The world is now faced with the managernent of patients who are immunodefIcient because of several different factors which contribute to a poor soil or terrain (Table 1).Let us study these factors which are responsible for poor resistance against disease. An antigen that penetrates the body’s external defences (skin, mucous membranes, cilia) will encounter two populations of circulating lymphocytes. Phagocytes reach the site of invasion by chemotaxis where they ingest and kill the foreign organism. Intrinsic cellular defects may render phagocytes important as in the chronic granulomatous disease of childhood.
Opsonization involves the preparation of bacteria for digestion by phagocytes through the coating of bacteria by the third component of complement (C3b).
Neuz’ropenia may be the result of a variety of causes amongst which are drugs, neoplasia, infections, connective tissue diseases and bypersplenism (Table II).
The human leucocyte system of antigens are on the membrane of all nucleated cells and platelets and are inherited on a pair of autosomal chromosomes. Malnutrition, ischaemia, disseminated neoplasia, drugs and chemotherapy may all profoundly alter the soil and contribute to the poor resistance of the patient. This epidemic disorder is most commonly seen in promiscuous male homosexuals, haemophiliac, and drug addicts with poor cellular immunity.
The immunologic pattern comprises 1-helper cell lymphopenia, an OKT4:OKT8 ratio reduced to less than unity, cutaneous anergy, decreased natural killer (Nt) cells, decreased response to proliferative mitogens (phytohaemagglutinin, Concanavalin A, pokeweed), normal neutrophil function, and normal or increased levels of immunoglobulins.
Kaposi’s sarcoma is a multifocal reticuloendothelial neoplasm which has attracted considerable attention in the last decade because of its high incidence in renal transplant recipients, immunosuppressed individuals and sick homosexuals. Homosexuals who engage in ano-genital intercourse with numerous partners have eleven times the risk of developing Kaposi’s sarcoma than less promiscuous homosexuals.
The immunological abnormalities found in the blood of such patients extend into the lymph nodes7  T-suppressor cells invade the follicles of the node where they are normally absent and numbers of T helper cells are decreased. French workers isolated lymphadenopathy associated virus (LAV) from a homosexual with pre-AIDS, and also found the same virus in fully-developed AIDS. It is recognised in homosexuals, drug addicts and in Haitians, but it also occurs in otherwise healthy individuals, who develop immunodeficiency,unaccountably due to ablation of the helper T cell subset. Pneumococcal bacteraernia in children is non-pulmonary, and has a case fatality of 13 per cent. This journal is a member of and subscribes to the principles of the Committee on Publication Ethics. ABCD sponsors treatment for those in need regardless of gender, race or creed, helping them to reach their full potential, to live life with dignity and to take their rightful place in their community. ABCD works through local Palestinian partners, the Bethlehem Arab Society for Rehabilitation (BASR) based in Beit Jala, The Sheepfold in Beit Sahour and two UNWRA Refugee Camps in Jalazone and Nour Shams.
Funding is constantly needed for new projects and to update and refurbish existing facilities.
Blood-brain barrier - The barrier between the brain and the blood that allows the brain to maintain a cerebrospinal fluid composition different from that of blood.
Coma - A state of unconsciousness from which patients cannot be aroused, even by the strongest stimuli. Meninges - The three membranes covering the brain and spinal cord: the dura, arachnoid, and pia.
Seizure - A sudden and transient disturbance of mental function or body movements that results from an excessive electrical discharge of a group of brain cells. Stroke - Sudden onset of symptoms caused by acute ischemia in the brain resulting from hemorrhage, embolism, or thrombosis, and evidenced by loss of neurological function. Ventricles - Four cavities within the brain filled with cerebrospinal fluid and lined by the pia and the choroid plexus. Xanthochromia - A yellow coloring of the cerebrospinal fluid caused by the presence of breakdown products of hemoglobin.
CSF is formed by the choroid plexus, presumably through the process of ultrafiltration and secretion. If changes of these solutes in blood are rapid, the concentration in CSF lags behind those in blood (compared with changes in synovial fluid). Other causes of increased pressure are presumably due to an increase in the rate of production of CSF (meningism), brain tumor, abscess, aneurysms, hematoma, cerebral edema, hemorrhage, and acute febrile disease. After the opening pressure is measured, collect a few mL of fluid in three portions using three separate collection tubes under strictly sterile conditions. Xanthochromia: Old blood (hemoglobin) is converted into bilirubin, which appears after 12 hours and may last 12-28 days. Normally protein content is lower in CSF obtained from ventricular or cisternal puncture, higher in lumbar puncture sample. Measurement of CSF total protein is based on turbidometry after addition of trichloroacetic acid or sulfosalicylic acid; albumin and globulin may contribute differently to turbidity. Increased CSF gamma-globulin may be seen when the total protein level is within normal limits. Oligoclonal bands have also been reported in other diseases such as amyotrophic lateral sclerosis, Guillain-Barre syndrome, meningoencephalitis, neurosyphilis, spinal cord compression, and subacute sclerosing panencephalitis. MBP is also elevated in diseases other than MS such as amyotrophic lateral sclerosis, presenile dementia, metastatic CA to the brain, cerebral palsy, cerebrovascular accidents, head trauma, meningoencephalitis, multiple myeloma, and spinal cord compression. The CNS synthesis rate of IgG by B cells infiltrating areas of active demyelination is a useful parameter for monitoring disease activity in multiple sclerosis.
A decrease is seen in bacterial meningitis (leukocytes are stimulated to more rapid glycolysis by bacteria). A decrease is noted with tumors of the meninges due to heavy neutrophilic reaction or widespread metastases. Gently swirl the fluid in the test tube for thorough mixing, because cells may have settled upon standing. With the aid of a pipet transfer a sufficient amount of the well-mixed fluid into the counting chamber of the hemocytometer to fill the space between the coverslip and the raised area of the counting grid completely and without air bubbles. Place hemocytometer onto the mechanical stage of the microscope and secure with the clamps. Scan entire area filled with fluid for formed elements other than white cells or red cells.
Objectives: To determine the level of serum procalcitonin, blood leukocyte count (TLC) and C-reactive protein (CRP) in children with bacterial and non bacterial meningitis and document their efficacy in differential diagnosis. Methods: From March 2005 to February 2008, we evaluated 38 clinically suspected meningitis patients in the paediatric departments, Al-Jedaany Hospital, Jeddah, KSA, for Serum procalcitonin, CRP, TLC and Lumbar punctures and CSF analysis. Conclusion: PCT can be used in the early diagnosis of bacterial meningitis and may be a useful adjunct in differentiating bacterial and non bacterial meningitis than CRP or TLC and diminishing the value of lumbar puncture performed 48-72 hours after admission to assess treatment efficacy. Meningococcal septicemia and meningitis remains is an important cause of morbidity and mortality in children despite the advent of highly effective bacterial conjugate vaccines. Procalcitonin, which is a calcitonin propeptide, is supposed to be synthesized in C cells of the thyroid gland and secreted from leukocytes of the peripheral blood. The present study was conducted to determine the level of serum procalcitonin, blood leukocyte count (TLC) and C-reactive protein (CRP) in children with bacterial and non bacterial meningitis and document their efficacy in differential diagnosis. Thirty eight most likely meningitis children patients (22 males and 16 females), with ages ranging from 2 months to 10 years attending the paediatric departments of Al-Jedaani Hospital, Jeddah, KSA in the period from March 2005 to February 2008 were included in this prospective study. Patients presenting with a further site of infection in addition to meningitis, or who had received prior antibiotic treatment for more than 2 consecutive days, were excluded from the study. Our study was approved by the clinical ethics committee of the hospital and performed according to ethical procedures. Measurement of Complete blood count: It was done as a part of routine laboratory test by Cell- Dyne 1600 System (Abbott Park Laboratories, Ilinois, USA).

The demographic and clinical characteristics of the studied patients are summarized in Table-1and shows that, there were no statistical differences in patient's demographic and clinical characteristics at time of admission.
The remaining 3 bacterial meningitis cases were transferred to government hospital for continuation of management as requested by their parents.
In this study we found that serum procalcitonin levels were exclusively high in patients with bacterial culture positive meningitis, prior to treatment and became very low during follow up with treatment.
An explanation for increased PCT levels in bacterial meningitis was a global increase of the first calcitonin gene (CALC-I gene) expression and a cardinal release of PCT from all parenchymal tissues and differentiated cell types throughout the body induced by a microbial infection.11 The largest tissue mass and major source of circulating PCT in sepsis is provided by Parenchymal cells (including liver, lung, kidney, adipocytes and muscle) and not the leukocyte population.
It has been long known that CRP and leukocyte count can differentiate bacterial and non bacterial infection especially meningitis.
Lacour et al19 showed that PCT, CRP, and urine dipstick are independent predictors of serious bacterial infection (SBI) in this population of children with fever of unknown origin. High PCT levels correlate positively with the severity of the disease, and the presence of multiple organ dysfunction syndrome or shock make it more valuable over serum CRP as a diagnostic and prognostic marker.
Follow up of our studied cases, showed a significant decrease in procalcitonin levels on day 3 and day 6 after antibiotic treatment. Potential limitations of our study are that, comparing serum PCT, CRP and TLC in their capacity to distinguish bacterial from non bacterial meningitis has a lot of valuable information but with the major methodological shortcoming of comparing quantitative PCT and TLC results with semi-quantitative CRP results. Serum PCT levels can be used in the early diagnosis of acute bacterial meningitis and is more valuable than CRP or TLC. These two systems, responsible for cellular and for circulating immunity, are the cornerstones of an elaborate and powerful defence system.
They carry memory, can affect B-cells, reject grafts, recognise cancer, and prevent viral and fungal infections. Impairment of function includes poor chemotaxis, intrinsic cellular defects, abnormal opsonization and neutropenia.
Poor leucocyte be locomotion may associated with inhibitors, and blocking factors, deficiencies in complement. Opsonic activity requires intact receptor sites, and neutrophil attachment to the organism occurs at the Fab site. Four HLA antigens are found in any individual, two derived from each of two closely linked genetic loci.
Splenectomy may lead to increased susceptibility of the individval to certain infections, particularly, pneumococcal and streptococcal (Table IV). Leukaemia patients) may be prone to Aspergillus, pseudomonas, Mycoplasma, and Salmonella infections, whilst those with poor macrophage function (e.g cystic fibrosis) may be especially liable to Staphylococcus and Pseudomonas infection. Numerous opportunistic infections are associated with weight loss, fever, diarrhoea, peripheral lymphadenopathy, lymphopenia, and Kaposi’s sarcoma (Table V).There is an overall mortality of 70% and treatments have all been uniformly unsuccessful.
Many patients have an unusual acid-labile form of human leucocyte or alpha-interferon4 and thymosin 1 serum levels may also be high.5 It is hoped that HTLV III antibodies prove to be serological markers of the disease. Kaposi6 originally described pea-sized brownish-red to bluish-red skin nodules that first appeared on the soles and dorsum of the feet and later spread to the rest of the skin and ulti­mately to the gut, liver, and upper respiratory tract.
It occurs particularly in the passive partner receiving semen into the gastro-intestinal tract by rectum or by swallowing it. There is a profound lymphopenia, and spinal fluid examination may reveal high protein and low glucose levels. Background factors include splenectomy, leukaemia, myeloma, sickle-cell disease, thalassaemia, systemic lupus and nephrotic syndrome. There are, of course, the obvious factors such as the correction of malnutrition and ischaemia, antibiotics and, where possible, the correction of the underlying disease. Splenectomised children should have polyvalent vaccines and prophylactic penicillin for at least two years. Following treatment with Coomassie Blue or Biuret reagent, protein in CSF may be measured colorimetrically.
Myelin is 70% lipid and 30% protein by weight with the protein portion consisting of 20% high molecular weight protein, 50% proteolipid, and 30% basic protein.
Do not shake vigorously as this may destroy cells and foaming may interfere with the testing procedures. With the low power objective (10 times magnification) visualize the upper left hand large square,* which with this magnification should be entirely visible in one microscopic field. Patients were classified into bacterial meningitis group I (18) and non bacterial meningitis group II (20).
The secretion of PCT was found to increase in the presence of bacterial lipopolysaccharides and cytokines that are associated with sepsis.3 In healthy subjects, circulating levels of PCT are below detection limits, increasing in patients with bacterial infections.
Also described are procalcitonin levels over the time during the treatment of acute bacterial meningitis. Blood samples for procalcitonin were taken from the waste of blood taken for routine investigations. The assay uses two antigen-specific monoclonal antibodies that bind PCT at two different binding sites. According to the manufacture manual (Vitro 950 analyzer, Johnson and Johnson, Rochester, New York, USA), It is a latex agglutination test for qualitative and semi-quantitative determination of CRP in serum. The type of organisms yielded from bacterial cultures of CSF are; Neisseria meningitides (five patients), Streptococcus pneumonia (five patients), Haemophilus influenza-b (four patients), E-coli (two patients), and Staphylcoccus aureus (two patients).
Our data of a significant difference in the mean CRP and leukocyte count between bacterial and non bacterial meningitis groups, are in agreement with those obtained from many investigators,10,13 who found that, CRP level and leukocyte count are valuable in distinguishing between bacterial and non bacterial infections.
They demonstrated that, leucocytosis was not an independent predictor of SBI when PCT, CRP, and urine dipstick have been taken into account.
In the time to come, bedside, rapid, semi-quantitative methods of serum PCT measurements could be more beneficial to the physician when they will be easily accessible.20,21 Our results disagree with Knudsen et al,22 who concluded that, PCT and CRP had very high diagnostic accuracy for distinguishing between bacterial and non bacterial infection in patients with spinal fluid pleocytosis.
It also had a higher sensitivity, specificity, positive predictive value, and negative predictive value.
This result is consistent with that obtained by many authors3,6,15,24 who found that, serum procalcitonin decreased to a very low, and may to an unidentifiable level with treatment, making it a valuable parameter for evaluating the efficacy of antibiotic treatment and hence diminishing the need for lumbar puncture performed 48-72 hours after admission to assess treatment efficacy. Similarly, they may be useful adjuncts in differential diagnosis of bacterial and non bacterial meningitis and diminishing the value of 2nd lumbar puncture performed 48-72 hours after admission to assess treatment efficacy.
Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Procalcitonin expression in human peripheral blood mononuclear cells and its modulation by lipopolysaccharides and sepsis-related cytokines in vitro. Decrease in serum procalcitonin levels over time during treatment of acute bacterial meningitis.
Comparison of procalcitonin with C -reactive protein and serum amyloid for the early diagnosis of bacterial sepsis in critically ill neonates and children. In vitro and in vivo calcitonin 1 gene expression in parenchymal cells: a novel product of human adipose tissue. Procalcitonin and C-reactive protein during systemic inflammatory response syndrome, sepsis and organ dysfunction.
Use of quantitative and semiquantitative procalcitonin measurements to identify children with sepsis and meningitis.
Serum procalcitonin level and other biological markers to distinguish between bacterial and aseptic meningitis in children: a European multicentre case cohort study. Procalcitonin as a diagnostic marker of meningococcal disease in children presenting with fever and a rash.
Comparison of procalcitonin with CRP, lnterleukin-6 and interferon-alpha for distinguishing of bacterial vs.
Diagnostic value of soluble CD163 serum levels in patients suspected of meningitis: comparison with CRP and procalcitonin.

Procalcitonin and C-reactive protein as diagnostic markers of severe bacterial infections in febrile infants and children in the emergency department. The potential role of procalcitonin in the emergency department management of febrile young adults during a sustained meningococcal epidemic.
Their chemical mediators are lymphokines and interleukins and they are involved in the production of interferons. These are responsible for the lysis of antigen by fixing complement, opsonization of bacteria and the neutralization of their products. Patients with various types of C3b deficiency have poor opsonic activity and are more prone to infections. These tissue antigens are a most important constituent of the terrain and there is now increasing recognition of associations between particular HLA antigens and diseases, some of which are highly significant. This suggests that an infectious agent in semen is transmitted or that semen ejaculated into a foreign environment causes an immunologic disturbance. In addition there is B cell hyperplasia within the node and an increase in the number of fully differentiated B cells in the peripheral blood. Bethesda, of the isolation of a human T leukaemia retrovirus (HTLVIII) from 48 AIDS patients but from none of 115 healthy controls. Marrow and thymus transplants may help to overcome poor cellular immunity due to T cell disorders.
The character of CSF indicates that it is an ultrafiltrate with modifications, a dialysate which is in hydrostatic and osmotic equilibrium with blood. The technique requires at least 10 mL of CSF because of the need to concentrate samples due to relatively low protein concentrations in CSF. Both the specificity and the predictive value of positive tests have been reported to be about 85%.
Production of procalcitonin in the body during inflammation is linked with bacterial endotoxin and with inflammatory cytokines interleukin-6 and tumor necrosis factor (IL6 and TNF).3 The increase of procalcitonin level is minimal in patients infected with viruses. Meningitis was diagnosed according to history, physical examination, CSF laboratory findings, identification of bacterial agents in CSF gram staining and cultures.
Luminescence was measured automatically by an analyzer (Behring Diagnostics, Marburg, Germany), and results were calculated using the software provided. It is based on the immunological reaction between human CRP in the serum and the corresponding antihuman CRP antibodies bound to latex particles. Lacour and his colleagues19 also developed a scoring system (Laboratory-score) based on the 3 predictive variables independently associated with SBI: PCT, CRP, and urinary dipstick.
Andreola and his colleagues23 agreed that CRP and PCT are both valuable markers for detection of severe bacterial infection in children. The likelihood ratio for positive results (LR+) and negative results (LR-) for diagnosing bacterial meningitis against CRP and total leukocytic count is better. T-cells are particularly involved in the defence against organisms that have an intracellular phase, for instance viruses, mycobacteria, Brucella, and fungi. Examples include the possession of HLA B27 predisposing the individual to sero-negative arthritis and joint complications of inflammatory bowel disease, and possession of DRw3 which increases the likelihood of, amongst others, some ‘autoim mune disorders’ including thyroiditis, Addison’s disease, and gluten-sensitive enteropathy (Table III).
The latter occur at the expense of the precursors and such polyclonal stimulation would be in keeping with, viral B cell activation in the absence of normal regulatory T cell influence. The French LAV and American HTLVIII are probably the same retrovirus, which has a selective tropism for T-helper cells.
Like-wise, impaired humoral immunity is being improved by intramuscular and intravenous inimunoglobulins and by plasmapherisis.
Isolation of a T-lymphotropic from a patient at risk for acquired immune deficiency syndrome (AIDS). Isolation of new lymphotropic retrovirus from two siblings with haemophilia B, one with AIDS.
Frequent detection and isolation of cytopathic retroviruses (HTKV-IH) from patients with AIDS and at risk for AIDS. Detection, isolation and continuous production of cytopathic retroviruses (HTLV-III) from patients with AIDS and pre-AIDS. Serological analysis of a subgroup of human T-lymphotropic retroviruses (HTLV-III) asso­ciated with aids. Prevalence of antibody to human T-Lympo­ tropic virus type III in AIDS and AIDS-risk patients in Britain. Seroepidemiology of HTLV-III antibody in Danish homosexual men; prevalence, trans­ mission, and disease outcome. The positive reaction is indicated by a distinctly visible agglutination of the latex particles in the test cell of the slide.
It means that, the highest value of procalcitonin seen in patients with non bacterial meningitis is still lower than the lower value of PCT seen in patients with bacterial meningitis.
The level rises dramatically in response to bacterial infection, making it as sensitive and more specific than CRP as a marker of systemic bacterial infection in children. The principal advantage of the Laboratory-score is its good specificity (81%) for the prediction of SBI associated with the security of a high sensitivity (94%). This is in agreement with many studies.24,25 Gendrel et al8 demonstrated that, procalcitonin had better specificity, sensitivity, predictive value and likelihood ratio than CRP, interleukin 6 and interferon-alpha in children for distinguishing between bacterial and viral infections.
There are now simplified techniques for recognising T cells and their subsets, and HLA-DR antigen in peripheral blood smears by immunoalkaline phosphatase staining. It is likely that there are several co-factors including, of course, T helper cell ablation, B cell overactivity, CMV irnmunosup. The future holds promise with the interferons, interleukin-2, monoclonal antibodies, and the use of patching genes (by the technique of recombinant DNA) to provide vaccination against disease (Table VI).
Altered distribution of B and T lymphocytes in the lymph nodes form homosexual men with Kaposi’s sarcoma.
Detection of lgG antibodies to lymphadenopathy associated virus (LAy), in patients with acquired Immunodeficiency syndrome or lymphadenopathy syndrome. This result is in agreement with that obtained by many investigators.9,10 They found that PCT concentration increased in bacterial meningitis with or without shock, but remained low in viral meningitis and inflammatory diseases.
The good specificity of the Laboratory-score should enable the reliable selection of children who need antibiotic treatment, without over treating those with viral infection. It is a more realistic predictor in the early hours of an infection, and if the time needed for its rise in the bloodstream, is considered.
It also indicates the severity of the bacterial infection and helps to decide antibiotic treatment in the emergency room.
However, the results are concordant with earlier studies showing results similar to the present one. The measurement of MBP is not a diagnostic test for MS but does provide an index for monitoring active demyelination. Based on the results of previous papers and this one, it seems possible that PCT is more accurate than CRP in distinguishing bacterial from non bacterial meningitis. We currently have no data on changes in serum PCT levels occurring among cases with different causative organisms and the question must be asked whether PCT could be reliably used to distinguish between different causative organisms of meningitis or not. The presence of HTLV-III serum antibodies is most strongly associated with sexual exposure to men in the United States and to anai receptive intercourse.

Symptoms of hypoglycemia low blood glucose test
Causes of reactive hypoglycemia hypothyroidism
Normal blood sugar levels for hypoglycemia quiz


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