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Patients seeking medical care with erythema migrans or flu-like symptoms after suspected or observed tick bite in the southeast of Sweden and previously investigated for Borrelia spp. and/or Anaplasma sp. were retrospectively examined for serological evidence of rickettsial infection (Study 1). Twenty of 206 patients had IgG and/or IgM antibodies to Rickettsia spp. equal to or higher than the cut-off titre of 1:64. Seven of these 20 patients showed seroconversion indicative of recent or current infection and 13 patients had titres compatible with past infection, of which five patients were judged as probable infection. Of 19 patients with medical records, 11 were positive for Borrelia spp. as well, and for Anaplasma sp., one was judged as positive. Five of the 19 patients had antibodies against all three pathogens. Erythema migrans or rash was observed at all combinations of seroreactivity, with symptoms including fever, muscle pain, headache and respiratory problems. The results were compared by screening an additional 159 patients (Study 2) primarily sampled for the analysis of Borrelia spp. or Mycoplasma pneumoniae. Sixteen of these patients were seroreactive for Rickettsia spp., of which five were judged as recent or current infection. Symptoms of arthritis, fever, cough and rash were predominant. In 80 blood donors without clinical symptoms, approximately 1 % were seroreactive for Rickettsia spp., interpreted as past infection. The study shows that both single and co-infections do occur, which illustrate the complexity in the clinical picture and a need for further studies to fully understand how these patients should best be treated.

To study the outcome of acute otitis media (AOM) with otorrhoea in children managed initially without antibiotics, in relation to bacterial and clinical findings, and to identify those who may benefit from antibiotics.Otherwise healthy, not otitis prone children aged 2-16 y, presenting with AOM with spontaneous otorrhoea, were recruited from primary care and followed at selected ear, nose and throat (ENT) clinics. Specimens for bacterial investigations were obtained; symptoms were registered on a daily basis. The main outcomes measured were the frequency of children treated with antibiotics due to persisting AOM within 9 days in relation to clinical and bacteriological findings, and new AOM within 3 months.Twelve of 71 children who completed the trial received antibiotics during the first 9 days due to lack of improvement. One received antibiotics after 16 days due to relapsing AOM and 6 received antibiotics after 30 days due to new AOM. At 2-4 days following inclusion, over 70% of children showed normalized eardrum status and markedly reduced secretion. Alloiococcus otitidis was found in 23 samples, Streptococcus pneumoniae in 12, Streptococcus pyogenes in 6, and Fusobacterium nucleatum in 5. Mycoplasma pneumoniae, Chlamydia pneumoniae, and Fusobacterium necrophorum were not detected. Antibiotics were prescribed more extensively to children with a pulsating eardrum and abundant purulent secretion. All children with S. pyogenes received antibiotics, whereas children with only A. otitidis did not.The results suggest that antibiotics are indicated in AOM with otorrhoea and the presence of abundant purulent secretion, a pulsating eardrum, or the presence of S. pyogenes. The presence of only A. otitidis was not associated with a more prolonged course or the need for antibiotics.

The family Chlamydiaceae contains several bacterial pathogens of important human and veterinary medical concern, such as Chlamydia trachomatis and Chlamydophila psittaci. Within the order Chlamydia ...

Anti-type 12 serum incorporated in agarose-polyethylene glycol gel in a concentration of 1.5% (vol/vol) was found to enable a distinct "rocket" precipitate in electro-immuno assay using hot hydrochloric acid extract of type 12 group A streptococci. This precipitate was removed by trypsin treatment of the extract and on addition of anti-M12 typing serum but not of five other typing sera to the extract. The streptococcal component responsible for this precipitate was eluted from a CM-cellulose ion exchange column at pH 6.5. These findings demonstrated that the precipitate was caused by the M12 antigen. Crossed immuno-electrophoresis of hot hydrochloric acid extracts of three different type 12 group A streptococci showed that the electrophoretic mobility of the M12 antigens was similar in the three extracts. A linear correlation was obtained between the concentration of the M12-antigen and the height of the precipitate obtained in the electro-immuno assay using different dilutions of a standard type 12 extract. M12 antigen could thus be quantitated by the electro-immuno assay. In quantitation experiments, uniformly prepared extracts of five randomly selected, freshly-isolated type 12 strains were found to contain from 130 to 1850% of M12 antigen, respectively (expressed in % of the content of the standard type 12 extract).

Various polyelectrolytes were investigated regarding their capacity to inhibit the binding of human IgG to Fc-receptors on group A streptococci, type M1. Of cationic substances, protamine and arginine-rich histone inhibited significantly, while lysine-rich histone, concanavalin A, lysozyme, polymyxin B, ribonuclease and tuftsin did not. Of anionic materials, liquoid was inhibitory, in contrast to chondroitin sulphate, dextran sulphate, DNA and heparin. Washing experiments showed that the inhibition was caused by binding of the polyelectrolytes to the streptococci. The finding that heated IgG inhibited the binding of histone to the streptococci also indicated a close relation between the binding sites for these compounds. Diffusion-in-gel experiments with alkaline extract of M1 demonstrated that the substances blocking the IgG Fc-receptor were bound to polyglycerophosphate, suggesting that the inhibition of the IgG uptake was due to interaction with lipoteichoic acid. Leukocyte and platelet extracts could modify the binding of IgG, probably by an enzymatic digestion of the receptors. The arginine-rich histone was also capable of inhibiting the binding of IgG to type M15 group A streptococci and to one group G strain. However, the polyelectrolytes had no effect on the binding of IgG to Staphylococcus aureus or of IgA to type 4 group A streptococci.

Precipitation patterns of sonicated, acid-extracted and other extracts from Branhamella catarrhalis were examined by double diffusion-in-gel technique, using antiserum to B. catarrhalis. Acid extract gave rise to 4 distinct precipitates. One of these lines was further studied. The bacterial component responsible for this line was trypsin-sensitive, indicating that it was a protein. It was anodally localized by crossed immunoelectrophoresis. By absorption of antiserum with whole bacteria, the precipitating capacity of the serum was diminished, suggesting that the protein antigen (P-antigen) was exposed on the bacterial surface. F(ab')2-fragments of IgG from antiserum, but not from normal rabbit serum, precipitated the P-antigen, indicating that it was a true antigen-antibody reaction. It was possible to make an IgG preparation monospecific for the P-antigen, by absorbing antiserum with trypsinized bacterial extract. 31 strains of B. catarrhalis, 9 strains of N. gonorrhoeae, 10 strains of N. meningitidis, 12 other Neisseria spp. and 2 strains of H. influenzae were investigated for presence of cross-reacting surface antigens, using IgG monospecific for the P-antigen and 125I-labelled protein A from Staphylococcus aureus. After antibody exposure, all 31 strains of B. catarrhalis showed abundant uptake of protein A. No significant uptake was detected on any other investigated strain. Hence, the P-antigen appears to be characteristic of B. catarrhalis. The possibility of a serological identification of the species is introduced. Precipitating antibodies against the P-antigen were demonstrated in 69% of normal human sera.

The aim of this study was to evaluate the synthetic C6 peptide test as a first-line test in a two-tiered scheme for Borrelia serology in a clinically well-characterized population of patients with Lyme borreliosis in Kalmar County, Sweden. The study population consisted of a prospective group (n = 200), a control group (n = 255), and a retrospective group (n = 29). The test panel consisted of the Immunetics Quick ELISA C6 Borrelia assay kit (Immunetics, Cambridge, MA, USA), the Virotech Borrelia burgdorferi ELISA (Genzyme Virotech, Rüsselsheim, Germany), and the Liaison Borrelia CLIA (DiaSorin, Saluggia, Vercelli, Italy). Seroprevalence among 200 healthy blood donors was significantly lower in the C6 test (8%) compared to the Virotech ELISA (14%) and the Liaison CLIA (12%). In convalescent sera (2-3 months and 6 months post infection) from 158 patients with erythema migrans, the seropositivity in the C6 test was also significantly lower compared to both the Virotech ELISA and the Liaison CLIA. Serosensitivity in the acute phase of erythema migrans and other clinical manifestations of borreliosis did not differ significantly between the C6 test and the Virotech ELISA or the Liaison CLIA. Overall, a positive C6 test seems to correlate well with acute borreliosis. Cross-reactivity was lower in the C6 test in sera positive for Epstein-Barr virus infection as compared to the Virotech ELISA. This study supports the use of the C6 test as a screening test for borreliosis, in endemic areas.

The tick-borne infectious agents, B. burgdorferi, A. phagocytophilum and the TBE-virus, can all cause clinical disease in humans and may all initially give rise to myalgia, arthralgia, headache and fever. The clinical manifestations of the infections range from subclinical or mild to severe, in some cases with a postinfectious sequel, and mixed infections may occur, confusing the clinical picture.The aim of this thesis was to investigate the occurrence and co-existence of these infections in a Scandinavian context. A further aim was to study aspects of the immunopathogenesis of B. burgdorferi infection and possible effects on the immune response when previously exposed to A. phagocytophilum. Finally, an attempt was made to improve the laboratory diagnosis of Lyme neuroborreliosis (LNB).In a prospective clinical study, patients were recruited based on two independent inclusion criteria; 1) patients with unspecific symptoms or fever, and 2) patients with erythema migrans (EM). Among 206 patients, we found 186 cases of Lyme borreliosis (LB) (174 with EM), 18 confirmed and two probable cases of human granulocytic anaplasmosis (HGA), and two cases of Tick-borne encephalitis (TBE). Thirteen of the HGA cases presented without fever. Furthermore, 22 of the EM patients had a subclinical co-infection with A. phagocytophilum, based on serology. Both TBE cases had co-infections, one with B. burgdorferi and one with A. phagocytophilum.In another investigation, IL-12p70 secretion in patients with current LB was compared in patients with or without previous A. phagocytophilum infection. Patients with serological evidence of previous exposure to A. phagocytophilum had a lower B. burgdorferi-induced IL-12p70 secretion. Since IL-12p70 induces the Th1 response, this finding indicates a reduced Th1 response, possibly caused by A. phagocytophilum. In a separate study, we showed that patients with LNB had increased levels of cytokines associated with cytotoxicity in cerebrospinal fluid (CSF), including the recently described cytokine IL-17.Since it is known that the adaptive immune system, especially the T cells, is activated during an infection with B. burgdorferi, a modified ELISPOT assay using cells from CSF was evaluated to be a useful complementary test in diagnosing LNB. However, we found that the diagnostic performance was too weak in our setting, and we could not recommend it for use in clinical laboratories at this stage.In conclusion, tick-borne co-infections are probably quite common in Sweden. Our HGA cases were most often discovered as co-infections with LB and would probably have been missed during a routine consultation. They presented with mild symptoms and often without fever, which in previous reports has been part of the disease definition.The immune response in LNB was shown to be compartmentalized to the target organ, also in terms of cytokine response. Furthermore, we found indications of possible long-term effects of A. phagocytophilum infection, demonstrated as a reduced IL-12p70 secretion in patients with ongoing LB. This could be a disadvantage when mounting a Th1 response to infection with B. burgdorferi. If this is so, the inter-play of these infectious agents in co-infections or consecutive infections may be of importance to clinical outcome.

In Scandinavia, tick-borne infections affecting humans include Lyme borreliosis (LB), tick-borne encephalitis (TBE) and human granulocytic anaplasmosis (HGA). Each of these infections can present with unspecific symptoms. In this prospective clinical study, we recruited patients based on two independent inclusion criteria; 1) patients with unspecific symptoms, i.e. fever (≥38.0˚C) or a history of feverishness and/or any combination of headache, myalgia or arthralgia and 2) patients with erythema migrans (EM), following an observed tick bite or tick exposure within one month prior to onset of symptoms. A total of 206 patients fulfilled the study. Among these, we could identify 186 cases of LB (174 with EM), 18 confirmed and two probable cases of HGA and two cases of TBE. Thirteen of the HGA cases presented without fever. Furthermore, 22 of the EM patients had a sub-clinical co-infection with Anaplasma phagocytophilum, based on serology. Both TBE cases had co-infections, one with Borrelia burgdorferi and one with Anaplasma phagocytophilum. We conclude that it is important to consider several causative agents and possible co-infections in the clinical management of infectious diseases where ticks may be suspected as vectors.

The family Chlamydiaceae contains several bacterial pathogens of important human and veterinary medical concern, such as Chlamydia trachomatis and Chlamydophila psittaci. Within the order Chlamydiales there are also an increasing number of chlamydia-like bacteria whose biodiversity, host range and environmental spread seem to have been largely underestimated, and which are currently being investigated for their potential medical relevance. In this study we present 16S rRNA, rnpB and ompA gene sequence data congruently indicating a novel chlamydia-like bacterium found in faecal specimens from opportunistic fish-eating sea birds, belonging to the Laridae and Alcidae families, from the Bering Sea. This novel bacterium appears to be closer to the Chlamydiaceae than other chlamydia-like bacteria and is most likely a novel genus within the Chlamydiaceae family.

The aim of this prospective study was to investigate the diagnostic performance of Borrelia (Bb)-induced interferon (IFN)-γ secretion detected by ELISPOT modified to be feasible for clinical laboratories as a supplementary test to the laboratory diagnosis of Lyme neuroborreliosis (LNB) in an endemic setting. Between 2002 and 2004, patients with symptoms of suspected clinical LNB were included in a study conducted on the Åland islands in the Finnish archipelago, which is a hyper-endemic area for Lyme borreliosis (LB). Fourteen patients with confirmed LNB and 103 patients with non-LNB were included, and the numbers of spontaneous and Bb-induced IFN-γ-secreting cells were assayed by the ELISPOT test. The ELISPOT assay showed a weak diagnostic performance with a sensitivity of 36% and a specificity of 82%. The findings in this study show that this ELISPOT-assay modified to be feasible in clinical routine laboratories is not useful as a supplementary diagnostic tool in the laboratory diagnosis of patients with clinically suspected LNB.

OBJECTIVES: The aim of this study was to evaluate the chemokine CXCL13 and C6 antibodies separately and in combination in paired serum/cerebrospinal fluid (CSF) samples in the laboratory diagnosis of Lyme neuroborreliosis (LNB). METHODS: A large retrospective material with paired serum/CSF samples from 261 patients with clinically suspected LNB was investigated. Patients were divided into three main diagnostic groups based on original results of CSF pleocytosis and intrathecal anti-borrelia antibodies (purified flagellum). Levels of CXCL13, albumin, total IgM and IgG in paired samples and C6 antibodies in CSF were compared across diagnostic groups. RESULTS: A sensitivity of 99% and a specificity of 96% were achieved for CSF-Serum CXCL13 ratio. CSF-C6 antibodies performed with a sensitivity of 99% and a specificity of 88.0%. A combination of CSF-Serum CXCL13 ratio and CSF-C6 antibodies, evaluated in parallel, revealed a sensitivity of 99% and specificity of 98%. CONCLUSIONS: This study confirms CSF-CXCL13 as a reliable marker of LNB and suggests improved diagnostic performance especially in children with possible LNB. Original Publication: Ivar Tjernberg, Anna J Henningsson, Ingvar Eliasson, Pia Forsberg and Jan Ernerudh, Diagnostic performance of cerebrospinal fluid chemokine CXCL13 and antibodies to the C6-peptide in Lyme neuroborreliosis., 2011, Journal of Infection, (62), 2, 149-158. http://dx.doi.org/10.1016/j.jinf.2010.11.005 Copyright: Elsevier Science B.V., Amsterdam http://www.elsevier.com/

Background: Persistent symptoms after treatment for neuroborreliosis are common for reasons mainly unknown. These symptoms are often unspecific and could be caused by dysfunctions in endocrine systems, an issue that has not been previously addressed systematically. We therefore mapped hormone levels in patients with previous confirmed Lyme neuroborreliosis of different outcomes and compared them with a healthy control group. Methods: Twenty patients of a retrospective cohort of patients treated for definite Lyme neuroborreliosis were recruited 2.3 to 3.7 years (median 2.7) after diagnosis, together with 23 healthy controls. Lyme neuroborreliosis patients were stratified into two groups according to a symptom/sign score. All participants underwent anthropometric and physiological investigation as well as an extensive biochemical endocrine investigation including a short high-dose adrenocorticotropic hormone stimulation (Synacthen (R)) test. In addition to hormonal status, we also examined electrolytes, 25-hydroxy-vitamin D and interleukin-6. Results: Eight patients (40%) had pronounced symptoms 2-3 years after treatment. This group had a higher cortisol response to synacthen as compared with both controls and the Lyme neuroborreliosis patients without remaining symptoms (p andlt; 0.001 for both comparisons). No other significant differences in the various baseline biochemical parameters, anthropometric or physiological data could be detected across groups. Conclusions: Apart from a positive association between the occurrence of long-lasting complaints after Lyme neuroborreliosis and cortisol response to synacthen, no corticotropic insufficiency or other serious hormonal dysfunction was found to be associated with remaining symptoms after treatment for Lyme neuroborreliosis. Original Publication:Ivar Tjernberg, Martin Carlsson, Jan Ernerudh, Ingvar Eliasson and Pia Forsberg, Mapping of hormones and cortisol responses in patients after Lyme neuroborreliosis, 2010, BMC INFECTIOUS DISEASES, (10), 20.http://dx.doi.org/10.1186/1471-2334-10-20Licensee: BioMed Centralhttp://www.biomedcentral.com/

Sales of antibiotics have increased in Sweden during the past decade. This has been paralleled by an increase in the frequency of beta-lactamase-producing respiratory tract bacteria. To investigate the effects of regional differences in use of antibiotics on beta-lactamase production in respiratory tract bacteria, we collected nasopharyngeal specimens and information about antibiotic use from 1133 children attending day-care centres in four rural municipalities with low use, and one urban municipality with high use of antibiotics, use being assessed from pharmacy sales. The frequency of beta-lactamase production among isolates of Branhamella catarrhalis and Moraxella nonliquefaciens was significantly higher in the urban municipality. This appeared to be a long-term ecological effect of differences in the level of use of antibiotics between the urban and rural populations, rather than an effect of recent antibiotic treatment of individual patients.

Borrelia garinii, a causative agent of Lyme borreliosis in Europe and Asia, is naturally maintained in marine and terrestrial enzootic cycles, which primarily involve birds, including seabirds and migratory passerines. These bird groups associate with, correspondingly, Ixodes uriae and Ixodes ricinus ticks, of which the latter species may bite and transmit the infection to humans. Studies of the overlap between these two natural cycles of B. garinii have been limited, in part due to the absence of representative collections of this spirochete's samples, as well as of the lack of reliable measure of the genetic heterogeneity of its strains. As a prerequisite for understanding the epidemiological correlates of the complex maintenance of B. garinii, the present study sought to assess the diversity and phylogenetic relationships of this species' strains from its natural hosts and patients with Lyme borreliosis from subarctic Eurasia. We used sequence typing of the partial rrs-rrl intergenic spacer (IGS) of archived and prospective samples of B. garinii from I. uriae ticks collected predominantly on Commander Islands in North Pacific, as well as on the islands in northern Sweden and arctic Norway. We also typed B. garinii samples from patients with Lyme borreliosis and I. ricinus ticks infesting migratory birds in southern Sweden, or found questing in selected sites on the islands in the Baltic Sea and Lithuania. Fifty-two (68%) of 77 B. garinii samples representing wide geographical range and associated with I. ricinus and infection of humans contributed 12 (60%) of total 20 identified IGS variants. In contrast, the remaining 25 (32%) samples recovered from I. uriae ticks from a few islands accounted for as many as 10 (50%) IGS types, suggesting greater local diversity of B. garinii maintained by seabirds and their ticks. Two IGS variants of the spirochete in common for both tick species were found in I. ricinus larvae from migratory birds, an indication that B. garinii strains are exchanged between different ecological niches. Notably, B. garinii variants associated with I. uriae ticks were found in each of the six clusters, representing two phylogenetic lineages of this species identified among the studied samples. Our findings suggest that B. garinii in subarctic Eurasia comprises two partially overlapping populations with different levels of genetic heterogeneity, presumably, due to distinctive selective pressures on the spirochete in its marine and terrestrial enzootic cycles.

The aim of this study was to evaluate the antibody responses to different VlsE protein IR6 peptide variants and the synthetic C6 peptide in acute and convalescent (2-3 and 6 months) serum samples from Swedish patients with clinical erythema migrans (EM). Serum samples were prospectively collected from 148 patients with EM and compared to serum samples obtained from 200 healthy blood donors. The IgG responses to 3 IR6 peptide variants originating from Borrelia burgdorferi (B. burgdorferi) sensu stricto, B. garinii, and B. afzelii were measured by enzyme-linked immunosorbent assays (ELISAs) and compared to a commercial C6 peptide ELISA. Seropositivity rate in the IR6 or C6 peptide ELISAs ranged from 32% to 58% at presentation, 30-52% after 2-3 months, and 20-36% after 6 months. At presentation, positive antibodies in any of the 4 ELISAs were found in 66%. In 7/52 (13%), C6-negative EM cases, serological reaction was found to the B. burgdorferi sensu stricto-derived IR6 peptide. In patients reporting previous LB compared to those without previous LB, significantly higher seropositivity rates were noted for all IR6 peptides, but not for the C6 peptide. In the serology of EM in Europe, C6 ELISA does not seem to cover all cases. An ELISA using a mixture of B. burgdorferi sensu stricto IR6 peptide and the C6 peptide could be of value in the serodiagnosis of LB in Europe. Further studies on combinations of variant IR6 peptides and the C6 peptide in other manifestations of LB are needed to address this issue. Original Publication:Ivar Tjernberg, H. Sillanpaa, I. Seppala, I. Eliasson, Pia Forsberg and P. Lahdenne, Antibody responses to borrelia IR6 peptide variants and the C6 peptide in Swedish patients with erythema migrans, 2009, International Journal of Medical Microbiology, (299), 6, 439-446.http://dx.doi.org/10.1016/j.ijmm.2008.10.006Copyright: Elsevier Science B. V. Amsterdamhttp://www.elsevier.com/

The aim of this study was to evaluate the usefulness of borrelia serology (Quick ELISA C6 Borrelia assay kit) as a diagnostic tool in cases of suspected neuroborreliosis. A retrospective patient material consisting of 124 paired serum and cerebrospinal fluid samples with a positive anti-borrelia antibody index (AI) using the IDEIA Lyme Neuroborreliosis test was compared with 124 AI-negative matched control subjects. The patients were divided into four groups based on presence of pleocytosis and age above or below 12 years. The presence of positive C6 serology in AI-positive patients with pleocytosis was 89% (83/93), significantly different (p0.01) from in patients without pleocytosis (58%, 18/31). In AI-positive patients agedor =12 years with pleocytosis, 94% (51/54) had a positive C6 serology. Of AI-positive patients with a symptom duration of more than 30 days, 93% (27/29) were positive by the C6 test. We conclude that the C6 serum test, together with clinical evaluation, is a powerful diagnostic tool in adult (or =12 years) European patients with suspected neuroborreliosis with a symptom duration of more than 30 days. Patients with suspected neuroborreliosis and positive C6 results should be further investigated by lumbar puncture for definite diagnosis.

purpose: To assess the ecologic impact, in terms of selection of beta-lactamase-producing respiratory tract bacteria, of a single course of peroral beta-lactam antibiotics. patients and methods: One-hundred fifty consecutive children with clinical signs of bacterial respiratory tract infection were randomly assigned to a seven-day course of treatment with either penicillin V, amoxicillin, or cefaclor. Bacteriologic specimens were collected before treatment, at its termination, and at follow-up four weeks later. results: All three drugs investigated caused a similar increase in beta-lactamase-producing bacteria, both in absolute and relative terms, an increase that persisted over a period of at least one month after completion of treatment. conclusion: Penicillin V, amoxicillin, and cefaclor all act as selective agents for beta-lactamase-producing bacteria in the upper respiratory tract. Treatment with a peroral beta-lactam antibiotic puts patients at risk of becoming persistent carriers of beta-lactamase-producing bacteria.

To study the clinical recovery from acute otitis media (AOM) in children, 2-16 years of age, managed with or without treatment with phenoxymethylpenicillin (PcV).An open, prospective randomized trial. Children aged between 2 and 16 years, presenting with one- or double-sided AOM (without perforation) with symptom duration of less than four days, were included. The children were randomized to PcV for five days or to no primary antibiotic treatment. A health score and compliance were registered on a daily basis for seven days.A total of 32 health centres and 72 GPs in south-east Sweden. Subjects. Children aged 2-16 presenting with earache.Recovery time, symptom duration, frequency of complications (up to three months) and consumption of healthcare services independent of treatment with or without antibiotics.A total of 179 patients carried out the trial; 92 were randomized to PcV, 87 to no primary antibiotic treatment. The median recovery time was four days in both groups. Patients who received PcV had less pain (p0.001) and used fewer analgesics. There were no significant differences in the number of middle-ear effusions or perforations at the final control after three months. Children randomized to PcV treatment consulted less (p0.001) during the first seven days.Our investigation supports that PcV treatment of AOM does not affect the recovery time or complication rates. PcV provided some symptomatic benefit in the treatment of AOM in otherwise healthy children, aged 2-16 years.

Aims: To genetically sub-type Campylobacter jejuni strains isolated from migratory birds, and to compare these with clinical strains collected in the same area and corresponding time period, with the aim to increase our knowledge on sub-types occurring among wild birds and their possible impact on human disease. Methods and Results: We sub-typed C. jejuni strains from migrating birds (n = 89) and humans (n = 47), using macrorestriction profiling by pulsed-field gel electrophoresis. Isolates from migrant birds often exhibited sub-types with higher levels of similarity to isolates from birds of the same species or feeding guild, than to isolates from other groups of birds. Likewise, could the vast majority of sub-types found among the migrant bird isolates not be identified among sub-types from human cases. Only two bird strains, one from a starling (Sturnus vulgaris) and one from a blackbird (Turdus merula), had sub-types that were similar to some of the human strain sub-types. Conclusions: Isolates from one bird species, or feeding guild, often exhibited high similarities, indicating a common transmission source for individuals, or an association between certain sub-types of C. jejuni and certain ecological guilds or phylogenetic groups of birds. Sub-types occurring among wild birds were in general distinctively different from those observed in patients. The two bird isolates that were similar to human strains were isolated from bird species that often live in close associations with human settlements. Significance and Impact of Study: Wild birds have often been mentioned as a potential route for transmission of C. jejuni to humans. Our study demonstrates that strains isolated from birds most often are different from clinical strains, but that some strain similarities occur, notably in birds strongly associated with human activities.

Between May and December 1998, tick-associated febrile illness was prospectively studied in Southeast Sweden in order to assess the occurrence of human granulocytic ehrlichiosis (HGE). Inclusion criteria were fever (or = 38.0 degrees C), with or without headache, myalgia or arthralgia in patients with an observed tick bite or tick exposure within 1 month prior to onset of symptoms. Patients with clinical signs of Lyme borreliosis were included. Of the 27 patients included, we identified 4 cases of HGE. Three of the patients had coinfection with Lyme borreliosis, which presented as erythema migrans. All 27 patients presented with a 2-5 d history of fever. None of the clinical signs or laboratory parameters monitored was helpful in predicting ehrlichiosis in this group with tick-associated fever conditions. Within the HGE-negative group (n = 23), 12 patients had clinical or laboratory signs of Lyme borreliosis. For 11 patients, the aetiology of the fever remained unclear. Our results suggest that HGE is common in tick-infested areas of Southeast Sweden, and may occur as a coinfection of Lyme borreliosis. Granulocytic ehrlichiosis should be suspected in patients who present with tick-associated fever, with or without erythema migrans. Ehrlichia serology and PCR should be employed to confirm the diagnosis.

We report the isolation and partial genetic characterization of two equine strains of granulocytic Ehrlichia of the genogroup Ehrlichia phagocytophila . Frozen whole-blood samples from two Swedish horses with laboratory-verified granulocytic ehrlichiosis were inoculated into HL-60 cell cultures. Granulocytic Ehrlichia was isolated and propagated from both horses. DNA extracts from the respective strains were amplified by PCR using primers directed towards the 16S rRNA gene, the groESL heat shock operon gene, and the ank gene. The amplified gene fragments were sequenced and compared to known sequences in the GenBank database. With respect to the 16S rRNA gene, the groESL gene, and the ank gene, the DNA sequences of the two equine Ehrlichia isolates were identical to sequences found in isolates from clinical cases of granulocytic ehrlichiosis in humans and domestic animals in Sweden. However, compared to amplified DNA from an American Ehrlichia strain of the E . phagocytophila genogroup, differences were found in the groESL gene and ank gene sequences.

The seroprevalence of granulocytic ehrlichiosis has been documented in several studies, but little data exists on incidence rates. Using sera stored from an earlier study on Lyme borreliosis, 290 residents of Aspö Island could be followed prospectively during two tick seasons (1992-1994). Immunoglobulin G antibodies to granulocytic ehrlichiosis were detected by an immunofluorescence assay using Ehrli- chia equi as antigen. Seroprevalence rates increased significantly over time, and at the 1994 follow-up, 28% of the residents were seropositive. Negative-to-positive seroconversion (incidence) rates were 3.9% and 11.1%, respectively, during the two seasons. A highly significant correlation was found between a positive serologic response for granulocytic ehrlichiosis and Borrelia burgdorferi. No such correlations were found for clinical Lyme borreliosis, self-reported arthralgia or number of recorded tick bites. It was concluded that granulocytic ehrlichiosis is highly endemic in this part of Sweden, with a seroconversion rate as high as 11% over a single tick season. Further studies are necessary to correlate these findings with clinical signs of human granulocytic ehrlichiosis.

Background factors, symptoms and signs were analysed in 40 consecutive patients with psychogenic dysphonia. Their voice profile was compared with that of 40 patients with infectious laryngitis. The majority of the patients were young females, non-smokers, who were not professional voice users. Criteria for acute infectious laryngitis prior the voice disorder were met in no more than 10% of the patients. Nevertheless as many as 40% of the patients had been treated with various antibiotics. The prevalence of reported asthma/allergy-like symptoms was high, 37.5%. Perceptual analysis of voice profiles demonstrated similarity of aberrancies in psychogenic dysphonia and in acute laryngitis. Since it may be difficult to distinguish psychogenic dysphonia from acute laryngitis, careful analysis of anamnestic data may be helpful for a correct diagnosis.

We studied sera from patients who had participated in a prospective study of borreliosis in Sweden and had acquired tick bites in areas of the country with a high prevalence of granulocytic ehrlichial infections in animals. The sera were examined for IgG anti Ehrlichia antibodies by an indirect immunofluorescence assay using a locally isolated bovine Ehrlichia antigen. Confirmation of the serological results was done at the Unite des Rickettsies, Marseille, France. Three out of 37 of the investigated patients and 1 out of 100 investigated healthy blood donors had significant antibody titres to granulocytotropic Ehrlichiae. No patient or blood donor had specific antibody titres to Ehrlichia chaffeensis. These data suggest that Scandinavian Ehrlichia species can infect and evoke immunological response in tick-exposed humans.

Moraxella catarrhalis and Hemophilus influenzae are isolated from the nasopharynx in 50% to 55% and 8% to 15%, respectively, of cases of acute laryngitis in adults. This finding indicates that these organisms, M catarrhalis in particular, are in some way involved in the pathogenesis of the disorder. In the present double-blind, placebo-controlled trial, the effect of erythromycin ethylsuccinate (0.5 g twice a day for 5 days) on the elimination of nasopharyngeal pathogens and reduction of clinical signs of upper respiratory tract infection, as well as on subjective complaints, was evaluated in 106 adults with acute laryngitis. The bacterial isolation rates at presentation were M catarrhalis 50%, H influenzae 18%, and Streptococcus pneumoniae 4%. In the 99 patients who completed the study, the elimination of M catarrhalis after 1 week was better in the erythromycin group (25 of 30 cases) than in the placebo group (6 of 19 cases; p ≤ .00038). The elimination of H influenzae was unaffected by erythromycin. Otolaryngologic examination did not reveal any significant group differences regarding laryngitis, pharyngitis, or rhinitis. Voice quality was improved after 1 week, irrespective of treatment. However, as compared to the placebo group, the erythromycin group reported fewer voice complaints after 1 week and fewer coughing complaints after 2 weeks. As acute laryngitis in adults is self-limiting, and subjective symptoms are spontaneously reduced after 1 week in most cases, antibiotic treatment does not seem warranted as a general policy. However, erythromycin may be justified in patients who are professionally dependent on voice function.

In Moraxella (Branhamella) catarrhalis and Moraxella nonliquefaciens strains isolated from clinical specimens in the south of Sweden two variants of beta-lactamase were distinguished by isoelectric focusing (IEF). The BRO-1 (Ravasio type) enzyme was the most common in Branhamella catarrhalis, constituting about 90% of the beta-lactamase found in this species, while the BRO-2 enzyme (1908 type) was as common as BRO-1 in Moraxella nonliquefaciens. The determinants mediating the production of BRO-1 and BRO-2 were both transferable by conjugation. Cell-bound beta-lactamase from reference strains producing BRO-1 and BRO-2 could be solubilized by papain digestion. The isoelectric point of the solubilized enzymes differed distinctly between BRO-1 (pI 6.5) and BRO-2 (pI 6.9). The molecular species of BRO-1 and BRO-2 released by papain digestion were purified by affinity chromatography with phenylboronic acid agarose gel. They had identical molecular weights of approximately 28,000. Their kinetic constants were indistinguishable for a number of substrates and beta-lactamase inhibitors.

Previous studies of acute laryngitis in adults have shown high nasopharyngeal isolation rates of B. catarrhalis and H. influenzae. Phenoxymethylpenicillin had no effect on the clinical course. In the present study, 106 patients with acute laryngitis were treated with erythromycin 0.5 g x 2 V or placebo. During the first week the isolation rate of B. catarrhalis was reduced from 60 to 10% in the erythromycin group compared to 34 to 27% in the placebo group (p less than 0.01). The elimination of H. influenzae, isolated in 19% at the acute visit, did not differ between the two groups. As compared to controls, erythromycin treated patients reported significantly lower scores of subjective voice disturbance after 1 week and cough after 2 weeks. Laryngological examination and voice evaluation failed to reveal any differences between the groups.

In order to determine the recovery rate of species of the genera Haemophilus and Moraxella (including subgenus Branhamella) from the upper respiratory tract and the incidence of beta-lactamase production within these genera, cultures were made of nose and throat swab specimens and adenoid tissue in 50 children undergoing adenoidectomy. Haemophilus influenzae was isolated from 92% of the children. All children harboured strains of Haemophilus spp. and in 46%, at least one strain produced the TEM-1 beta-lactamase. Branhamella catarrhalis and/or Moraxella nonliquefaciens were isolated from 82% of the children and strains producing the BRO-1 beta-lactamase from 34%. Overall, TEM-1 and/or BRO-1 producing strains were recovered from 60% of the investigated patients. The beta-lactamase production was found to be transferable by conjugation within the respective genera. It is suggested that the apathogenic species may be a source of transferable determinants mediating beta-lactamase production in the upper respiratory tract.

Various cationic polyelectrolytes (poly-alpha-amino acids and histones), lectins, the chemotactic peptide, f-methionyl-leucyl-phenylalanine (fMLP), the calcium ionophore A23187, and phorbol myristate acetate (PMA) were investigated regarding their capacity to induce luminol-dependent chemiluminescence (LDCL) and superoxide production by human blood leukocytes. Although when tested individually, poly-L-arginine (PARG), phytohemagglutinin (PHA), concanavalin A (Con A), or fMLP induced only a low to moderate LDCL response, very intense synergistic CL reactions were obtained by mixtures of PARG + PHA, PARG + Con A, PARG + PHA + fMLP, Ca2 + ionophore + PARG + PHA + fMLP, and PARG + PMA. The sequence of addition of the various agents to WBC in the presence of luminol absolutely determined the intensity of the LDCL signals obtained, the highest reactions being achieved when the WBC were preincubated for 2-3 min with A23187 followed by the sequential addition of fMLP, PARG, and PHA. These "multiple hits" induced CL reactions which were many times higher than those obtained by each factor alone. On the other hand, neither poly-L-lysine, poly-L-ornithine, poly-L-histidine, nor poly-L-asparagine, when employed at equimolar concentrations, cooperated efficiently with PHA and fMLP to trigger synergistic LDCL responses in leukocytes. Concomitantly with the induction of LDCL, certain ligand mixtures also triggered the production of superoxide. The LDCL which was induced by the "cocktail" of agents was markedly inhibited by sodium azide (93% inhibition), but to a lesser extent by catalase (10% inhibition) or by superoxide dismutase (20%-60% inhibition). On the other hand, scavengers of singlet oxygen and OH (sodium benzoate, histidine) did not affect the synergistic LDCL responses induced by these multiple ligands. Cytochalasin B also markedly inhibited the LDCL responses induced either by soluble stimuli or by streptococci preopsonized either with histone or with polyanethole sulfonate. The LDCL responses which were induced by mixtures of PARG and concanavalin A were also strongly inhibited by mannose, alpha-methyl mannoside, and poly-L-glutamic acid. The data suggest that the LDCL responses induced by the soluble ligands involved a myeloperoxidase-catalyzed reaction. The possible employment of "cocktails" of ligands to enhance the bactericidal effects of PMNs, macrophages, and natural killer cells on microbial cells and mammalian targets is discussed.

The plasmid-mediated Branhamella catarrhalis beta-lactamase BRO-1, also found in Moraxella nonliquefaciens, was characterized as regards substrate profile, isoelectric point and relative substrate affinity index (RSAI) to various substrates and compared in these aspects with the TEM-1 enzyme of Haemophilus influenzae. As measured by a biological assay and with high performance liquid chromatography (HPLC), BRO-1 was found to hydrolyse carbenicillin, mecillinam, methicillin and cefaclor with a higher rate than TEM-1. The only substrates having a relative rate of hydrolysis higher for TEM-1 than for BRO-1 were ampicillin and cephaloridine. The rates of hydrolysis registered with these two methods were comparable for all but 2 of 13 tested substrates. Isoelectric focusing yielded a main band at pH 5.6 and several satellite bands consistent with those reported by other authors for Branhamella enzymes having a substrate profile similar to that of BRO-1. A tenfold or higher difference in RSAI between BRO-1 and TEM-1 was recorded for five of the 15 compounds tested. BRO-1 seems to be the most common beta-lactamase in Bran. catarrhalis, irrespective of geographic origin. Its substrate profile, isoelectric pattern and RSAI differ from those of other known plasmid-mediated beta-lactamases described, thus justifying a specific designation.

The plasmid-mediated beta-lactamase in Branhamella catarrhalis (BRO-1), also occurring in Moraxella nonliquefaciens, differs from other known plasmid-mediated beta-lactamases in Gram-negative bacteria regarding substrate profile and isoelectric point. B. catarrhalis strains previously reported to produce beta-lactamases deviating from BRO-1 were tested, and the beta-lactamases did not differ significantly from BRO-1 in substrate profile, isoelectric point or relative substrate affinity index (RSAI). Further investigations of strains of various geographic origin should be undertaken. RSAI seems to be a useful tool for screening of beta-lactamases in B. catarrhalis since values for a large number of strains can easily be determined. The previously reported conjugational transfer of BRO-1 production within species B. catarrhalis and from M. nonliquefaciens to B. catarrhalis was confirmed. Four bands of extrachromosomal DNA were regularly detected by agarose gel electrophoresis in beta-lactamase-producing as well as in beta-lactamase-negative strains of B. catarrhalis and M. non-liquefaciens, provided that the excessive nuclease activity in the preparations was inhibited.

A protein antigen — P-antigen — itcharacteristic of Branhamella catarrhalis has been described. Precipitating antibodies against this antigen occur in a majority of healthy human sera; serological evidence for a pathogenic role of B. catarrhalis is accumulating. The occurrence of complement-fixing antibodies has been demonstrated during broncho-pulmonary infection with B. catarrhalis and in maxillary sinusitis. Increases in antibody titres assessed by an enzyme-linked immunosorbent assay (ELISA) technique have been reported in children with acute otitis media. An ELISA, using purified P- antigen, for the evaluation of IgG, IgM and IgA antibodies against B. catarrhalis is being developed.

Four qualitative methods for the detection of beta-lactamase production in Staphylococcus and Micrococcus species were evaluated and compared with a quantitative macroiodometric reference method. The disc diffusion test with penicillin G and the cloverleaf method could not separate beta-lactamase-positive from beta-lactamase-negative strains. Two applications of the chromogenic cephalosporin test, using uninduced strains and strains grown on blood agar plates, gave a large number of false negative and false positive results. False negative reactions were most common among uninduced strains, while the false positive reactions were most often recorded for Staphylococcus saprophyticus. A high degree of efficiency was recorded for the nitrocefin spot test, using induced strains grown on antibiotic susceptibility agar, and for the starch-iodine plate method. The starch-iodine plate with methicillin as inducer gave the most reliable results.

In radiobinding tests many group A, C and G streptococci react with IgG and IgA, irrespective of the antigen-combining sites, as well as with various other serum proteins, e.g. human serum albumin (HSA). The present study demonstrated that glutaraldehyde-aggregated, radiolabelled HSA (a*HSA), in comparison to monomeric HSA, binds more avidly to streptococci. Of group A streptococci, strains representing types M6, M12, M18, M46, M55 and M57 displayed pronounced binding of a*HSA whereas a number of other serotypes were non-reactive. The streptococcal sites involved proved to be relatively heat-resistant and highly sensitive to trypsin treatment. Human fibrinogen counteracted the binding of a*HSA. The uptake by M12 was inhibited strongly by rabbit antiserum raised against M12, whereas other antisera were less active. The results suggest that the bacterial structure binding a*HSA is a protein and that, in at least one serotype, M12, the binding occurs to the M-protein.

Patients with acute laryngitis following an upper respiratory tract infection are often treated with antibiotics for their voice complaints, although, to our knowledge, the effect of such therapy has not been examined. In the present study, comprising 100 adults with laryngitis, the rate of resolution of vocal symptoms, as estimated from voice recordings or subjectively by the patients, was the same in patients who received penicillin V (pcV) as in those who received placebo. Similarly, the degree of rhinorrhea/nasal congestion and cough was not significantly influenced by pcV treatment. At the acute visit, nasopharyngeal cultures revealed Branhamella catarrhalis in 50%, Hemophilus influenzae in 15% and Streptococcus pneumoniae in 1% of the patients; the rate of elimination of these bacteria was the same in the pcV as in the placebo group. Thus, while suggesting that B catarrhalis and H influenzae are important for the pathogenesis of the disorder, our results do not provide support for the use of pcV in acute laryngitis.

The occurrence of beta-lactamase production in Haemophilus influenzae, Branhamella catarrhalis and Moraxella nonliquefaciens was compared in 191 healthy children attending day nurseries in 2 municipalities differing with regard to the prescription rate of beta-lactam antibiotics. A significantly higher frequency of beta-lactamase production was recorded in M. nonliquefaciens isolated in the municipality with the higher prescription rate. A corresponding difference was not recorded for H. influenzae or B. catarrhalis. Approximately 75% of the nasopharyngeal pathogens H. influenzae, B. catarrhalis and Streptococcus pneumoniae, as well as the commensal M. nonliquefaciens, were eliminated and often replaced by other strains of either species over a period of one month. Although none of the children were on antibiotics a substantial proportion of the acquired strains produced beta-lactamase. This suggested that the carrier rate of beta-lactamase producing strains of the respiratory tract is not only related to the effect of recent antibiotic treatment but also to the prevalence of such strains in the population.