A Case Series of Children with Acute Hepatitis and Human Adenovirus Infection.

BACKGROUND: Human adenoviruses typically cause self-limited respiratory, gastrointestinal, and conjunctival infections in healthy children. In late 2021 and early 2022, several previously healthy children were identified with acute hepatitis and human adenovirus viremia. METHODS: We used International Classification of Diseases, 10th Revision, codes to identify all children (<18 years of age) with hepatitis who were admitted to Children's of Alabama hospital between October 1, 2021, and February 28, 2022; those with acute hepatitis who also tested positive for human adenovirus by whole-blood quantitative polymerase chain reaction (PCR) were included in our case series. Demographic, clinical, laboratory, and treatment data were obtained from medical records. Residual blood specimens were sent for diagnostic confirmation and human adenovirus typing. RESULTS: A total of 15 children were identified with acute hepatitis - 6 (40%) who had hepatitis with an identified cause and 9 (60%) who had hepatitis without a known cause. Eight (89%) of the patients with hepatitis of unknown cause tested positive for human adenovirus. These 8 patients plus 1 additional patient referred to this facility for follow-up were included in this case series (median age, 2 years 11 months; age range, 1 year 1 month to 6 years 5 months). Liver biopsies indicated mild-to-moderate active hepatitis in 6 children, some with and some without cholestasis, but did not show evidence of human adenovirus on immunohistochemical examination or electron microscopy. PCR testing of liver tissue for human adenovirus was positive in 3 children (50%). Sequencing of specimens from 5 children showed three distinct human adenovirus type 41 hexon variants. Two children underwent liver transplantation; all the others recovered with supportive care. CONCLUSIONS: Human adenovirus viremia was present in the majority of children with acute hepatitis of unknown cause admitted to Children's of Alabama from October 1, 2021, to February 28, 2022, but whether human adenovirus was causative remains unclear. Sequencing results suggest that if human adenovirus was causative, this was not an outbreak driven by a single strain. (Funded in part by the Centers for Disease Control and Prevention.).

Acute Hepatitis and Adenovirus Infection Among Children - Alabama, October 2021-February 2022.

During October-November 2021, clinicians at a children's hospital in Alabama identified five pediatric patients with severe hepatitis and adenovirus viremia upon admission. In November 2021, hospital clinicians, the Alabama Department of Public Health, the Jefferson County Department of Health, and CDC began an investigation. This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy.

Holiday Discharges Are Associated with Higher 30-Day General Internal Medicine Hospital Readmissions at an Academic Medical Center.

OBJECTIVE: Academic medical centers face unique challenges in educating physician trainees in effective discharge practices to prevent readmissions. Meanwhile, residents must handle high workloads coupled with frequent rotations to different services. This study aimed to determine whether daily service census, service turnover, time of discharge, and day of discharge increase the risk of 30-day readmission. METHODS: All of the discharges from two academic general internal medicine teaching services between October 1, 2013 and September 30, 2014 were included in this observational data analysis. Variables were fit to a 30-day, all-cause readmission outcome using multiple logistic regression with inverse probability of treatment weighting and multiple imputations with chained equations. The following potential confounding variables were included in the model: health system utilization, demographics, laboratory values, and comorbidities. RESULTS: Among 1935 total discharges, 258 patients (13.3%) were readmitted within 30 days of the index discharge. Turnover, service census, weekend discharge, and time of discharge were not significantly associated with the risk of readmission. Patients discharged during holiday periods had higher odds of readmission (odds ratio 2.56, 95% confidence interval 2.01-3.25), whereas patients discharged on an intern switch day had lower odds of readmission (odds ratio 0.33, 95% confidence interval 0.27-0.41). CONCLUSIONS: Patients who are discharged during holiday periods are at a higher risk of readmission after adjusting for potential confounders. These results also suggest that discharge on an intern switch day had a protective effect on readmission. Further work is needed to examine whether these findings can be replicated, and, if confirmed, to determine to what extent these associations are causal.

Acute Cytomegalovirus (CMV) Infection Associated with Hemophagocytic Lymphohistiocytosis (HLH) in an Immunocompetent Host Meeting All Eight HLH 2004 Diagnostic Criteria.

Hemophagocytic lymphohistiocytosis (HLH) is a rare and often deadly syndrome characterized by severe inflammation and cytokine dysregulation. The disease is defined by the HLH-2004 criteria, requiring five of eight findings, and is further differentiated into either primary or secondary causes. Primary HLH tends to be of genetic etiology, while secondary HLH results from other insults such as infection. Secondary HLH is most commonly associated with viral infections in immunocompromised patients. Acute cytomegalovirus (CMV) associated HLH in the immunocompetent host is exceedingly rare and only documented in four case reports to date. We describe the fifth documented case of CMV-associated HLH in an immunocompetent patient, and furthermore, we demonstrate that this patient is the first published case of its type to satisfy all eight of HLH-2004 criteria.

Anal Dysplasia Screening and Treatment in a Southern Human Immunodeficiency Virus Clinic.

BACKGROUND: Persistent human papillomavirus infection in human immunodeficiency virus (HIV)-infected individuals has been strongly associated with anal squamous cell carcinoma. The incidence of anal squamous cell carcinoma continues to increase in this population despite advances in HIV therapy. There are few studies describing the prevalence of anal cancer precursors, treatment outcomes, and associated factors among HIV-infected populations in the southern United States. METHODS: A retrospective chart review was performed on 355 HIV-infected patients from a Southern HIV clinic who were 18 years or older and had received at least one anal Pap smear. Demographic and clinical variables were collected. Descriptive statistics, single variable, and multivariate logistic regression analysis were performed to evaluate for predictors of high-grade squamous intraepithelial lesion (HSIL). Odds ratios and 95% confidence intervals were constructed for independent measures. RESULTS: After the first anal Pap smear, 38.3% (70/183) of patients with abnormal results were lost to follow-up. Comparing patients with biopsy proven HSIL versus low-grade squamous intraepithelial lesions, patients were less likely to have HSIL if they had a higher CD4 count (odds ratio, 0.81; 95% confidence interval, 0.72-0.93; P = 0.0022). Treatment success after the first round of treatment for topical and infrared coagulation therapy was 36.7% (18/49, all therapy types), and of those who achieved biopsy proven treatment success at follow-up screening, 94.4% (17/18) required subsequent therapy. CONCLUSIONS: Patients with a higher CD4 count were less likely to have HSIL. CD4 nadir, number of sexual partners, and race/ethnicity were not significantly associated with the presence of HSIL.

Syphilis ascendant: a brief history and modern trends.

To provide a miniature review of recent literature surrounding a brief history of syphilis, to discuss the recently increasing incidence of syphilis, to discuss recent United State Preventative Service Task Force recommendations for syphilis screening, and to discuss congenital syphilis. The literature review was conducting using PubMed with the following search terms: syphilis, congenital syphilis, MSM and syphilis, prenatal syphilis, neurosyphilis, and other related terms. Treponema pallidum has been a constant, and unwanted, companion of humankind since antiquity. This sexually transmitted infection (STI) has the potential to affect virtually every rung of society-young and old, rich and poor, but it has a proclivity for the most vulnerable groups among us. Since record high rates of infection in the World War II era, tremendous progress has been made in effectively controlling the infection, and this has been largely mediated by the efficacy of penicillin on the causative spirochete. However, 2014 data from the Centers for Disease Control and Prevention demonstrated a sharp increase in the rate of new cases of syphilis, predominantly in men who have sex with men. Additionally, the numbers of newly diagnosed cases of congenital syphilis are on the rise as well. In effect, a burgeoning crisis has come to the doorstep of the medical community. We are faced with changing attitudes regarding sexual interactions. The authors believe that geolocation dating and sex applications for smart phones increase the availability of sexual encounters. Pre-exposure prophylaxis may be leading to more laissez-faire attitudes toward unprotected intercourse, and with increased opportunities for sexual encounters, co-infected states with other diseases may be altering the landscape of STIs. In 2016, in response to increasing rates of newly diagnosed syphilis, the United States Preventative Health Services Task Force reaffirmed the need for syphilis screening in at-risk populations. However, primary care physicians and advanced practice providers may not always be aware of which patients fall into that category. Due to the highly personal nature of discussing sexuality, sexual behavior may not be explored at all. Numerous challenges lie ahead of the infectious diseases, primary care, and public health communities in attempting to bend the curve of the ascendant rise in syphilis. To adequately combat this infection, sufficient funding will need to be provided to public health departments, adequate access to health care resources will be needed to allow for the necessary screening of patients, and primary care practitioners will need thoroughly engage with their patients to understand their sexual practices and to offer the necessary interventions.