The epidemiology of infection with the human herpesviruses in Navajo children

Investigations of serum antibody status to the five human herpesviruses--herpes simplex virus type 1, herpes simplex virus type 2, cytomegalovirus, Epstein-Barr virus, and varicella-zoster virus--were conducted on 197 Navajo children, aged 1-15 years, at a reservation pediatric outpatient clinic in Crownpoint, New Mexico, from 1981-1984. To determine the severity of infection with the human herpesviruses, the authors reviewed lifetime medical records of 166 of the children for evidence of herpesvirus-related diseases, and to illuminate potential modes of transmission of the viruses, they completed home interviews on the families of 87 of the children. The investigation showed that the children had a high prevalence of antibody to herpes simplex virus type 1 (73% of total sample), cytomegalovirus (78%), Epstein Barr virus (98%), and varicella-zoster virus (77%), and that prevalence tended to increase with age. None of the children demonstrated herpes simplex virus type 2 antibodies. The medical records showed that 30% of the children had suffered from gingivostomatitis prior to the study. When age was controlled for, the study showed herpes simplex virus type 1 seropositivity to be associated with children who slept in the same bed as their parents during infancy (p = 0.003) and with frequent attendance at community events (p = 0.02); cytomegalovirus seropositivity was shown to be associated with female sex (p = 0.007) and with living in a traditional Navajo dwelling (p = 0.007). The Navajo children also demonstrated a greater frequency of symptomatic oral herpes simplex virus type 1 infection than is usually recorded. The findings suggest a relation between certain patterns of cultural behavior and transmission of herpesvirus infections.     

The use of acyclovir in suspected encephalitis.

The early use of intravenous acyclovir in herpes simplex encephalitis (HSE) is essential. However, rapid diagnostic tests are not freely available. Hence, all patients with suspected encephalitis may need to be commenced on acyclovir. In our study, of 34 patients with suspected encephalitis, only two eventually had HSE confirmed, 19 had encephalitis not due to herpes simplex and in 13 a non-encephalitis illness was finally diagnosed. Guidelines for the use of acyclovir in suspected encephalitis are given aimed at minimizing the drug cost whilst still protecting all cases of presumed HSE.     

Herpes encephalitis presenting as mild aphasia: Case report

Background

Encephalitis presenting as a change in mental status can be challenging to recognize in the primary care setting. However, early detection via a low threshold of suspicion can be useful, leading in turn to early treatment and improved survival.

Case presentation

We present a case which we consider relevant to primary care practitioners. The patient in question presented with relatively mild mental status changes, progressing to confusion, dysnomia and delirium over a period of three days. While infection did not appear to be the leading cause on her differential diagnosis, she was found on extensive workup to have encephalitis caused by Herpes Simplex Virus type 1.

Conclusion

The case is instructive for general practitioners and other clinicians to maintain vigilance for central nervous system (CNS) infections which may present atypically.     

Atypical computed tomographic appearance of herpes simplex encephalitis

In cases of herpes simplex encephalitis, a low density lesion in the temporal lobe is a common CT finding, whereas hemorrhagic lesion is rarely observed on CT in this disorder despite the frequent occurrence on pathologic studies. Two cases of hemorrhagic lesion observed on CT in herpes simplex encephalitis are reported, and atypical CT findings of herpes simplex encephalitis is discussed.     

Psychiatric patient: the most vulnerable traveller

Authors analyse questions of medical evacuation of the psychotic patient from abroad to homeland. This task can be considered the most difficult problem for the attending physician and the escorting medical team as well. The main challenge is to recognise the psychotic patient in a foreign country with a different health-care system and to overcome the language barrier and the different cultural background. The second issue is to prepare the patients - who are usually in a poor condition - for the medical evacuation by commercial aircraft. Another important issue is to take the patient through the strict security control. All of these (partially unsolved) problems make the mentally ill patient defenceless. Although the repatriation of a mentally ill patient is vital and urgent, travel insurance policy mostly excludes to cover the cost of treatment and repatriation. The high cost of treatment and repatriation of the patient should be paid by the patient or the family, who are often in the position of insolvency. In this paper authors present the history of a patient and give a brief review on travel-related mental disorders, the epidemiology of mental alterations during travel as well as the problems of appropriate evacuation. Authors conclude that there is a need for a better approach of the airport authorities and insurance decision makers to the mentally ill patient travelling abroad.     

To biopsy or not to biopsy in suspected herpes simplex encephalitis: a quantitative analysis

The authors performed a decision analysis to determine whether a patient suspected to have herpes simplex encephalitis (HSE) should undergo a brain biopsy or be treated empirically with medical therapy. In most cases, empiric treatment with acyclovir would be slightly favored; brain biopsy was not essential in management. However, brain biopsy was found useful for patients who had low CSF glucose at the time of initial lumbar puncture; such patients may have a very high risk to have other treatable conditions such as tuberculosis, brain abscess, toxoplasmosis, or cryptococcosis. The results of the analysis suggest that even with the advent of safe antiviral drug therapy such as acyclovir, brain biopsy is useful in a well-defined subset of patients with possible HSE. The rationale, however, is not to confirm HSE but rather to detect other treatable conditions.     

Infectious encephalitis in France from 2000 to 2002: the hospital database is a valuable but limited source of information for epidemiological studies

Many virus and bacteria can cause encephalitis but are rarely identified as the aetiological agent by individual diagnosis. In France, the only continuous source of information about encephalitis is the national hospital medical database (NHMD). Data from the VIH-negative patients recorded in mainland France between 2000 and 2002 with a diagnosis of encephalitis were extracted and analysed according to demographic, geographical and temporal distribution. Hospitalisation details were described. An average of 1200 patients was recorded each year. They were residents of all French districts and equally hospitalized in university hospitals and non university hospitals. Their mean age was 38, and most were men. The aetiological diagnosis was unknown for 80%. The most frequent aetiological diagnosis was herpes simplex virus in adults, and VZV virus in children. These results give us some clues to design a national study on encephalitis. The study will be implemented in mainland France in 2007 and will last one year. We invite all voluntary hospitals to include their encephalitic patients in our study.     

Federal law protects AIDS patients on managed-care plan, judge rules

A managed-care plan physician was sued by his AIDS patient under the Rehabilitation Act and the Americans with Disabilities Act (ADA). The patient argued that his physician treated him like an outcast because he was HIV-positive and that the doctor never made any bona fide medical judgments about his condition. The doctor argued that the Rehabilitation Act and the ADA did not apply to medical benefits. The court stated that a primary-care physician "who receives federal funds to provide health care benefits may not withhold medical benefits, without reasonable accommodation, solely based on a participant's disability, but may only act pursuant to a bona fide medical reason." The court cited case law showing that the physician fell within the purview of the ADA because private hospitals and health-care providers are places of public accommodation. The court also held that nothing in the language of the ADA law required the patient to prove the doctor treated all HIV-positive patients differently than HIV-negative patients. Punitive damages could also be considered against a physician who refused to treat his patient because of the patient's HIV status.     

Microbial study of meningitis and encephalitis cases

Meningitis and/or encephalitis can pose a serious public health problem especially during outbreaks. A rapid and accurate diagnosis is important for effective earlier treatment. This study aimed to identify the possible microbial causes of meningitis and/or encephalitis cases. CSF and serum samples were collected from 322 patients who had signs and symptoms suggestive of meningitis and/or encephalitis. Out of 250 cases with confirmed clinical diagnosis, 83 (33.2%) were definitely diagnosed as bacterial meningitis and/or encephalitis cases (by using CSF culture, biochemical tests, latex agglutination test, and CSF stain), 17 (6.8%) were definitely diagnosed as having viral causes ( by viral isolation on tissue culture, PCR and ELISA), and one (0.4%) was diagnosed as fungal meningitis case (by India ink stain, culture, and biochemical tests). Also, there was one encephalitis case with positive serum ELISA IgM antibodies against Sandfly scilian virus. N. meningitidis, S. pneumonia and M. tuberculosis were the most frequently detected bacterial agents, while Enteroviruses, herpes simplex viruses and varicella zoster viruses were the most common viral agents encountered. Further studies are needed to assess the role of different microbial agents in CNS infections and their effective methods of diagnosis.     

Etiology of Encephalitis in Australia, 1990�C2007

Encephalitis is a clinical syndrome commonly caused by emerging pathogens, which are not under surveillance in Australia. We reviewed rates of hospitalization for patients with encephalitis in Australia’s most populous state, New South Wales, from January 1990 through December 2007. Encephalitis was the primary discharge diagnosis for 5,926 hospital admissions; average annual hospitalization rate was 5.2/100,000 population. The most commonly identified pathogen was herpes simplex virus (n = 763, 12.9%). Toxoplasma encephalitis and subacute sclerosing panencephalitis showed notable declines. The average annual encephalitis case-fatality rate (4.6%) and the proportion of patients hospitalized with encephalitis with no identified pathogen (69.8%, range 61.5%–78.7%) were stable during the study period. The nonnotifiable status of encephalitis in Australia and the high proportion of this disease with no known etiology may conceal emergence of novel pathogens. Unexplained encephalitis should be investigated, and encephalitis hospitalizations should be subject to statutory notification in Australia.     

Viral Encephalitis in England, 1989–1998: What Did We Miss?

We analyzed hospitalizations in England from April 1, 1989, to March 31, 1998, and identified approximately 700 cases, 46 fatal, from viral encephalitis that occurred during each year; most (60%) were of unknown etiology. Of cases with a diagnosis, the largest proportion was herpes simplex encephalitis. Using normal and Poisson regression, we identified six possible clusters of unknown etiology. Over 75% of hospitalizations are not reported through the routine laboratory and clinical notification systems, resulting in underdiagnosis of viral encephalitis in England. Current surveillance greatly underascertains incidence of the disease and existence of clusters; in general, outbreaks are undetected. Surveillance systems must be adapted to detect major changes in epidemiology so that timely control measures can be implemented.     

Another case of West Nile fever in the Netherlands: a man with encephalitis following a trip to Canada

Shortly after his return to the Netherlands from a trip to Ontario, a part of Canada where infection with West-Nile virus has been reported, a 69-year-old man became increasingly confused and generally unwell, accompanied by fever. The clinical picture was compatible with viral encephalitis and this was supported by EEG findings and the results of the cerebrospinal-fluid examination. MRI of the brain did not contribute to the diagnosis. The patient was treated with aciclovir because herpes simplex encephalitis was suspected, and he recovered from his illness within a few days. The EEG normalised as well. The most important remaining symptom was diminished short-term memory function. After the patient was discharged, rising antibody titres against West-Nile virus were found in two consecutive sera; there were no antibodies to other encephalitis-causing viruses (such as Q fever virus and St. Louis encephalitis virus). This case report concerns the second imported case of West-Nile fever in the Netherlands and the first one with encephalitis.     

Delirium During Acute Events in Nursing Home Patients

ObjectivesAssess the frequency of delirium during any acute event, its risk factors, and the duration of delirium in nursing home patients.DesignProspective 2-month follow-up study.Setting and Participants145 nursing home patients living in 3 Norwegian nursing homes.MethodsAt baseline, known risk factors for delirium were obtained from medical records. During any acute events where the nurses decided that a physician had to be alerted, the Confusion Assessment Method was used to identify delirium on days 1, 2, 4, and 6 and thereafter weekly if delirium was present on day 6. The precipitating cause of delirium was registered based on diagnostics performed and treatment given.ResultsOne or more acute events occurred in 57 patients, and 34 (60%) of these patients developed delirium. In 91% of the patients with delirium, the delirium was present when the physician was alerted about the acute change. Delirium lasted for more than 1 week in 15 of the 34 patients. In 18 of the 34 patients with delirium, an infection was its precipitating factor. Regular use of benzodiazepines and a diagnosis of vascular dementia were significantly associated with delirium in the logistic regression model adjusted for age, number of drugs, and comorbidity [adjusted odds ratio (95% confidence interval) 3.75 (1.44-9.74) and 5.59 (1.53-20.43), respectively].Conclusions and ImplicationsAcute events and illness were common in nursing home patients, and in our study, 60% had delirium associated with the event. In 9 of 10 patients, the delirium was present when the physician was alerted about the acute change, and infection was the most frequent cause of the delirium. Regular use of benzodiazepines and a diagnosis of vascular dementia were independent predisposing factors for delirium.     

Linkage with primary medical care in a prospective cohort of adults with addictions in inpatient detoxification: room for improvement

OBJECTIVE: To identify patient characteristics and health care experiences associated with primary care linkage after alcohol or drug detoxification. DATA SOURCES/STUDY SETTING: Primary data collected over two years. Subjects were adults without primary medical care, in an urban residential detoxification program. STUDY DESIGN: A prospective cohort study in the context of a randomized trial of a linkage intervention, and an expansion of Medicaid benefits. DATA COLLECTION/EXTRACTION METHODS: Data were collected by interview assessment of predisposing, enabling, and illness variables. Linkage was defined as self-report of at least one visit with a primary care clinician during follow-up. PRINCIPAL FINDINGS: Of 400 subjects, 63 percent linked with primary medical care. In a multivariable model adjusting for randomization assignment, predisposing, enabling, and illness variables, women, those with no recent incarceration, those with support for abstinence by family or friends, and those who had visited a medical clinic or physician recently were significantly more likely to link with primary care. Those with health insurance during follow-up were also more likely to link. Recent mental health or addictions treatment utilization and health status were not associated with linkage. CONCLUSIONS: A substantial proportion of adults with addictions do not link with primary medical care. These data suggest that efforts could be focused on those least likely to link, that contacts with mental health and addictions treatment providers are underutilized opportunities for these efforts, and that health policy changes such as expanding health insurance benefits may improve entry of substance-dependent patients into primary medical care.     

Delirium? Admission to the general hospital, rather than a psychiatric hospital

Delirium is often not recognized either by psychiatrists or by other physicians. In two men, aged 78 and 70 years, a diagnosis of delirium was not recognized at admission. The first patient had Alzheimer's disease with superimposed delirium caused by pulmonary embolism, which led to cardiopulmonary arrest during his stay in a psychiatric hospital. The other patient had a delirium due to multiple somatic causes (carbon monoxide poisoning with cerebral damage, pulmonary infection, heart attack) which was not recognized leading to an early discharge from the general hospital. The first patient died later on because of complications of a pneumonia and the other patient was transferred to a nursing home on a maintenance dose of haloperidol. Since delirium is a symptom of a medical disorder, delirious patients should be referred primarily to a general hospital.     

Lewy body dementia: case report and discussion

BACKGROUND: Lewy body dementia is a common but frequently underdiagnosed cause of dementia often mistaken for the more familiar entity of Alzheimer disease. Clinically the distinction is important, because it can have profound implications for management. METHODS: The medical literature was searched using the keywords "Lewy bodies," "Lewy body dementia," "Alzheimer dementia," and "parkinsonian disorders." A case of Lewy body dementia is described. RESULTS: An elderly man had long-standing diagnoses of Alzheimer disease and Parkinson disease. After he was evaluated thoroughly, the diagnosis was revised to Lewy body dementia, leading to changes in treatment that were associated with dramatic improvement in the patient's mental status. Evidence from the literature suggests that Lewy body dementia can be diagnosed in primary care settings based on clinical criteria. The physician should be alert to this diagnosis, and special attention should be paid to dementia patients who exhibit parkinsonism, hallucinations, fluctuating cognition, or prominent visuosperceptual deficits. CONCLUSIONS: The diagnosis of Lewy body dementia has important implications. It is associated with a high incidence of neuroleptic sensitivity, necessitating great caution in the use of these common antipsychotic agents. Early studies indicate cholinesterase inhibitors can be beneficial for treating the hallucinations and behavior disturbances that afflict these patients and might also improve cognition.     

35例EB病毒性脑炎临床分析

目的:探讨EB病毒性脑炎(Epstein-Barr virus encephalitis,EBE)临床特点及诊断依据。方法:通过多重PCR方法检测脑脊液确诊35例EBE和96例病原分别为肠道病毒(EV)、疱疹病毒(HSV)Ⅰ、Ⅱ型或巨细胞病毒(CMV)脑炎患儿,对其临床资料进行回顾性分析。结果:EBE脑脊液恢复时间、IgG蛋白定量和热程与其它病毒性脑炎比较,差异显著(P<0.05);EBE在头痛和惊厥发作持续时间上与其他病毒性脑炎无明显差异(P>0.05);在中枢神经系统影像学和脑脊液改变方面,EBE与HSV脑炎相似,但较其它病毒性脑炎改变明显,差异显著(P<0.05)。结论:EBE对中枢神经系统损害较重,临床上具有易迁延特点,免疫性损害可能是EBE的主要原因。     

Are mental status questionnaires of clinical value in everyday office practice? An affirmative view

The prevalence of dementia in older people, the poor clinical recognition of this problem by physicians, the opportunities for tertiary prevention, and the availability of reliable and convenient screening instruments all support the value of mental status questionnaires in everyday office practice. These instruments may also be helpful in longitudinal evaluation of patients with known progressive dementias. The case for screening will be substantially stronger when an effective treatment for Alzheimer's disease is found. To avoid inappropriate labeling of patients, abnormal results on a mental status questionnaire must be interpreted with caution. A thorough history is the most effective diagnostic strategy to differentiate progressive dementia from a delirium or a reversible chronic problem. An abnormal score on a mental status screening instrument should never be equated with the diagnosis of Alzheimer's disease. To document the usefulness of mental status screening in office practice, more research is clearly needed. While the value of traditional secondary prevention maneuvers may decrease in the very old, routine, careful assessment of function may prove to assist the family physician in offering important benefits to elderly patients and their families.     

Peptic ulcer disease in children: report of a case and a problem-oriented review

The family physician who sees many children with vague abdominal pain must include peptic ulcer disease in the differential diagnosis. A case report is presented and the characteristics of primary and secondary ulcers in children are reviewed with respect to symptoms, signs, diagnosis, and treatment. Ulcers in children may be primary or secondary (stress) ulcers. Clinical and radiographic diagnosis is difficult. Medical therapy suffices in most cases, but there is a high recurrence rate in adolescence and adulthood. Peptic ulcer disease in children is a diagnostic dilemma, but the family physician may be in an excellent position to make the diagnosis since he/she is often the first physician to see the patient and is aware of altered family dynamics, which may play a role in this disease.