The Radiological Manifestations of Phagocytic Primary Immunodeficiencies in Children

Primary immunodeficiencies are a diverse group of rare genetic disorders, among which phagocytic dysfunction impairs neutrophil function in a wide range of inherited disorders. Due to the heterogeneity of the disorders a multidisciplinary approach is often required for early diagnosis and initiation of appropriate treatments. The aim of this study was to evaluate the imaging findings in children admitted with phagocytic primary immunodeficiencies. Thirty-five children who fulfilled the inclusion criteria for phagocytic dysfunction were enrolled in this study. The patients were under close observation and monitoring from January 2011 until data locking in December 2017. The diagnosis of phagocytic immunodeficiency was confirmed by the patient's clinical course, presentation features, and laboratory data.  Among the 35 patients studied, the most frequent condition was chronic granulomatous disease (CGD) (23 patients), followed by different types of neutropenia (8 patients) and Job's syndrome (4 patients). Mediastinal and hilar lymphadenopathies and consolidation were the most frequent presentations. There was a significant relationship between mediastinal/hilar lymphadenopathies and fungal infections. A meaningful relationship was also found between pulmonary nodules without halo signs in patients with concomitant tuberculosis and fungal infections. A significant correlation was found between CGD, pulmonary fibrotic changes, and mediastinal lymphadenopathies. The most frequent radiological manifestations in children included mediastinal and hilar consolidations. Physicians' awareness of the radiological and clinical manifestations of these inherited diseases may be helpful in the early diagnosis and timely initiation of specific prophylaxis measures to prevent infections and also to initiate hematopoietic stem cell transplantation as the curative management modality.

Epidemiology, Sociodemographic Factors and Comorbidity for Allergic Rhinitis, Asthma, and Rhinosinusitis Among 15 to 65-year-Old Iranian Patients

Background: It is well established that upper and lower airways are often clumped together when diagnosing and treating a disease. This study was designed to determine the prevalence of upper and lower airway diseases and to assess the effect of sociodemographic factors on the prevalence and the comorbidity of these disorders. Methods: This cross-sectional population-based study included patients with ages ranging between 15 to 65 years, who were referred to allergy outpatient clinics in various provinces of Iran from April to September 2020. A modified global Allergy and Asthma European Network (GA2LEN) screening questionnaire was filled out by local allergists of the 12 selected provinces in Iran. Information about the patients and sociodemographic factors was also recorded. Statistical analysis was done by univariate statistical analyses and multiple logistic regressions in SPSS software Version 26. Results: Out of 4988 recruited patients, 1078 (21.6%) had the symptoms of allergic rhinitis (AR) and 285 (5.7%) met the criteria of asthma. The prevalence of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) was 21.6 % and 22%, respectively. The highest prevalence of AR and ARS was in Tehran with the arateof of 33.9% each. Asthma was more prevalent in Khuzestan (14.2%) and CRS in Baluchestan (57.5%). Our analysis showed that the patients with asthma were most likely to have other allergic diseases as well-CRS (OR = 4.8; 95% CI, 2.02- 5.82), AR (OR= 2.5, 95% CI, 2.10-3), ARS (OR = 1.8; 95% CI, 2.10-3), followed by eczema (OR = 1.4; 95% CI, 1.13-1.67).We found that those individuals with CRS were most likely to have painkiller hypersensitivity (OR= 2.1; 95% CI, 1.21-3.83). Furthermore, smoking has been found more than 1.5 folds in patients with ARS. After adjusting variables, there was no correlation between education, occupation, and ethnicity with the studied diseases. Conclusion: Rhinosinusitis is a common condition among Iranian patients. This study confirmed that inflammation of the upper and lower airways can occur simultaneously. Gender, education, occupation, and ethnicity were found to be irrelevant in the development of either AR, asthma, ARS, or CRS.

Allergic shiners in a patient with cough-variant asthma: a case report

BACKGROUND

Chronic cough, with a duration of coughing of more than 8 weeks in adults, affects 5-10% of the general population. One of the most common causes of chronic cough is cough-variant asthma, which accounts for approximately one-third of cases. This phenotype of asthma is characterized by extreme sensitivity of the neuronal pathways mediating cough to environmental irritants, which results in an urge to cough. This case is an example of cough-variant asthma presenting with allergic shiners due to her severe cough.

CASE PRESENTATION

A 38-year-old Iranian woman, who was well before the start of the coronavirus disease 2019 pandemic, presented with a nonproductive hacking cough that had begun after excessive use of antiseptic solutions. The only positive finding on physical examination was a reddish-purple rash on and around the eyelids mimicking a heliotrope rash, which had probably evolved due to the severity of the cough. The results of the pulmonary function test were within normal limits. Methacholine challenge test and chest x-ray were both normal. Chest high-resolution computed tomography revealed hyperinflation and tree-in-bud opacities. All other laboratory tests were normal. Because of the reversibility in her pulmonary function test, despite normal baseline parameters, asthma treatment was initiated, resulting in disappearance of the cough and the eye discoloration, being indicative of the correct diagnosis and proper treatment.

CONCLUSION

Patients with cough-variant asthma may often have no other classic symptoms of asthma other than cough.

Pulmonary Radiological Manifestations of Humoral and Combined Immunodeficiencies in a Tertiary Pediatric Center

Respiratory diseases are considered as significant causes of morbidity and mortality in primary immunodeficiencies. This study aimed to reveal the radiologic patterns of thoracic involvement in these disorders. A total of 58 patients, including 38 cases with combined cellular-humoral and 20 cases with humoral immunodeficiencies, were enrolled in this study. The "combined" group consisted of 12 cases with severe combined immunodeficiency (SCID) and 26 cases with combined immunodeficiency. The "humoral" group included seven patients with Hyper IgM syndrome (HIGMs), seven cases with common variable immunodeficiency (CVID), three patients with X-linked agammaglobulinemia, and three patients with other types of humoral primary immunodeficiencies (PIDs). The mean age of patients at the time of evaluation was 3.3±3.8 and 5.3±3.9 years in combined and humoral groups, respectively. The findings of chest X-rays and CT scans were interpreted and compared. There was a significant difference for alveolar opacification between combined and humoral immunodeficiencies (58% vs. 30%). The bronchopneumonia-like pattern was detected as a significant finding in patients with SCID (42%) and HIGMs (43%). Atrophy of the thymus was detected significantly often in cases of SCID (67%). Two patients with CVID and lipopolysaccharide-responsive and beige-like anchor protein deficiency showed parenchymal changes of granulomatous lymphocytic interstitial lung disease. No significant difference was detected for bronchiectasis, bronchitis/bronchiolitis patterns, pleural effusion, and thoracic lymphadenopathy. Distinct subtypes of primary immunodeficiency may provoke differing and comparable radiological patterns of thoracic involvement; which can clue the clinician and radiologist to the diagnosis of the disease.

Oral Wheat Immunotherapy: Long-Term Follow-Up in Children with Wheat Anaphylaxis

INTRODUCTION

There has been substantial increase in food allergies in recent decades. The management of severe food allergy often includes strict avoidance and medical therapies. However, oral immunotherapy (OIT) is a promising treatment option for these patients, which is still being investigated.

METHODS

The study recruited children from 2 years onward with a history of wheat anaphylaxis who had been referred to the Mofid Children Hospital. Wheat allergy was confirmed by a double-blind placebo-controlled food challenge. OIT was started to reach 5.28 g of wheat protein supplied in 60 g of bread. Besides immunologic measurements, a second and third oral food challenge (OFC) was performed after 3 months and 1 year of maintenance therapy to evaluate the long-term efficacy of wheat OIT (WOIT).

RESULTS

Seventeen patients completed the 3-month maintenance phase; 8 of them demonstrated negative OFCs. All of the 9 with positive OFCs were asked to continue the daily consumption of 60 g of bread for another year. Three patients with positive OFCs were followed for 1 more year and were asked to continue eating 60 g of bread every other day. The serum level of wheat sIgE was significantly increased at the end of the buildup phase (p = 0.026) and dramatically dropped at the end of the maintenance phase (p = 0.022).

CONCLUSION

To conclude, WOIT is an effective and safe modality of treatment if it is administered under strict supervision.

A Report of Two Patients with Food Protein-induced Enterocolitis Mimicking Bartter Syndrome

Food protein-induced enterocolitis syndrome (FPIES), is a non-IgE mediated food allergy presenting in infants younger than 12 months. Diagnostic delay may occur due to overlapping clinical symptoms with several conditions. Here, we present two cases of FPIES, mistakenly diagnosed and treated as Bartter syndrome. This study aims to emphasize the several features of this syndrome that may mimic other diagnoses and sometimes leading to near-death events due to delay in the diagnosis and improper treatment. The first patient was a 30-month-old boy with multiple episodes of profuse vomiting and diarrhea within 1 hour after breastfeeding, beginning from the first month of life progressing to hypokalemia and metabolic alkalosis at the age of 5 months leading to the diagnosis of Bartter syndrome. The second patient had a history of unremitting diarrhea which had been started soon after his first breastfeeding followed by biliary vomiting on the 7th day of life. He was treated in another hospital for neonatal sepsis, however, without an appropriate response to treatment. To conclude, despite the current belief on the rarity of FPIES, it is a more prevalent disease than expected with various non-specific manifestations imitating other conditions which may result in diagnostic delay and sometimes fatalities. To shed light on the importance of the physicians' awareness of this syndrome, these two cases are presented here as examples of FPIES imitating other disorders.

Autoimmune manifestations among 461 patients with monogenic inborn errors of immunity

BACKGROUND

The inborn errors of immunity (IEIs) are a group of heterogeneous disorders mainly characterized by severe and recurrent infections besides other complications including autoimmune and inflammatory diseases. In this study, we aim to evaluate clinical, immunologic, and molecular data of monogenic IEI patients with and without autoimmune manifestations.

METHODS

We have retrospectively screened cases of monogenic IEI in the Iranian PID registry for the occurrence of autoimmunity and immune dysregulation. A questionnaire was filled for all qualified patients with monogenic defects to evaluate demographic, laboratory, clinical, and molecular data.

RESULTS

A total of 461 monogenic IEI patients (290 male and 171 female) with a median (IQR) age of 11.0 (6.0-20.0) years were enrolled in this study. Overall, 331 patients (72.1%) were born to consanguineous parents. At the time of the study, 330 individuals (75.7%) were alive and 106 (24.3%) were deceased. Autoimmunity was reported in 92 (20.0%) patients with a median (IQR) age at autoimmune diagnosis of 4.0 (2.0-7.0) years. Sixteen patients (3.5%) showed autoimmune complications (mostly autoimmune cytopenia) as the first presentation of the disease. Most of the patients with autoimmunity were diagnosed clinically with common variable immunodeficiency (42.4%). The frequency of sinusitis and splenomegaly was significantly higher in patients with autoimmunity than patients without autoimmunity. In patients with autoimmunity, the most common pathogenic variants were identified in LRBA (in 21 patients, 23.0%), ATM (in 13 patients, 14.0%), and BTK (in 9 patients, 10.0%) genes. In the evaluation of autoimmunity by different genes, 4 of 4 IL10RB (100%), 3 of 3 AIRE (100%), and 21 of 30 LRBA (70.0%) mutated genes had the highest prevalence of autoimmunity.

CONCLUSIONS

Autoimmune phenomena are common features among patients with monogenic IEI and are associated with a more complicated course of the disease. Therefore, when encountering autoimmune disorders, especially in the setting of dysgammaglobulinemia, it would be appropriate to conduct next-generation sequencing to discover responsible genes for the immune dysregulation at an early stage of the disease.

Rare clinical presentations of hyper-IgE syndrome in a patient with dental abnormalities: A case report

Asthma and anaphylaxis are two atypical presentations of hyper-IgE syndrome (HIES). Early diagnosis and management of HIES can improve quality of life of patients through minimizing orthodontic problems and other complications related to this disorder.

The Effect of Aspirin on Moderate to Severe Asthmatic Patients with Aspirin Hypersensitivity, Chronic Rhinosinusitis, and Nasal Polyposis

Asthmatic patients may have aspirin-exacerbated respiratory disease and experience acute dyspnea and nasal symptoms within 3 hours after the ingestion of aspirin. This study aimed to evaluate the effect and outcome of daily low-dose aspirin in the treatment of moderate to severe asthma in patients with concomitant aspirin hypersensitivity and chronic rhinosinusitis with nasal polyposis (CRSwNP). This clinical trial was conducted from February 2014 to February 2015 on 46 adult patients with moderate to severe asthma accompanied by CRSwNP. Patients with a positive aspirin challenge were blindly randomized in three groups receiving placebo/day (A); aspirin 100 mg/day (B); and aspirin 325mg/day (C), respectively. Clinical findings, FEV1 and ACT scores were recorded and compared before, during, and after treatment for 6 months. Of 46 participants at baseline, 30 patients completed this 6-month trial study. The level of asthma control was significant; based on Asthma Control Test (ACT) when comparing the results in groups A and C and also groups B and C, but it was not significant when comparing ACT scores between groups A and B. FEV1 before and after treatment was significant when comparing groups A and B, groups A and C, and groups B and C. To conclude, aspirin desensitization with a daily dose of 325 mg aspirin resulted in the improvement of long-term control of asthma. A daily aspirin dose of 100 mg was not associated with such an increase in ACT score.

The effect of a cow's milk-free diet on asthma control in children: a quasi-experimental study

BACKGROUND

Food allergy which usually develops in the first year of life is a risk factor for persistent asthma in young children. Cow's milk has been demonstrated to be the most commonly identified food allergen in children. Considering the central role of non-IgE-mediated food allergies in the development of hidden gastroesophageal reflux and consequently asthma, we evaluated the effect of eliminating food allergens to better control asthma.

METHOD

A total of eighty infants and children up to the age of 12 referred to the Asthma Clinic of Mofid Children Hospital for a period of one year were enrolled in this study. In those patients whose asthma remained uncontrolled (Childhood Asthma Control Test ≤19) despite a 2-week period of treatment, we advocated a 2-week-diet based on eliminating cow's milk in conjunction with asthma conventional therapy. For breast-fed infants, mothers were requested to eliminate these products from their daily intake regimens and for formula-fed infants, the elemental based formula was started.

RESULTS

Three of the patients were lost in follow-up and six of them were excluded from the study because of non-compliance. The Asthma Control Test score which was less than or equal to 19 in the entire study population, increased to 20 or more after we began a diet based on the elimination of cow's milk in all but 13 participants.

CONCLUSION

To conclude, the results were promising, demonstrating that a cow's milk protein elimination diet is a prudent approach in the management of patients with recalcitrant asthma, and can be considered as the missing link in asthma treatment.

Aspirin Sensitivity in Patients with Moderate to Severe Asthma

Asthma induced by ingestion of aspirin occurs when symptoms arise within 30 minutes to three hours after aspirin consumption. Previous data indicate that sensitivity to aspirin may be associated with poorly controlled asthma. This study aims to evaluate the frequency of aspirin sensitivity in patients with moderate to severe asthma receiving conventional asthma therapy. This clinical trial was conducted on 65 patients aged 18 to 65 years with moderate to severe asthma from February 2015 to February 2016 at the Allergy Department, Hazrat-e-Rasoul Hospital, Iran University of Medical Sciences, Tehran. To assess treatment responses in patients, forced expiratory volume in the first second (FEV1) and asthma control test (ACT) scores were measured at baseline and after 3 months. The results of the oral aspirin challenge revealed a prevalence of 35.38% for sensitivity to aspirin. Hypersensitivity reactions to aspirin were detected in 60.9% of the patients with moderate asthma and 39.1% of the patients with severe asthma. All patients with positive aspirin challenge tests suffered from rhinosinusitis and in 56.5% of cases, history of previous hypersensitivity reactions to non-steroidal anti-inflammatory drugs (NSAIDs) was detected. No meaningful differences were found between those patients with aspirin sensitivity and those with aspirin tolerance neither in mean pre-bronchodilator FEV1 nor in ACT scores pre- and post-treatment. To conclude, aspirin sensitivity was not found to have an association with an unfavorable response to conventional treatment in patients with uncontrolled asthma.

A novel evaluation of genetic polymorphism in BCG adenitis

Hassanzad M, Farnia P, Darougar S, Velayati AA. A novel evaluation of genetic polymorphism in BCG adenitis. Turk J Pediatr 2019; 61: 466-470. Bacillus Calmette-Guerin (BCG) is a live attenuated vaccine which has been used to prevent tuberculosis, according to the World Health Organization (WHO) recommendation in parts of the world with an incidence of tuberculosis infection more than 1%. The incidence of BCG adverse reactions differs between regions with regional lymphadenitis as the most common presentation. The aim of this study was to detect the impact of polymorphisms causing BCG lymphadenitis in children receiving BCG vaccination at birth. Eight healthy infants with BCG adenitis from 4 to 12 months old were enrolled. All these patients underwent a thorough physical examination, abdominopelvic ultrasound evaluation to detect distant lymphadenopathies and immunodeficiency screening tests for any possible underlying immunodeficiency disorders. Then genotyping for known mutations was performed using restriction fragments length polymorphism (PCR-RFLP) assays. Sequencing was performed for IL-12 Rβ1, IFN-ϒ receptor 1, IL-10, TNF-α and P2X7. The mean age of onset of the adenitis was 6.5 months. TNF-857, IL-12Rβ1 705, IL-10 1082, and IFN-ϒ- 56 single nucleotide polymorphisms (SNPs) were common in the children studied. The most frequent polymorphism found in the patients with BCG adenitis except one, was the P2X7 -762 polymorphism. To conclude, these polymorphisms are more common in some ethnic populations but not others and make the genetic basis of immunity to BCG strains and the occurrence of post-BCG lymphadenitis in otherwise healthy children.

Monogenic Primary Immunodeficiency Disorder Associated with Common Variable Immunodeficiency and Autoimmunity

BACKGROUND

Common variable immunodeficiency (CVID) is the most frequent primary immunodeficiency disorder mainly characterized by recurrent bacterial infections besides other immunological defects including loss of or dysfunction of B cells and decreased immunoglobulin levels. In this study, our aim is to evaluate clinical, immunological, and molecular data of patients with a primary clinical diagnosis of CVID and autoimmune phenotype with a confirmed genetic diagnosis.

METHODS

Among 297 patients with CVID, who were registered in the Iranian Primary Immunodeficiency Registry at Children's Medical Center Hospital in Iran, 83 patients have been genetically examined and 27 patients with autoimmunity and confirmed genetic mutations were selected for analysis. Whole-exome sequencing and confirmatory Sanger sequencing methods were used for the study population. A questionnaire was retrospectively filled for all patients to evaluate demographic, laboratory, clinical, and genetic data.

RESULTS

In the 27 studied patients, 11 different genetic defects were identified, and the most common mutated gene was LRBA, reported in 17 (63.0%) patients. Two patients (7.7%) showed autoimmune complications as the first presentation of immunodeficiency. Eleven patients (40.7%) developed one type of autoimmunity, and 16 patients (59.3%) progressed to poly-autoimmunity. Most of the patients with mono-autoimmunity (n = 9, 90.0%) primarily developed infectious complications, while in patients with poly-autoimmunity, the most common first presentation was enteropathy (n = 6, 37.6%). In 13 patients (61.9%), the diagnosis of autoimmune disorders preceded the diagnosis of primary immunodeficiency. The most frequent autoimmune manifestations were hematologic (40.7%), gastrointestinal (48.1%), rheumatologic (25.9%), and dermatologic (22.2%) disorders. Patients with poly-autoimmunity had lower regulatory T cells than patients with mono-autoimmunity.

CONCLUSION

In our cohort, the diagnosis of autoimmune disorders preceded the diagnosis of primary immunodeficiency in most patients. This association highlights the fact that patients referring with autoimmune manifestations should be evaluated for humoral immunity.

Disseminated Bacille Calmette-Guérin infection at a glance: a mini review of the literature

INTRODUCTION

Immunodeficient children are at a high risk of disseminated Bacillus Calmette-Guérin [BCG] infection. We assessed the literature on clinical manifestations of BCGosis in children with specific primary immunodeficiencies.

MATERIAL AND METHODS

We conducted a systematic review of clinical practice articles by searching Medline, PubMed, Embase, Scopus, Web of Science and Google Scholar from their inception to date.

RESULTS

Thirty-seven articles were included regarding BCG vaccination and its dissemination in children with primary immunodeficiencies. Articles on dissemination after intravesicular BCG were excluded from the study.

CONCLUSIONS

Since disseminated BCG vaccination may be the first manifestation of a primary immunodeficiency disease, a comprehensive search for immunological defects in children developing these problems after BCG vaccination seems rational.

Pulmonary complications of predominantly antibody immunodeficiencies in a tertiary lung center

Background and aims

Respiratory infections are expressed very soon in the life in humoral immunodeficiencies and often lead to chronic irreversible complications such as bronchiectasis and chronic airflow limitation. This study was conducted to evaluate the pulmonary complications of predominantly antibody immunodeficiencies to show the benefits of timely diagnosis and appropriate therapy.

Patients and methods

The information of 48 patients involved with a type of predominantly antibody immunodeficiencies, including sex, type of primary immunodeficiency, age at the onset of symptoms, age at diagnosis, recurrent infections, respiratory symptoms, and pulmonary radiological and functional abnormalities were recorded and analyzed.

Results

In 48 patients evaluated, the mean age at diagnosis was 25.63 years. The mean diagnostic delay was estimated to be 13.62 years. The most recurring clinical manifestations, sinusitis (69.6%), otitis (43.5%), and recurrent pneumonia were the cause of frequent admissions in 68.8% of these patients. Bronchiectasis was frequently found (58.3%) in these patients mostly involving the middle and lower lobes (48.8% and 41.5%, respectively).

Conclusions

Respiratory complications, infectious or non-infectious, determine the prognosis of the disease in patients with predominantly antibody immunodeficiencies. Timely diagnosis and appropriate management may improve life expectancy and the quality of life in these patients.

Fourth Update on the Iranian National Registry of Primary Immunodeficiencies: Integration of Molecular Diagnosis

BACKGROUND

The number of inherited diseases and the spectrum of clinical manifestations of primary immunodeficiency disorders (PIDs) are ever-expanding. Molecular diagnosis using genomic approaches should be performed for all PID patients since it provides a resource to improve the management and to estimate the prognosis of patients with these rare immune disorders.

METHOD

The current update of Iranian PID registry (IPIDR) contains the clinical phenotype of newly registered patients during last 5 years (2013-2018) and the result of molecular diagnosis in patients enrolled for targeted and next-generation sequencing.

RESULTS

Considering the newly diagnosed patients (n = 1395), the total number of registered PID patients reached 3056 (1852 male and 1204 female) from 31 medical centers. The predominantly antibody deficiency was the most common subcategory of PID (29.5%). The putative causative genetic defect was identified in 1014 patients (33.1%) and an autosomal recessive pattern was found in 79.3% of these patients. Among the genetically different categories of PID patients, the diagnostic rate was highest in defects in immune dysregulation and lowest in predominantly antibody deficiencies and mutations in the MEFV gene were the most frequent genetic disorder in our cohort.

CONCLUSIONS

During a 20-year registration of Iranian PID patients, significant changes have been observed by increasing the awareness of the medical community, national PID network establishment, improving therapeutic facilities, and recently by inclusion of the molecular diagnosis. The current collective study of PID phenotypes and genotypes provides a major source for ethnic surveillance, newborn screening, and genetic consultation for prenatal and preimplantation genetic diagnosis.

Association of specific viral infections with childhood asthma exacerbations

Introduction

Asthma exacerbations may occur due to a variety of triggers including respiratory viruses. The aim of this study was to determine the role of particular viral infections in asthma exacerbations in children.

Materials and methods

The study was performed at Dr. Daneshvari Hospital Pediatric Emergency Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran between 2014 and 2015. A nasopharyngeal aspirate or swab was obtained from each patient during admission. All samples were maintained at 4 °C until submission to the virology laboratory and were tested for respiratory viruses by nucleic acid testing.

Results

A total of 60 patients with asthma exacerbations were recruited for this study. Of the 60 samples collected from the patients with acute asthma exacerbations, rhinovirus was detected in 12 patients (20%), respiratory syncytial virus in 5 (8%), adenovirus in 5 (8%), and influenza virus in 1 (1.6%). Respiratory pathogens were not detected in 37 (61%) samples. All the samples investigated showed single viral infection.

Conclusions

To conclude, the most common viruses detected were rhinovirus followed by respiratory syncytial virus (RSV) and adenovirus. RSV was more commonly associated with more severe attacks. Both the study design (e.g., time of sampling, age of the patients, etc.) and also the method used for viral detection influence the frequency of detection of the respiratory viruses.

Is the Atopy Patch Test Reliable in the Evaluation of Food Allergy-Related Atopic Dermatitis?

BACKGROUND

Aeroallergens and food allergens are found to be relevant in atopic dermatitis. The atopy patch test (APT) can help to detect food allergies in children with atopic dermatitis. This study evaluates if the APT is a valuable tool in the diagnostic workup of children with food allergy-related atopic dermatitis.

METHODS

42 children between 6 months and 12 years of age were selected at the Mofid Children Hospital. Atopic dermatitis was diagnosed, and the severity of the disease was determined. At the test visit, the patients underwent a skin prick test (SPT), APT, and serum IgE level measurement for cow's milk, egg yolk, egg white, wheat, and soy.

RESULTS

We found a sensitivity of 91.7%, a specificity of 72.7%, a positive predictive value (PPV) of 88%, a negative predictive value (NPV) of 80%, and an accuracy of 85.7% for APT performed for cow's milk. APT performed for egg yolk had a sensitivity and a NPV of 100%, while the same parameters obtained with egg white were 84.2 and 75%, respectively. The sensitivity, specificity, and NPV of the APT for wheat were 100, 75, and 100%, respectively. The sensitivity, PPV, and NPV of the APT for soy were 87.5, 70, and 87.5%, respectively.

CONCLUSIONS

Our data demonstrate that the APT is a reliable diagnostic tool to evaluate suspected food allergy-related skin symptoms in childhood and infancy.

Amyloidosis as a Renal Complication of Chronic Granulomatous Disease

Chronic granulomatous disease is a rare primary immunodeficiency disorder, which leads to increased susceptibility to recurrent infections and severe inflammatory manifestations.  There have been reports regarding different aspects of genitourinary involvement in chronic granulomatous disease, some of which are hydronephrosis, granulomatous cystitis, and glomerulonephritis, but among these complications, amyloidosis is rather rare. We report a patient with chronic granulomatous disease that developed amyloidosis later in the course of the disease.

Interleukin-17 gene expression and serum levels in children with severe asthma

BACKGROUND

IL-17 is a major cytokine player in T cell mediated leukocyte associated inflammation. IL-17 is also recognized to participate in the pathophysiology of asthma.

OBJECTIVE

To determine the role of IL-17 in predicting severe asthma.

METHODS

We obtained serum samples from asthmatic children under the age of 5-year in three different groups of mild (n=33), moderate (n=28) and severe (n=32) persistent asthma. IL-17 serum concentrations and mRNA expression were determined by ELISA and real time PCR assays, respectively.

RESULTS

Serum IL-17 concentrations were significantly higher in patients with severe asthma than the other two groups of children with mild and moderate disease (p=0.00). Mean serum IL-17 values were 142.04 pg/ml in mild group, 180.4 pg/ml in moderate group and 251.25 pg/ml in severe group. IL-17 mRNA levels were also significantly elevated in severe asthmatic patients compared to mild and moderate asthmatic children (p=0.00).

CONCLUSION

Our data reveal an increase in the serum IL-17 concentration and IL-17 mRNA expression in children with severe asthma compared to those with mild and moderate forms of the disease.

Upper respiratory system involvement as the only manifestation of granulomatosis with polyangiitis in a child with marfan phenotype

We report a 9-year old girl with an unusual presentation of granulomatosis with polyangiitis in association with Marfan phenotype. The patient presented with recurrent sinusitis, epistaxis, hearing loss and hyperplastic gingivitis, without any signs or symptoms of major organ involvement.

Silicone rubber/hydrogel composite ophthalmic inserts: preparation and preliminary in vitro/in vivo evaluation

The present report describes the development and in vitro/in vivo testing of rod-shaped mucoadhesive ophthalmic inserts fitting the upper or lower conjunctival fornix. Cylindrical devices (diameter 0.9 mm, length 6-12 mm, weight 3-8 mg) all containing 0.8 mg oxytetracycline HCl (OXT) were prepared from appropriate mixtures of silicone elastomer, OXT and sodium chloride as release modifier. A stable polyacrylic acid (PAA) or polymethacrylic acid (PMA) interpenetrating polymer network (IPN; 30 or 46% w/w) was grafted onto the inserts' surface by treatment with a mixture of acrylic (or methacrylic) acid and ethylene glycol dimethacrylate in xylene at 100 degrees C. Mucoadhesion studies in vitro showed that the mucoadhesive properties increased significantly with increasing thickness of the IPN layer. The inserts were tested for drug release in vitro, and for drug release and retention in rabbit eyes. The presence of IPN, as well as of NaCl, in general increased the drug release rate. The PMA-grafted devices released OXT at lower rates when compared with the PAA-grafted ones. A nearly zero-order release rate for about 1 week was observed in vitro for some types of inserts. When tested in rabbits, some IPN-grafted inserts maintained in the lacrimal fluid a OXT concentration of 20-30 microg/ml for several days: the in vitro minimum inhibitory concentration values (MIC 90%) of OXT against micro-organisms responsible of common ocular infections range from 0.8 to 2.0 microg/ml, while MIC 90% values in the range 14-50 microg/ml have been indicated for Pseudomonas aeruginosa. The ocular retention of IPN-grafted samples was significantly higher with respect to ungrafted ones. The presently described mucoadhesive silicone inserts might prove efficient therapeutic systems for chemotherapy of ocular bacterial infections, such as trachoma.

STDS in women attending family planning clinics: a case study in Addis Ababa

For cultural reasons modern contraception has been slow to gain acceptance in Ethiopia. Knowledge about contraception and abortion is still limited in many family and community settings in which it is socially disapproved. By 1990 only 4% of Ethiopian females aged 15-49 used contraception. Little is known of sexually transmitted disease (STD) prevalence in family planning (FP) attenders in Africa in general and Ethiopia in particular, even though attenders of family planning clinics (FPCs) are appropriate target groups for epidemiological studies and control programmes. A study of 2111 women of whom 542 (25.7%) attended FPCs in Addis Ababa showed utilisation rates to be highest in women who were: Tigre (33%) or Amhara (31%), aged 20-34 years (30%), age 16 or older at first marriage/coitus (28%:38% in those first married after 25 years); who had a monthly family income of 10 Ethiopian Birr (EB) or more (33%:36% for those with income 100-500 EB), three or more children (37%), more than five lifetime husbands/sexual partners (39%); or were bargirls (73%) or prostitutes (43%). The seroprevalence rates for all STDs, higher in FPC attenders compared with other women, were syphilis (TPHA) 39%, Neisseria gonorrhoeae 66%, genital chlamydia 64%, HSV-2 41%, HBV 40% and Haemophilus ducreyi 20%. Only 4% of FPC attenders had no serological evidence of STD: 64% were seropositive for 3 or more different STD. Clinical evidence of pelvic inflammatory disease (PID) was also more common in the FPC attenders (54%), 37% having evidence of salpingitis. The FPC provides a favourable setting for screening women likely to have high seroprevalence of STD, who for lack of symptoms will not attend either an STD clinic nor a hospital for routine check up. We recommend that measures be taken to adequately screen, treat and educate FPC attenders, their partners, and as appropriate and when possible their clients, in an attempt to control STDs and ultimately HIV in the community. Social, economic and cultural factors in the occurrence of STDs, prostitution, family planning and modern contraception coverage in Ethiopia are identified and deficiencies of current programmes briefly discussed with the objective of targeting services more effectively.

Chlamydial infection in a population of Ethiopian women attending obstetric, gynaecological and mother and child health clinics

The prevalence of chlamydial infection was assessed in 1,846 Ethiopian women attending clinics in Addis Ababa. Sera were tested for type-specific anti-chlamydial antibodies using purified chlamydial antigens (C. trachomatis A-C (CTA-C), C. trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGVI-3), and C. pneumoniae (CPn), in a micro-immunofluorescence (micro-IF) test. Three levels of chlamydial infection were established. Sera with: 1) antibodies to CTA-C, CTD-K, LGV 1-3 and CPn singly or in combination, are considered as evidence of overall exposure to chlamydial species (OEC); 2) antibodies to CTD-K and LGV 1-3 are considered as evidence of exposure to genital chlamydial pathogens (GENCI); 3) IgM titre > or = 1/8, or Ig G titre > or = 1/64 to CTD-K and LGV 1-3 alone or at a similar level with antibodies to CTA-C and CPn is considered as being evidence of active genital chlamydial infection (AGCI). OEC was found in 84 pc, GENCI in 60 pc and AGCI in 42 pc. Infection was highest in family planning and lowest in antenatal clinic attenders. OEC increased progressively with age while GENCI and AGCI peaked at ages 35 to 49. Chlamydial infection was highest in those married and sexually active < 13 years of age (OEC 88 pc, GENCI 69 pc, AGCI 49 pc); the lowest income groups (OEC 85 pc, GENCI 65 pc, AGCI 45 pc); those with more than five sexual partners (OEC 92 pc, GENCI 78 pc and AGCI 65 pc); with highest prevalence in bargirls (OEC 97 pc, GENCI 84 pc, AGCI 75 pc). Fifty pc had clinical evidence of past or present infection in the urethra, salpinges or bartholin glands (USB). OEC, GENCI and AGCI were associated with PID. The association of seropositivity with USB was remarkably similar for both gonorrhoea and chlamydial infection: we recommend adoption of a treatment regimen effective for both infections. The micro-IF test is a useful epidemiological tool for identifying the of antibodies to chlamydial pathogens. Use of antigen pools CTA-C, CTD-K LGVI-3 and CPn enables a distinction to be made between genital and non-genital infections. The problem of symptomatic and asymptomatic chlamydial disease needs to be addressed urgently.

Teenage obstetric and gynaecological problems in an African city

OBJECTIVE

To measure the prevalence of sexually transmitted diseases (STD), pelvic inflammatory disease (PID), cervical cancer, pregnancy and use of contraception in teenagers, and to determine socioeconomic factors associated with these conditions to aid planners of medical services and promotion of sexual health.

SUBJECTS

181 Ethiopian teenagers and 1,845 women aged 20 to 45 years for comparison.

SETTING

Gynaecological outpatient department, antenatal, postnatal and family planning clinics, in two teaching hospitals and a mother and child heath centre in Addis Ababa, Ethiopia.

METHODS

Results of serologic tests for STD, clinical evidence of PID, and cervical cytology were analysed against socio-economic factors.

RESULTS

In teenagers early age at first marriage/coitus, more common in those of rural origin, was associated with poverty, a greater number of lifetime sexual partners, and prostitution: 40 pc were first sexually active before the menarche. Prevalence of seropositivity to specific STD pathogens was; Treponema pallidum (TPHA) 21 pc, Neisseria gonorrhoeae (gonococcal antibody test: GAT) 40 pc, genital chlamydiae 51 pc, hepatitis B virus 36 pc, herpes simplex virus (HSV-2) 32 pc, and Haemophilus ducreyi 16 pc: 92 pc of teenagers were seropositive to one or more STD's. STD seroprevalence was higher in those with more than one sexual partner, those sexually active by age 15 (very high in those sexually active by age 12), those involved in prostitution and those attending the family planning clinic. Forty three pc had clinical evidence of PID; one married at age 10 had invasive cervical cancer by age 18; 40 pc of teenagers were pregnant compared with 25 pc of those aged 20 to 45; 21 pc attended for family planning; of regular FPC attenders 81 pc were GAT seropositive.

CONCLUSION

Despite legislation early age of sexual debut is common, STD and PID are widely prevalent, the pregnancy rate in adolescents is high and contributes to the national population growth rate. Action is required at family, medical and governmental level to encourage cultural acceptance that marriage and sexual activity should not occur before the age of 16 years, with education appropriate to culture to prevent STD. Similar studies are recommended in other countries to establish a baseline for informed strategy regarding prevention of STD and health education.

A socioeconomic, clinical and serological study in an African city of prostitutes and women still married to their first husband

The aim of this paper was to compare women involved in prostitution with a group of women still married to their first husband and reporting having had only one sexual partner, in order to ascertain what factors if any contributed to women going into prostitution or staying still married to their first husband, their only sexual partner, and thereafter to compare clinical and serological aspects of the gynaecological conditions of the women in these two groups. The role of prostitutes in transmission of sexually transmitted diseases (STD) is widely recognised. Socioeconomic factors determining whether a woman will drift into prostitution or have a stable first marriage are largely unknown as are prevalence rates of STD, pelvic inflammatory disease (PID) and cervical cancer in these women. A socioeconomic, clinical and serologic study is reported for 2111 Ethiopian women attending teaching hospitals and maternal and child health clinics in Addis Ababa, analysing basic demographic data of three groups of women: (i) 278 engaged in prostitution, (ii) 730 still married to their one and only sexual partner, and (iii) 1103 single, widowed, divorced or married to their second or subsequent partner. Thereafter groups (i) and (ii) were compared and contrasted with regard to further socioeconomic, clinical and serological associations. The most significant socioeconomic associations for women in prostitution were low income (95% had < 50 Ethiopian birr [< U.S. $25] per month), ethnic group, and the timing of first coitus in relation to the menarche (81% were first married by age 15), in that order. Women still married to their first sexual partner had higher income, higher age at first marriage and longer duration of marriage. Sero-prevalence rates of STD in prostitutes were high: gonorrhoea 88%, genital chlamydiae 78%, syphilis (TPHA) 62%, HSV2 and HBV 46%, and chancroid 19%: 67% had PID and 2.9% cervical cancer. In comparison, rates for women married to their first and only sexual partner were: gonorrhoea 40%, genital chlamydiae 54%, syphilis (TPHA) 19%, HSV2 33%, HBV 35%, chancroid 13%, PID 47% and cervical cancer 1%. While the very high prevalence of STD in women involved in prostitution is not so unexpected, the high rate of STD in women still married to their first and only sexual partner is indicative of male promiscuity. Control of prostitution and diseases spread by it, together with education of both men and women is a national priority.

Antibodies to Chlamydia species in patients attending a genitourinary clinic and the impact of antibodies to C. pneumoniae and C. psittaci on the sensitivity and the specificity of C. trachomatis serology tests

In a retrospective study, the prevalence of antibodies to Chlamydia trachomatis serovars D to K, C. pneumoniae, and C. psittaci in cases attending a genitourinary clinic was examined. Blood samples were collected from 7,002 cases attending the clinic in Doncaster, England between May 1983 and May 1990. Sera from these samples were tested by a modified microimmunofluorescence test using panels of microdots of egg-grown, purified elementary bodies representing a pool of C. trachomatis D to K, a single C. pneumoniae agent, a single C. psittaci agent, and a negative control. Serum specimens were tested for the presence of IgG and IgM at starting dilutions of 1/16 and 1/8, respectively. Chlamydial IgG at a level of 1/16 or higher and IgM at a level of 1/8 or higher was present in 66.6% and 2.6% of samples, respectively. Species-specific or cross-reactive IgG against C. trachomatis D to K, C. pneumoniae, and C. psittaci was present in 32.6%, 25.1%, and 0.1% of the samples, respectively. In 8.7% of samples, the level of IgG was similar against two or all three species (group-specific). IgM against C. trachomatis D to K, C. pneumoniae, or C. psittaci was present in 2.5%, 0.03%, and 0.04% of the samples, respectively. The results of the study show that antibodies to C. pneumoniae and C. psittaci account for up to half of all chlamydia IgG positive cases attending genitourinary clinics.(ABSTRACT TRUNCATED AT 250 WORDS)

Chlamydia pneumoniae in Swedish patients

Chlamydia pneumoniae infections have earlier been described as mycoplasma-like illnesses in young people, and also appear to be associated with community-acquired pneumonia in adults. In this retrospective study, 12.2% (23/188) of patients with pneumonia who required hospitalization during the 3 years 1985-87 had serological evidence of recent C. pneumoniae infection. Many of these patients had symptoms similar to ornithosis. The most interesting finding was that half of the patients with a 4-fold IgG antibody titre rise to C. pneumoniae also had an increased alkaline phosphatase concentration.

Seroepidemiological and socioeconomic studies of genital chlamydial infection in Ethiopian women

OBJECTIVE

To measure the prevalence of chlamydial genital infection in Ethiopian women attending gynaecological, obstetric and family planning clinics; to identify the epidemiological, social and economic factors affecting the prevalence of infection in a country where routine laboratory culture and serological tests for chlamydial species are unavailable; to determine the risk factors for genital chlamydial infection in those with serological evidence of other sexually transmitted diseases.

SUBJECTS

1846 Ethiopian women, outpatient attenders at two teaching hospitals and a mother and child health centre in Addis Ababa, Ethiopia.

SETTING

Gynaecological outpatient department, antenatal, postnatal and family planning clinics.

METHODS

Sera were tested for type-specific anti-chlamydial antibodies using purified chlamydial antigens (C. trachomatis A-C (CTA-C), C. trachomatis D-K (CTD-K), Lymphogranuloma venereum (LGV1-3), and C. pneumoniae (CPn)), in a micro-immunofluorescence test. The genital chlamydia seropositivity was analysed against patient's age, clinic attended, ethnic group, religion, origin of residence, age at first marriage and first coitus, income, number of sexual partners, duration of sexual activity, marital status/profession, obstetric and contraceptive history, and seropositivity for other sexually transmitted diseases.

RESULTS

Overall exposure to chlamydia species was found in 84%, genital chlamydial infection in 62%, and titres suggestive of recent or present genital infection in 42% of those studied. Genital chlamydial infection was highest (64%) in family planning and lowest (54%) in antenatal clinic attenders. Exposure to genital chlamydia species was influenced by ethnic group and religion. Those married and sexually active under 13 years of age had greater exposure (69%) to genital chlamydial infection than those first sexually active aged over 18 (46%). Prevalence of infection was highest in those with more than five sexual partners (78%) and in bargirls (84%). The lowest income groups had a higher prevalence (65%) of genital chlamydial infection than the wealthiest (48%). Multivariate analysis showed the most important factors to be age at first coitus, religion, prostitution and present age of the woman in that order. Risk for genital chlamydial infection was increased in those with seropositivity for syphilis, gonorrhoea, HSV-2 but not HBV infection. CONCLUSION/APPLICATION: Chlamydial genital infections are highly prevalent in both symptomatic and asymptomatic Ethiopian women. The high prevalence of infection reported reflects a complexity of socioeconomic factors: very early age at first marriage and first coitus, instability of first marriage, subsequent divorce and remarriage or drift into prostitution, all of which are influenced by ethnic group, religion and poverty--together with transmission from an infected group of prostitutes by promiscuous males to their wives, lack of diagnostic facilities and inadequate treatment of both symptomatic and asymptomatic men and women. The problem of chlamydial disease in Ethiopia needs to be addressed urgently in the context of control of STD.

Causes of conjunctivitis and keratoconjunctivitis in Karachi, Pakistan

The causes of conjunctivitis and keratoconjunctivitis in 388 patients who attended eye casualty departments in Karachi, Pakistan, during a 5 month period were investigated. Most of these infections were diagnosed as adenovirus (291, 75%) or bacterial (71, 18.3%). Of the remainder, 9 cases (2.3%) were caused by herpes simplex virus and 7 (1.8%) by Chalmydia trachomatis. There was no evidence of typical active trachoma in this urban population. Bacteria or Candida albicans were also grown from 44 of the adenovirus cases (15%). Many of the bacteria grown from eyes in this study were resistant to antibiotics, probably because of inadequate and/or inappropriate self-medication with antibiotics in this community.

An outbreak of acute haemorrhagic conjunctivitis in Kaduna, Nigeria

Clinical studies were carried out on two groups of patients with acute haemorrhagic conjunctivitis (AHC) during an epidemic in 1985 in Northern Nigeria. Group 1 consisted of 99 students attending a girls' boarding school, group 2 of 200 patients selected randomly from 1000 examined at the local clinic. Moderate to severe hyperaemia and papillary responses were present in the palpebral conjunctiva of all patients, and 234 (66%) had subconjunctival haemorrhages. Transient superficial punctate keratitis was noted in over 60% of patients. A transient flare suggestive of a low grade iritis was seen in five patients. No neurological disorders were noted. Serological studies were carried out on patients from group 2. Fifteen paired and 20 single serum samples were titrated against adenovirus type 4 (Ad-4) and enterovirus type 70 (EV-70). Two pairs of sera showed a 4-fold rise in antibody levels to EV-70, whereas the antibody titres to EV-70 in the rest of the sera ranged from 1:20 (no antibody) to 1:160. None of the paired serum samples showed a 4-fold rise in antibody levels to adenovirus. The results of clinical studies and serological findings support EV-70 as a probable cause of AHC in Nigeria.

Double-label immunofluorescence method for simultaneous detection of adenovirus and herpes simplex virus from the eye

The development and application of a double-label immunofluorescence method which has the potential to screen for single or dual infections from any site, in single shell vial cultures, is described. In this study, a total of 1,141 ocular specimens were inoculated in shell vials, centrifuged at 15,000 X g for 1 h, incubated at 37 degrees C for 48 h, and fixed in methanol at room temperature for 15 min. The virus inclusions were detected by staining with a double-label indirect immunofluorescence procedure using mixtures of appropriate first antibodies, followed by fluorescein- and rhodamine-conjugated second antibodies. Each specimen was also inoculated in parallel by the conventional virus isolation method. The sensitivity and specificity of the double-label shell vial procedure were comparable to those with the conventional method, and the former test took only 48 h to complete. The test offers a rapid and simple single-vial procedure which allows for individual or simultaneous detection of multiple pathogens. It results in savings in time and cost over the conventional virus isolation method and other shell vial procedures.

Colposcopy, biopsy, and cytology results in women with chlamydial cervicitis

Colposcopy and biopsy were carried out at diagnosis and at follow up of 222 women. Of 322 cervical biopsy specimens taken, 174 were from women with chlamydial cervicitis (patients) and 48 from control women (both at diagnosis) and 100 from 76 patients and seven controls at follow up. Of the 174 patients with chlamydial cervicitis, 158 (91%) had erythema compared with 9/48 (19%) controls, and 140 (81%) had "follicles" and lumps compared with three (6%) controls. The cervical polymorphonuclear leucocyte (PMNL) count in a high power (x 1000) field (HPF) was 85 in patients compared with 47/HPF in controls. Cervical ectopia was found in 154 (89%) patients compared with 32 (67%) controls. After treating the 174 patients, we found erythema in nine (5%) and "follicles" in 16 (9%); both conditions were disappearing. Lymphocytic germinal follicles were found on histology in only 5/165 patients compared with none in controls or in patients at follow up examination (after treatment for chlamydial cervicitis). Inclusions were found in 6/165 patients compared with none in controls or patients at follow up. Chlamydiae were found on electron microscopy in slides from seven out of 159 patients compared with none from controls or 81 subjects at follow up. Estimating numbers of inflammatory cells and measuring vascularity showed diffuse increases in lymphocytes and plasma cells and increases in vascularity in both endocervical and exocervical tissue of patients with chlamydial cervicitis. These increases were lessened by treatment.

Management and prevention of ocular viral and chlamydial infections

A majority of cases of preventable and/or curable ocular morbidity and blindness are caused by ocular infections. They may account for 70 to 90% of all ocular morbidity seen by family doctors, general practitioners, health centers, and local ophthalmologists in both developed and developing countries. Unfortunately, most health authorities and doctors, including ophthalmologists, consider these diseases to be of little or no importance because they are not fully aware of the high prevalence of these infections and the blinding sequelae which may occur following incorrect diagnosis and treatment. Also, they are not aware of the social and economic impact of these infections in the absence of proper management and implementation of preventive measures. In this review, we examine present knowledge of chlamydial and common viral ocular infections. We discuss the problems of diagnosis, management, and prevention and propose solutions relevant to developed and developing countries.

Marginal corneal abscess associated with adult chlamydial ophthalmia

In four patients with an adult chlamydial ophthalmia small, marginal corneal abscesses were detected. These corneal abscesses were associated with unilateral papillary and follicular conjunctivitis and punctate keratitis. In these patients no bacteria was isolated from the abscesses, but Chlamydia trachomatis was isolated from materials collected from the abscesses and from the conjunctival swabbings. In addition all patients had microbiologically proved concomitant chlamydial genital infections. The clinical signs resolved after topical treatment with rifampicin or tetracycline eye ointment for six weeks or systemic treatment with tetracycline for two weeks. Because of concomitant chlamydial genital infection it is advisable to treat patients with adult chlamydial ophthalmia with systemic tetracycline and to refer these patients and their consorts for investigation and treatment of their genital infection.

Sensitivity of mitomycin-C treated McCoy cells for isolation of Chlamydia trachomatis from genital specimens

A new cell culture method was developed for the diagnostic isolation of Chlamydia trachomatis using McCoy cells pretreated with mitomycin-C. This drug acts on the cell by producing cross links between strands of DNA and results in the production of large, flat cells, which are similar to irradiated cells, and large chlamydial inclusions. In tests using a laboratory isolate of Chlamydia trachomatis, there were significantly more inclusions produced in mitomycin-treated monolayers than in cycloheximide-treated monolayers. Using clinical specimens, significantly more isolates were obtained in mitomycin-treated cells than in cycloheximide-treated cells. The new cell culture technique therefore offers a cell culture method which has the advantages of producing large inclusions similar to irradiated cells but with the convenience of drug treatment.

Recurrent herpes simplex virus ocular infection: epidemiological and clinical features

The epidemiological and clinical features of recurrent herpes simplex virus ocular infection (RHSV) were studied. Of 108 patients with primary herpes simplex virus ocular infection (PHSV) who were followed up for two to 15 years 35 (32%) suffered one or more recurrent attacks. The recurrence rate was significantly higher in patients under 20 years of age, but there was no significant difference between recurrence rates in males and females. Of 35 patients with RHSV 17 (49%) had one recurrent attack, 14 (40%) had between two and five, and four (11%) had between six and 15 attacks. The mean time interval between PHSV and the first four RHSV attacks was 10 months, and was shorter in subsequent attacks. The duration and severity of RHSV were reduced in successive recurrences. Patients with more severe conjunctivitis and lid lesions during PHSV ocular infection had a higher incidence of recurrent infection. The severity of the corneal signs in PHSV had no influence on the incidence of recurrent infection. Several clinical forms of RHSV were observed. Conjunctivitis associated with lid lesions was observed in 29 (83%) patients. In six (17%) patients the disease presented as an acute follicular conjunctivitis without characteristic lid or corneal lesions. Dendritic ulcer was found in three (9%) patients, and in one of them it was associated with a disciform keratitis. A chronic blepharoconjunctivitis developed in eight (23%) patients. The epidemiological and clinical features of RHSV were compared with those of PHSV.

Value and cost effectiveness of double culture tests for diagnosis of ocular viral and chlamydial infections

Swabbings from the eyes of 4132 patients attending ophthalmic casualty and outpatients clinics were tested for chlamydiae, adenovirus, and herpes simplex virus. Laboratory isolation tests gave positive results for one of these three agents in 696 (16.8%) cases. When a positive isolation was obtained, only 341 (49%) agreed with the clinical diagnosis while 355 (51%) either had no definite diagnosis marked on the request card or had been clinically diagnosed incorrectly. Routine testing of ocular specimens for all likely organisms can enable the correct treatment to be started sooner than doing one test at each visit, thereby reducing the number of times the patient has to visit the clinic and the expenses involved.

Responses to tuberculin in the guinea-pig eye as a model of cell mediated immune responses in the external eye

The clinical and histological findings in an animal model of ocular cell mediated immune responses are described. These were evoked in sensitised guinea-pigs by dropping tuberculin into the conjunctival sac or injecting it under the palpebral conjunctiva. When tuberculin was dropped into the conjunctival sac, higher doses were required to evoke a strong response than when it was injected subconjunctivally. When high doses of antigen were used for challenge, a mild response was observed in unchallenged contralateral eyes. The cellular response at low doses of tuberculin consisted predominantly of mononuclear cells. At higher doses the cellular infiltrate was more pronounced, and polymorphonuclear cells tended to predominate 24 hours after challenge, while at 48 hours mononuclear cells predominated.

Development of an immunofluorescence test for the serodiagnosis of herpes zoster ophthalmicus

An indirect immunofluorescence test has been developed and evaluated for the serodiagnosis of herpes zoster ophthalmicus (HZO) by the detection of antivaricella zoster virus (VZV) antibody. The results show that, in patients with HZO, anti-VZV IgG antibody titre usually rises rapidly after onset. One hundred and seven of the 134 sera (80%) from patients with a clinical diagnosis of HZO had an anti-VZV IgG titre of greater than or equal to 256, and IgM antibody at a level of 1 in 8 was present in six of them. In comparison only two of the 216 sera (1%) from patients with a clinical diagnosis of ocular infections other than those caused by VZV had such IgG titres. It was concluded that, on the basis of results of a single sample of serum, it is possible to make a provisional diagnosis of HZO with a high degree of confidence.

Comparison of two immunofluorescence tests for detecting antibodies to C. trachomatis

Two immunofluorescence tests were compared for detecting antibodies to chlamydiae. The inclusion antigen test was more sensitive, detecting antibodies in more sera and at higher titres. The micro-IF test was more specific, differentiating between antibodies to C. trachomatis and those to C.IOL 207. Antibodies to this non-genital chlamydial type accounted for half the positive results. These antibodies can cause the prevalence of C. trachomatis infections to be over estimated when genus-specific serology tests are used.

Sequential antibody changes following ulcerative herpetic keratitis

Blood and tear levels of immunoglobulins against herpes simplex virus (HSV) were examined in 28 patients with dendritic keratitis over a period of 28 days. By means of an indirect micro-immunofluorescent technique blood and tear HSV IgG were detected, but neither circulating HSV IgM nor local HSV IgA were found. Over a four-week interval non-diagnostic fluctuations of HSV IgG occurred in most patients, though seven (25%) developed a rising blood IgG titre. Tear IgG appeared to be an exudate from blood. HSV was isolated from 68% of corneal swabbings and 11% of conjunctival swabbings. This study provides guidelines for laboratory testing in recurrent herpetic keratitis.

Oral doxycycline in the treatment of adult chlamydial ophthalmia

Ninety-three consecutive patients with adult chlamydial ophthalmia were treated with four different regimens of oral doxycycline. In patients treated with a single dose of 5 mg/kg of body weight (300 mg) of doxycycline the severity of clinical signs was reduced, and in half of the patients shedding of the infective agent was stopped. Treatment with a weekly dose of 300 mg of doxycycline for three weeks or a daily dose of 1.5 mg/kg of body weight (100 mg) for one week produced a clinical and microbiological cure in 100% of patients. However, in some of these patients mild to moderate papillary responses were present up to six months from completion of the treatment. The best results were obtained with a daily dose of 100 mg for two weeks, which produced rapid clinical and microbiological cure in all patients.

A rapid and sensitive culture test for the laboratory diagnosis of genital herpes in women

A rapid and sensitive cell culture test has been developed to detect herpes simplex virus (HSV) in women with genital herpes. The virus is cultured by inoculation and centrifugation of cell monolayers, and the virus inclusions are detected using an indirect immunofluorescence test. The test takes only 48 hours to complete compared with the conventional cell culture test, which may take up to eight days. Of a total of 2100 cervical specimens collected from unselected women attending a sexually transmitted diseases (STD) clinic and inoculated in parallel, HSV was isolated from 55 specimens by either or both tests. Of these 55 positive specimens, 54(98%) were positive by the rapid test but only 24(44%) by the conventional test (McNemars test; p less than 0.001).