A SYNDROME RESEMBLING INFECTIOUS MONONUCLEOSIS AFTER OPEN-HEART SURGERY

Resistant pathogens, fungi, and viruses

Although originally described in Staphylococcus aureus, resistance among bacteria has now become a race to determine which classes of bacteria will become more resistant. Availability of antibacterial agents has allowed the development of entirely new diseases caused by nonbacterial pathogens, related largely to fungi that are inherently resistant to antibacterials. This article presents the growing body of knowledge of the herpes family of viruses, and their occurrence and consequences in patients with concomitant surgical disease or critical illness. The focus is on previously immunocompetent patients, as the impact of herpes viruses in immunosuppressed patients has received thorough coverage elsewhere.

Incidence of cytomegaloviremia in blood-bank donors and in infants with congenital cytomegalic inclusion disease

During a 15-month period, cytomegalovirus (CMV) isolations were attempted from leukocytes derived from 290 healthy blood-bank donors. The major proportion of the specimens were tested 2 to 5 hr after donation. However, CMV was not recovered from any of the specimens examined. At the time of donation, 75% of donors had CMV complement-fixing antibodies demonstrable in titers of 10 to >/=320. The age of the study group ranged from 17 to 57 years. During the same time period and with the use of identical isolation techniques, postnatal cytomegaloviremia was demonstrated in four infants with cytomegalic inclusion disease. Failure to detect cytomegaloviremia in 290 normal blood donors questions its occurrence outside pathological conditions. These results do not support the concept that CMV infection, concurrent with post-transfusion mononucleosis syndrome, is transmitted through the blood donor's leukocytes.

Direct assessment of cytomegalovirus transfusion-transmitted risks after universal leukoreduction

BACKGROUND

Cytomegalovirus (CMV) transfusion-transmitted disease (TTD) remains a clinical concern. Universal leukoreduction has become one of the main strategies for the prevention of CMV-TTD. Through prospective clinical follow-up and testing of transfusion recipients (TRs), the risk for CMV-TTD was studied.

STUDY DESIGN AND METHODS

Transfused units were all leukoreduced and not prospectively screened for CMV. For TRs with negative baseline CMV testing results (CMV total antibody and DNA), all follow-up TR samples were tested for CMV total antibody and DNA, and retained linked donor serum samples were tested for CMV total antibody. In cases when CMV-TTD was suspected, donor sera were also tested for CMV DNA and selected TR samples were tested for CMV immunoglobulin M antibody. Evaluable transfusion was defined as a transfusion with TR sample(s) collected 14 to 180 days posttransfusion.

RESULTS

Forty-six TRs were negative for CMV at baseline. There were 1316 evaluable cellular blood transfusions to these TRs. Of 1316 evaluable cellular products, 460 (35%) were positive for CMV total antibody tested using linked donor samples. Three cases of probable CMV-TTD were found; however, there was no definitive proof from donor follow-up that they were transfusion associated.

CONCLUSION

Among all 46 baseline seronegative recipients and 1316 evaluable transfusions, the calculated overall CMV-TTD risk was up to 6.5% (95% confidence interval [CI], 1.0%-18.0%) in terms of TRs and up to 0.23% (95% CI, 0.06%-0.62%) in terms of non-CMV-screened leukoreduced cellular products. In summary, after universal leukoreduction, CMV-TTD, while uncommon, may still occur.

Transfusion-Transmitted Cytomegalovirus: Lessons From a Murine Model

Transfusion-transmitted cytomegalovirus (CMV) infection (TT-CMV) continues to complicate blood transfusion therapy, which can lead to severe morbidity or mortality in immunocompromised or immuno-immature recipients. The biological mechanisms that underlie TT-CMV (eg, viral latency in donor monocytes or stimulatory signals in the transfusion recipient leading to cytomegalovirus reactivation) are difficult to study in humans, but can be addressed in animal models. In this review, we discuss a mouse blood transfusion model, which can be used to investigate these issues as well as to validate methods to prevent TT-CMV in at-risk patients.

Towards the prevention of transfusion-transmitted infectious diseases

Transfusion-transmission of viral infections, such as HIV and hepatitis C virus, were once the scourge of blood transfusion. However, due to remarkable progress over the last 30 years, tests for viral proteins, antibody responses and more recently, viral nucleic acids, have virtually eliminated these risks. This review summarizes these advances in an historical context, describes new methodologies on the horizon, and discusses residual infectious risks associated with blood transfusion.

CMV and blood transfusions

Among the human herpesviruses, cytomegalovirus (CMV) is the only one that has assumed significant importance in blood transfusion. Transfusion transmission of CMV (TT-CMV) to seronegative immunocompromised patients can lead to lethal CMV disease. Studies over the past 30 years have demonstrated that monocytes latently infected with CMV represent the primary vector for TT-CMV, and that TT-CMV can be largely abrogated by transfusing at-risk patients with either seronegative units or blood filtered to remove white blood cells. However, the small number of cases of breakthrough TT-CMV that follow transfusion of either seronegative or filtered blood still produce morbidity and mortality. These circumstances have motivated ongoing efforts to provide improved protection from TT-CMV, including the use of CMV DNA amplification for blood screening, and pathogen inactivation to sterilise all blood components prior to transfusion.

Rheumatic symptoms after cardiac surgery: a prospective study

The incidence of different types of shoulder pain after open heart surgery was studied prospectively. Of 101 patients studied, 45 developed rheumatic symptoms during the first six weeks after the operation. Thirty eight patients reported pain in the region of the shoulder girdle with no loss of shoulder function (postpericardiotomy rheumatism). Three of these patients also had features compatible with the postpericardiotomy syndrome (fever, malaise, or pleuritic chest pain), and seven developed the syndrome without pain in the shoulder girdle. Of these 10 patients, one had generalised myalgia. Postpericardiotomy rheumatism alone was not associated with increased inflammation (measured by the erythrocyte sedimentation rate and concentration of C reactive protein); immunological tests including measurement of antibodies to cardiac muscle yielded inconclusive results. Replies to a postal questionnaire showed that symptoms of postpericardiotomy rheumatism were present for over three months in 18 patients and for six months or longer in 14. In view of the large number of patients now having open heart surgery postpericardiotomy rheumatism should be considered when patients report pain around the shoulders so that it is not misdiagnosed as angina.

Transfusion-associated viral infections

Viral infections are a frequent occurrence following transfusion of blood products. While generally benign, these infections are capable of causing significant morbidity and mortality. Therefore, it is prudent to follow several general approaches diligently to reduce the risks of these infections in patients undergoing transfusions of blood products. These suggested measures include the following: 1. Prescribe and administer blood and blood products only when absolutely needed. 2. Use volunteer blood donors only. 3. Avoid use of pooled blood products when possible. 4. Use only blood and blood products that have been appropriately tested for HBsAg and HIV. 5. Use ALT determinations to screen blood products and eliminate those with high level. 6. Avoid the use of clotting-factor concentrates but, if necessary, use only those which have been heat-treated. 7. Limit use of leukocyte transfusion. 8. Use only CMV seronegative blood and blood products or frozen deglycerolized red cells in patients at high risk for posttransfusion CMV infection.

Neonatal cytomegalovirus infections due to blood

Infants with very low birthweights (less than 1250g) are immunocompromised and have immature hematopoietic systems. They require frequent blood transfusions and have an increased susceptibility to infection. These very low birthweight infants who lack passively acquired antibody against CMV, acquire transfusion-associated CMV infections with a frequency of approximately 30%. These infections are associated with significant morbidity and mortality. The source of these postnatally acquired CMV infections are seropositive blood donors. These infections can be prevented by appropriate donor selection and/or blood processing. Recent but limited data suggests that all infants (regardless of birthweight or the presence of antibody against CMV) should receive CMV seronegative blood products if they are likely to receive multiple transfusions from multiple donors.

Effects of surgery and nutritional support on some lymphocyte and PMN leucocyte functions in man

The purpose of the present study was to evaluate the effect on some leucocyte functions of 1) an elective surgical procedure; 2) nutritional repletion provided by parenteral alimentation (TPN). The rates of cellular proliferation and protein synthesis in lymphocyte cultures were measured by the incorporation of respectively 3H-thymidine and 3H-leucine; both measures were performed without and with additions of mitogenic agents. Random migration and chemotaxis of PMN leucocytes were measured under agarose. In 10 well-nourished patients, both lymphocyte proliferation and protein synthesis in stimulated cultures decreased after elective surgery, respectively by 50% (p < 0.01) and by 32% (p < 0.05) while random migration of PMN leucocytes was increased by 50% (p < 0.02). Stimulated lymphocyte proliferation and protein synthesis measured in 10 nutritionally depleted non-cancer patients prior to TPN were lower in comparison to the values obtained in a control population (respectively p < 0.006 and p < 0.04). These parameters rose progressively during TPN and reached the normal range after 3 weeks. Before TPN, PMN leucocyte random migration was slower in depleted patients than in control subjects; this parameter reached normal values after one week of TPN, while chemotaxis tended to decrease. Both parameters were in the normal range after 3 weeks of TPN. Conclusions 1) an elective operation depresses lymphocyte functions but stimulates PMN leucocyte random migration in well-nourished patients; 2) in depleted patients, previously depressed leucocyte responses are restored within 3 weeks of adequate nutritional support.

Association of a circulating immunosuppressive polypeptide with operative and accidental trauma

The serum from 109 traumatized patients was examined for immunosuppressive activity which might explain diminished host immune responsiveness following operative or accidental injury. Twenty-eight fo 31 (90%) severely tralmatized patients, 25 of 60 (42%) moderately traumatized patients, and 0 of 18 minimally traumatized patients developed serum which suppressed the response of normal human lymphocytes to phytohemagglutinin. The degree and duration of serum immunosuppressive activity paralleled the severity of the clinical course but did not correlate with serum cortisol or barbiturate levels. Suppressive sera were not cytotoxic. The immunosuppressive factor(s) was contained in a low molecular weight (less than 10,000 daltons) peptide fraction and was present in 5--10 times the amount recoverable from normal serum. By size and activity the trauma serum factor resembled immunoregulatory alpha globulin, a naturally-occurring serum inhibitor of T-lymphocyte reactions. Thus, depressed immunoreactivity following trauma may be due in part to high concentrations of an endogenous immunosuppressive polypeptide.

Diagnosis and management of complications of prosthetic heart valves

Complications after heart valve replacement remain a substantial source of morbidity and mortality despite continuing advances in surgical care and prosthetic design. Infectious endocarditis occurs in about 4 percent of patients and may appear early (within 60 days) or late after operation. Endocarditis of early onset is commonly due to staphylococcal, fungal or gram-negative organisms and is fatal in 70 percent or more of cases. Infection of late onset is more often of streptococcal origin and the mortality rate is lower, about 35 percent. With either type, prompt recognition, vigorous and appropriate antimicrobial therapy and early consideration of surgical intervention are crucial. The postperfusion and postpericardiotomy syndromes are relatively common and relatively benign syndromes associated with postoperative fever. Their recognition is important to prevent confusion with endocarditis or sepsis and thus to reassure the patient and physician. Treatment is primarily symptomatic. Intravascular hemolysis occurs with most prosthetic heart valves but is more common with certain prostheses and with paraprosthetic valve regurgitation, with significant hemolytic anemia in 5 to 15 percent. Oral iron replacement therapy is effective in the majority of patients, but occasionally blood transfusion or reoperation for leak around the prosthesis is necessary. Prosthesis dysfunction due to thrombus may be recognized clinically by recurrence of heart failure, syncope, cardiomegaly and altered prosthetic valve sounds or new murmurs. Hemodynamic studies verify the diagnosis, and prompt reoperation is indicated for this potentially lethal problem. Systemic embolization has decreased markedly with the introduction of cloth-covered prostheses and is frequently related to erratic or ineffective anticoagulant therapy. We continue to recommend anticoagulant therapy for all patients with prosthetic heart valves unless there is a major contraindication.

Syndromes of infectious mononucleosis

Physicians are becoming more aware of the existence and diversity of the infec tious-mononucleosislike responses which patients may develop in certain circum stances. Differentiation and identification call for knowledgable familiarity with these various clinical-hematologic responses.

Cardiac presentation of infectious mononucleosis

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Infection risks of haemodialysis--some preventive aspects. A report to the Public Health Laboratory Service by the Working Party on Haemodialysis Units

THREE ASPECTS OF HAEMODIALYSIS ARE OF SPECIAL CONCERN TO THE MICROBIOLOGIST: (1) the hepatitis risk, (2) shunt sepsis, and (3) the hygiene of the equipment used. It is suggested that the risks of infection and cross-infection in haemodialysis units may be diminished by several measures, including the avoidance of overcrowding the patients, setting up codes of practice for the staff, topical disinfection of the patient's skin, and sterilization of equipment. In addition pathologists should emphasize to laboratory staff dealing with specimens from patients that these carry major risks to health.

Infectious-mononucleosis-like syndrome following haemodialysis for carbon tetrachloride poisoning

A patient with renal failure after carbon tetrachloride poisoning is presented. Haemodialysis was required and renal function recovered completely. Convalescence was complicated by the development of an infectious-mononucleosis-like syndrome. The aetiology of this condition is discussed. The present case is the first to be reported after haemodialysis and transfusion of blood stored for at least 2 days.

Seronegative glandular fever

Seven sporadic cases of ;seronegative glandular fever' have been examined in detail; five of the patients were adults aged more than 30, two were children. None showed evidence of ;incomplete' or heat-labile sheep cell agglutinins, but in three very weak, though otherwise typical, glandular fever agglutinins were detected. Three of the other four showed evidence of certain infections, but these infections probably accounted for no more than a part of each illness. It is suggested that some, and possibly most, sporadic cases of seronegative glandular fever are of the same disease as seropositive cases, the patients' ages influencing the serological response. Certain conditions of known aetiology may, however, be clinically and haematologically indistinguishable from seronegative glandular fever.

Infectious mononucleosis

A short review of past and recent works pertinent to the etiology and pathogenesis of infectious mononucleosis is presented. Epidemiological studies have led to the elaboration of hypotheses concerning the etiology, the length of the incubation period and the mode of transmission of the disease. An unusual type of infectious mononucleosis of rickettsial origin has been reported by Japanese workers. Studies of accidental and experimental transmission suggest that more than one agent may give rise to the same disease. Isolation attempts in tissue cultures have been unrewarding except for the uncovering of possible agents by interference and immunofluorescence.The atypical lymphocyte is the site of increased RNA and DNA synthesis. It does not seem to be involved in antibody synthesis. The heterophile agglutinins and other mononucleosis-associated antibodies apparently account for only part of the excess 19S antibody material found in mononucleosis sera. The origin and function of these antibodies and of the atypical lymphocyte are the subject of speculation.The final elucidation of the pathogenesis of the disease and the confirmation of the reviewed hypotheses are all dependent on the eventual discovery of the elusive etiological agent(s) of infectious mononucleosis.