TRANSACTIONSOF THEROYALSOCIETYOFTROPICALMEDICINEAND H~~m1~(1992)86,298-300
Concomitant intestinal adenovirus infection and pulmonary infection in children causing fatal enteritis and pneumonia
cytomegalovirus
Thomas Butler*, Dale Dunn and Jane Colmer Departments of Internal Medicine and Pathology, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA and the International Centre for Diarrhoeal Disease Research, G.P.O. Box 128, Dhaka, Bangladesh Abstract Three children in Bangladesh who presented with diarrhoea, cough! dyspnoea, fever, and signs of malnutrition and died in the hosoital were shown at nest-mortem examination to have both adenovirus infection of the intestine (by immunofluorescence) and cytomegalovirus infection of the lung (by immunoperoxidase staining). This finding of dual viral infections of the intestine and lung in patients with concomitant enteritis and pneumonia provides a basis for symptoms emanating simultaneously from these two organ systems. Introduction The leading causes of childhood death in developing countries are pneumonia (DENNY & LODA, 1986) and diarrhoea (SNYDER & MERSON, 1982), and some natients present with both conditions simultaneously (BUTLER et al., 1987). The occurrence of distinct groups of infectious pathogens in the respiratory tract (BERMAN & MCINTOSH, 1985) and intestinal tract (GUERRANT et al., 1983) has been invoked to exnlain diseases of the two organs: The viral pathogens, cytomegalovirus and adenovirus, may infect both the lung and the intestine (HO, 1982; SHIELDS et al., 1985). Since both viruses produce giant cells with intranuclear inclusions, their differentiation in tissues sometimes requires immunological staining. Materials and Methods Patients admitted to the Dhaka hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh with histories of diarrhoea and/or pneumonia who died were eligible for inclusion in an autopsy protocol after informed consent was obtained. The 3 patients described in this naner were included in a nrevious description of 140 p&i&its in an autopsy protocol (BUTLER et al.. 1987) and a histoloaical analvsis of 93 uatients with pneumonia (TOMASHEFS~Y et al.,” 1989). Inpatient care consisted of rehydration with intravenous fluid (containing sodium 133 mmolilitre, potassium 13 mmolilitre, chloride 98 mmolilitre, and acetate 48 mmol/litre) and liberal antibiotic usage. Autopsies were done using standard procedures. In 3 cases which showed intranuclear inclusions in both lung and intestine, sections were deparaffinized, treated with 1% bovine serum albumin in phosphate-buffered saline, and stained with the indirect immunofluorescent stain for adenovirus using Bartel’s viral respiratory screening and identification kit (Baxter Microscan, West Sacremento, California, USA) with an affinity purified mouse monoclonal antibody directed against types 1-3, 5-8, 14, 18, 31, 40 and 41 (GARY et al., 1979). Cytomegalovirus was detected by immunoperoxidase staining (Str Ari Gen@, Biogenex Laboratories, San Ramon, California, USA) (WILCOX et al., 1990). Results Patients The 3 children presented with histories of diarrhoea and respiratory complaints and all appeared poorly nourished. Case I. A 4 month-old female nresented with a historv of watery stools 5 times a day for 2 d and dyspnoea for one dav. Her mother had died in childbirth. and the natient had failed to gain weight on soya milk feeding since birth. Her temperature was 38.9’C and chest radiography showed infiltrates in upper lung fields. Stool examination showed 3-12 leucocytes per high power field, no ova or parasites, and negative culture for bacterial pathogens. A blood culture was negative. Blood leucocyte count was 8200/mm3 with 40% lymphocytes. “Author for offprinr requests.
The blood CO2 content was reduced to 10.7 mmolilitre. The patient was treated with ampicillin for suspected bacterial nneumonia but died on the fifth dav in hosnital. Case 2: A one month-old male was brought &I the clinic with a history of watery stools 10 times a day for one day and development of cyanosis and obtund&on for one dav. He had been fed on a combination of breast milk and goat’s milk. His temperature was 38.3”C. Stool showed 8 leucocytes per high power field, no ova or parasites, and negative culture for bacterial pathogens. The blood CO2 content was reduced to less than 7 mmolilitre and serum glucose was reduced to 10 mgilO0 ml. The patient received glucose infusion but died on the day of admission before further diagnostic tests could be carried out. Case 3. A 10 year-old female presented with a history of loose stools, sometimes blood-stained, for 30 d and a drv cough for 20 d. About 20 d before admission she noticed ‘ihe onset of weight loss and pedal oedema. Her temperature was normal but subsequently in hospital she showed temperature spikes. Chest radiography showed interstitial infiltrates. Stool examination showed 50 leucocytes per high power field and ova of Ascaris Zumbricoides and Trichuris tt-ichiura. but negative culture for bacterial pathogens. Blood leucocyte count was raised at 26 800 /mm3 with 37% lvmnhocvtes. Blood orotein concentration was reduced to ‘3.3 g/l00 ml. A blood culture was negative. The patient received ampicillin for suspected bacterial pneumonia but died on the tenth day in hospital. Gross autopsy findings In case 1, the serosal surface of the distal ileum was purple and the ileal mucosa was friable with areas of ulceration and darkened discolouration. In cases 2 and 3, the mucosa of the distal ileum and colon showed areas of erythema and superficial ulceration. The lungs of all cases showed scattered areas of congestion, purple colouration, and induration indicative of inflammation and consolidation. Microscopical findings In all 3 cases, the lamina propria of the ileum and colon showed areas of infiltration with nredominantlv mononuclear cells and the presence of occasional large cells with intranuclear inclusions. In areas of mucosal ulceration, there were polymorphonuclear leucocytes. The lungs in all 3 cases showed infiltration of interstitial areas with mononuclear leucocytes and the presence of cytomegalovirus inclusion cells. Other organs that were affected by giant cells with intranuclear inclusions were the kidney in case 1, liver in cases 2 and 3, and nancreas in case 3. Indirect -immunofluorescent staining-for adenovirus gave positive results on inclusions in the colons of all 3 cases -(Figure) and gave negative results when applied to the lunas. Immunoperoxidase staining for cvtomegalovirus gave negative results when app&d to colonic lesions but positive results for the lungs of all 3 cases.
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Figure. Colon of case 1. A. The lamina propria showing an infiltrate of pn ominantly mononuclear cells with enlarged cells demonstrating intranuclear inelusions (arrow). Haematoxylin and eosin (X 100).B. Intranuclear inclusion in crypts positive for adenovirus (arrow). Immunofluorescent stain (x400).
Discussion
Only one case of diarrhoea caused by enteric adenovirus has been previously reported as fatal (MADELEY, 1986). Adenovirus and cytomegalovirus have not heretofore been considered important pathogens in tropical developing countries for either diarrhoeal syndromes or pneumonia. The viruses that have been best studied in developing countries are rotavirus in the intestine (GUERRANT et al., 1983) and respiratory syncytial virus and adenoviruses in the lung (BERMAN & MCINTOSH, 1985). A prevalence of 100% for cytomegalovirus infection has been reported in serosurveysin the Philippines, Uganda, and Tanzania (HO, 1982), but the prevalence of symptomatic diseaseis unknown. In India, children with acute diarrhoea were shown to be excreting non-enteric or enteric adenoviruses in about 2% and 13% of 2 samplesof patients (BHAN et al., 1988), and in Brazil about 5% of chidlren with diarrhoea excreted adenoviruses that were enteric types in 36% of the cases(LEITE et al., 1985). Serological testing of children for adenoviruses of the enteric types 40 and 41 in both developing and developed countries showed prevalencesof infection ranging from 0 to 60% (KIDD et al., 1983). Our finding of inflammation and ulceration in the colon are consistent with other reports of pathology of the gastrointestinal tract in immunocompromised patients with adenovirus infection. OKANOet al. (1988) reported fatal intestinal bleeding in a patient with chronic Epstein-Barr infection who had colonic ulcers that were demonstrated by immunological staining to contain both adenovirus and Epstein-Barr virus. Immunodeficiency is frequently present in symptomatic infection due to adenovirus or cytomegalovirus, as is recognized now in patients with cancer treated with chemotherapy, acquired immune deficiency syndrome (AIDS), and after renal and bone marrow transplants (PETERSON et al., 1980; REED et al., 1990; SHIELDSet al., 1985; WILCOXet al., 1990). The malnutrition that affects children in developing countries is characterized by defective cell-mediated immunity (CHANDRA,1983). The normal peripheral blood lymphocyte counts in our patients suggest that the immune deficiency predisposing them to adenovirus and cytomegalovirus infections was qualitatively different from that of AIDS. Acknowledgements We thank Dr Moyenul Islam and Dr A. K. Azad for their assistance. References Berman, S. & McIntosh, K. (1985). Selective primary health care: strategies for control of disease in the developing world. XXI. Acute respiratory infections. Reviews of Infectious Diseases, 7,674-691.
Bhan, M. K., Raj, I’., Bhandari, N., Svensson, L., Stintzing, G., Prasad, A. K., Jayashree, S. & Srivastava, R. (1988). Role of enteric adenoviruses and rotaviruses in mild and severe acute enteritis. Pediatric Infectious Disease Journal, 7, 320.323. Butler, T., Islam, M., Azad, A. K., Islam, M. R. & Speelman, P. (1987). Causes of death in diarrhoeal diseases after rehydration therapy: an autopsy study of 140 patients in Bangladesh. Bulletin of the World Health Organization, 65, 317-321. Chandra, R. K. (1983). Nutrition, immunity, and infection: present knowledge and future directions. Lancet, i, 688-691. Denny, F. W. & Loda, F. A. (1986). Acute respiratory infections are the leading cause of death in children in developing countries. American Journal of Tropical Medicine and Hygiene, 35, l-2. Gary, G. W., jr, Hierholzer, J. C. & Black, R. E. (1979). Characteristics of noncultivable adenoviruses associated with diarrhea in ‘infants: a new subgroup of human adenoviruses. Journal of Clinical Microbiology, 10,96103. Guerrant, R. L., Kirchhoff, L. V., Shields, D. S., Nations, M. K., Leslie, J., de Sousa, M. A., Araujo, J. G:, Correia, L. L., Sauer, K. T., McClelland, K. E., Trowbridge, F. L. & Hughes, J. M. (1983). Prospective study of diarrhea1 illnesses in north-eastern Brazil: patterns of disease, nutritional impact,etiologies,andrisk factors.Journalof Infectious Diseases, 14,986-997. Ho, M. (1982). Cytomegalovirus. Biology and Infection. New York: Plenum Medical Book Company, pp. 79-104. Kidd, A. H., Banatvala, J. E. & de Jong, J. C. (1983). Antibodies to fastidious faecal adenoviruses (species 40 and 41) in sera from children.Joumal of Medical Virology, 11,333-341. Leite, J. I’. G., Pereira, H. G., Azeredo, R. S. & Schatzmayr, H. G. (1985). Adenoviruses in faeces of children with acute gastroenteritis in Rio de Janiero, Brazil. 3ournal of Medical Virology, 15,203-209. Madeley, C. R. (1986). The emerging role of adenoviruses as in: ducers of gastroenteritis. Pediatric Infectious Disease, 5, S63Sh4. Okano, M., Thiele, G. M., Davis, J. R., Nauseef, W. M., Mitros, F. & Purtilo, D. T. (1988). Adenovirus type-2 in a patient with lethal hemorrhagic colonic ulcers and chronic active Epstein-Barr virus infection. Annals of Internal Medicine, 108, 693-699. Peterson, P. K., Balfour, N. H., Marker, S. C., Fryd, D. S., Howard, R. J. & Simmons, R. L. (1980). Cytomegalovirus disease in renal allograft recipients: a prospective study of the clinical features, risk factors and impact on renal transplantation. Medicine, 59, 283-300. Reed, E. C., Wolford, J. L., Kopecky, K. J., Lilleby, K. E., Dandliker, P. S., Todaro, J. L., McDonald, G. B. & Meyers, G. D. (1990). Ganciclovir for the treatment of cytomegalovirus gastroenteritis in bone marrow transplant patients. Annals of Internal Medicine, 112,505-5 10. Shields, A. F., Hackman, R. C., Fife, K. H., Corey, L. & Meyers, J. D. (1985). Adenovirus infections in patients undergoing bone-marrow transplantation. New EnglundJournal ofMedicine, 312,529-533. Snyder, J. D. & Merson, M. H. (1982). The magnitude of the
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global problem of acute diarrhoeal disease:a review of active surveillance data. Bulletin of the World Health Organization, 60,605-613.
Jacobson, M. A. (1990). Cytomegalovirus esophagitis in patients with AIDS. A clinical, endoscopic, and pathological correlation. Annalsof Internal Medicine, 113,589-593.
Tomashefsky, J. F., Butler, T. &Islam, M. (1989). Histopathology and etiology of childhood pneumonia: an autopsy study of 93 patients in Bangladesh. Pathology, Z&71-78. Wilcox, C. M., Diehl, D. L., Cello, J. P., Margaretten, W. &
for publication I3 September 1991
TRANSACTIONS OFTHEROYAL SOCIETYOF TROPICAL MEDICINE AND HYGIENE (1992)
86,30&30
1Short Report 1 Tropical spastic paraparesis associated with HTLV-1 in Egypt* Niel T. Constantine’, Daniel A. Scott’, Mohamed Kamalz, Chester R. Robert+, Arndt Rolfs4, H. C. Schumacher4 and Peter Marx4 IUS Naval Medical Research Unit No. 3, Cairo, Egypt; 2Abbassia Fever Hospital, Cairo, Egypt; 3Walter Reed Army Institute of Research, Washington, DC, USA; “Free University of Berlin, Berlin, Germany Human T-lymphotrophic virus type 1 (HTLV-1) is associated with a form of malignancy, adult T-cell leukaemia (BLATTNER et al., 1982), a-chronic degenerative neurological disease. HTLV-l-associated mvelonathv, and tropical spastic ‘paraparesis (TSP) (GE&N et ai.; et al., 1988). This report de1985; RODGERS-JOHNSON scribes the first documented case of HTLV-l-associated TSP in a patient from Egypt. The patient was a 45 years old man who appeared healthy, but complained of weakness in his legs and inability to run. Neurological symptoms first appeared in 1976, one year following a 6-litre blood transfusion for a bleeding ulcer. At that time, the patient experienced a gradual onset of urinary difficulty, constipation, and impotency. Over the next 12 years, he gradually developed weakness in his left, then right, leg, without discrete remissions or exacerbations. There was no history of paresthaesias, visual disturbances, or a family history of neurological disease. Neurological examination revealed hyper-reflexia in both lower extremities, bilateral Babinski signs, and a scissors gait. There was slight spasticity in the lower extremities without wasting or fasciculations. Cranial nerves and the upper extremities were normal, as well as a normal sensory examination, a negative Romberg sign, and normal fine motor co-ordination. Cranial and spinal magnetic resonance imagery did not reveal mass lesions or white matter plaque. Cerebral spinal fluid (CSF) analysis revealed 34 mg/dl protein, 50 mgidl glucose, and 20 lymphocytesidl. Blood chemistries and a complete blood count were normal, and a serum rapid plasma reagin test and a fluorescent treponemal antibody test were negative for Treponema pallidurn. Serological screening for HTLV-1 by enzyme immunoassay (EIA) was repeatedly reactive and the presence of antibodv to HTLV-1 was confirmed bv Western blot (strong reactivity to all major antigens including gp46) and radio-immunonrecinitation (RIPA). The CSF was *This study was supported by the Naval Medical Research and Development Command, Naval Medical Command, National Capital Region, Bethesda, MD 20814, Work Unit No. 3M463105.H29.AA.335. The opinions and assertions contained herein are the private onesof the authors and are not to be construed as official or as reflecting the view of the Navy Department, the Department of Defense, the Government of the United Statesor the World Health Organization. Correspondence and requests for Gffprints should be addressed to: Research Publications Branch, NAVMEDRSCHU THREE, code: lOlA, PSC 452 Box 5000, FPO AE 09835-0007, USA.
Received I7 June 1991; revised 2 September 1991; accepted
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also reactive for antibodies to HTLV-1 by EIA, and was confirmed as positive by Western blot and RIPA. Peripheral lymphocytes were positive for HTLV-1 deoxyribonucleic acid bv the Dolvmerase chain reaction. Several env, gag, pol, and LFR legions were detected and, by comnarison to the MT-2 reference cell line. there was one HTLV-1 gene per 15 000 mononuclea; cells. Attempts to culture the virus from either the CSF or peripheral lymphocytes were unsuccessful. Sera collected from the natient’s wife. 13 vear old daughter. mother. and broth& were all negativi for antibodks to’HTLV-i by EIA. His father was deceased. The patient’s symptoms and neurological examination were compatible with TSP, and the laboratory data suggested an association with HTLV-1 infection. The epidemiological association of TSP with HTLV-1 has been well documented (GESSAIN et al., 1985) and HTLV-1 has been isolated from the DeriDheral 1vmDhocvtes and CSF of patients with TSI? (GCKHANN et-al.; 1985). The most likely source of HTLV-1 was the blood transfusion received by the patient in 1975. Initial observations in Japan suggested that TSP was contracted by blood tranif&ion a;d more recent data confirmed an aisociation between TSP and HTLV-1 infection acauired by transfusions (OSAME et al., 1986; OSAME & ~~ATA, 1989). Patients in Japan had an onset of symptoms within 12 months of their transfusion, as described for the patient in this report. The prevalence of HTLV-1 infection is low in northeast Africa and the Middle East (FOX et al., 1988; OSAME & IGATA, 1989; SCOTTetal., 1989; CONSTANTINEetal., 1989: KHALIFA et al.. 1990) and the onlv other case of TSP’reported from tLe region was an Eihiopian immigrant to Sweden (RYBERG et al., 1987). This report is of the first case of HTLV-l-associated TSP in a resident of Egypt which was apparently contracted by blood transfusion. We thank Dr Zoheir Farid, Prof. Dr Mamdouh Salama and Dr N. I. Girgis for their assistancewith the evaluation of this patient, and Dr Douglas M. Watts for reviewing the manuscript. References Blattner, W. A., Kayanaraman, V. S., Robert-Guroff, M., Lister, T. A., Galton, D. A., Sarin, I’. S., Crawford, M. H., Catovsky, D., Greaves, M. & Gallo, R. C. (1982). The human type-C retrovirus, HTLV, in Blacks from the Carribean region, and relationships to adult T-cell leukemiailymphoma. InternationalJournal of Cancer,30,257-264. Constantine, N. T., Corwin, A., Scott, D. A., Mohamed, M. A., Osman, N. M. & Watts, D. M. (1989). HTLV-1 infection among blood donors, children, and high risk groups in north-east Africa. 38th Annual Meeting of the American Society of Tropical Medicine and Hygiene, Honolulu, December 1989. Abstract no. 333. Fox, E., Constantine, N. T., Abbatte, E. A., Said-Salah & Rodier, G. (1988). Low prevalence of infection by human Tlymphotropic virus type 1 in populations at risk for human immunodeiiciency virus in Djibouti, East Africa. Annales de I’lnstitut PasteurlViroloeie. 139.443-447. Gessain, A., Barin, F., \Je&ant; J. C., Gout, O., Maurs, L., Calender, A. & de The, G, (1985). Antibodies to human Tlymphotropic virus type-l in patients with tropical spastic paraparesii. Lancet, ii, 407-410. Khalifa, A. S., Khalil, R., Gawad, A. A., Constantine, N. T. & Woodv, 1. N. (19901.Surveillance for exoosure to HTLV-1 in E&titian iniants grid children with vaiious malignancies. Journal of InfectiousDiseases,162,995-996.
Concomitant intestinal adenovirus infection and pulmonary infection in children causing fatal enteritis and pneumonia
cytomegalovirus
Thomas Butler*, Dale Dunn and Jane Colmer Departments of Internal Medicine and Pathology, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA and the International Centre for Diarrhoeal Disease Research, G.P.O. Box 128, Dhaka, Bangladesh Abstract Three children in Bangladesh who presented with diarrhoea, cough! dyspnoea, fever, and signs of malnutrition and died in the hosoital were shown at nest-mortem examination to have both adenovirus infection of the intestine (by immunofluorescence) and cytomegalovirus infection of the lung (by immunoperoxidase staining). This finding of dual viral infections of the intestine and lung in patients with concomitant enteritis and pneumonia provides a basis for symptoms emanating simultaneously from these two organ systems. Introduction The leading causes of childhood death in developing countries are pneumonia (DENNY & LODA, 1986) and diarrhoea (SNYDER & MERSON, 1982), and some natients present with both conditions simultaneously (BUTLER et al., 1987). The occurrence of distinct groups of infectious pathogens in the respiratory tract (BERMAN & MCINTOSH, 1985) and intestinal tract (GUERRANT et al., 1983) has been invoked to exnlain diseases of the two organs: The viral pathogens, cytomegalovirus and adenovirus, may infect both the lung and the intestine (HO, 1982; SHIELDS et al., 1985). Since both viruses produce giant cells with intranuclear inclusions, their differentiation in tissues sometimes requires immunological staining. Materials and Methods Patients admitted to the Dhaka hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh with histories of diarrhoea and/or pneumonia who died were eligible for inclusion in an autopsy protocol after informed consent was obtained. The 3 patients described in this naner were included in a nrevious description of 140 p&i&its in an autopsy protocol (BUTLER et al.. 1987) and a histoloaical analvsis of 93 uatients with pneumonia (TOMASHEFS~Y et al.,” 1989). Inpatient care consisted of rehydration with intravenous fluid (containing sodium 133 mmolilitre, potassium 13 mmolilitre, chloride 98 mmolilitre, and acetate 48 mmol/litre) and liberal antibiotic usage. Autopsies were done using standard procedures. In 3 cases which showed intranuclear inclusions in both lung and intestine, sections were deparaffinized, treated with 1% bovine serum albumin in phosphate-buffered saline, and stained with the indirect immunofluorescent stain for adenovirus using Bartel’s viral respiratory screening and identification kit (Baxter Microscan, West Sacremento, California, USA) with an affinity purified mouse monoclonal antibody directed against types 1-3, 5-8, 14, 18, 31, 40 and 41 (GARY et al., 1979). Cytomegalovirus was detected by immunoperoxidase staining (Str Ari Gen@, Biogenex Laboratories, San Ramon, California, USA) (WILCOX et al., 1990). Results Patients The 3 children presented with histories of diarrhoea and respiratory complaints and all appeared poorly nourished. Case I. A 4 month-old female nresented with a historv of watery stools 5 times a day for 2 d and dyspnoea for one dav. Her mother had died in childbirth. and the natient had failed to gain weight on soya milk feeding since birth. Her temperature was 38.9’C and chest radiography showed infiltrates in upper lung fields. Stool examination showed 3-12 leucocytes per high power field, no ova or parasites, and negative culture for bacterial pathogens. A blood culture was negative. Blood leucocyte count was 8200/mm3 with 40% lymphocytes. “Author for offprinr requests.
The blood CO2 content was reduced to 10.7 mmolilitre. The patient was treated with ampicillin for suspected bacterial nneumonia but died on the fifth dav in hosnital. Case 2: A one month-old male was brought &I the clinic with a history of watery stools 10 times a day for one day and development of cyanosis and obtund&on for one dav. He had been fed on a combination of breast milk and goat’s milk. His temperature was 38.3”C. Stool showed 8 leucocytes per high power field, no ova or parasites, and negative culture for bacterial pathogens. The blood CO2 content was reduced to less than 7 mmolilitre and serum glucose was reduced to 10 mgilO0 ml. The patient received glucose infusion but died on the day of admission before further diagnostic tests could be carried out. Case 3. A 10 year-old female presented with a history of loose stools, sometimes blood-stained, for 30 d and a drv cough for 20 d. About 20 d before admission she noticed ‘ihe onset of weight loss and pedal oedema. Her temperature was normal but subsequently in hospital she showed temperature spikes. Chest radiography showed interstitial infiltrates. Stool examination showed 50 leucocytes per high power field and ova of Ascaris Zumbricoides and Trichuris tt-ichiura. but negative culture for bacterial pathogens. Blood leucocyte count was raised at 26 800 /mm3 with 37% lvmnhocvtes. Blood orotein concentration was reduced to ‘3.3 g/l00 ml. A blood culture was negative. The patient received ampicillin for suspected bacterial pneumonia but died on the tenth day in hospital. Gross autopsy findings In case 1, the serosal surface of the distal ileum was purple and the ileal mucosa was friable with areas of ulceration and darkened discolouration. In cases 2 and 3, the mucosa of the distal ileum and colon showed areas of erythema and superficial ulceration. The lungs of all cases showed scattered areas of congestion, purple colouration, and induration indicative of inflammation and consolidation. Microscopical findings In all 3 cases, the lamina propria of the ileum and colon showed areas of infiltration with nredominantlv mononuclear cells and the presence of occasional large cells with intranuclear inclusions. In areas of mucosal ulceration, there were polymorphonuclear leucocytes. The lungs in all 3 cases showed infiltration of interstitial areas with mononuclear leucocytes and the presence of cytomegalovirus inclusion cells. Other organs that were affected by giant cells with intranuclear inclusions were the kidney in case 1, liver in cases 2 and 3, and nancreas in case 3. Indirect -immunofluorescent staining-for adenovirus gave positive results on inclusions in the colons of all 3 cases -(Figure) and gave negative results when applied to the lunas. Immunoperoxidase staining for cvtomegalovirus gave negative results when app&d to colonic lesions but positive results for the lungs of all 3 cases.
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Figure. Colon of case 1. A. The lamina propria showing an infiltrate of pn ominantly mononuclear cells with enlarged cells demonstrating intranuclear inelusions (arrow). Haematoxylin and eosin (X 100).B. Intranuclear inclusion in crypts positive for adenovirus (arrow). Immunofluorescent stain (x400).
Discussion
Only one case of diarrhoea caused by enteric adenovirus has been previously reported as fatal (MADELEY, 1986). Adenovirus and cytomegalovirus have not heretofore been considered important pathogens in tropical developing countries for either diarrhoeal syndromes or pneumonia. The viruses that have been best studied in developing countries are rotavirus in the intestine (GUERRANT et al., 1983) and respiratory syncytial virus and adenoviruses in the lung (BERMAN & MCINTOSH, 1985). A prevalence of 100% for cytomegalovirus infection has been reported in serosurveysin the Philippines, Uganda, and Tanzania (HO, 1982), but the prevalence of symptomatic diseaseis unknown. In India, children with acute diarrhoea were shown to be excreting non-enteric or enteric adenoviruses in about 2% and 13% of 2 samplesof patients (BHAN et al., 1988), and in Brazil about 5% of chidlren with diarrhoea excreted adenoviruses that were enteric types in 36% of the cases(LEITE et al., 1985). Serological testing of children for adenoviruses of the enteric types 40 and 41 in both developing and developed countries showed prevalencesof infection ranging from 0 to 60% (KIDD et al., 1983). Our finding of inflammation and ulceration in the colon are consistent with other reports of pathology of the gastrointestinal tract in immunocompromised patients with adenovirus infection. OKANOet al. (1988) reported fatal intestinal bleeding in a patient with chronic Epstein-Barr infection who had colonic ulcers that were demonstrated by immunological staining to contain both adenovirus and Epstein-Barr virus. Immunodeficiency is frequently present in symptomatic infection due to adenovirus or cytomegalovirus, as is recognized now in patients with cancer treated with chemotherapy, acquired immune deficiency syndrome (AIDS), and after renal and bone marrow transplants (PETERSON et al., 1980; REED et al., 1990; SHIELDSet al., 1985; WILCOXet al., 1990). The malnutrition that affects children in developing countries is characterized by defective cell-mediated immunity (CHANDRA,1983). The normal peripheral blood lymphocyte counts in our patients suggest that the immune deficiency predisposing them to adenovirus and cytomegalovirus infections was qualitatively different from that of AIDS. Acknowledgements We thank Dr Moyenul Islam and Dr A. K. Azad for their assistance. References Berman, S. & McIntosh, K. (1985). Selective primary health care: strategies for control of disease in the developing world. XXI. Acute respiratory infections. Reviews of Infectious Diseases, 7,674-691.
Bhan, M. K., Raj, I’., Bhandari, N., Svensson, L., Stintzing, G., Prasad, A. K., Jayashree, S. & Srivastava, R. (1988). Role of enteric adenoviruses and rotaviruses in mild and severe acute enteritis. Pediatric Infectious Disease Journal, 7, 320.323. Butler, T., Islam, M., Azad, A. K., Islam, M. R. & Speelman, P. (1987). Causes of death in diarrhoeal diseases after rehydration therapy: an autopsy study of 140 patients in Bangladesh. Bulletin of the World Health Organization, 65, 317-321. Chandra, R. K. (1983). Nutrition, immunity, and infection: present knowledge and future directions. Lancet, i, 688-691. Denny, F. W. & Loda, F. A. (1986). Acute respiratory infections are the leading cause of death in children in developing countries. American Journal of Tropical Medicine and Hygiene, 35, l-2. Gary, G. W., jr, Hierholzer, J. C. & Black, R. E. (1979). Characteristics of noncultivable adenoviruses associated with diarrhea in ‘infants: a new subgroup of human adenoviruses. Journal of Clinical Microbiology, 10,96103. Guerrant, R. L., Kirchhoff, L. V., Shields, D. S., Nations, M. K., Leslie, J., de Sousa, M. A., Araujo, J. G:, Correia, L. L., Sauer, K. T., McClelland, K. E., Trowbridge, F. L. & Hughes, J. M. (1983). Prospective study of diarrhea1 illnesses in north-eastern Brazil: patterns of disease, nutritional impact,etiologies,andrisk factors.Journalof Infectious Diseases, 14,986-997. Ho, M. (1982). Cytomegalovirus. Biology and Infection. New York: Plenum Medical Book Company, pp. 79-104. Kidd, A. H., Banatvala, J. E. & de Jong, J. C. (1983). Antibodies to fastidious faecal adenoviruses (species 40 and 41) in sera from children.Joumal of Medical Virology, 11,333-341. Leite, J. I’. G., Pereira, H. G., Azeredo, R. S. & Schatzmayr, H. G. (1985). Adenoviruses in faeces of children with acute gastroenteritis in Rio de Janiero, Brazil. 3ournal of Medical Virology, 15,203-209. Madeley, C. R. (1986). The emerging role of adenoviruses as in: ducers of gastroenteritis. Pediatric Infectious Disease, 5, S63Sh4. Okano, M., Thiele, G. M., Davis, J. R., Nauseef, W. M., Mitros, F. & Purtilo, D. T. (1988). Adenovirus type-2 in a patient with lethal hemorrhagic colonic ulcers and chronic active Epstein-Barr virus infection. Annals of Internal Medicine, 108, 693-699. Peterson, P. K., Balfour, N. H., Marker, S. C., Fryd, D. S., Howard, R. J. & Simmons, R. L. (1980). Cytomegalovirus disease in renal allograft recipients: a prospective study of the clinical features, risk factors and impact on renal transplantation. Medicine, 59, 283-300. Reed, E. C., Wolford, J. L., Kopecky, K. J., Lilleby, K. E., Dandliker, P. S., Todaro, J. L., McDonald, G. B. & Meyers, G. D. (1990). Ganciclovir for the treatment of cytomegalovirus gastroenteritis in bone marrow transplant patients. Annals of Internal Medicine, 112,505-5 10. Shields, A. F., Hackman, R. C., Fife, K. H., Corey, L. & Meyers, J. D. (1985). Adenovirus infections in patients undergoing bone-marrow transplantation. New EnglundJournal ofMedicine, 312,529-533. Snyder, J. D. & Merson, M. H. (1982). The magnitude of the
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for publication I3 September 1991
TRANSACTIONS OFTHEROYAL SOCIETYOF TROPICAL MEDICINE AND HYGIENE (1992)
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1Short Report 1 Tropical spastic paraparesis associated with HTLV-1 in Egypt* Niel T. Constantine’, Daniel A. Scott’, Mohamed Kamalz, Chester R. Robert+, Arndt Rolfs4, H. C. Schumacher4 and Peter Marx4 IUS Naval Medical Research Unit No. 3, Cairo, Egypt; 2Abbassia Fever Hospital, Cairo, Egypt; 3Walter Reed Army Institute of Research, Washington, DC, USA; “Free University of Berlin, Berlin, Germany Human T-lymphotrophic virus type 1 (HTLV-1) is associated with a form of malignancy, adult T-cell leukaemia (BLATTNER et al., 1982), a-chronic degenerative neurological disease. HTLV-l-associated mvelonathv, and tropical spastic ‘paraparesis (TSP) (GE&N et ai.; et al., 1988). This report de1985; RODGERS-JOHNSON scribes the first documented case of HTLV-l-associated TSP in a patient from Egypt. The patient was a 45 years old man who appeared healthy, but complained of weakness in his legs and inability to run. Neurological symptoms first appeared in 1976, one year following a 6-litre blood transfusion for a bleeding ulcer. At that time, the patient experienced a gradual onset of urinary difficulty, constipation, and impotency. Over the next 12 years, he gradually developed weakness in his left, then right, leg, without discrete remissions or exacerbations. There was no history of paresthaesias, visual disturbances, or a family history of neurological disease. Neurological examination revealed hyper-reflexia in both lower extremities, bilateral Babinski signs, and a scissors gait. There was slight spasticity in the lower extremities without wasting or fasciculations. Cranial nerves and the upper extremities were normal, as well as a normal sensory examination, a negative Romberg sign, and normal fine motor co-ordination. Cranial and spinal magnetic resonance imagery did not reveal mass lesions or white matter plaque. Cerebral spinal fluid (CSF) analysis revealed 34 mg/dl protein, 50 mgidl glucose, and 20 lymphocytesidl. Blood chemistries and a complete blood count were normal, and a serum rapid plasma reagin test and a fluorescent treponemal antibody test were negative for Treponema pallidurn. Serological screening for HTLV-1 by enzyme immunoassay (EIA) was repeatedly reactive and the presence of antibodv to HTLV-1 was confirmed bv Western blot (strong reactivity to all major antigens including gp46) and radio-immunonrecinitation (RIPA). The CSF was *This study was supported by the Naval Medical Research and Development Command, Naval Medical Command, National Capital Region, Bethesda, MD 20814, Work Unit No. 3M463105.H29.AA.335. The opinions and assertions contained herein are the private onesof the authors and are not to be construed as official or as reflecting the view of the Navy Department, the Department of Defense, the Government of the United Statesor the World Health Organization. Correspondence and requests for Gffprints should be addressed to: Research Publications Branch, NAVMEDRSCHU THREE, code: lOlA, PSC 452 Box 5000, FPO AE 09835-0007, USA.
Received I7 June 1991; revised 2 September 1991; accepted
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also reactive for antibodies to HTLV-1 by EIA, and was confirmed as positive by Western blot and RIPA. Peripheral lymphocytes were positive for HTLV-1 deoxyribonucleic acid bv the Dolvmerase chain reaction. Several env, gag, pol, and LFR legions were detected and, by comnarison to the MT-2 reference cell line. there was one HTLV-1 gene per 15 000 mononuclea; cells. Attempts to culture the virus from either the CSF or peripheral lymphocytes were unsuccessful. Sera collected from the natient’s wife. 13 vear old daughter. mother. and broth& were all negativi for antibodks to’HTLV-i by EIA. His father was deceased. The patient’s symptoms and neurological examination were compatible with TSP, and the laboratory data suggested an association with HTLV-1 infection. The epidemiological association of TSP with HTLV-1 has been well documented (GESSAIN et al., 1985) and HTLV-1 has been isolated from the DeriDheral 1vmDhocvtes and CSF of patients with TSI? (GCKHANN et-al.; 1985). The most likely source of HTLV-1 was the blood transfusion received by the patient in 1975. Initial observations in Japan suggested that TSP was contracted by blood tranif&ion a;d more recent data confirmed an aisociation between TSP and HTLV-1 infection acauired by transfusions (OSAME et al., 1986; OSAME & ~~ATA, 1989). Patients in Japan had an onset of symptoms within 12 months of their transfusion, as described for the patient in this report. The prevalence of HTLV-1 infection is low in northeast Africa and the Middle East (FOX et al., 1988; OSAME & IGATA, 1989; SCOTTetal., 1989; CONSTANTINEetal., 1989: KHALIFA et al.. 1990) and the onlv other case of TSP’reported from tLe region was an Eihiopian immigrant to Sweden (RYBERG et al., 1987). This report is of the first case of HTLV-l-associated TSP in a resident of Egypt which was apparently contracted by blood transfusion. We thank Dr Zoheir Farid, Prof. Dr Mamdouh Salama and Dr N. I. Girgis for their assistancewith the evaluation of this patient, and Dr Douglas M. Watts for reviewing the manuscript. References Blattner, W. A., Kayanaraman, V. S., Robert-Guroff, M., Lister, T. A., Galton, D. A., Sarin, I’. S., Crawford, M. H., Catovsky, D., Greaves, M. & Gallo, R. C. (1982). The human type-C retrovirus, HTLV, in Blacks from the Carribean region, and relationships to adult T-cell leukemiailymphoma. InternationalJournal of Cancer,30,257-264. Constantine, N. T., Corwin, A., Scott, D. A., Mohamed, M. A., Osman, N. M. & Watts, D. M. (1989). HTLV-1 infection among blood donors, children, and high risk groups in north-east Africa. 38th Annual Meeting of the American Society of Tropical Medicine and Hygiene, Honolulu, December 1989. Abstract no. 333. Fox, E., Constantine, N. T., Abbatte, E. A., Said-Salah & Rodier, G. (1988). Low prevalence of infection by human Tlymphotropic virus type 1 in populations at risk for human immunodeiiciency virus in Djibouti, East Africa. Annales de I’lnstitut PasteurlViroloeie. 139.443-447. Gessain, A., Barin, F., \Je&ant; J. C., Gout, O., Maurs, L., Calender, A. & de The, G, (1985). Antibodies to human Tlymphotropic virus type-l in patients with tropical spastic paraparesii. Lancet, ii, 407-410. Khalifa, A. S., Khalil, R., Gawad, A. A., Constantine, N. T. & Woodv, 1. N. (19901.Surveillance for exoosure to HTLV-1 in E&titian iniants grid children with vaiious malignancies. Journal of InfectiousDiseases,162,995-996.
