were investigated in their tick vector, Rhipicephalus appendiculatus. The exoskeletons of adult ticks were initially pierced with bacteria-coated, saline-coated, or sterile dry glass needles. Haemolymph was extracted from the ticks at 6, 24, 48, and 72 h postinjection and applied to bacterial plates to measure the growth inhibition effects. The inhibition zones were larger with all the injected groups compared to uninjected controls. The largest inhibition zones were seen 24 h after injection with bacteria-coated needles. An experiment was carried out to investigate whether antibacterial immune responses were relevant to the parasite/tick relationship and, if so, which parasite form was most vulnerable. R. appendiculatus nymphs were infected with T. parva by feeding on an infected calf and were then injected with needles on days 7, 13, 15, and 17 throughout their moult in an attempt to induce tick immune responses at the same time as different lifecycle forms of T. parva would be present. Salivary glands from the moulted adult ticks in the control and different treatment groups were dissected out and examined for the presence of T. parva sporoblasts. No difference in infection levels was seen in any of the treatment groups compared with the controls, suggesting that immune responses in R. appendiculatus, induced by bacterial injection, do not affect T. parva infections. The fecundity of injected ticks was compared with that of uninjected controls to ensure that the injection procedure itself was not detrimental to the ticks. Injected females had higher engorgement masses than controls but reduced levels of egg hatching.

Age structure of a population of Ixodes ricinus (Acari: Ixodidae) in relation to its seasonal questing

Three sites in south west Scotland, each having one deciduous and one coniferous woodland with populations of roe deer, were sampled over three years for Ixodes ricinus Linnaeus ticks using cloth drags. Nymphs and adult ticks were age graded by dissection of gut and Malpighian tubules and staining for lipid with Sudan red. Temperature and relative humidity were recorded in developmental and questing microclimates. Two annual cohorts of both nymphs and adults were found. For both instars one cohort became apparent in early spring and the other in autumn. The timing of the cohorts of nymphs corresponded to peaks of numbers questing, but neither females nor males had any clear seasonal pattern of questing. The maximum life of questing nymphs and adults was three to four months. Nymphs and adults were found questing at all months of the year and at temperatures ranging from 3.5 degrees C to 29.3 degrees C. Questing of larvae in summer peaks of numbers was positively correlated with temperature and negatively correlated with relative humidity. These results are explained by a descriptive model which invokes behavioural and morphogenetic diapause. Tests of the model are discussed and it is proposed that the main adaptive advantage of the complex life cycle is to permit moulting and oviposition to occur at favourable summer temperatures in ticks that have engorged at any time of the year.

Hyponatremic seizures in infancy: association with retinal hemorrhages and physical child abuse?

We present two cases of infants with hyponatremic seizures who had an unexpected finding of retinal hemorrhages. A review of the literature found no prior association between hyponatremic seizures and retinal hemorrhages. The retinal hemorrhages found in the first patient were a result of shaken baby syndrome (SBS) and associated with long bone fractures and a subdural hematoma. The second patient had retinal hemorrhages and cerebral edema, presumed to be a result of SBS. We suggest that children who become hyponatremic owing to neglect, lack of education, or intentional water poisoning may be at risk for other forms of child abuse. Additional research needs to be done to further elucidate the relationship between hyponatremic seizures and child abuse.

The frequency of blood pressure measurements in children in four EDs

The study's objective was to assess the frequency of triage blood pressure measurements in pediatric patients and the recognition of an elevated blood pressure. The design was retrospective and included chart review. The setting consisted of four emergency departments associated with one medical school, including one level I academic center, two level II Community departments, and a regional children's hospital. A convenience sample of 437 patients, aged 1 month to 18 years, was selected. The frequency of triage blood pressure measurements was recorded. The number of patients whose blood pressure was higher than the 90th percentile for age and sex as established by the Second Task Force on Blood Pressure Control in Children was also recorded. The frequency of a second blood pressure measurement in patients with an elevated initial blood pressure was recorded. All frequency data were stratified by hospital and by age group. The results showed 294/437 (66%) of children had blood pressures measured at triage. Of these measurements, 153/294 (52%) reflected blood pressures greater than the 90th percentile for age and sex, but only 58/153 (38%) of patients with such blood pressures had a second blood pressure measured. Hospitals varied in their frequency of blood pressure measurement. Adolescents had their blood pressure measured more frequently, 981105 (93%) than two to 12-year-olds, 144/185 (78%) or 1-month to 2-year-olds, 52/147 (35%). Frequency of triage blood pressure measurements in children varied by institution and increased in frequency with age.