Epidemiology, management and outcomes of Cryptococcus gattii infections: A 22-year cohort.

BACKGROUND: Cryptococcus gattii is a globally endemic pathogen causing disease in apparently immune-competent hosts. We describe a 22-year cohort study from Australia's Northern Territory to evaluate trends in epidemiology and management, and outcome predictors. METHODS: A retrospective cohort study of all C. gattii infections at the northern Australian referral hospital 1996-2018 was conducted. Cases were defined as confirmed (culture-positive) or probable. Demographic, clinical and outcome data were extracted from medical records. RESULTS: 45 individuals with C. gattii infection were included: 44 Aboriginal Australians; 35 with confirmed infection; none HIV positive out of 38 tested. Multifocal disease (pulmonary and central nervous system) occurred in 20/45 (44%). Nine people (20%) died within 12 months of diagnosis, five attributed directly to C. gattii. Significant residual disability was evident in 4/36 (11%) survivors. Predictors of mortality included: treatment before the year 2002 (4/11 versus 1/34); interruption to induction therapy (2/8 versus 3/37) and end-stage kidney disease (2/5 versus 3/40). Prolonged antifungal therapy was the standard approach in this cohort, with median treatment duration being 425 days (IQR 166-715). Ten individuals had adjunctive lung resection surgery for large pulmonary cryptococcomas (median diameter 6cm [range 2.2-10cm], versus 2.8cm [1.2-9cm] in those managed non-operatively). One died post-operatively, and 7 had thoracic surgical complications, but ultimately 9/10 (90%) treated surgically were cured compared with 10/15 (67%) who did not have lung surgery. Four patients were diagnosed with immune reconstitution inflammatory syndrome which was associated with age <40 years, brain cryptococcomas, high cerebrospinal fluid pressure, and serum cryptococcal antigen titre >1:512. CONCLUSION: C. gattii infection remains a challenging condition but treatment outcomes have significantly improved over 2 decades, with eradication of infection the norm. Adjunctive surgery for the management of bulky pulmonary C. gattii infection appears to increase the likelihood of durable cure and likely reduces the required duration of antifungal therapy.

Massive haemoptysis in a woman with left lower lobe pulmonary artery interruption-A rare clinical presentation.

Proximal interruption of the pulmonary artery (PA) is a rare congenital vascular anomaly with varying presentation. These patients can be asymptomatic or symptomatic with breathlessness, haemoptysis, recurrent chest infections and pulmonary hypertension. Here, we present a patient who presented with massive haemoptysis secondary to interruption of the left lower lobe PA. To the best of our knowledge, massive haemoptysis due to isolated interruption of the left lower lobe PA has been rarely reported in the English medical literature.

Laboratory Risk Indicator for Necrotizing Fasciitis score for early diagnosis of necrotizing fasciitis in Darwin.

BACKGROUND: Soft tissue infections are a major health burden in the Top End of the Northern Territory of Australia. Necrotizing fasciitis (NF) is associated with mortality rates from 8 to 40%. Early recognition and aggressive surgical debridement are the cornerstones of successful treatment. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, developed by Wong et al., uses six routine biochemical variables to aid early diagnosis. We aim to assess the diagnostic efficacy of the LRINEC score in our population. METHODS: A retrospective review of patients with NF between 2005 and 2013 was conducted. A time matched cohort of abscesses/cellulitis was selected. Admission bloods were used to calculate the LRINEC score. An intraoperative finding of NF was used as the gold standard definition for comparison. The diagnostic accuracy of the LRINEC score was assessed. RESULTS: Ninety-eight patients with NF and 205 control patients were identified. The area under the receiver operator curve for the LRINEC score in detecting NF was 0.925 (0.890-0.959, P < 0.001). The sensitivity of the LRINEC ≥5 for NF was 76.3%, with a specificity of 93.1%. The positive and negative predictive values were 95.5 and 88.1%, respectively. The positive and negative likelihood ratios were 11 and 0.25. CONCLUSION: The LRINEC score is a useful, robust, non-invasive and easily calculated scoring system that can be used as an adjunct to early diagnosis of NF. However, a high degree of clinical suspicion remains the most important factor in early diagnosis of NF.

Providing specialist services in Australia across barriers of distance and culture.

Most of Australia's population live in urban environments and have ready access to high-quality specialist surgical services. The 1% of Australians (210,600 people) who live in the Northern Territory of Australia sparsely occupy more than one-sixth of Australia's land mass and have varied cultural backgrounds. The organization of surgical services in the Northern Territory provides a case study in providing specialist surgical services to disadvantaged, rural and remote populations in a developed country. Historical and current initiatives to overcome barriers of distance include a coordinated network of health clinics, regional hospitals, and specialist surgical facilities staffed by health care practitioners with broad training and a wide scope of practice. Aeromedical services that facilitate patient and medical team transport were among the first worldwide. Recent initiatives to overcome barriers posed by cultural differences include an Indigenous Languages Interpreter Service, dedicated Indigenous health educators, and specialist outreach visits. Specialist services in the Northern Territory are delivered locally by appropriately trained generalists in cooperation with and supported by specialists from larger centers. This cooperative model of delivery of specialist services maximizes population access to the whole range of surgical therapies and encourages the efficient use of both specialists and generalists. Adoption of the principles of this model may lead to increasingly efficient delivery of specialist services in more densely populated regions.

Prostatic abscess due to Burkholderia pseudomallei: 81 cases from a 19-year prospective melioidosis study.

PURPOSE: We review the epidemiology, clinical presentation, management and outcome of prostatic abscess secondary to Burkholderia pseudomallei infection in the Northern Territory, Australia. We highlight the frequency of prostatic abscess occurrence in melioidosis, and formulate recommendations for its detection and management. MATERIALS AND METHODS: We reviewed a prospective database of all culture confirmed melioidosis cases in the Northern Territory between October 1989 and July 2008. This review was supplemented with data obtained from a review of case notes and postmortem records during the same period. RESULTS: There were 514 patients with 561 episodes of melioidosis, and of these patients 394 (70%) were male. A prostatic abscess was identified, usually by computerized tomography, in 81 (21%) of these episodes, in 77 patients. In 75 (93%) of the 81 episodes there was clinical evidence of prostatic infection or positive urine culture for B. pseudomallei. Kava use and hazardous alcohol use were independent predictors of prostatic abscesses compared to male patients without prostatic abscesses. All were treated with antibiotics and in 57 of the 81 episodes the abscesses were drained. Ultrasound guided needle drainage was used in 51 instances and open drainage in 28 (transurethral 13, transrectal 11, transperineal 4). There were 20 patients who underwent multiple procedures while 24 underwent no procedures. CONCLUSIONS: Prostatic abscess is common in melioidosis. Clinical signs are usually present but may be subtle. Detection is enhanced by routine computerized tomographic screening of the abdomen and pelvis for occult visceral abscesses in all cases of melioidosis. Ultrasound guided needle drainage is adequate initial therapy in conjunction with appropriate antibiotics.

Streptococcal necrotising fasciitis from diverse strains of Streptococcus pyogenes in tropical northern Australia: case series and comparison with the literature.

BACKGROUND: Since the mid-1980's there has been a worldwide resurgence of severe disease from group A streptococcus (GAS), with clonal clusters implicated in Europe and the United States. However GAS associated sepsis and rheumatic fever have always remained at high levels in many less developed countries. In this context we aimed to study GAS necrotising fasciitis (NF) in a region where there are high background rates of GAS carriage and disease. METHODS: We describe the epidemiology, clinical and laboratory features of 14 consecutive cases of GAS NF treated over a seven year period from tropical northern Australia. RESULTS: Incidence rates of GAS NF in the Aboriginal population were up to five times those previously published from other countries. Clinical features were similar to those described elsewhere, with 7/14 (50%) bacteremic and 9/14 (64%) having associated streptococcal toxic shock syndrome. 11/14 (79%) had underlying chronic illnesses, including all four fatalities (29% mortality overall). Important laboratory differences from other series were that leukocytosis was absent in 9/14 (64%) but all had substantial lymphopenia. Sequence typing of the 14 NF-associated GAS isolates showed no clonality, with only one emm type 1 and two emm type 3 strains. CONCLUSIONS: While NF clusters can occur from a single emergent GAS clone, this was not evident in our tropical region, where high rates of NF parallel high overall rates of GAS infection from a wide diversity of strains. The specific virulence factors of GAS strains which do cause NF and the basis of the inadequate host response in those patients who develop NF on infection with these GAS require further elucidation.

The demand for surgery: an analysis of referrals from Australian general practitioners.

BACKGROUND: Optimal planning for surgical training and the surgical workforce requires knowledge of the need and demand for surgical care in the community. This has previously relied on indirect indicators, such as hospital throughput. We aimed to describe referrals from general practitioners (GPs) to surgeons in Australia using a classification of surgical disorders developed especially for primary care settings. METHODS: Terms in the International Classification of Primary Care Version 2-Plus were reclassified into categories delineated by specialist surgeons, resulting in the Surgical Nosology In Primary-care Settings (SNIPS). Referrals to surgeons were analysed using data on 303,000 patient encounters by a random sample of 3030 GPs involved in the Bettering the Evaluation and Care of Health (BEACH) study. RESULTS: Thirty-two per cent (143,013) of all problems were classified as potential surgical problems, of which 9.5% (13,570) were referred to surgeons at an overall rate of 44.8 referrals per 1000 GP encounters. Patients with surgical problems were significantly older than the overall general practice patient population. Women and patients with health care cards were significantly less likely than men and patients without health care cards to be referred when a surgical problem was managed by the GP. Forty-two per cent of all surgical referrals were accounted for by the following categories: skin lesions, skin infection/injury, upper gastrointestinal, breast lumps/cancer, spine, knee arthritis/pain, knee injury/instability, infective and non-infective ear disorders. Many commonly referred problems are usually managed as outpatients. CONCLUSIONS: The data from this study may have application for surgical workforce planning and ensuring trainees receive adequate exposure to commonly referred conditions. The classification system (SNIPS) may be useful for future research concerning the interface between primary care and specialist surgical practice.