Fatal primary cutaneous aspergillosis in a bone marrow transplant recipient: nosocomial acquisition in a laminar-air flow room

A case of primary cutaneous aspergillosis occurring in an allogeneic bone marrow transplant recipient in a laminar airflow room is reported. The patient developed grade III graft-versus-host-disease and epidermolysis. Although the patient had remained in his laminar airflow room from the graft onward, he subsequently developed primary cutaneous aspergillosis. The aspergillosis became invasive and the patient died. The patient was probably contaminated by air containing conidia when he left the sterile room for endoscopy, and the fluidized bed used may have contributed to the local development of the disease. This nosocomial aspergillosis stresses the necessity of performing invasive procedures under laminar airflow protection to prevent Aspergillus contamination in immunocompromised hosts at risk for aspergillosis.

Microsatellite polymorphism in the promoter sequence of the elongation factor 3 gene of Candida albicans as the basis for a typing system

The polymorphism of a TTC/TTTC microsatellite in the promoter sequence of the elongation factor 3 gene of Candida albicans was investigated by PCR. One primer was fluorescein labeled, and PCR signals were read with an automatic sequencer. Twenty-nine reference strains and 31 independent clinical isolates were studied. Eleven different alleles were identified, giving 16 different profiles among the 60 strains tested, with a discriminatory power of 0.88. This marker is stable upon subculture, and reproducibility was achieved by automated procedures. When several microsatellite markers are available, many isolates can be rapidly and reproducibly tested for epidemiological questions, such as the prevalence of a given strain in a hospital setting and transmission between patients.

Invasive Fusarium infections: a retrospective survey of 31 cases. The French 'Groupe d'Etudes des Mycoses Opportunistes' GEMO

A retrospective study was conducted in France to investigate Fusarium infections which are now recognized as emerging opportunistic infections. The clinical and mycological findings for 31 cases diagnosed between 1984 and 1993 by members of the French Groupe d'Etudes des Mycoses Opportunistes were analysed. All suffered from haematological disease, most often acute leucaemia (n = 19). Twenty-two had received cytostatic chemotherapy and ten had undergone bone marrow transplantation. Prolonged aplasia and pancytopenia were present in 18 and 11 patients, respectively. Skin (61%) and blood (42%) were the sites most frequently involved. Fusarium solani (n = 7), Fusarium oxysporum (n = 7), Fusarium verticilloides (n = 7) were the species most frequently isolated. Nine antifungal treatments were used, associated with colony-stimulating factors in five cases. None was unambiguously superior to all the others. The overall mortality was 51.6% with a specific mortality > or = 25.8%. The disseminated form of the infection was associated with poor prognosis (P < 0.02) whereas improving granulocyte count improved prognosis (P < 0.001). More aggressive cytostatic regimens used for patients with haematological malignancies have favoured the emergence of Fusarium infections. As prognosis is closely correlated with neutrophil recovery, the promising results obtained with the use of colony-stimulating factors should be further evaluated.

Improvement of a polymerase chain reaction assay for the detection of Echinococcus multilocularis DNA in faecal samples of foxes

A polymerase chain reaction (PCR) method was developed in order to permit a sensitive and specific identification of Echinococcus multilocularis DNA from fox faecal specimens. In an attempt to overcome problems related to the presence of endogenous PCR inhibitors in faecal extracts, we investigated a DNA extraction technique using an anion binding resin (Gene-Fizz). This simple and rapid procedure was applied to 61 faecal samples. Compared with the traditional microscopic examination, the sensitivity of PCR using Gene-Fizz was 82.3% and the specificity was 95.5%. No PCR signal was obtained for 20 Echinococcus granulosus isolates, showing that this method allowed discrimination between E. multilocularis and E. granulosus. Large-scale epidemiological surveys of fox excrements may be possible by using Gene-Fizz treatment prior to PCR amplification reactions.

Identification of intracellular stages of Cyclospora species by light microscopy of thick sections using hematoxylin

Cyclospora sp is a recently identified coccidia responsible for enteric infection in humans. Most reports have failed to detect this parasite in intestinal biopsies by light microscopy, although the different stages have been ultrastructurally described in jejunum enterocytes. Very recently, some investigators have reported the detection by light microscopy of parasitophorous vacuoles in intestinal biopsies; however, only transmission electron microscopy (TEM) could clearly identify the parasitic stages. To improve the histological diagnosis without using TEM, we have tested different staining methods in biopsies obtained from a patient infected by the human immunodeficiency virus who was shedding Cyclospora oocysts. Hematoxylin stain alone for 15 minutes on 5 micrometer-thick sections of duodenal biopsies was found to be the most efficient method for observing different stages of the parasite. In particular, the banana-shaped merozoites were visualized and appeared very similar to the human coccidia Isopora belli. This simple technique may be useful in diagnosing Cyclospora infection.

PCR enzyme-linked immunosorbent assay for diagnosis of leishmaniasis in human immunodeficiency virus-infected patients

A PCR enzyme-linked immunosorbent assay (ELISA) involving the use of bone marrow aspirates (BMA) and blood samples (BS) for the diagnosis of visceral leishmaniasis (VL) in human immunodeficiency virus-infected patients was developed with primers selected from the sequence of the small-subunit rRNA gene and compared with direct examination and in vitro cultivation. The PCR was optimized for routine diagnosis: processing of samples with lysis of erythrocytes without isolation of leukocytes, enzymatic prevention of contamination, internal control of the reaction, and ELISA testing in a microtitration plate hybridization. Of 79 samples (33 BMA and 46 BS) from 77 patients without VL, all the results were negative. Fifty-three samples (9 BMA and 44 BS) were obtained from 13 patients with VL: 6 samples drawn during anti-Leishmania treatment were negative whatever the technique used, and 47 samples (9 BMA and 38 BS) were positive with at least one technique. The sensitivities were 51% (24 of 47), 81% (38 of 47), and 98% (46 of 47) for direct examination, culture, and PCR, respectively. Thus, PCR ELISA is reliable for diagnosing VL in human immunodeficiency virus-infected patients, and blood sampling should be sufficient for the follow-up.

Quantitative competitive PCR with bronchoalveolar lavage fluid for diagnosis of toxoplasmosis in AIDS patients

Of 121 AIDS patients, 12 (10%) had Toxoplasma gondii DNA detected by competitive PCR in their bronchoalveolar lavage samples. Quantitation of the PCR results showed a correlation between the parasite burden and the serum lactic dehydrogenase titer. Quantitative competitive PCR could be useful to assess the diagnosis and the severity of pulmonary toxoplasmosis.

Detection of Aspergillus species DNA in bronchoalveolar lavage samples by competitive PCR

A competitive PCR assay involving the use of bronchoalveolar lavage (BAL) samples for the diagnosis of invasive pulmonary aspergillosis (IPA) was developed. For this purpose, a 1-kb mitochondrial DNA fragment of Aspergillus fumigatus was sequenced. The primers used allowed amplification of A. fumigatus, A. flavus, A. terreus, and A. niger DNAs but not DNAs of other fungi and yeasts. BAL samples from 55 consecutively enrolled patients were tested. Three samples were excluded because of failure of correct amplification of the internal competitive control. Of 28 immunocompromised patients, 6 were PCR positive; 3 died of IPA and their BAL cultures yielded A. fumigatus; and 3 were culture negative and did not develop IPA. Of 15 human immunodeficiency virus-positive patients and 9 immunocompetent patients, 5 and 4, respectively, were both PCR positive and culture negative, and none developed aspergillosis. Thus, PCR confirmed IPA in three patients but gave positive results for 25% (12 of 49) of the patients who did not develop aspergillosis. The predictive value of PCR-positive results seems low for patients at risk for aspergillosis. Moreover, the risk of contamination of reaction buffers or biological samples with Aspergillus conidia seems high and has to be weighed in regard to the potential diagnostic benefit of PCR testing as a routine procedure.

Late toxoplasmosis evidenced by PCR in a marrow transplant recipient

We report a case of disseminated toxoplasmosis occurring 12 months after allogeneic BMT. The patient was seropositive for Toxoplasma gondii, and the donor was seronegative, so the patient was given anti-Toxoplasma prophylaxis. One year after BMT, he developed fever and muscle pain without other clinical symptoms. PCR amplification for T. gondii performed on blood was positive. Toxoplasma were found in bronchoalveolar lavage by PCR and in the marrow by special stains. With treatment, the PCR signal disappeared in 3 days while clinical symptoms resolved over 15 days. This case emphasizes the possibility of late toxoplasmosis after BMT despite prophylatic treatment, and the value of PCR in making the diagnosis.

Lichen planus and hepatitis C virus--related chronic active hepatitis

BACKGROUND AND DESIGN

An increased prevalence of chronic liver disease has been reported in patients with lichen planus (LP). We report six cases of LP associated with chronic active hepatitis and actively replicating hepatitis C virus (HCV).

RESULTS

We studied six patients (three men and three women; mean age, 61 years; age range, 47 to 70 years) with various forms (cutaneous and/or mucosal) of LP and abnormal liver test results. Four patients had severe mucosal lesions. Cutaneous and mucosal lesions had a long-term evolution. Liver disease was discovered 2 to 6 years before LP in three cases and was diagnosed at the same time as LP in the three other cases. Liver biopsy performed in five patients showed chronic active hepatitis without cirrhosis in all five cases. Anti-HCV antibodies were detected in all cases by second-generation enzyme-linked immunosorbent assay and confirmed by second-generation recombinant immunoblot assay. Hepatitis C virus RNA was evidenced by means of polymerase chain reaction in the serum samples from the six patients, proving active viral replication.

CONCLUSIONS

Lichen planus may be associated with HCV-related chronic active hepatitis. As interferon treatment may induce viral inactivation in some patients with HCV-related chronic liver disease, a search for HCV infection should be systematically performed in patients with chronic LP.

Detection of Toxoplasma gondii by competitive DNA amplification of bronchoalveolar lavage samples

The prevalence of pulmonary toxoplasmosis was assessed by a prospective analysis of 144 bronchoalveolar lavage (BAL) samples using competitive polymerase chain reaction (PCR) to avoid false-negative results due to PCR techniques. Six samples were excluded because they contained amplification reaction inhibitors. None of the samples from the 37 immunocompetent patients and only 1 sample (1.7%) from the 59 immunocompromised patients without human immunodeficiency virus infection were PCR-positive. In contrast, Toxoplasma gondii DNA was found in 6 (14%) of 42 samples from patients with AIDS. All 6 patients had < or = 40 CD4 cells/microL and anti-Toxoplasma antibodies, and 5 had other sites of Toxoplasma infection. Six other AIDS patients who had received treatment for cerebral toxoplasmosis were PCR-negative. Thus, pulmonary toxoplasmosis is frequent in AIDS patients who have other sites of Toxoplasma infection and low CD4 lymphocyte counts and who are not receiving prophylaxis.

Detection of Echinococcus multilocularis DNA in fox faeces using DNA amplification

In order to identify Echinococcus multilocularis DNA in fox faeces for epidemiological purposes, we have developed a new method to prepare DNA suitable for PCR amplification. DNA isolation from fox excrement was performed according to a novel procedure involving lysis in KOH, phenol-chloroform extraction and a purification step on a matrix (Prep-A-Gene). The target sequence for amplification was the E. multilocularis U1 snRNA gene. PCR products were indistinguishable for 32 different E. multilocularis isolates and no signal was observed after ethidium bromide staining with DNAs from other tapeworm species, including E. granulosus. The sensitivity of amplification was monitored by the addition of E. multilocularis DNA or eggs to faeces free of E. multilocularis and was estimated to be 1 egg per 4 g of faeces. PCR products were blotted onto nylon membranes and hybridized with an internal oligonucleotide probe in order to confirm the results. Twenty nine faecal samples from foxes shot in Franche-Comté (East France) were tested. Out of 10 samples from foxes in which no E. multilocularis adult worms could be observed after necropsy, 7 were PCR positive, showing that the PCR test is more sensitive than microscopical examination. Out of 19 samples from foxes harbouring E. multilocularis adult worms, 18 were PCR positive. The remaining PCR-negative sample could be due either to the misidentification of the species of adult worm (E. granulosus and E. multilocularis), or to DNA variation between different isolates of E. multilocularis. Further work in the field should be initiated in order to confirm these results.

Hepatitis C virus infection can mimic type 1 (antinuclear antibody positive) autoimmune chronic active hepatitis

Hepatitis C virus (HCV) has been shown to induce anti-liver-kidney microsomal-1 (LKM1) antibody positive chronic active hepatitis, simulating type 2 autoimmune chronic active hepatitis. The cases of five patients presenting with features of type 1 (antinuclear antibody positive) autoimmune chronic active hepatitis and extrahepatic autoimmune manifestations, in whom immunosuppressive treatment had no effect on liver disease are presented. In these patients, HCV infection could be shown by the presence in serum of anti-HCV antibodies and HCV-RNA detected by polymerase chain reaction. These cases suggest the following: (a) chronic HCV infection can mimic type 1, as well as type 2, autoimmune chronic active hepatitis; (b) HCV infection might be systematically sought in patients presenting with features of type 1 autoimmune chronic active hepatitis, with special care in patients who are unresponsive to immunosuppressive treatment.

[Detection of the eggs of Echinococcus multilocularis Leuckart, 1863, in the feces of the fox (Vulpes vulpes Linnaeus, 1758) by the polymerase chain reaction]

The polymerase chain reaction (PCR) was applied to the identification of eggs of Echinococcus multilocularis in faeces from foxes. The test was positive in three of six faeces samples from foxes which were harbouring adult worms, and in one of four samples from foxes in which no adult E. multilocularis was found in the intestines. These initial results show that it is possible to use PCR to identify E. multilocularis eggs in faeces. PCR can be used to complement examination of intestinal contents, showing that the distribution of eggs in faeces is uneven. The sensitivity of the test was estimated to be 50 eggs in 5 g of faeces. Further work is needed to confirm these initial results before the test can be used more widely.

Structure of the Echinococcus multilocularis U1 snRNA gene repeat

The gene encoding U1 snRNA in Echinococcus multilocularis has been cloned and sequenced. This gene is contained within a 1300-bp sequence which is tandemly repeated in the E. multilocularis genome. E. multilocularis U1 snRNA is 50-70% homologous to U1 snRNAs of other species. E. multilocularis U1 snRNA could assume a predicted secondary structure similar to that proposed for other U1 snRNAs, and appears shorter (157 bases) than the U1 snRNAs of higher eukaryotes (163-166 bases).

[Cryptosporidiosis in children: epidemics and sporadic cases]

From April 16 1987 through May 16 1987, during an outbreak of gastroenteritis, stool specimens were obtained from 53 children aged 18 to 36 months among the 90 children attending an on-site day-care center for the staff of a large teaching hospital in the Paris urban area (59%). Oocysts of Cryptosporidium were found in 11 specimens (21%) using an auramine staining technique. Children with diarrhea were more likely to have stools containing Cryptosporidium (p less than 0.01). Subsequently, a prospective study was carried out in the same day care center from July 1987 through January 1988. Among the 103 episodes of diarrhea observed during the study period, there were five cases of cryptosporidiosis (5%). In all these cases, diarrhea was moderate and resolved within ten days. Furthermore, among 148 hospitalized children aged 2 months to 10 years, 2 (1.4%) had positive stool specimens for Cryptosporidium and significant failure to thrive. Thus, Cryptosporidium is a common cause of diarrhea in immunocompetent children, especially in child group settings. Further studies are needed to determine the prevalence and spectrum of the clinical patterns of this parasitic disease.

Rapid technique for cryopreservation of Echinococcus multilocularis metacestodes

Cysts of E. multilocularis were minced to prepare a crude homogenate and after addition of glycerol at a final concentration of 10%, cryopreservation was performed at a rate of 1 degree C min-1 in a controlled-rate freezer. The aliquots were subsequently stored in liquid nitrogen. All 22 isolates tested were successfully cryopreserved and their viability maintained.

Comparison of the viability and developmental characteristics of Echinococcus multilocularis isolates from human patients in France

Alveolar echinococcosis, due to E. multilocularis, is usually a fatal disease in patients whether treated by benzimidazolecarbamates or not. However, aborted infections have been described, suggesting the existence of strains of parasites of varying pathogenicity. These observations led us to analyse the viability of larvae in 20 patients. After observation of human lesions, the viability of metacestodes was tested by intraperitoneal infection in two intermediate host species, Meriones unguiculatus and AKR inbred mice. Parasitic development was more frequent in mice than in M. unguiculatus, but in the latter, growth was more rapid and the larval mass produced was greater. Isolates which originated from patients undergoing treatment had an abortive growth; two others were characterized by a steady, though slow, development, producing a poorly budding larva; lastly there were some which were morphologically similar with a multivesicular appearance but differing development times. These results may serve as a guide for more basic studies leading to an understanding of the problem of intraspecific variations in E. multilocularis.