Artesunate: investigational drug for the treatment of severe falciparum malaria in Hawai'i.

INTRODUCTION: There are hundreds of millions of cases of malaria each year worldwide resulting in a million deaths. These deaths are mostly due to Plasmodium falciparum. The only Federal Drug Administration approved treatment for severe malaria is intravenous quinidine gluconate. Intravenous quinidine is increasingly unavailable in the United States. In 2007, the Center for Disease Control and Prevention implemented an investigational new drug protocol to allow the use of intravenous artesunate for cases of severe malaria in the United States. The authors present such a case treated under this protocol at Tripler Army Medical Center, Hawai'i. CASE REPORT: A 49-year-old man presented to Tripler Army Medical Center, Hawai'i in February 2009 with a one-month history of fever, chills, and weight loss. He recently travelled to multiple malaria endemic areas. Physical examination was significant for fever and prostration. Laboratory studies revealed anemia, thrombocytopenia, and a high parasite load of Plasmodium falciparum. A strategic network was activated to obtain and administer intravenous artesunate. His condition rapidly improved as his parasitemia cleared. He was discharged after six days with no adverse medication effects and full recovery upon six-month follow-up. DISCUSSION: Our patient met the criteria for severe Plasmodium falciparum malaria. He was immediately treated with intravenous artesunate and manifested a quick and durable response to therapy. At present, intravenous artesunate is awaiting Federal Drug Administration approval but available via a strategic network controlled by the Centers for Disease Control and Prevention. This case highlights a common delay in diagnosis, importance of optimal prophylaxis, and attention to travel history as they relate to the development of severe malaria.

Antibiotic desensitization therapy in secondary syphilis and Listeria infection: case reports and review of desensitization therapy.

Two adult cases, one of secondary syphilis and one of Listeria monocytogenes bacteremia, in which antibiotic desensitization therapy was utilized to assist treatment of active infection in the face of severe penicillin allergy. Clinical considerations are discussed that led to the decision to employ a formal desensitization procedure. Antibiotic desensitization protocols can facilitate optimal and safe antibiotic therapy in the appropriate clinical setting.

Persistent and relapsing babesiosis in immunocompromised patients.

BACKGROUND: Human babesiosis is a tickborne malaria-like illness that generally resolves without complication after administration of atovaquone and azithromycin or clindamycin and quinine. Although patients experiencing babesiosis that is unresponsive to standard antimicrobial therapy have been described, the pathogenesis, clinical course, and optimal treatment regimen of such cases remain uncertain. METHODS: We compared the immunologic status, clinical course, and treatment of 14 case patients who experienced morbidity or death after persistence of Babesia microti infection, despite repeated courses of antibabesial treatment, with those of 46 control subjects whose infection resolved after a single course of standard therapy. This retrospective case-control study was performed in southern New England, New York, and Wisconsin. RESULTS: All case patients were immunosuppressed at the time of acute babesiosis, compared with <10% of the control subjects. Most case patients experienced B cell lymphoma and were asplenic or had received rituximab before babesial illness. The case patients were more likely than control subjects to experience complications, and 3 died. Resolution of persistent infection occurred in 11 patients after 2-10 courses of therapy, including administration of a final antimicrobial regimen for at least 2 weeks after babesia were no longer seen on blood smear. CONCLUSIONS: Immunocompromised people who are infected by B. microti are at risk of persistent relapsing illness. Such patients generally require antibabesial treatment for >or=6 weeks to achieve cure, including 2 weeks after parasites are no longer detected on blood smear.

Absence of erythrocyte sequestration in a case of babesiosis in a splenectomized human patient.

BACKGROUND: The importance of vascular occlusion in the pathogenesis of human haemoprotozoal disease is unresolved. METHODS: Giemsa-stained tissue sections from a human case of Babesia microti infection in a splenectomized patient with chronic lymphocytic leukaemia and colon cancer were examined to ascertain the distribution of parasitized erythrocytes within the vascular lumen. RESULTS: No evidence of sequestration was observed. CONCLUSION: This first report on the vascular location of B. microti in human tissue suggests that severe multi-organ failure due to babesiosis is independent of sequestration of parasitized erythrocytes. A similar pathogenesis may also cause multi-organ failure in other intraerythrocytic protozoal infections, including falciparum malaria.

Optimization of time to initial vancomycin target trough improves clinical outcomes.

BACKGROUND: Outcomes data for the efficacy of interventions designed to decrease the time to initial target vancomycin troughs are sparse. OBJECTIVE: A vancomycin therapeutic drug monitoring (TDM) program was initiated to reduce the time to initial target troughs and to examine the impact on clinical outcomes. METHODS: Single-center, pre- and post-intervention observational study in a 250 bed teaching facility. Adult inpatients treated with physician-guided, vancomycin therapy (historical control, CTRL) were compared to high trough, pharmacist-guided vancomycin therapy (TDM). Nephrotoxicity analyses were conducted to the ensure safety of the TDM. Clinical outcome analysis was limited to patients with normal renal function and culture-confirmed gram positive infections and a pre-defined MRSA subset. RESULTS: 340 patients met initial inclusion criteria for the nephrotoxicity analysis (TDM, n = 173; CTRL, n = 167). Acute kidney injury occurrence was similar between the CTRL (n = 20) and TDM (n = 23) groups (p = 0.7). Further exclusions yielded 145 patients with gram positive infections for clinical outcomes evaluation (TDM, n = 66; CTRL, n = 75). The time to initial target trough was shorter in the TDM group (3 vs. 5 days, p < 0.001). Patients in the TDM group discharged from the hospital more rapidly, 7 vs. 14 days (Hazards Ratio (HR), 1.41; 95% Confidence Interval [CI] 1.08-1.83; p = 0.01), reached clinical stability faster, 4 vs. 8 days (HR, 1.51; 95% CI 1.08-2.11; p = 0.02), and had shorter courses of vancomycin, 4 vs. 7 days (HR, 1.5; 95% CI 1.15-1.95; p = 0.003). In the MRSA infection subset (TDM, n = 36; CTRL, n = 35), patients in the TDM group discharged from the hospital more rapidly, 7 vs. 16 days (HR, 1.89; 95% CI 1.08-3.3; p = 0.03), reached clinical stability faster, 4 vs. 6 days (HR, 2.69; 95% CI 1.27-5.7; p = 0.01), and had shorter courses of vancomycin, 5 vs. 8 days (HR, 2.52; 95% CI 1.38-4.6; p = 0.003). Attaining initial target troughs in <5 days versus ≥5 days was associated with improved clinical outcomes. All cause in-hospital mortality, and vancomycin treatment failure occurred at comparable rates between groups. CONCLUSIONS: Interventions designed to decrease the time to reach initial target vancomycin troughs can improve clinical outcomes in gram positive infections, and in particular MRSA infections.

A case of severe septicemia following traditional Samoan tattooing.

Traditional Samoan tattoos, or tatau, are created by master tattooists, or tufuga ta tatau, and their assistants using multi-pointed handmade tools. These tools are used to tap tattoo pigment into the skin, usually over several days. This traditional process is considered an honor to the one receiving the tatau. Unfortunately, as it is typically practiced according to cultural traditions, the sanitary practices are less than ideal. There have been several reported cases of severe infection, sepsis, shock, and even death as a result of traditional Samoan tattoos. Although Hawai'i is the home of the second largest Samoan population in the United States, short of only American Samoa, literature review found no published case reports in this state. Presented is a case of a 46-year-old man, who, after undergoing a modified version of traditional Samoan tattooing for 5 days, was admitted to the intensive care unit with severe septic shock due to poly-microbial bacteremia with Group A Streptococcus and Methicillin-sensitive Staphylococcus Aureus. In addition, we will discuss the previously reported cases, mainly documented in New Zealand, and review some of the mandatory sanitary standards put into place there.

Rapid multiplex PCR assay to identify respiratory viral pathogens: moving forward diagnosing the common cold.

Upper respiratory tract infections (URIs) can be a serious burden to the healthcare system. The majority of URIs are viral in etiology, but definitive diagnosis can prove difficult due to frequently overlapping clinical presentations of viral and bacterial infections, and the variable sensitivity, and lengthy turn-around time of viral culture. We tested new automated nested multiplex PCR technology, the FilmArray(®) system, in the TAMC department of clinical investigations, to determine the feasibility of replacing the standard viral culture with a rapid turn-around system. We conducted a feasibility study using a single-blinded comparison study, comparing PCR results with archived viral culture results from a convenience sample of cryopreserved archived nasopharyngeal swabs from acutely ill ED patients who presented with complaints of URI symptoms. A total of 61 archived samples were processed. Viral culture had previously identified 31 positive specimens from these samples. The automated nested multiplex PCR detected 38 positive samples. In total, PCR was 94.5% concordant with the previously positive viral culture results. However, PCR was only 63.4% concordant with the negative viral culture results, owing to PCR detection of 11 additional viral pathogens not recovered on viral culture. The average time to process a sample was 75 minutes. We determined that an automated nested multiplex PCR is a feasible alternative to viral culture in an acute clinical setting. We were able to detect at least 94.5% as many viral pathogens as viral culture is able to identify, with a faster turn-around time.

Expect the unexpected: two cases of penetrating head and neck trauma from Operation Iraqi Freedom.

The protocol for treating penetrating head and neck trauma in a war zone differs from the standard protocol. Rather than first securing an airway, as is standard in civilian trauma cases, the primary emphasis is on assessing and controlling hemorrhage because it is the leading cause of morbidity and mortality in a battlefield setting. Once that has been addressed, we shift to standard advanced-trauma life-support protocols. We describe two cases we encountered at our combined medical clinic in Western Baghdad--one involving a 4-year old Iraqi child with an ammunition round lodged in her neck and one involving a 38-year-old female U.S. soldier with a round lodged in her right superolateral orbit. Both cases were transferred to combat support hospitals for further treatment after our initial assessment and treatment, and both had successful outcomes.

Coccidioidomycosis and tuberculosis coinfection at a tuberculosis hospital: clinical features and literature review.

Tuberculosis (TB) and coccidioidomycosis can have similar clinical and radiologic presentations but require different treatments. Coinfection with TB and Coccidioides immitis is uncommonly reported and may be underdiagnosed in endemic areas.We performed a retrospective review of the medical records of all patients admitted to a TB referral hospital between 1995 and 2007, and selected all cases of TB and coccidioidomycosis coinfection in patients aged 18 years or older. All admitted patients had a diagnosis of TB and had sputum cultures for both pathogens. We reviewed clinical, laboratory, and radiologic features of the cases, and noted antimicrobial treatments received and outcomes.We identified 9 patients, of whom 7 (78%) were Hispanic. Most patients were male (8/9, 89%), and all were diagnosed with coccidioidomycosis after TB. Three (33%) patients had drug-resistant TB. Six patients had culture-positive TB at the time of the double diagnosis, and 2 patients developed active coccidioidomycosis during their hospital stay. Only 1 had human immunodeficiency virus/acquired immunodeficiency syndrome (HIV-AIDS) (CD4 count, 20 cells/mm). All but 2 patients were treated with antifungal agents. Two patients died, 1 of whom had AIDS. Radiologic studies were unable to distinguish between TB and coccidioidomycosis, except for a patient who developed a new air-fluid level in a previously stable cavity.TB and coccidioidomycosis coinfection should be suspected in coccidioidomycosis-endemic regions among patients with TB who fail to improve clinically or radiologically despite adequate, culture-directed therapy.