OBJECTIVES:In order to analyze the molecular epidemiology of human astroviruses (HAstV) in Germany, a retrospective long-term study was performed to characterize circulating human astrovirus in patients with acute gastroenteritis in Germany. METHODS:A total of 2877 stool samples, collected between January 2010 and December 2015 from sporadic cases and outbreaks of acute gastroenteritis were retrospectively analyzed for astrovirus. A two-step PCR algorithm was developed and used to identify and characterize human astrovirus infections. RESULTS:Overall, 143 samples were astrovirus-positive (5.0%). Astrovirus infection was most frequently detectable in samples from children of 3-4 years (15%) followed by children of 1-2 years (8.6%), detection rates in adults were lower (1%-3.6%). A high number (71.3%) of co-infections, mainly with noro- or rotaviruses, were identified. Genotyping revealed that at least ten genotypes from all four human MAstV species were circulating in the study population. HAstV-1 was predominant in different age groups. Novel HAstV (MLB and VA genotypes) were also circulating in Germany. CONCLUSION:Our findings give new insights into the circulation and genetic diversity of human astroviruses in patients with acute gastroenteritis. The novel HAstV-MLB and -VA genotypes could be characterized firstly in Germany while the analysis showed that these viruses have been dispersed in Germany since 2011 as a causative agent of acute gastroenteritis.

Since early November 2016, the number of laboratory-confirmed norovirus infections reported in Germany has been increasing steeply. Here, we report the detection and genetic characterisation of an emerging norovirus recombinant, GII.P16-GII.2. This strain was frequently identified as the cause of sporadic cases as well as outbreaks in nine federal states of Germany. Our findings suggest that the emergence of GII. P16-GII.2 contributed to rising case numbers of norovirus gastroenteritis in Germany.

Norovirus infection is the main cause of epidemic non-bacterial gastroenteritis in humans. Although human norovirus (HuNoV) infection is self-limiting, it can persist for extended periods of time in immune deficient patients. Due to the lack of robust cell culture and small animal systems, little is known about HuNoV pathogenicity. However, murine norovirus (MNV) can be propagated in cell culture and is used as a model to study norovirus infection. Several MNV are known to persist in mice. In this study, we show that the MNV strain MNV-S99 persists in wild type inbred (C57BL/6J) mice over a period of at least 5 weeks post infection. Viral RNA was detectable in the jejunum, ileum, cecum, and colon, with the highest titers in the colon and cecum. To characterize the effect of MNV-S99 on the innate immune response, Stat1 phosphorylation and IFN-β production were analyzed and compared to the non-persistent strain MNV-1.CW3. While MNV-S99 and MNV-1.CW3 showed comparable growth characteristics in vitro, Stat1 phosphorylation and IFN-β release is strongly decreased after infection with MNV-S99 compared to MNV-1.CW3. In conclusion, our results show that unlike MNV-1.CW3, MNV-S99 establishes a persistent infection in mice, possibly due to interfering with the innate immune response.

OBJECTIVE:Human norovirus (HuNoV) and Clostridium difficile are common causes of infectious gastroenteritis in adults in the US. However, limited information is available regarding HuNoV and C. difficile coinfections. Our study was designed to evaluate the prevalence of HuNoV and C. difficile coinfections among adult patients in a hospital setting and disease symptomatology.STUDY DESIGN AND SETTING:For a cross-sectional analysis, 384 fecal samples were tested for the presence of C. difficile toxins from patients (n=290), whom the provider suspected of C. difficile infections. Subsequent testing was then performed for HuNoV genogroups I and II. Multinomial logistic regression was performed to determine symptoms more frequently associated with coinfections.RESULTS:The final cohort consisted of the following outcome groups: C. difficile (n=196), C. difficile + HuNoV coinfection (n=40), HuNoV only (n=12), and neither (n=136). Coinfected patients were more likely to develop nausea, gas, and abdominal pain and were more likely to seek treatment in the winter season compared with individuals not infected or infected with either pathogen alone.CONCLUSION:Our study revealed that patients with coinfection are more likely to experience certain gastrointestinal symptoms, in particular abdominal pain, suggesting an increased severity of disease symptomatology in coinfected patients.

Human norovirus is the main cause of non-bacterial gastroenteritis worldwide. It is transmitted from person to person, by fecally contaminated food or water or through virus containing aerosols originating during vomiting of infected persons. In September and October 2012, the largest foodborne norovirus outbreak in Germany so far spread over 5 Federal States (Berlin, Brandenburg, Saxony, Saxony-Anhalt, and Thuringia) affecting nearly 11,000 people mainly in schools and child care facilities. Epidemiological and trace-back investigations supported the assumption that a batch of frozen strawberries imported from China was the likely source of the outbreak. Sequence analysis of the capsid region encoding the P2 domain was used successfully for identification of transmission routes and epidemiologic relationship but was hampered by a lack of universal primers for all known genotypes so far. In the present study, a molecular approach was designed to track outbreak-related samples from the affected states of the large foodborne outbreak in Germany. Therefore, sequence analysis within the highly variable P2 domain of the capsid gene using newly developed universal P2 primers for genogroup I and genogroup II strains in combination with sequencing of the polymerase gene (region A) and the orf1/orf2 junction (region c) was used. The sequence analysis of 138 norovirus positive stool samples suspected to be outbreak-related revealed a considerable genomic diversity. At least 3 strains of genogroup I (I.3, I.4, and I.9) and 5 strains of genogroup II (II.6, II.7, II. 8, and recombinants II.P7_II.6, and II.P16_II.13) as well as 19 samples containing mixtures of these strains were detected. Six samples were considered as not linked to the outbreak. The most prevalent genotype was GI.4 (48/132; 36%). Genotype I.9 and the recombinant strain II.P16_II.13 were detected for the first time in Germany. Notably, the genotype II.P16_II.13 could also be determined in one of the samples of the frozen strawberry lot suspected as infection source. Especially, due to the good concordance of the P2 sequences from infected patients of 5 Federal States the outbreak-relation of the strains could be demonstrated. The high diversity of virus strains and the occurrence of sub-clusters within genotypes I.3, II.8, II.P16_II.13, and II.7 revealed the complex mixture of the outbreak source suggesting a possible waterborne fecal contamination of the strawberries. The typing system described here is in general useful for analysis of outbreaks caused by mixed infection sources. Extensive sequence analysis of different gene regions including the highly variable P2 domain in a sufficient number of cases is required to confirm the epidemiological relation of samples from outbreaks with high diversity of strains spreading over several geographic locations.

To the Editors: Quinn et al.1 demonstrated reduced morbidity and mortality from acute gastroenteritis by rotavirus vaccination in young children in Australia. We agree with the consensus statement highlighting these benefits in both developed and developing settings, which clearly outweigh the small increased risk of intussusception.2 Nevertheless, we think that the additional risk rotavirus vaccination poses for children with severe combined immunodeficiency (SCID) needs comment. Recently, we saw a 21-month-old boy from a country in the Middle-East who was in reduced general condition for further diagnosis and management at our center. Although his older brother died at 20 months of age suffering from postvaccinational BCGitis and severe cytomegalovirus infection, our patient had received rotavirus vaccine (Rotarix, GlaxoSmithKline Biologicals, Rixensart, Belgium) twice at 3 and 4 months of age. Ever since, he suffered from chronic gastroenteritis, which resulted in severe stunting and wasting. The patient had a x-linked hemizygous mutation in Exon 2 of the IL2RG gene (c.252C>A, p.Asn84Lys; MIM# 300400) and curative therapy with stem cell transplantation was initiated at our specialized medical center.3 We identified rotavirus vaccine strain in stool samples by sequencing of 8 different gene segments (VP1, VP2, VP4, VP6, VP7, NSP2, NSP4 and NSP5). In all segments vaccine-associated sequences harboring few new mutations were found, leading to the conclusion that the child’s chronic gastroenteritis was caused by persisting infection with the vaccine rotavirus strain (see Table, Supplemental Digital Content 1, https://links.lww.com/INF/B978). No other pathogen could be identified in multiple stool samples, including uncommon parasites, coccidia and helminths. Notably, all stool, blood and respiratory specimens were also tested by Luminex xTAG respiratory and xTAG gastrointestinal pathogen panel (Abbott Molecular, Wiesbaden, Germany). In samples from the respiratory tract, we detected high copy numbers of human bocavirus (HBoV) and rhinovirus, which most likely subsequently caused respiratory failure in our patient. Despite all intensive supportive care and treatment, the boy’s condition deteriorated and he died on day 1 after stem cell transplantation. In addition to the association with intussusception, shedding of rotavirus for a period of time after oral vaccination and vaccine-induced severe gastroenteritis including infection of healthy siblings have been reported.4 The observation of acute and chronic infections by vaccine strain rotavirus in immunocompromised children led to the addition of SCID as contraindication for administration of rotavirus vaccine.5–7 Our SCID patient presented already with advanced disease and severely reduced general condition. We believe that viral shedding of rotavirus for such a prolonged period of time has not been previously reported and might be explained by the lack of timely adequate medical management. We cannot completely exclude that other gastrointestinal infections and other comorbidities might have been involved, but we propose that vaccine-acquired rotavirus-infection had probably contributed significantly to the fatal outcome. The clinical manifestation and diagnosis of SCID patients might be delayed well into the life period after the recommended vaccination schedule. Therefore, we emphasize the negative effect that rotavirus vaccination might have in these endangered patients and we strongly support efforts of mandatory newborn screening for SCID.8TABLE 1: Comparison of Rotavirus Sequences From Patient Sample and Vaccine StrainDennis Klinkenberg, MD Martin Blohm, MD Department of Paediatrics University Medical Center Hamburg-Eppendorf Hamburg, Germany Marina Hoehne, PhD Andreas Mas Marques, PhD Robert-Koch-Institute Berlin, Germany Monika Malecki, PhD Kliniken der Stadt Köln gGmbH Institut für Hygiene Köln-Merheim, Germany Verena Schildgen, PhD Klinken der Stadt Köln gGmbH Institut für Pathologie Furth, Germany Reinhard Schneppenheim, MD, PhD Ingo Müller, MD, MSc Department for Paediatric Haematolog and Oncology University Medical Center Hamburg-Eppendorf Bone Marrow Transplantation Unit Hamburg, Germany Oliver Schildgen, PhD Klinken der Stadt Köln gGmbH Institut für Pathologie Furth, Germany Robin Kobbe, MD Department of Paediatrics University Medical Center Hamburg-Eppendorf Hamburg, Germany

SUMMARY We analysed data on laboratory or epidemiologically confirmed cases (n = 856 539) and on outbreaks (n = 31 644) notified during week 31 (2001) to week 30 (2009), and performed molecular typing of specimens from 665 outbreaks. We aimed at identifying demographic and molecular characteristics to inform on potential additional approaches to prevent disease spread in the population. The mean incidence by norovirus season (week 31 in one year to week 30 in the following year) was 130 (range 19–300) cases/100 000 population and was highest in persons aged <5 years (430/100 000) and ⩾75 years (593/100 000). The proportion hospitalized in community-acquired cases was 8–19% per season. The mean norovirus-associated mortality was 0·05/100 000 per season and 0·5/100 000 in the ⩾75 years age group. Most outbreaks with known setting (75%) occurred in hospitals (32%), nursing homes (28%), households (24%) and childcare facilities (10%). GII strains dominated in the outbreak specimens. GII.4 strains were found in 82% of nursing home outbreaks, 85% of hospital outbreaks, and 33% of childcare facility and school outbreaks. Cases in younger individuals were notified earlier during the season than adult cases, and outbreaks in childcare facilities and schools preceded those in nursing/residential homes, hospitals and private households. We suggest future studies to investigate more closely potential transmission patterns between children and adults.

Background: In the German federal state Mecklenburg-Western Pomerania, routine rotavirus (RV) vaccination in infants has been recommended since 2009. The effectiveness of RV vaccination was investigated after an unexpectedly high number of RV infections in fully vaccinated children occurred. Methods: Intensified RV surveillance was performed in Mecklenburg-Western Pomerania between 2010 and 2011. The screening method was applied to assess vaccine effectiveness (VE) in children up to 24 months after vaccination. To identify risk factors for breakthrough infections, a case-control study and genotyping were conducted in vaccinated and unvaccinated RV-infected children. Results: VE for the prevention of RV infection requiring medical attention or hospitalization was 68% (95% confidence interval [CI]: 61–71) and 80% (95% CI: 77–83), respectively. VE for preventing hospitalization but not medical attention remained stable over 2 years. Vaccinated were less often hospitalized (23%) than unvaccinated RV-infected children (61%; P < 0.001). Breastfeeding (odds ratio, 3.99; 95% CI: 1.92–8.27) and attending daycare (odds ratio, 3.42; 95% CI: 1.64–7.12) were independently associated with breakthrough infections. Genotype G1P[8] was detected more frequently in RotaTeq-vaccinated (44% versus 11%; P < 0.03) and G2P[4] in Rotarix-vaccinated children (42% versus 6%; P < 0.02). Conclusions: RV vaccination protects young children effectively from RV disease and can reduce disease severity. Breastfeeding might impair VE, but further research is needed to identify the critical time window for this interference and to develop appropriate recommendations.

On 28th November 2011, a school physician informed the Austrian Agency for Health and Food Safety (AGES) of 40 cases of gastroenteritis that occurred on 24th and 25th November in a vocational school in the city of Salzburg, Austria. Two out of five students with gastroenteritis tested positive for norovirus (NV). A probable case involved diarrhoea or vomiting in a student, which occurred between 21st November and 5th December 2011. A confirmed case was a probable case with an NV-positive stool sample. Epidemiological findings led to suspect food items prepared by the school kitchen and consumed between 21st and 25th November as outbreak sources. All students at the school were eligible to be included in a retrospective cohort study. Forty-eight cases fulfilled the outbreak case definitions including three (6%) confirmed cases among a total of 351 responding students. The outbreak started on 23th November, peaked on 24th and ended on 5th December. The cohort study indicated a sour cream sauce (food-specific relative risk (RR): 16.1; 95% CI: 3.9-67.5) and a turkey-strip salad (RR: 5.2; 95% CI: 2.3-11.8) as the most likely sources, accounting for 85% of the 39 suspected foodborne cases.

Background The principle of a capture ELISA is binding of specific capture antibodies (polyclonal or monoclonal) to the surface of a suitable 96 well plate. These immobilized antibodies are capable of specifically binding a virus present in a clinical sample. Subsequently, the captured virus is detected using a specific detection antibody. The drawback of this method is that a capture ELISA can only function for a single virus captured by the primary antibody. Human Apolipoprotein H (ApoH) or β 2 -glycoprotein 1 is able to poly-specifically bind viral pathogens. Replacing specific capture antibodies by ApoH should allow poly-specific capture of different viruses that subsequently could be revealed using specific detection antibodies. Thus, using a single capture ELISA format different viruses could be analysed depending on the detection antibody that is applied. In order to demonstrate that this is a valid approach we show detection of group A rotaviruses from stool samples as a proof of principle for a new method of capture ELISA that should also be applicable to other viruses. Results Stool samples of different circulating common human and potentially zoonotic group A rotavirus strains, which were pretested in commercial EIAs and genotyped by PCR, were tested in parallel in an ApoH-ELISA set-up and by quantitative real-time PCR (qPCR). Several control samples were included in the analysis. The ApoH-ELISA was suitable for the capture of rotavirus-particles and the detection down to 1,000 infectious units (TCID 50/ml ). Subsets of diagnostic samples of different G- and P-types were tested positive in the ApoH-ELISA in different dilutions. Compared to the qPCR results, the analysis showed high sensitivity, specificity and low cross-reactivity for the ApoH-ELISA, which was confirmed in receiver operating characteristics (ROC) analysis. Conclusions In this study the development of a highly sensitive and specific capture ELISA was demonstrated by combining a poly-specific ApoH capture step with specific detection antibodies using group A rotaviruses as an example.

BACKGROUND Norovirus infection is the most common cause of acute self-limiting gastroenteritis. Only 3 cases of chronic norovirus infection in adult solid organ transplant recipients have been reported thus far. METHODS This case series describes 9 consecutive kidney allograft recipients with chronic norovirus infection with persistent virus shedding and intermittent diarrhea for a duration of 97-898 days. The follow-up includes clinical course, type of immunosuppression, and polymerase chain reaction for norovirus. Detailed molecular analyses of virus isolates from stool specimens over time were performed. RESULTS The intensity of immunosuppression correlated with the diarrheal symptoms but not with viral shedding. Molecular analysis of virus strains from each patient revealed infection with different variants of GII.4 strains in 7 of 9 patients. Another 2 patients were infected with either the GII.7 or GII.17 strain. No molecular evidence for nosocomial transmission in our outpatient clinic was found. Capsid sequence alignments from follow-up specimens of 4 patients showed accumulation of mutations over time, resulting in amino acid changes predominantly in the P2 and P1-2 region. Up to 25 amino acids mutations were accumulated over a 683-day period in the patient with an 898-day shedding history. CONCLUSION Norovirus infection may persist in adult renal allograft recipients with or without clinical symptoms. No evidence for nosocomial transmission in adult renal allograft recipients was found in our study. Molecular analysis suggests continuous viral evolution in immunocompromised patients who are unable to clear this infection.

OBJECTIVE:Norovirus is the most common cause of acute gastroenteritis in humans worldwide. Typical symptoms are vomiting, nausea and severe watery diarrhea. Because of the lack of cell lines susceptible to human norovirus infection, pathomechanisms and replication cycle are largely unknown. Here, we address the issue of how norovirus infection could lead to epithelial barrier dysfunction.MATERIAL AND METHODS:Expression of the non-structural norovirus protein p20 in the epithelial cell line HT-29/B6 was activated through a tetracycline sensitive promoter. Tight junction proteins were studied by Western blot and confocal laser scanning microscopy. Apoptoses were detected in TUNEL stainings. Epithelial restitution was monitored by conductance scanning after induction of single cell lesions.RESULTS:Changes in the expression or localization of the tight junction proteins occludin and/or claudin-1, -2,- 3, -4, -5, -7 and -8 could be ruled out to mediate epithelial barrier modulation. Cell motility was also unaltered by p20. Investigation of epithelial apoptosis revealed an accumulation of apoptic cells in epithelial monolayers after induction of p20 expression. In epithelial cell restitution assays, an arrest was identified in p20 expressing cells. Fluorescence microscopy revealed an inability for condensation and redistribution of cellular actin, which led to a reduced transepithelial electrical resistance.CONCLUSIONS:Functional data for norovirus protein p20 suggest a role in modulation of the actin cytoskeleton leading to barrier dysfunction through impairment of restitution of epithelial defects.

minimum of 10 d.Patients should be retested for ongoing viral secretion every 5 d and negative results confi rmed with a follow-up sample after 48 h.Classic virus isolation in addition to molecular methods may also identify potentially infectious patients.Prophylactic neuraminidase inhibitor use in such patients also needs to be addressed.Resistance is more likely with the reduced prophylactic dose of oseltamivir and is more likely to be a problem in immunocompromised patients.Zanamivir is now the drug of choice for prophylaxis for such patients, although some experts propose no prophylaxis and instead early treatment after symptom onset (9).Immunocompromised patients are more likely to shed virus for prolonged periods and are more likely to develop oseltamivir-resistance, especially when this drug is used as monotherapy.Further clinical experience and trials will support or refute newer guidelines on the management of pandemic (H1N1) 2009 in such patients.

BACKGROUND:Norovirus is often transmitted from person-to-person. Transmission may also be food-borne, but only few norovirus outbreak investigations have identified food items as likely vehicles of norovirus transmission through an analytical epidemiological study.During 7-9 January, 2009, 36 persons at a military base in Germany fell ill with acute gastroenteritis. Food from the military base's canteen was suspected as vehicle of infection, norovirus as the pathogen causing the illnesses. An investigation was initiated to describe the outbreak's extent, to verify the pathogen, and to identify modes of transmission and source of infection to prevent further cases.METHODS:For descriptive analysis, ill persons were defined as members of the military base with acute onset of diarrhoea or vomiting between 24 December 2008, and 3 February 2009, without detection of a pathogen other than norovirus in stools. We conducted a retrospective cohort study within the headquarters company. Cases were military base members with onset of diarrhoea or vomiting during 5-9 January. We collected information on demographics, food items eaten at the canteen and contact to ill persons or vomit, using a self-administered questionnaire. We compared attack rates (AR) in exposed and unexposed persons, using bivariable and multivariable logistic regression modelling. Stool specimens of ill persons and canteen employees, canteen food served during 5-7 January and environmental swabs were investigated by laboratory analysis.RESULTS:Overall, 101/815 (AR 12.4%) persons fell ill between 24 December 2008 and 3 February 2009. None were canteen employees. Most persons (n = 49) had disease onset during 7-9 January. Ill persons were a median of 22 years old, 92.9% were male. The response for the cohort study was 178/274 (72.1%). Of 27 cases (AR 15.2%), 25 had eaten at the canteen and 21 had consumed salad. Salad consumption on 6 January (aOR: 8.1; 95%CI: 1.5-45.4) and 7 January (aOR: 15.7; 95%CI: 2.2-74.1) were independently associated with increased risk of disease.Norovirus was detected in 8/28 ill persons' and 4/25 canteen employees' stools, 6/55 environmental swabs and 0/33 food items. Sequences were identical in environmental and stool samples (subtype II.4 2006b), except for those of canteen employees. Control measures comprised cohort isolation of symptomatic persons, exclusion of norovirus-positive canteen employees from work and disinfection of the canteen's kitchen.CONCLUSIONS:Our investigation indicated that consumption of norovirus-contaminated salad caused the peak of the outbreak on 7-9 January. Strict personal hygiene and proper disinfection of environmental surfaces remain crucial to prevent norovirus transmission.

Norovirus-like particles were imaged using atomic force microscopy. The mechanical stability of the virus-like particles (VLPs) was probed by nanoindentation at pH values ranging from 2 to 10. This range includes pH values of the natural environment during the life cycle of noroviruses. The resistance of VLPs to indentation was constant at acidic and neutral pH. The Young's modulus was of the order of 30 MPa. At basic pH the compliance of the capsid increased along with an increase in diameter. This specific pH-dependent mechanical response of the capsid may be related to mechanisms controlling uptake and release of the RNA during infection. Consecutive indentations with pressures ≤ 300 bar demonstrated the ability of the capsids to fully recover from deformations comparable with the size of the capsid. The capsids can be viewed as nanocontainers with an inbuilt self-repair mechanism. At pH 10 the capsids lost their stability and were irreversibly destroyed after one single indentation.

Background. Noroviruses (NoVs) are the most common cause of viral gastroenteritis. Their high incidence and importance in health care facilities result in a great impact on public health. Studies from around the world describing increasing prevalence have been difficult to compare because of differing nomenclatures for variants of the dominant genotype, GII. 4. We studied the global patterns of GII. 4 epidemiology in relation to its genetic diversity.Methods. Data from NoV outbreaks with dates of onset from January 2001 through March 2007 were collected from 15 institutions on 5 continents. Partial genome sequences (n = 775) were collected, allowing phylogenetic comparison of data from different countries.Results. The 15 institutions reported 3098 GII. 4 outbreaks, 62% of all reported NoV outbreaks. Eight GII. 4 variants were identified. Four had a global distribution-the 1996, 2002, 2004, and 2006b variants. The 2003Asia and 2006a variants caused epidemics, but they were geographically limited. Finally, the 2001Japan and 2001Henry variants were found across the world but at low frequencies.Conclusions. NoV epidemics resulted from the global spread of GII. 4 strains that evolved under the influence of population immunity. Lineages show notable (and currently unexplained) differences in geographic prevalence. Establishing a global NoV network by which data on strains with the potential to cause pandemics can be rapidly exchanged may lead to improved prevention and intervention strategies.

A 10-month-old boy presented in our emergency department n a severely reduced general condition, apathetic and sleepy. He ad non-bloody diarrhea and had been vomiting for two days prior o admission. As medication he did receive dimenhydrinate, which id not improve his symptoms. His mother also had diarrhea at the ame time. Beginning at the evening before admission to our hospial he refused eating and drinking. At 3 am on the day of admission is mother found him in a stuporous state, not reacting properly. onsequently he was brought to the hospital. Until that day the atient had developed regularly and was otherwise well. In the mergency room he did not react much to stimulation and often ell asleep. The examination revealed a heavily inflated abdomen. here was no pain during palpation, no enlargement of liver and pleen, no resistance. The blood results showed reduced blood glucose (25mg/dl), ery low sodium (125mmol/l) and mildly reduced potassium 3.48mmol/l). The white blood cells were increased (WBC 3.420/ l) of which 62% were segmented neutrophils and 3% and neutrophils, the marker of infection C-reactive protein (CrP) as marginally increased (5.6mg/l). The liver enzymes were ignificantly raised (GOT 323U/l, GPT 183U/l, GGT 12U/l) and he blood coagulation was compromised (Quick 50%, INR 1.41, TT 27 s). The creatinine was within normal range (0.37mg/dl). urther blood results revealed high creatinine kinase (972U/l) nd high cortisol (857nmol/l). Further endocrinological workup evealed no abnormalities. Kidney and the thyroid function vales as well as immunoglobulin IgA, IgG and IgM were within ormal range. The initial venous blood gas analysis was mainly ithin normal range: pH 7.36, pCO2 33.1mmHg, pO2 46.6mmHg, icarbonate 18.4mmol/l, base excess−5.9mmol/l. Investigation of