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1.  Postpartum Invasive Group A Streptococcal Disease in the Modern Era 
To describe the clinical features of individuals hospitalized for postpartum invasive group A Streptococcus (GAS) infection, a retrospective, population-based study of hospitalized patients in the state of Florida was conducted. Cases of postpartum invasive GAS infection (occurring within 42 days of delivery) were compared to women with other manifestations of invasive GAS disease with respect to their age at the time of admission. Four cases of postpartum invasive GAS infection were detected in this population, yielding a prevalence of 1.6% (4/257) of postpartum disease in this invasive GAS infection database. Patients presented a median of 4 days (mean of 9 days) after delivery with signs and symptoms of infection. Three cases were complicated by bacteremia and one patient had streptococcal toxic shock syndrome. Each patient received multiple antibiotics and survived. No patients received intravenous immunoglobulin. For comparison, a secondary retrospective investigation of a large hospital discharge dataset obtained from the Florida Agency for Health Care Administration was assessed for patients with puerperal GAS infections. This method yielded an additional three cases, whose clinical and demographic characteristics were summarized. These data highlight that postpartum invasive GAS infection continues to complicate pregnancy, though the frequency has decreased markedly over the past century.
PMCID: PMC2612756  PMID: 19125207
2.  Chlamydia trachomatis Serology in Women with and without Ovarian Cancer 
Pelvic inflammation has been implicated in the genesis of ovarian cancer. We conducted serologic measurements of Chlamydia trachomatis antibodies as a surrogate marker of chlamydial pelvic inflammatory disease. Women with ovarian cancer (n = 521) and population-based controls (n = 766) were tested. IgG antibodies to serovar D of chlamydia elementary bodies (EBs) were detected using an ELISA assay. The odds of having ovarian cancer among women with the highest titers (≥0.40 OD units) were 0.6 (95% CI 0.4–0.9). These data do not support our earlier finding of elevated titers for antibodies to C. trachomatis among women with ovarian cancer.
PMCID: PMC2605844  PMID: 19125176
3.  The Metabolism and Transplacental Transfer of Oseltamivir in the Ex Vivo Human Model 
Oseltamivir phosphate is extensively metabolized in the ex vivo human placenta model, and the transplacental passage of the metabolite oseltamivir carboxylate is incomplete. Objective. To evaluate the metabolism and transplacental transfer of oseltamivir (Tamiflu) in the ex vivo human placental model. Study Design. Perfusion studies were performed in six placentas from term, uncomplicated deliveries. Concentrations of oseltamivir phosphate (OP) that were 5-6 fold, 20–30 fold, and 600–800 fold above the therapeutic peak were tested, as neither OP nor its active metabolite, oseltamivir carboxylate (OC), could be detected at near-therapeutic concentrations. The transplacental transfer and accumulation of OC were assessed using the 14C antipyrine reference method. Results. OP was extensively metabolized to OC. In the 4 placentas with the highest concentration of OP, OC had a mean clearance index of 0.13 ± 0.08, suggesting that transplacental passage occurs at a relatively low rate. Measurable fetal accumulation occurred in the two placentas with the highest initial concentrations. Conclusions. Oseltamivir phosphate was extensively metabolized in the ex vivo model. Transplacental transfer of the metabolite was incomplete and accumulation was minimal.
PMCID: PMC2413047  PMID: 18551180
4.  Tetracycline Effects on Candida Albicans Virulence Factors 
Object. To determine if tetracycline, previously reported to increase the probability of developing symptomatic vaginal yeast infections, has a direct effect on Candida albicans growth or induction of virulent phenotypes. Method. In vitro, clinical isolates of yeast were cultivated with sublethal concentrations of tetracycline and yeast cell counts, hyphal formation, drug efflux pump activity, biofilm production, and hemolysin production were determined by previously reported methods. Results. Tetracycline concentrations above 150 μg/mL inhibited Candida albicans, but at submicrogram/mL, a modest growth increase during the early hours of the growth curve was observed. Tetracycline did not inhibit hyphal formation at sublethal concentrations. Hypha formation appeared augmented by exposure to tetracycline in the presence of chemically defined medium and especially in the presence of human serum. Efflux pump CDR1 was upregulated and a nonsignificant trend toward increased biofilm formation was noted. Conclusion. Tetracycline appears to have a small growth enhancing effect and may influence virulence through augmentation of hypha formation, and a modest effect on drug efflux and biofilm formation, although tetracycline did not affect hemolysin. It is not clear if the magnitude of the effect is sufficient to attribute vaginitis following tetracycline treatment to direct action of tetracycline on yeast.
PMCID: PMC2408679  PMID: 18528520
5.  Human Granulocytic Ehrlichiosis Complicating Early Pregnancy 
Background. The goal of this case is to review the zoonotic infection, human granulocytic ehrlichiosis, presenting with pyrexia. Case. A 22-year-old multigravid female presented to the emergency department with a painful skin rash, high fever, and severe myalgias. The patient underwent a diagnostic evaluation for zoonotic infections due to her geographical and seasonal risk factors. Treatment of human granulocytic ehrlichiosis was successful though the patient spontaneously aborted presumably due to the severity of the acute illness. Conclusion. Treatment of human granulocytic ehrlichiosis in pregnancy presents unique challenges. Management of pyrexia during pregnancy is limited to external cooling in the setting of thrombocytopenia and elevated aminotransferases. Extensive counseling regarding teratogenic potential of medications allows the patient to weigh the pros and cons of treatment.
PMCID: PMC2396214  PMID: 18509484
6.  Pulmonary Tuberculosis in a Young Pregnant Female: Challenges in Diagnosis and Management 
Background. With the world becoming a global village, tuberculosis is no longer limited to endemic areas. Our case emphasizes the impact of immigration on infectious disease epidemiology and challenges associated with diagnosis and treatment in pregnancy. Case. A 21-year-old Hispanic female presented in preterm labor and was found to be hypoxic. Chest X-ray revealed a paratracheal mass which a CT scan confirmed. PPD test was positive. Bronchoalveolar lavage did not reveal acid-fast bacilli and biopsy revealed caseating granulomas. Diagnosis and treatment were challenging due to constraints in radiological investigations, lack of initial evidence of acid-fast bacilli, and toxic profile of medications. Due to her high risk, she was started on antituberculosis regimen. The diagnosis was confirmed on Day 26 when Mycobacterium tuberculosis was isolated by DNA probe. Conclusion. A high index of suspicion is required to recognize the changing face and disease spectrum of tuberculosis and initiate treatment for better outcomes.
PMCID: PMC2276602  PMID: 18382614
7.  Tubercular Sinus of Labia Majora: Rare Case Report 
Tuberculosis of the female external genitalia is unusual and primary infection is rare. We report a 50-year-old female patient admitted to Department to Surgery with swelling over left inguinal area with discharging sinus from labia majora to left inguinal crease which was found to be tubercular sinus on histopathology.
PMCID: PMC2248239  PMID: 18301724
8.  Ampicillin Resistance and Outcome Differences in Acute Antepartum Pyelonephritis 
Objective. To measure the incidence of ampicillin-resistant uropathogens in acute antepartum pyelonephritis and to determine if patients with resistant organisms had different clinical outcomes. Study design. This was a secondary analysis of a prospective cohort study of pregnant women admitted with pyelonephritis, diagnosed by standard clinical and laboratory criteria. All patients received ampicillin and gentamicin. Results. We identified 440 cases of acute pyelonephritis. Seventy-two percent (316 cases) had urine cultures with identification of organism and antibiotic sensitivities. Fifty-one percent of uropathogens were ampicillin resistant. The patients with ampicillin-resistant organisms were more likely to be older and multiparous. There were no significant differences in hospital course (length of stay, days of antibiotics, ECU admission, or readmission). Patients with ampicillin-resistant organisms did not have higher complication rates (anemia, renal dysfunction, respiratory insufficiency, or preterm birth). Conclusion. A majority of uropathogens were ampicillin resistant, but no differences in outcomes were observed in these patients.
PMCID: PMC2565579  PMID: 18923674
9.  The Role of Obstetrician/Gynecologists in the Management of Hepatitis C Virus Infection 
Chronic infection with hepatitis C virus (HCV) is a major cause of liver disease-related death and is also the most frequent indication for liver transplantation in USA. Infected individuals can remain asymptomatic for 20 years or more, but they remain at risk for progressive liver disease. They also represent a potential source of infection for others. For reducing the future disease burden due to HCV, obstetrician/gynecologists and primary health care practitioners should be aware of the factors that promote HCV transmission: how to provide counseling and testing, and when specialist referral is needed.
PMCID: PMC2551737  PMID: 18818775
10.  Progressive Hypertrophic Genital Herpes in an HIV-Infected Woman despite Immune Recovery on Antiretroviral Therapy 
Most HIV-infected individuals are coinfected by Herpes simplex virus type 2 (HSV-2). HSV-2 reactivates more frequently in HIV-coinfected individuals with advanced immunosuppression, and may have very unusual clinical presentations, including hypertrophic genital lesions. We report the case of a progressive, hypertrophic HSV-2 lesion in an HIV-coinfected woman, despite near-complete immune restoration on antiretroviral therapy for up to three years. In this case, there was prompt response to topical imiquimod. The immunopathogenesis and clinical presentation of HSV-2 disease in HIV-coinfected individuals are reviewed, with a focus on potential mechanisms for persistent disease despite apparent immune reconstitution. HIV-infected individuals and their care providers should be aware that HSV-2 may cause atypical disease even in the context of near-comlpete immune reconstitution on HAART.
PMCID: PMC2531199  PMID: 18784844
11.  Hydatidosis of the Pelvic Cavity: A Big Masquerade 
We report and discuss a case of primary hydatidosis of the pelvic cavity in a woman who presented with severe weight loss and abdominal pain. This unusual presentation was initially considered as a tumor process until surgical exploration and microscopic studies confirmed the diagnosis. The gynecologists should be aware of possibility of primary hydatid cyst of the pelvic cavity and should be considered in the differential diagnosis of cystic pelvic masses, especially in areas where the disease is endemic.
PMCID: PMC2526177  PMID: 18769555
12.  Effect of Semen on Vaginal Fluid Cytokines and Secretory Leukocyte Protease Inhibitor 
The presence of semen in vaginal fluid, as identified by an acid phosphatase spot test, does not influence vaginal proinflammatory cytokine concentrations. Objective: determine whether semen, as detected by acid phosphatase, influences vaginal cytokines or secretory leukocyte protease inhibitor concentrations. Methods: 138 pregnant women had vaginal fluid collected for Gram stain, acid phosphatase detection by colorimetric assay, and interleukin 1-Beta, interleukin-6, interleukin-8, and secretory leukocyte protease inhibitor measurement by enzyme immunoassay. Results for women with and without acid phosphatase were compared by Mann-Whitney test. Results: of 138 subjects, 28 (20%) had acid phosphatase detected; of these, only 19 (68%) reported recent intercourse and 3 (11%) had sperm seen on Gram stain. There were no significant differences in proinflammatory cytokine concentrations; however, secretory leukocyte protease inhibitor concentrations were significantly higher among women with acid phosphatase. Conclusions: proinflammatory cytokine measurement does not appear to be affected by the presence of semen, but secretory leukocyte protease inhibitor is significantly higher when semen is present. Detection of semen by acid phosphatase was associated with higher vaginal SLPI concentrations, however, the presence of semen did not appear to influence vaginal proinflammatory cytokine concentrations.
PMCID: PMC2443399  PMID: 18615190
13.  Necrotizing Pneumonia Caused by Panton-Valentine Leucocidin-Producing Staphylococcus aureus Originating from a Bartholin's Abscess 
Background. Panton-Valentine leukocidin (PVL-)producing Staphylococcus aureus is emerging as a serious problem worldwide. There has been an increase in the incidence of necrotizing lung infections in otherwise healthy young people with a very high mortality associated with these strains. Sporadic severe infectious complications after incision of Bartholin's abcesses have been described but involvement of S. aureus is rare. Case report. We present a 23-year-old apparently healthy female patient without any typical predisposing findings who developed severe sepsis with necrotizing pneumonia and multiple abscesses following incision of a Bartholin's abscess. Methicillin-sensitive S. aureus harbouring Panton-Valentine leucocidin genes were cultured from the abscess fluid, multiple blood cultures and a postoperative wound swab. Aggressive antibiotic therapy with flucloxacillin, rifampicin and clindamycin, drainage and intensive supportive care lead finally to recovery. Conclusions. S. aureus, in particular PVL-positive strains, should be considered when a young, immunocompetent person develops a fulminant necrotizing pneumonia. Minor infections—such as Bartholin's abscess—can precede this life-threating syndrome. Bactericidal antistaphylococcal antibiotics are recommended for treatment, and surgical procedures may become necessary.
PMCID: PMC2492175  PMID: 18682803
14.  Spermicidal Activity of the Safe Natural Antimicrobial Peptide Subtilosin 
Bacterial vaginosis (BV), a condition affecting millions of women each year, is primarily caused by the gram-variable organism Gardnerella vaginalis. A number of organisms associated with BV cases have been reported to develop multidrug resistance, leading to the need for alternative therapies. Previously, we reported the antimicrobial peptide subtilosin has proven antimicrobial activity against G. vaginalis, but not against the tested healthy vaginal microbiota of lactobacilli. After conducting tissue sensitivity assays using an ectocervical tissue model, we determined that human cells remained viable after prolonged exposures to partially-purified subtilosin, indicating the compound is safe for human use. Subtilosin was shown to eliminate the motility and forward progression of human spermatozoa in a dose-dependent manner, and can therefore be considered a general spermicidal agent. These results suggest subtilosin would be a valuable component in topical personal care products aimed at contraception and BV prophylaxis and treatment.
PMCID: PMC2565553  PMID: 18923673
15.  High Rate of Severe Fetal Outcomes Associated with Maternal Parvovirus B19 Infection in Pregnancy 
Objective. To augment the understanding of parvovirus B19 infection in pregnancy with respect to maternal characteristics and their corresponding fetal outcomes. Study Design. Retrospective case-series of all women referred to Magee-Women_s Hospital with serologically-documented parvovirus B19 infection during pregnancy from 1998–2001. Results. All 25 cases that are available for analysis occurred from January through June. The frequency of cases varied substantially from year to year, with 14 cases in 1998, 0 cases in 1999 and 2000, and 11 cases in 2001. In contrast to previous reports, the minority of women [4/25(16%)] experienced symptoms attributable to parvovirus B-19 infection although 3 of 25 (12%) fetuses developed hydrops fetalis and 4/25 (16%) suffered an intrauterine of fetal death. Conclusions. These findings suggest that parvovirus B19 infection in pregnancy follows seasonal and annual trend variation, may produce a lower frequency of maternal symptoms and a higher fetal loss rate than previously reported. Synopsis. Maternal parvovirus B19 infection follows seasonal and annual variation is often asymptomatic and may have higher fetal loss rates than previously reported. Continued surveillance is warranted.
PMCID: PMC2358947  PMID: 18464909
16.  The Relationship between Cocaine Use and Human Papillomavirus Infections in HIV-Seropositive and HIV-Seronegative Women 
Objective. Animal data suggest that cocaine has an immunosuppressive effect, but no human studies have been conducted to assess the relation of cocaine use with human papillomavirus (HPV) infection, the viral cause of cervical cancer. Since both cocaine use and HPV infection are common among HIV-positive women, we sought to determine whether use of cocaine and/or crack influences the natural history of HPV among women with or at high risk of HIV. Methods. Women enrolled in the Women's Interagency HIV Study (2278 HIV-seropositive and 826 high-risk seronegative women) were examined every six months for up to 9.5 years with Pap smear, collection of cervicovaginal lavage (CVL) samples, and detailed questionnaires regarding health and behavior, including use of crack and cocaine (crack/cocaine). CVLs were tested for HPV DNA by PCR, with genotyping for over forty HPV types. Results. In multivariate logistic regression models, censoring women treated for cervical neoplasia, crack/cocaine use within the last six months was associated with prevalent detection of oncogenic HPV DNA (odds ratio [OR] = 1.30 (1.09–1.55)), and with oncogenic HPV-positive squamous intraepithelial lesions (SIL) (OR = 1.70 (1.27–2.27)), following adjustment for age, race, HIV-serostatus, and CD4+ T-cell count, the number of sexual partners in the past six months, and smoking. In multivariate Cox models crack/cocaine use was also associated with a trend that approached significance in regard to incident detection of oncogenic HPV-positive SIL (HR = 1.51, 95% CI 0.99–2.30), and while the rate of oncogenic HPV clearance was not related to cocaine use, the clearance of any SIL was significantly lower in those with versus those without recent crack/cocaine use (HR = 0.57, 95% CI 0.34–0.97). Conclusions. Cocaine use is associated with an increased risk of detection of both prevalent and incident oncogenic HPV infection, as well as an increased risk of HPV-positive SIL over time.
PMCID: PMC2324195  PMID: 18437233
17.  Provider Knowledge, Attitudes, and Practices regarding Obstetric and Postsurgical Gynecologic Infections Due to Group A Streptococcus and Other Infectious Agents 
Background. Knowledge, attitudes, and practices of obstetricians and gynecologists regarding the Centers for Disease Control and Prevention (CDC) recommendations for prevention of healthcare-associated group A streptococcal (GAS) infections as well as general management of pregnancy-related and postpartum infections are unknown. Methods. Questionnaires were sent to 1300 members of the American College of Obstetricians and Gynecologists. Results. Overall, 53% of providers responded. Postpartum and postsurgical infections occurred in 3% and 7% of patients, respectively. Only 14% of clinicians routinely obtain diagnostic specimens for postpartum infections; providers collecting specimens determined the microbial etiology in 28%. Microbiologic diagnoses were confirmed in 20% of postsurgical cases. Approximately 13% and 15% of postpartum and postsurgical infections for which diagnoses were confirmed were attributed to GAS, respectively. Over 70% of clinicians were unaware of CDC recommendations. Conclusions. Postpartum and postsurgical infections are common. Providing empiric treatment without attaining diagnostic cultures represents a missed opportunity for potential prevention of diseases such as severe GAS infections.
PMCID: PMC2248426  PMID: 18301725
18.  Morbidly Obese Woman Unaware of Pregnancy until Full-Term and Complicated by Intraamniotic Sepsis with Pseudomonas 
A 32-year-old Caucasian woman of body mass index (BMI) 46 presented with urinary symptoms to accident and emergency (A&E). Acute pyelonephritis was the diagnosis. Transabdominal scan revealed a live term fetus. Both the partners were unaware of the ongoing pregnancy until diagnosed. She underwent emergency cesarean under general anaesthesia (GA) for nonreassuring CTG, severe chorioamnionitis, and moderate preecclampsia. A live male baby weighing 4400 grams delivered in poor condition. Placental tissue on culture exhibited scanty growth of pseudomonas aeruginosa. Chorioamnionitis due to pseudomonas is rare, with high neonatal morbidity and mortality. It is mostly reported among preterm prelabor rupture of membranes (PPROM). Educating the community especially morbidly obese women if they put on excessive weight or with irregular periods should seek doctor's advice and exclude pregnancy. For the primary care provider, it is of great importance to exclude pregnancy in any reproductive woman presenting with abdominal complaints. This case also brings to clinicians notice that pseudomonas can be community-acquired and can affect term pregnancies with intact or prolonged rupture of membranes.
PMCID: PMC2246062  PMID: 18301713
19.  Human Papillomavirus in Endometrial Adenocarcinomas: Infectious Agent or a Mere “Passenger”? 
Aims. To investigate the possible association of human papillomavirus (HPV) with endometrial hyperplasias and neoplasia. Does HPV play any role in the initiation or prognosis of endometrial adenocarcinomas? Methods. Twenty-five endometrial adenocarcinomas of the endometrioid cell type, with and without squamous differentiation, and twenty-four endometrial hyperplasias of various forms (simple, complex, and atypical) were analyzed for the presence of type 16 and 18 HPV by the polymerase chain reaction (PCR). The results were related to histopathological features of the tumour, and the patients' age, and prognosis. Results. Six of 25 endometrial adenocarcinomas were HPV 16-positive (24%), and 5 of 25 (20%) were HPV 18-positive. Simple endometrial hyperplasias was associated somewhat more commonly with HPV 16 and 18 (2/8 and 1/8 cases, resp.) than hyperplasias progressing to endometrial adenocarcinomas, namely, atypical endometrial hyperplasia (1/8 and 0/8 cases, resp.). None of the positive cases in the series, whether hyperplastic or neoplastic, demonstrated cytological evidence of HPV infection. There was no relation between HPV-positive cases and squamous differentiation, depth of myometrial invasion, lymphatic involvement, lymphocytic response, patients' age, or prognosis. Conclusion. It appears that the presence of HPV in the endometrium, as detected by PCR, does not play any role in the initiation or prognosis of endometrial adenocarcinoma.
PMCID: PMC2233766  PMID: 18274613

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