Leishmaniasis of the tongue treated with liposomal amphotericin B

A 66-year-old man, immunosuppressed because of a lymphoma and with severe ischaemic heart disease and proteinuria, presented with a swelling on the tongue due to leishmaniasis. His travel history suggested that he had acquired the infection in the Mediterranean area some years earlier. He was treated with liposomal amphotericin B for 21 days and made a good recovery despite a temporary deterioration in renal function. Oral lesions are a rare manifestation of Old World leishmaniasis. Liposomal amphotericin B is a novel treatment that may be well tolerated when there is concern about the toxicity of more established drugs.

Value of electron microscopy in diagnosis of renal disease

AIMS

To assess the role and value of electron microscopy in the diagnosis of renal disease.

METHODS

Retrospective evaluation of 88 renal biopsy specimens received for primary diagnosis by assessment of the contribution of electron microscopy to the final diagnosis in the knowledge of the light microscopy and immunofluorescence findings.

RESULTS

Electron microscopy had an important diagnostic role in 75% of cases and was essential or necessary for diagnosis in 25%. In 25% of cases electron microscopy was considered unhelpful in diagnosis.

CONCLUSION

Electron microscopy has an integral role in the diagnosis of renal disease, and tissue should be taken for electron microscopy in all cases if possible. In some selected cases once the light microscopy and immunofluorescence findings are known it may be possible to forego electron microscopic examination. Electron microscopy is particularly useful in the differential diagnosis of minimal change disease and the nephrotic syndrome.

Characterization of Encephalitozoon hellem (Microspora) isolated from the nasal mucosa of a patient with AIDS

A microsporidium of the genus Encephalitozoon was isolated into culture from the nasal epithelium of a patient with AIDS. It was compared with in vitro isolates of Encephalitozoon cuniculi and the type isolate of Encephalitozoon hellem by SDS-PAGE and by Western blotting with murine antisera raised to E. cuniculi, E. hellem and the nasal isolate, monoclonal antibodies raised to E. cuniculi and sequential sera from the patient. All tests showed similarities between E. hellem and the nasal isolate but differences between these two isolates and E. cuniculi. Minor protein differences between E. hellem and the nasal isolate were not considered sufficient to separate them at the specific level. The new isolate is named the Wainwright isolate of E. hellem. The ultrastructure of the Wainwright isolate in vitro was similar to that of the parasite in vivo but there was a greater tendency for disruption of the parasitophorous vacuoles. The deposition of the electron-dense surface coat on the sporogonic stages of E. hellem, as a uniform layer which later thickens, is in contrast to its deposition as broad bands, which later join up, in E. cuniculi. This may be a useful character in distinguishing the species without recourse to analysis of protein profiles.

Caring for the bicultural family: the Korean-American example

Bicultural families are increasing in US society, and family physicians will see more of these families for medical care. They can exhibit problems unique to their bicultural experience that arise from the stresses caused by cultural differences in such areas as family roles, emotion expression, child rearing, interpersonal relationships, and methods of communication. If coping mechanisms do not resolve these stresses, the family will come to the family physician with physical manifestations of illness or distress. The symptoms are usually related to depression or depressive equivalents. To care for these families successfully, family physicians should treat both family members and the individual patient. When caring for bicultural families, it is important to recognize the high-risk factors that put them at risk for dysfunction. Treatment goals should be centered on communication and education. In short-term counseling, support, education, listening, and referral to appropriate community resources are useful treatment modalities.

Campylobacter jejuni adapts to aerobic metabolism in the environment

Campylobacter jejuni, when left on blood agar for prolonged periods, was found to survive better in air than under micro-aerobic conditions. After a period of 2-3 days in air, all strains of C. jejuni examined grew freely in air on subculture, and could be further subcultured apparently indefinitely in air. This adaptation to aerobic metabolism was accompanied by a change in colony morphology and some changes in outer-membrane protein patterns, but no change in serotyping reactions. The ability to colonise mice was unaltered as was the helical morphology of growing cells. The important survival phase of C. jejuni, when outside the animal gut, involves not only a change to coccal morphology but also fundamental changes in the metabolism of the organism. These changes are likely to be relevant to techniques required for culturing C. jejuni from foods and environmental sources.

Chronic microsporidian infection of the nasal mucosae, sinuses and conjunctivae in HIV disease

A case of chronic infection of the nasal mucosae, sinuses and conjunctivae with a microsporidian parasite in association with HIV infection and immune deficiency is reported. This microsporidian resembles both Encephalitozoon cuniculi and the newly described Encephalitozoon hellem by electron microscopy. This occurred in an adult male resident in the UK with no history of foreign travel. Although there are previous descriptions of conjunctival infections from the USA, this is the first description of infection of the nasal epithelium. Further studies are underway to classify this protozoan.

The serum resistance of gonococci in the majority of urethral exudates is due to sialylated lipopolysaccharide seen as a surface coat

Examined before subculture, gonococci in 18 urethral exudates collected from different patients were serum-resistant. For 15 exudates, the resistance was drastically reduced by treatment with neuraminidase and by one subculture on laboratory media. It was restored by incubation with cytidine 5'-monophospho-N-acetyl neuraminic acid (CMP-NANA). Electron microscopic examination of gonococci in eight exudates showed a surface structure stained by Ruthenium red which disappeared in most samples when they were treated with neuraminidase. These results were identical with those of previous studies on in vitro grown gonococci which had shown that serum resistance is due to sialylation of a 4.5-kDa conserved component of gonococcal lipopolysaccharide (LPS) by host CMP-NANA, which masks the target site for bactericidal IgM and renders surface LPS stainable by Ruthenium red. The serum resistance of gonococci in the remaining three exudates was not reduced by neuraminidase nor by subculture. The mechanism of this stable resistance is unknown.

Microsporidial keratoconjunctivitis in a patient with AIDS

A male patient is described with acquired immune deficiency syndrome (AIDS) who developed chronic keratoconjunctivitis and chronic sinusitis due to infection with the microsporidian Encephalitozoon cuniculi. Diagnosis was confirmed by electron microscopic examination of conjunctival epithelial cells and nasal polypectomy specimens. Treatment with propamidine isethionate 0.1% (Brolene) eye drops six times daily led to a prompt resolution of the keratoconjunctivitis.

Family separations in the military

Family separations are an intrinsic part of military life. The temporary loss of a family member through deployment brings unique stresses to a family in three different stages: predeployment, survival, and reunion. Most families adapt to these stresses well. In families without adequate coping skills, however, these stresses can lead to problems which the family presents to the health care system. Health care providers must be aware of these stresses, the high-risk families, their clinical manifestations, and techniques for preventing and treating them. This article provides some help for health care providers dealing with these issues.

Recovery of viable but non-culturable Campylobacter jejuni

Suspensions of Campylobacter jejuni became non-culturable after storage in sterilized pond water at 4 degrees C for periods between 18 and 28 d, depending on the strain. Suspensions of four strains of C. jejuni that had been in water for 6 weeks, and shown to be non-culturable, were fed to suckling mice. Colonization of mice was established with two of the strains and failed with the other two strains. Examination of these suspensions under the electron microscope showed some cocci having the appearance of being viable, but most cocci and all remaining spiral forms showed extensive degeneration. The results indicate that non-culturable coccal forms of C. jejuni are capable of infecting mice but that this property may differ between strains.

The surface structure seen on gonococci after treatment with CMP-NANA is due to sialylation of surface lipopolysaccharide previously described as a 'capsule'

Phenotypic serum resistance of gonococci in urethral exudates is due to sialylation of lipopolysaccharide (LPS) by host cytidine 5'-monophospho-N-acetyl neuraminic acid (CMP-NANA). A surface structure was visible on gonococci [strain BS4 (agar)] that had been stained with ruthenium red after incubation with CMP-NANA. This structure was not visible after neuraminidase treatment, which released sialic acid but not LPS. The LPS profiles of strain BS4 (agar) had another in vivo-selected strain Gc40 (variant D1), were similar. A monoclonal antibody (mAb) which recognises epitope C on the LPS of 'capsulated' gonococci was shown by immunoblotting to react with several LPS components, including one of about 4.5 kDa which contains the probable site of sialylation by CMP-NANA. The reactions with the mAb were not affected by growing the strains with CMP-NANA nor by neuraminidase treatment of the sialylated LPS. The mAb also gold-labelled the surface of both strains before and after treatment with CMP-NANA. These data indicate that sialylation by CMP-NANA and staining with ruthenium red renders more visible the surface LPS which, sometimes in the past, has been seen as a 'capsule'.

Returning home with confidence. Discharge planning in stoma care: a conceptual framework

People in hospital for formation of a stoma have a great deal to learn and come to terms with. Careful discharge planning is essential to ensure all their practical and emotional needs are met, and here, a conceptual framework for this planning is described.

Spinous injury caused by a sea urchin

A bather on holiday in Kenya injured a finger on a spiny marine creature living on the sea bed. A skin biopsy specimen from the injured finger contained several black spines about 0.5 mm in diameter and up to 1.5 cm in length. Spines removed from the specimen were embedded in plastic resin to facilitate transverse sectioning. Light microscopical examination using crossed polarisers showed an ornate symmetrical structure brightly illuminated against a dark background. These features are characteristic of sea urchin (Echinoderm) spines which are composed of ornately formed calcite crystals covered by an epithelium. The spines of sea mice, on the other hand, are chitinous in nature; they are also much finer and lack the ornate symmetry of sea urchin spines.

Opportunistic protozoan infections in human immunodeficiency virus disease: review highlighting diagnostic and therapeutic aspects

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Electron microscopic reporting of gastrointestinal viruses in the United Kingdom, 1985-1987

We examined some epidemiological features of the viruses associated with gastrointestinal illness, using national data reported by electron microscopists in the United Kingdom. During the 3 years analyzed (1985-1987), a total of 1,993 positive detections of astroviruses, caliciviruses, coronaviruses, and small round structured viruses (SRSVs) were reported. In 1 year of this period, 8,210 rotaviruses were reported. More than 90% of the astroviruses and caliciviruses were detected in children under 5 years of age, while coronaviruses and SRSVs were detected in adults as well as children. Detections of astroviruses increased in the winter and were infrequent during the summer, a seasonal pattern similar to that observed for rotaviruses. There was some variability between reporting regions in rates of detection of fecal viruses. We have attempted to identify the reasons for this. We make suggestions for improving the detection of human fecal viruses, and we recognize the need for continued surveillance of these agents.

Severe granulomatous arthritis due to spinous injury by a "sea mouse" annelid worm

A case of destructive arthritis and soft tissue granulomatous inflammation occurred in a 25 year old man who had injured his right index finger while snorkelling in the Mediterranean. It was initially thought that he had fallen on a sea-urchin. He removed some spines at the time of injury but the finger became stiff, swollen, and painful, and after eight months with no symptomatic improvement amputation through the proximal phalanx was performed. Examination showed an exuberant granulomatous and foreign body type inflammation in the dermis and subcutaneous tissues and affecting the bone, with erosion of the cartilaginous surfaces of the proximal interphalangeal joint. Spines present in soft tissue sections contained no calcium but did contain chitin as shown by a von Wisseling reaction for chitosan. It is concluded that the chitinous spines almost certainly came from a sea-mouse (Phylum Annelida, family Aphroditidae). Sea mice are inconspicuous creatures which live on the sea floor and which may cause some injuries thought to be attributable to sea-urchins.

Intestinal microsporidiosis in AIDS

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A surface polysaccharide forms when gonococci are converted to serum resistance by cytidine 5'-monophospho-N-acetyl neuraminic acid

A serum-susceptible, guinea-pig chamber-passaged, laboratory strain (BS4 (agar)) of Neisseria gonorrhoeae was converted to serum resistance by incubation with cytidine 5-monophospho-N-acetyl neuraminic acid (CMP-NANA) and examined by electron microscopy after staining with ruthenium-red. In contrast to serum susceptible gonococci incubated without CMP-NANA, the majority (60-70%) of the serum resistant organisms showed a surface accumulation of polysaccharide. This surface polysaccharide was enhanced on all the resistant gonococci after incubation with fresh human serum. Control susceptible gonococci were devoid of the polysaccharide after incubation with heated human serum. Identical results were obtained with a fresh gonococcal isolate which had lost serum resistance on subculture but which, in common with 3 other isolates, was restored to serum resistance by incubation with CMP-NANA.

Bacterial calcification in infective endocarditis

The present report is the first description to our knowledge of a clinical case of bacterial calcification in human infective endocarditic vegetations. Partial calcification of bacteria within vegetations may be a further mechanism of bacterial protection from host defences and antibiotics. Similar calcification has recently been reported in vegetations formed on porcine valvular prostheses implanted experimentally in sheep.