pdninquiry

Disease: Hepatitis

Hepatitis B Virus (HBV; serum hepatitis) is an ENVELOPED, dsDNA virus (class I). It is a serious disease that aggressively attacks the liver, causing injury and scarring (CIRRHOSIS). HBV can cause a life-long, chronic infection (>1 million Americans affected) that can lead to liver cancer, liver failure, and death. There are 70,000-160,000 symptomatic infections and about 5,000-6,000 deaths from chronic liver disease and primary liver cancer every year.

Hepatitis C Virus (HCV) is an ENVELOPED, ssRNA (+ strand) virus (class IV). Due to a high mutation rate, HCV escapes immune surveillance by the host, leading to chronic infections (4 million Americans affected). There are 10,000-70,000 symptomatic infections and 8,000-10,000 deaths each year. In the next 10 years, it is estimated that 20% of patients with chronic infections will develop cirrhosis and 1-5% of cirrhotic individuals will develop liver cancer.

Egypt has one of the highest hepatitis C prevalence rates in the world. About one in every 10 presons is infected with the hepatitis C virus. It is widely believed that mass vaccinations of Egypt’s rural population against a parasitic disease called schistosomiasis in the 1960s and 1970s is responsible for the current rates. Egyption health officials did not use clean needles or follow rigorous hygiene standards. But that was in a developing nation with poor sanitary conditions. Such infections in a developed nations, such as the United States, is almost unthinkable, yet it happened–big time– about a year ago.

Nearly 40,000 people learned that a trip to a surgical center or any of five affiliated clinics in Las Vegas may have made them sick. Apparently the center and clinics had been reusing syringes and vials of medication for the past four years! This announcement was the biggest public health notification ever in U.S. history. The surgical center and clinics were immediately closed.

Such careless and irresponsible practices may have led to an outbreak of the potentially fatal hepatitis C virus and exposed patients to HIV, the virus responsible for AIDS.

As a result, thousands of patients were urged to be tested for the viruses. In fact, six acute cases of hepatitis C had already been confirmed at the time of the announcement. Michael Bell, an associate director at the Centers for Disease Control and Prevention (CDC) in Atlanta found it “baffling that in this day and age anyone would think it was safe to reuse a syringe.”

Michael Washington, 67, a retired airplane mechanic, was the first to report his infection. It all started in July when his doctor schedule a routine colon exam at the Endoscopy Center of Southern Nevada.

In September, Washington started to get sick. He was losing weight, his urine turned dark, and his stomach hurt. By January, it was clear what had happened–he had hepatitis C.

In letters that began arriving that week, patients who received injected anesthesia at the endoscopy center between March 2004 to mid-January, 2008 were urged to get tested for hepatitis B and C, and HIV.

Since all three viruses are transmitted by blood, they could have been passed from one patient to the next by the unsafe practices at the clinic. Health officials said they are most worried about the spread of hepatitis C, which targets the liver but shows no symptoms in as many as 80% of infections.

Hepatitis C results in the swelling of the liver and can cause stomach pain, fatigue and jaundice. It may eventually result in liver failure. Even when no symptoms occur, the virus can slowly cause damage to the liver.

Officials estimated that 4% of the patients already had the virus when they entered the clinic, compared with 0.5% for heaptitis B and less than 0.5% for HIV. Hepatitis C is easier to transmit than HIV.

However, it’s sophisticated tests were needed to make a complete evaluation of risk factors, and a clear pattern of infection to determine whether the virus was caught at the facility.

Health inspectors say they observed clinic staff using the syringe twice to textract anesthesia from a single vial, which was then inappropriately used to treat more than one patient. Such a practice allows contaminated blood in a used syringe to contaminate the vial and infect the next patients.

Of the six patients diagnosed with acute hepatitis C at the time of the announcement, five had been treated at the clinic on the same day in late September.

Health officials say that the improper procedures appeared to be more common in outpatient surgical centers like the endoscopy center. Unlike hospitals, such centers often do not have employees whose sole responsibility is to monitor and educate staff on best practices.

In Las Vegas, clinic staff told inspectors they had been ordered by management to reuse the vials and syringes. Investigators were told the practice was an attempt to cut costs.

Washington’s wife, Josephine, a registered nurse, wonders how any health care professional could be so reckless: “To maximize profit? For what? What are you going to save?”

Disease: Shigellosis

Shigellosis is a disease caused by a gram negative bacteria, Shigella dysenteriae. The symptoms of this disease includes blooy diarrhea, fever, stomache cramps and possible seizures in children under the age of 2 for severe infections. Usually, shigellosis only last 5 to 7 days and doesn’t require hospitalization. The antibiotics commonly used for treatment are ampicillin, trimethoprim/sulfamethoxazole (also known as Bactrim or Septra), ceftriaxone (Rocephin), or, among adults, ciprofloxacin. The disease is distributed from an infected individual to another through a fecal-oral route meaning the bacteria travel from an infectious stool of a person to another person’s hand and Without proper hygienic behavior such as hand-washing, this individual can then transmit the bacteria through the mouth of another individual. Shigellosis can also be transmitted through sexual contact.

Cancun, Mexico: From January 1 to August 1, 1988, 17 cases of shigellosis were reported to the CDC. 15 of those reported cases came from individuals who visited Cancun, Mexico while 2 visited other areas in Mexico. Within the 15 patients, 13 were hospitalized while 2 had dveloped hemolytic-uremic syndrome. Six were resistant to chloramphenicol and tetracycline; two were resistant to ampicillin and trimethoprim-sulfamethoxazole. This bacterial outbreak was caused by type 1 S. dysenteriae which could be resistant against trimethoprim, sulfamethoxazole and tetracycline.

Disease: Bacterial meningitis

Although several different bacterial genera can cause meningitis, Neisseria meningitidis, a NON-MOTILE, ENCAPSULATED, GRAM-NEGATIVE DIPLOCOCCUS, is one of the most important because of its potential to cause epidemics. The WHO estimates that there have been an estimated 700,000 cases of epidemic meningococcal disease (EMD) in the past 10 years, of which about 70,000 individuals have died worldwide, but primarly in Africa.

October 9, 2007 - The meningitis season from December 2006 to May 2007 in Africa’s meningitis belt saw an estimated 53,000 cases of meningitis, with an estimated 4,000 deaths. This was the highest number of cases and deaths since the 2001 meningitis season. To fight last season’s epidemic, the World Health Organization (WHO) and its partners amassed 7 million doses of vaccine to protect 400 million people across the 21 countries of the so called “meningitis belt,” an area that extends from Senegal to Ethiopia with an estimated total population of 300 million. This stretch of land is home to some of the world’s poorest and most war-scarred places, including Sudan and Nigeria.

These 21 countries are at risk because they are prone to exteremly dusty winds during the winter dry season (from December to May), which along with usually cold nights decreases the immunity of the pharynx. The meningitis bacteria are most easily transmitted through close contact, especially through sneezing, coughing, sharing eating utensils, or kissing. Throughout much of the meningitis belt, people often live in crowded family quarters and sometimes travel to large markets, making transmission of the disease easier.

During the 2007 season in Burkina Faso, meningitis infected more than 20,000 people, disabling 2,000 and killing more than 1,300. Across Africa, more than 1,600 died from the disease.

To prevent such a crises from occurring again in 2008, the World Health Organization (WHO) convened an urgent donor’s meeting to ask donors to pledge $13.8 million, enough to buy 12 million doses of vaccine.

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Geneva, 20 December 2007 - The International Federation of Red Cross and Red Crescent Societies launched a prevention campaign and surveillance in 14 countries of the meningitis belt to get ready for possibly one of the worst meningitis epidemics in a decade. In fact, it could be worse than the one that hit Africa in 1996 when there were 250,000 cases of the disease and 25,000 people died in Sudan alone.

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February 1, 2008 - Amid warnings of a major meningitis outbreak in Africa, epidemic levels of the bacterial infection broke out in parts of Burkina Faso. The vaccination campaign did not reach all the districts facing the outbreak. More than 774 cases were reported.

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February 12, 2008 - Aid agencies and the authorities in the Central African Republic (CAR) joined forces to vaccinate hundreds of thousands of people at risk of meningitis in the northwest of the country. Meningitis was spreading across three northwestern districts and threatening up to one million people.

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February 13, 2008 - Epidemic levels of meningitis reached two additional districts in Burkina Faso that were just 20 km from the Ivory Coast border, making it likely the epidemic in Burkina Faso is being boosted by infected people entering from neighboring countries. It is estimated that 5 million people are now at risk across 20 health districts in Burkina Faso.

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February 26, 2008 - Other than the major outbreak in Burkina Faso, surveillance indicates that the meningitis belt so far is actually experiencing lower levels of meningitis cases, compared with same period last year. There have been 2312 cases and 324 deaths, which actually is 14% lower than the corresponding time from 2007.

-Dr. Pommerville-

Disease: Anthrax

Anthrax is an acute infectious disease caused by Bacillus anthracis, a GRAM-POSITIVE ROD. The cells of B. anthracis produce very resistant ENDOSPORES that can remain viable in the soil for years and even decades. The vegetative cells produce three toxins responsible for the clinical disease.

Anthrax most commonly occurs in wild and domestic vertebrates (cattle, sheep, goats, and other herbivores) and, in the United States, the incidence of naturally-acquired human anthrax is extremely rare. There are three clinical forms of human anthrax: CUTANEOUS (skin); GASTROINTESTINAL (digestive system); and, the most dangerous, as the scenario described, INHALATIONAL (respiratory system).

Federal Bureau of Investigation (FBI) offices in five U.S. cities have received warnings of an imminent bioterrorist attack unless certain demands are met immediately. One of these cities is Bigtown with a population of 2 million. The threats were credible, but no information was relayed to any city officials.

On the evening of November 1, a professional football game is being played in Bigtown’s outdoor stadium before 74,000 fans. The evening sky is overcast, the temperature mild, a breeze blows from west to east. During the game’s first quarter, an unmarked truck drives along an elevated highway a mile upwind of the stadium. As it passes, the truck releases an aerosol of powdered bacterial spores, creating an invisible, odorless cloud more than a third of a mile in breadth. The wind blows the cloud across the stadium parking lots, into and around the stadium, and onward for miles over the neighboring business and residential districts. After the release, the truck continues driving and is more than 100 miles away from the city by game’s end. The perpetrators will be out of the country by the next day.

Three days later, hundreds of people in and around Bigtown are becoming ill with fever, cough, shortness of breath, and chest pain. Some of the sick self-administer over-the-counter cold or flu remedies; some seek phone advice from physicians and nurses; others are seen in clinics, doctor’s offices, and hospital emergency departments.

On November 6, nurses and physicians note the increased volume of serious upper respiratory illness,  and some contact the city health department for treatment recommendations. Blood cultures from the earliest patients grow gram positive bacilli in seven laboratories around the city. No further identification is requested, and none is pursued.

By evening, the earliest patients are experiencing severe complications, including difficulty with breathing, shock, and even meningitis. An alarmed state health department contacts the Centers for Disease Control and Prevention (CDC).

By November 8, patients who first experienced complications are dying. In fact, by midnight, 1,200 people around the city have fallen ill and 80 have died.

By mid-day on November 9, intensive-care units and isolation beds across the city are full. Even patients receiving the most advanced medical care are dying; still, there is no diagnosis.

The illness and unexplained deaths has created an atmosphere of desperation and confusion among hospital and clinic staff. The recommended isolation protocols quickly fall apart as staffs struggle to cope with the surge of patients. Many nurses and support staff do not report to work, fearing the disease can spread from infected individuals.

In the early evening, a university laboratory makes a preliminary diagnosis from the blood culture of a young patient who died. The laboratory immediately notifies the state health department, which in turn notifies the CDC and FBI. Antibiotics are prescribed.

By November 11, there are effectively no antibiotics left in the city and no records of who received them. By evening, 2,700 persons have become ill, 500 of whom have died.

On November 12, distribution centers receive Federal shipments of antibiotics and vaccine. Increasing numbers of the city’s critical work force are absent, including police and firefighters. Some are absent because of illness or death, while others, fearing contagious spread, leave the city. By evening, a total of 4,800 persons have become ill; 1,400 have died.

By November 20, the disease has begun to subside. Of the 20,000 persons infected in and around Bigtown, 5,000 died, most who did not receive antibiotics in the first 10 days after the attack. In all, approximately 250,000 persons received antibiotics.

-Dr. Pommerville-

Streptococcus pyogenes

Description: Streptococcus pyogenes is a small (0.5 to 2.0 µm) spherical, non-motile, bacterial species. The Centers of Disease Control and Prevention (CDC) estimates that about 10,000 to 15,000 people in the United States develop S. pyogenes illnesses each year, and about 2,000 die. As with many other diseases, infants, the elderly, and those with underlying health problems are the most susceptible.

Invasive infections occur when the bacterial cells break through an infected person’s immune defenses. This may occur when a person has sores or other breaks in the skin that allow the bacterial cells to get into the tissue (e.g., child bed fever), or when the person’s ability to fight off the infection is decreased because of chronic illness or a condition that affects the immune system.

In September 2003, a previously healthy 17-year-old male underwent elective anterior cruciate ligament (ACL) repair with a tendon graft at an ambulatory surgical center in Colorado. Six days after the procedure, he was admitted to a local hospital with pain and skin redness at the incision site, fever of 39°C (102°F), and chills. The graft tissue was removed, and the patient underwent surgical exploration and additional tissue removal of the affected thigh.

Cultures of his blood, wound fluid, and removed tissue grew a small, spherical bacterium with the cells appearing in chains. The microbe was identified as Streptococcus pyogene. His hospital course required a stay in the intensive care unit and was complicated by persistent fever and fluid collection in the affected leg, which was managed with computerized tomography - guided needle aspiration. After 7 days of treatment with the antibiotics clindamycin and cefazolin, the wound fluid again yielded more streptococci. The patient was discharged afer 17 days and complete a course of intraveneous antibiotics at home; he was later readmitted to the hosptial for related complications and discharged subsequently.

The tendon graft received by the patient came from a cadaveric donor. After the patient’s surgeon was alerted to this case of presumptive graft infection, the Food and Drug Administration (FDA) was notified. Tendon grafts from the donor had been implanted in five other patients; however, as of December 1, 2003, no adverse outcomes had been detected by their surgeons. All remaining grafts recovered from the donor and processed for graft transplant were placed on hold or recalled.

According to the medical examiner’s records, the donor had undergone cervical spinal fusion three weeks before his death; autopsy findings included a generalized rash and potentially toxic levels of a muscle relaxant and an analgestic medication. On autopsy, the cause of death was attributed to the toxic effects of these drugs.

Cultures of the donor’s tissues, obtained by the tissue recovery organization before distribution to two tissue processors, again yieldedstreptococcal cells. The company that processed the grafts reportedly used aseptic technique and an antimicrobial solution, but no sterilization procedure was used. After the recovered tissues were processed, all post-processing cultures were reported as negative, and these grafts were distributed. Other tissues recovered from the donor were distributed to a second tissue processor and were held for further review.

The Centers for Disease Control and Prevention (CDC), FDA, and the Colorado Department of Public Health and Environment conducted an investigation to determine whether the tendon graft had been the source of infection in the recipient. The processing companies provided CDC with donor tissues that had not undergone antimicrobial processing; identical S. pyogenes cells were identified in the specimens as well as from the donor’s blood, which had been stored by the tissue processing company. DNA sequence analysis confirmed that blood and tissue bacterial isolates from both donor and recipient were a newly discovered subtype of S. pyogenes that had not been identified previously.

-Dr. Pommerville-

Escherichia coli

Description: Escherichia coli is one of the predominant bacterial species found in human and animal intestinal tracts. The bacterium is a GRAM-NEGATIVE rod. The species often is subdivided into strains by virulence (disease-causing) factors (O= cell; H = flagella; K = capsule). The strains forming part of the normal human gut microbiota are not pathogenic.

On October 6, the McAuliffe family from a large city in Connecticut decided to take a Sunday drive in the country. It was such a nice day that the family decided to have a picnic. They stopped to purchase a picnic lunch at a general store along the highway. The family purchased a complete picnic lunch that included chicken sandwiches, potato salad, and ice cream for desert. The father and two daughters had apple cider, while the mother had a soda to drink. After lunch the family continued on their drive and returned safely home that night.

On Wednesday, the two daughters woke up with abdominal pains and vomiting. Moreover, there was blood in their stools. That night, their father also experienced similar symptoms. The mother had no symptoms.

One of the daughters, Vicki, became worse and had to be admitted to the emergency room at the local hospital at 2 AM on Thursday. The presence of bloody diarrhea was noted by the attending ER doctor.

On interviewing the rest of the family, it was evident to the attending ER physician that some type of food poisoning had occurred among the three family members. Therefore, later Thursday morning, the physician contacted the Connecticut Department of Public Health (CDPH) to report the cases. The CDPH informed the physician they already had been notified of the five additional cases among local residences all with disease onset during the same period.

Of the eight case-patients, six were female, and ages of all eight ranged from 2 to 73 years (mean: 25 years). Case-patients resided in six near-by towns within the county. Symptoms included bloody diarrhea and abdominal pain (eight patients), vomiting (five), and fever (four). Duration of illness ranged from 3 to 11 days (median 7 days). Five patients were hospitalized, including one with hemolytic uremic syndrome (HUS).

The CDPH produced a case definition, which was defined as:

An infection of variable severity with bloody diarrhea (three or more loose stools per day) and cramps lasting less than seven days.

A stool sample from the McAuliffe’s daughter Vicki was sent to the clinical lab to identify the infectious agent. Meanwhile, her kidneys began to fail so the doctor transferred her to intensive care and advised dialysis to assist the kidney function.

The laboratory results identified and confirmed the presence of gram-negative rods as the cause of infection. Further tests were ordered to identify the specific bacterial species - it was Escherichia coli O157:H7.

After CDPH officials were notified of the lab results, they began a telephone survey to find out if anyone else were similarly infected. Over two dozen cases were found. All were asked about food consumption during the seven days preceding the illness.

Based on the interviews, increased risk of illness was associated with drinking fresh apple cider from cider mill A.

When inspectors visited cider mill A, which was located across the street from a dairy farm, the inspectors were told that the apples were purchased from one apple orchard in New York state, and then the apples were washed and brushed using water from the mill’s 45-foot drilled well. Inspectors then interviewed the owner of the orchard. He stated that the apples were picked directly from the trees; no apples were picked up from the ground.

Further testing identified E. coli O157: H7 in the well water at cider mill A. Appropriate control measures were instituted immediately to prevent further cases. Vicki McAuliffe recovered as did all the affect patients.

-Dr. Pommerville-

 Human Herpes Virus

The human herpesviruses (HHV) are a very large family of DNA viruses, many of cause disease in humans. Following the primary infection, all herpesviruses establish a LATENT INFECTION in the host. At a later time, the virus may reactivate and frequently, but not always, is associated with further disease.

(not a true story)

It was April, and the freshness of spring had just begun to wash away the gloom of winter. But this spring brought 25-year-old Melissa to the ER with shaking chills, night sweats, and vomiting-the flu. Her prescription was simple: plenty of rest, plenty of fluids.

The plan worked until she became angry and mean-spirited, and lost interest in her personal appearance. “Just the flu,” her doctor said to her anxious husband. Then she stopped eating, and seizures started to occur. Again the ER physician said it was just the flu, and Melissa was sent home.

Within days, she was almost catatonic, unable to do little more than drool. This time her husband, in an act of devotion that saved Melissa’s life, refused to leave the emergency room until the attending physician agreed to admit her.

Dr. MacKenzie was on call. He started by reviewing the lab data. The only hint of infection was her elevated white-blood-cell count. Where was the infection? Blood and urine cultures were negative, and her chest X ray didn’t show any pneumonia. The clinical presentation suggested a central nervous system disease. A lumbar puncture showed spinal fluid consistent with a viral infection. But another detail about the spinal-fluid analysis caught the physician’s attention - red blood cells, a sign of bleeding in the brain. Perhaps she had encephalitis. Many viruses can infect the brain, but he knew of only one with that signature: herpes simplex.

Herpes simplex viruses type 1 and type 2 tend to infect mucous membranes and the central nervous system. HSV-1 causes cold sores and spreads through contact with virus-laden saliva or sores. People usually get infected in childhood or adolescence. Sometimes there are no symptoms, but more often people have cold sores, or “fever blisters,” in or around the mouth. After the first infection the virus lies latent in the trigeminal ganglia, a structure in the base of the brain that gives rise to the trigemincal nerve, which predominantly provides sensation to the face. For reasons that are not clear, the virus can reactivate years later and travel along the trigeminal nerve to the meninges, the coverings of the brain and spinal cord, at the base of the brain. From there it can launch an attack on its preferred target: the temporal lobes, brain regions just above each ear that help carry out the complex functions of hearing, learning, memory, and emotion.

Untreated herpes encephalitis can be fatal in up to 70 percent of cases. Malaise, fever, and headache herald its onset, often quickly followed by behavioral abnormalities, seizures, olfactory hallucinations, and bizarre or psychotic behavior - all symptoms of disease in the temporal lobes.

Fortunately, effective antiviral therapy is available, and early treatment reduces mortality to 30 percent. But making the diagnosis promptly is vital. And even with treatment, survivors of herpes encephalitis are almost never neurologically normal and will often experience amnesia, seizures, and a loss of smell.

When Dr. MacKenzie first examined Melissa, she was comatose. An electroencephalogram showed slowing of the normally brisk electrical activity of the brain. That finding fit with her comatose condition, but it is not typical of the waveforms often seen in herpes encephalitis.

Still, Melissa was dying and something had to be done now. Dr. MacKenzie followed his instinct and treated her for herpes encephalitis with acyclovir, and antivial drug.

His gut instinct paid off. Melissa eventually recovered, but her return home was like stepping onto the set of a movie she’d never seen. She couldn’t find the guest bedroom, and she didn’t remember she had been taking tennis lesson. She didn’t even recognized faces. Pictures of high school friends were the faces of strangers. She could identify a face as a face, its parts, and even certain emotions, but she was unable to identify a particular face as belonging to a specific person. She could not even recognize her own face in the mirror, although she recognized that it was a face.

Still, Melissa didn’t lose her knowledge of people’s identities. She just couldn’t count on using facial recognition to make identifications. Because humans are remarkably adaptive, patients like Melissa can often be taught how to compensate. Over time, Melissa learned to recognize people by context, such as where she last saw a person and what he or she was wearing. Dr. MacKenzie saw this firsthand when he met her for a follow-up visit. Only when they were seated in the customary positions in his office did he see a glimmer of recognition flash across her face.

After several months of rehabilitation, Melissa was able to return to teaching. She now leads a near-normal life. During her last visit with Dr. MacKenzie, he said he was pleased at her recovery. With a twinkle in her eye, and as if to make light of it, she smiled slyly and said, “Doc, it’s just a matter of recognition.”

-Dr. Pommerville-

Disease: Valley fever

Coccidioidomycosis (valley or desert fever is a respiratory infection caused by the dimorphic soil fungus Coccidioides immitis (California) and C. posadasii (Arizona). The fungus is endemic to the warm, arid regions of central California, the southwest U.S. especially the Phoenix and Tucson areas, the northwest part of Mexico, and South America.

C. immitis is probably the most infectious of all fungi. According to the CDC, about 10-50% of the people living in endemic region will have evidence of exposure to Coccidioides. The incidence is around 9 cases per 100,000 population. Outbreaks of coccidioidomycosis do occasionally occur, particularly following earthquakes or other events that disturb large amounts of soil in endemic regions. Besides people, domestic and wild animals also suffer from coccidioidomycosis.

During October 8-12, a previously healthy, 51 year-old-man from Atlanta, Georgia had attended the world championship of model airplane flying in Lost Hills, California, located in Kern County in San Joaquin Valley. On October 25, the patient came to a local Atlanta hospital complaining of influenza-like symptoms that began 1 week after returning from Lost Hills.

He came to the hospital with a fever of 39°C and a history of night sweats, productive cough, and weight loss. A chest X ray showed diffuse nodular lung lesions in both lobes.

Antimicrobial drugs (amoxicillin/clavulanic acid and ciprofloxacin) and antituberculosis therapy (including isoniazid, rifampin, ethambutol, and pyrazinamide) were administered. Blood and sputum specimens were negative for bacteria; HIV antibody test results were negative, but the fever persisted. A follow-up chest film showed an excess of fluid in the left side of the pleural cavity (the fluid-filled space that surrounds the lungs).

A CT (computed tomography) scan of the patient’s chest showed collapse of the left lower lung with central necrosis (dead tissue). A pleural biopsy showed no evidence of malignancy, but heavy lymphocyte infiltration and a necrotizing inflammation were found. On December 17, 30 mg/day of the oral anti-inflammatory drug prednisolone were prescribed for intermittent fever. Biopsy material and cultures of blood samples taken at admission grew an unidentified mold, which was also isolated from the biopsy wound. The patient was discharged afebrile from the hospital on January 20.

On January 25, the patient returned to the hospital complaining of fever, with a disturbance in consciousness. Another CT scan of the brain revealed no obvious organic lesions. He was referred to the university hospital on January 26 for further examination.

After the patient was admitted, his fever persisted and respiratory distress worsened rapidly. He developed severe headache, seizures, and loss of consciousness.

The patient was transferred to the intensive care unit for aggressive management of acute respiratory disease syndrome and deterioration of renal function. A chest X ray showed coalescence of nodular shadows and almost complete destruction of bilateral lung regions. Meropenem (a bacterial drug used to treat meningitis and pneumonia), antituberculosis agents, and intravenous voriconazole (an antifungal drug used to treat invasive fungal infections), 200 mg every 12 hours, were administered.

Both the unidentified mold, which was sent to our hospital for futher identification, and a mold cultured from the previous biopsy wound at our hospital were identified as Coccidioides immitis by their characteristic gross and microscopic characteristics. Hematoxylin and eosin staining of the biopsied tissue showed many spherules, typical of a disseminated coccidioidomycosis infection.

A lumbar puncture was performed on January 30, cultures of cerebrospinal fluid (CSF) were negative for bacteria and fungi. After the diagnosis of disseminiated coccidioidomycosis, voriconazole was replaced by intravenous fluconazole, 400 mg/day. The patient’s intensive care course was complicated by Pseudomonas pneumonia and repeated episodes of upper gastrointestinal bleeding. Uncontrolled coccidioidomycosis meningigits was suspected, and amphotericin B treatment directly into the spinal cord was planned.

Unfortunately, the patient did not respond to therapy and died on February 16.

-Dr. Pommerville-

 Disease:

The term “staph infection” covers all infections caused by bacteria of the genus Staphyloccocus. Some gram positive, facultatively anaerobic cocci in this genus (e.g., S. epidermidis) normally live on the skin without causing problems. S. aureus also lives harmlessly on 10 percent of the human population. However, S. aureus can cause fatal disease and is the major cause of NOSOCOMIAL INFECTION and becoming important as a COMMUNITY-ACQUIRED INFECTION. Of grave concern, is the S. aureus’ increasing resistance to most antibiotics, especially methicillin (METHICILLIN-RESISTANT S. AUREUS; MRSA) and a last resort antibiotic vancomycin (VANCOMYCIN-RESISTANT S. AUREUS; VRSA). Without effective antibiotics to fight this pathogen, few options, short of surgery are available to the S. aureus-infected patient.

During the 2006-07 influenza season, between December 2006 and January 2007, 10 cases of community-acquired pneumonia (CAP) were reported to state health agencies in Louisiana and Georgia. Ten was a higher number than expected for a two-month period, especially since six of these patients died. Described here are three CAP cases.

Louisiana Case 1. On December 6, 2007, a previously healthy 10-year-old boy became ill with fever, cough, sore throat, and earache, and was treated with acetaminophen at home. The next day, his symptoms worsened and he was taken to a local emergency department (ED) in respiratory distress with a fever of 104 °F (40°C).

A chest X ray revealed bilobar pneumonia. The patient was transferred to another hospital and admitted to the pediatric intensive care unit (PICU), where he required endotracheal intubation and mechanical ventilation. He was treated initially on December 7 with intravenous antibiotics. On December 8, a nasopharyngeal secretion assay was positive for influenza. A sputum culture obtained the same day grew gram-positive cocci; blood cultures were negative.The patient had a low white blood cell count and worsening low blood pressure and inadequate tissue oxygen. He died on December 9, 42 hours after admission to the PICU. The cause of death was reported as bilateral penumonia.

Louisiana Case 2. On December 26, 2007, a 14-year old boy exhibited influenza-like illness symptoms when taken to a local ED, where he was treated with clarithromycin and penicillin for atypical penumonial and sore throat. A rapid test for Streptococcus pyogenes was negative.

The following day, the patient was taken to his primary-care provider with worsening symptoms and was prescribed an antiviral drug for suspected influenza. On December 28,the youth returned to the ED in respiratory distress and was noted to have bloody, frothy sputum; a fever of  40°C; and inadequate tissue oxygen.In the ED, the patient was intubated, placed on mechanical ventilation, and administered antibiotics.

A chest X ray revealed diffuse bilateral fluids and an immunological assay on nasopharyngeal secretions was positive for influenza; a blood culture grew gram-positive cocci. The patient died on December 28, 6 hours after arrival in the ED. The case of death was recorded as pneumonia.

Lung examination at autopsy indicated the presence of gram-positive cocci in the lung and the lung tissues examined did not indicate evidence of influenza. An antibiotic sensitivity assay from a tonsil swab and lung specimen indicated the bacterium was resistant to the antibiotic methicillin. The deceased’s medical history was unremarkable except for a culture-confirmed armpit abscess identified as caused by a gram-positive coccus that was diagnosed on October 9, 2006 and treated with antibiotics for 7 days.

Georgia case. On December 17, 2006, a previously healthy 8-year-old girl was taken to her primary-care provider after 3 days of fever, cough, and vomiting. She was treated with antibiotics and an aerosolized asthma drug.

Her condition worsened, and she was transported to a local ED, where she received additional antibiotics and asthma drugs. A high-resolution CT scan revealed right lobe pneumonia. She was transported to a referral hospital, where she was noted to have low blood pressure and inadequate tissue oxygen. She was intubated on arrival and placed on membrane oxygenation. During intubation, she had cardiac arrest and was resuscitated.

Also on December 17, viral and sputum cultures tested positive for influenza and gram-positive cocci; blood cultures were negative for cocci. After a long hospital course complicated by renal and hepatic failure and a heart abscess, the patient died on January 7, 2007, 25 days after onset of symptoms. Cause of death was listed as pneumonia.

-Dr. Pommerville-

 Disease: Syphilis

Overview:

“Syphilis remains a serious STD even in the United States. In 2004, syphilis ranked fifth in terms of the notifiable cases of infectious disease, with more than 33,401 reported cases. in 2005, the cCenters for Disease Control and Prevention (CDC) reported 33,278 new cases, including 792 in Arizona.” - Dr. Pommerville

Syphilis is a sexually transmitted disease (STD) that can be contagious caused by the microorganism Treponema pallidum.

Transmission: Sexual contact or from mother to child.

Types and Symptoms: There are typically 5 types of syphilis listed below.

1. Primary syphilis: Primary syphilis is transmitted through sexual contact. The symptom of this stage is lesion (chancre - a firm, painless skin ulceration) on the skin usually on the genital area. It will heal spontaneously after 4 to 6 weeks. Other than swelling in the lymph nodes, there are no other symptoms. This is why patients usually don’t seek medical attention for primary syphilis.
2. Secondary syphilis: This occurs 1 - 6 months after primary infection and is much easier to transmit so it is more contagious. Reddish-pink, non-itchy rash will appear on the trunk and lower extremities while flat broad whitish lesion can appear on area with moisture. Symptoms include fever, sore throat, malaise, weight loss, headache, meningismus, and enlarged lymph nodes.
3. Latent syphilis: There is a proof of infection but no symptoms of disease. Latent syphilis divided into two stages, early and late. Early stage is before 2 years and later stage is after 2 years. Typically the earlier stage is the most contagious stage for latent syphilis.
   
4. Tertiary syphilis:This stage occured 1-10 years after the initial stage. Gummas, soft, tumor like balls of inflammation begins to form, and it could appear anywhere on the body even in the blood vessels or the skeleton. This stage can affect personality and emotion along with disease such as heart failures and disorder of the spinal cord.
   
5. Neurosyphilis: This can occur at any stage of syphilis and it is where the microbe affects the central nervous system (CNS). It is most common in people with HIV disease and causes atrophies to the brain. People with neurosyphilis tends to be in dementia most of the time and experience personality changes, memory loss, mania and depression.

Preventions: Abstinence and avoid infections through open wounds and mucosa.

Treatments: Penicillin