Persistence of vaccinia at the site of smallpox vaccination.

Persistence of vaccinia at vaccination sites may help determine the risk associated with secondary transmission. Culture, PCR, and antigen detection were performed on serial vaccination site swab specimens. On day 21 after vaccination, 37% of volunteers were culture positive, most of whom had received vaccine for the first time. Vaccinia is detectable at least through day 21 after vaccination.

Effectiveness of highly-active antiretroviral therapy by race/ethnicity.

OBJECTIVE: To determine the effectiveness of HAART by race/ethnicity. DESIGN: Prospective multicenter cohort study. METHODS: We studied 991 African-Americans and 911 European-Americans enrolled in the United States Military's Tri-Service AIDS Clinical Consortium Natural History Study who had dates of HIV seroconversion known within 5 years and followed between 1990 and 2002. We determined the rate of disease progression to AIDS and death for subjects in this cohort. Multivariable models evaluated race, pre-HAART (1990-1995) and HAART (1996-2002) eras, age, gender and military service. RESULTS: In the pre-HAART era, African-Americans had a statistically nonsignificant trend towards better outcomes: the relative hazards (RH) of AIDS and death for African-Americans compared to European-Americans were 0.85 [95% confidence interval (CI), 0.68-1.05] and 0.77 (95% CI, 0.55-1.08), respectively. In the HAART era, outcomes were similar by race: 1.17 (95% CI, 0.86-1.61) for AIDS and 1.11 (95% CI, 0.81-1.53) for death with overlapping Kaplan-Meier curves. Relative to the pre-HAART era, the adjusted RH of AIDS in the HAART era was 0.41 (95% CI, 0.31-0.54) and 0.30 (95% CI, 0.22-0.40) for African-American and European-American participants, respectively. Analogous RH for death were 0.55 (95% CI, 0.38-0.80) and 0.38 (95% CI, 0.27-0.54). The precipitous declines in AIDS and death in the HAART era were not statistically different by race. CONCLUSIONS: : In a large multi-racial cohort with equal access to health care, HIV treatment outcomes by race/ethnicity were similar.

Varicella zoster virus meningitis complicating sodium stibogluconate treatment for cutaneous leishmaniasis.

Sodium stibogluconate (Pentostam(R); GlaxoSmithKline) is a pentavalent antimonial compound used in the treatment of leishmaniasis, which has an association with reactivation of varicella zoster virus (VZV). We report the first known case of an immunocompetent adult who developed VZV aseptic meningitis and dermatomal herpes zoster during treatment with sodium stibogluconate.

Lack of vaccinia viremia after smallpox vaccination.

Although the transmission of certain viral infections (human immunodeficiency virus, hepatitis B and C viruses, and West Nile virus) through donated blood products is well described, the risk of transmitting vaccinia virus after smallpox vaccination is unknown. Blood samples from patients receiving the smallpox vaccine were obtained before vaccination; then from one-half of the study group on alternate days for each of the first 10 days after vaccination; then from all patients on days 14 and 21 after vaccination. Samples were analyzed by culture, polymerase chain reaction, and antigen detection (electrochemiluminescence) assay for the presence of vaccinia virus. Two hundred and twenty samples from 28 volunteers were processed by all 3 laboratory detection methods and all were negative for the presence of vaccinia virus (confidence interval, 0%-12.3%). Viremia with vaccinia virus after smallpox vaccination appears to be an uncommon occurrence.

Apparent exacerbation of Hansen's disease despite appropriate antimicrobial therapy.

In 1991, the World Health Organization and its member states resolved to reduce the global prevalence of Hansen's disease (leprosy) by at least 90%. Despite its waning prevalence, however, the disease remains endemic in parts of Africa, Asia, and Latin America. Moreover, imported cases are occasionally encountered innonendemic areas. This fact, coupled with the current tempo of overseas deployments, makes it imperative that military physicians familiarize themselves with both the presentation and potential complications of Hansen's disease. Here, we present the case of a soldier referred to Walter Reed Army Medical Center for apparent worsening of his disease despite appropriate antibiotic therapy. On evaluation, the patient was diagnosed with reversal reaction, an immune-mediated phenomenon resembling disease exacerbation and requiring prompt intervention to avert lasting sequelae. Following the case presentation, we discuss the clinical manifestations, pathophysiology, and management of reversal reactions as well as the related entity erythema nodosum leprosum.

Apparent exacerbation of Hansens disease despite appropriate antimicrobial therapy

In 1991, the World Health Organization and its member states resolved to reduce the global prevalence of Hansen's disease (leprosy) by at least 90%. Despite its waning prevalence, however, the disease remains endemic in parts of Africa, Asia, and Latin America. Moreover, imported cases are occasionally encountered innonendemic areas. This fact, coupled with the current tempo of overseas deployments, makes it imperative that military physicians familiarize themselves with both the presentation and potential complications of Hansen's disease. Here, we present the case of a soldier referred to Walter Reed Army Medical Center for apparent worsening of his disease despite appropriate antibiotic therapy. On evaluation, the patient was diagnosed with reversal reaction, an immune-mediated phenomenon resembling disease exacerbation and requiring prompt intervention to avert lasting sequelae. Following the case presentation, we discuss the clinical manifestations, pathophysiology, and management of reversal reactions as well as the related entity erythema nodosum leprosum.

Hospitalizations for cytomegalovirus disease after renal transplantation in the United States.

PURPOSE: Risk factors, sites, and mortality of hospitalized cytomegalovirus (CMV) disease in renal transplant recipients have not been studied in a national population. METHODS: Therefore, 33,479 renal transplant recipients in the United States Renal Data System from 1 July 1, 1994 to June 30, 1997 were analyzed in an historical cohort study of patients with a primary discharge diagnosis of CMV disease (ICD9 Code 078.5x). RESULTS: Renal transplant recipients had an incidence density of hospitalized CMV disease of 1.26/100 person years, and 79% of hospitalizations for CMV disease occurred in the first six months post transplant. The leading manifestation of hospitalized infection was pneumonia (17%). In logistic regression analysis controlling for transplant era, pre-transplant dialysis > or = 6 months, maintenance mycophenolate mofetil (MMF) therapy, and allograft rejection, but not induction antibody therapy, were significantly associated with hospitalized CMV disease. Compared with recipients with negative CMV serology (R-) who had donor kidneys with negative CMV serology (D-), D+/R- had the highest risk of hospitalization for CMV disease [adjusted odds ratio (AOR) 5.19, 95% confidence interval (CI) 3.89-6.93] followed by D+/R+ recipients, whereas D-/R+ were not at significantly increased risk. In Cox Regression analysis the relative risk of death associated with hospitalized CMV disease was 1.32 (95% CI 1.02-1.71). CONCLUSIONS: Even in modern era, renal transplant recipients were at high risk for hospitalizations for CMV disease, which were associated with decreased patient survival. Current prophylactic measures have apparently not reduced the high risk of D+/R- recipients. Prolonged pre-transplant dialysis and maintenance MMF should also be considered risk factors for hospitalized CMV infection, and prospective trials of prophylactic antiviral therapy should be performed in these subgroups.

Hospitalizations for bacterial pneumonia after renal transplantation in the United States.

PURPOSE: Bacterial pneumonia has been cited as the leading cause of infectious death in renal transplant recipients but has not been studied in a national transplant population. SUBJECT AND METHODS: Retrospective analysis of the incidence, risk factors and mortality of hospitalized bacterial pneumonia (ICD9 Code 481.x486.x) for 33,479 renal transplant recipients in the United States Renal Data System transplanted from 1 July 1994-30 June 1997. RESULTS: Among all transplant recipients, 4.7% were hospitalized for a primary discharge diagnosis of pneumonia in the study period (2.86 episodes per 100 person years). 9.9% had bronchoscopy and 4.8% had open lung biopsy. A specific etiology was not identified in 72.5% of patients. The hospitalization rate for pneumonia and hazard for mortality due to hospitalized pneumonia were both constant over time. In logistic regression analysis, pneumonia prior to transplant (odds ratio 1.73, 95% confidence interval, 1.32-2.26), older recipient age, diabetes, delayed graft function, rejection (occurring at any time after transplant during the time of the study), duration of pre-transplant dialysis, and positive recipient cytomegalovirus serology were associated with pneumonia. In Cox Regression, hospitalization for pneumonia was associated with greater risk of mortality (hazard ratio 1.64, 95% CI, 1.42-1.89). CONCLUSIONS: Renal transplant recipients with a previous history of pneumonia are at increased risk for subsequent pneumonia, which is associated with substantially decreased patient survival. Given the low rate of specific etiologies identified in this study, invasive diagnosis may be underutilized in this population.