A MacConnachie

Faecal transplant for recurrent Clostridium difficile-associated diarrhoea: a UK case series

BACKGROUND Clostridium difficile-associated diarrhoea (CDAD) is an increasingly common and life threatening consequence of modern medical practice. Recurrent disease is seen in up to one-third of patients and there is no consensus on optimal therapy. Restoration of normal colonic flora addresses the underlying pathogenic mechanism in CDAD. METHODS We describe the use of nasogastrically administered faecal transplant in the treatment of 15 patients with recurrent CDAD. Retrospective case note review was used to review the success and safety of therapy. RESULTS Of 15 patients treated using this technique, 11 were cured of CDAD. Two patients required a further course of metronidazole after transplantation and one patient required a second treatment. One patient had recurrence of CDAD 4 weeks after treatment following a course of broad-spectrum antibiotics. No adverse events were noted. CONCLUSION In our experience, this technique is an effective and safe treatment for recurrent CDAD. Faecal transplantation via a nasogastric tube could be considered in patients with refractory relapsing CDAD.

Late Ebola virus relapse causing meningoencephalitis: a case report

Summary Background There are thousands of survivors of the 2014 Ebola outbreak in west Africa. Ebola virus can persist in survivors for months in immune-privileged sites; however, viral relapse causing life-threatening and potentially transmissible disease has not been described. We report a case of late relapse in a patient who had been treated for severe Ebola virus disease with high viral load (peak cycle threshold value 13·2). Methods A 39-year-old female nurse from Scotland, who had assisted the humanitarian effort in Sierra Leone, had received intensive supportive treatment and experimental antiviral therapies, and had been discharged with undetectable Ebola virus RNA in peripheral blood. The patient was readmitted to hospital 9 months after discharge with symptoms of acute meningitis, and was found to have Ebola virus in cerebrospinal fluid (CSF). She was treated with supportive therapy and experimental antiviral drug GS-5734 (Gilead Sciences, San Francisco, Foster City, CA, USA). We monitored Ebola virus RNA in CSF and plasma, and sequenced the viral genome using an unbiased metagenomic approach. Findings On admission, reverse transcriptase PCR identified Ebola virus RNA at a higher level in CSF (cycle threshold value 23·7) than plasma (31·3); infectious virus was only recovered from CSF. The patient developed progressive meningoencephalitis with cranial neuropathies and radiculopathy. Clinical recovery was associated with addition of high-dose corticosteroids during GS-5734 treatment. CSF Ebola virus RNA slowly declined and was undetectable following 14 days of treatment with GS-5734. Sequencing of plasma and CSF viral genome revealed only two non-coding changes compared with the original infecting virus. Interpretation Our report shows that previously unanticipated, late, severe relapses of Ebola virus can occur, in this case in the CNS. This finding fundamentally redefines what is known about the natural history of Ebola virus infection. Vigilance should be maintained in the thousands of Ebola survivors for cases of relapsed infection. The potential for these cases to initiate new transmission chains is a serious public health concern. Funding Royal Free London NHS Foundation Trust.

First confirmed case of Crimean-Congo haemorrhagic fever in the UK

In October, 2012, a 38-year-old Afghan man presented to an emergency department in Glasgow, UK, 2 h after returning on a fl ight from Kabul via Dubai, after a 3 week stay in Afghanistan, where he had attended a wedding in Samangan Province. His symptoms had started 5 days before presentation and included fever, epigastric pain, bloody diarrhoea, and haematemesis. On examination he was languid but orientated, with physical observations within normal limits. Conjunctival suff usion was present and a haematoma rapidly developed at the site of venepuncture. Initial blood results showed transaminitis and thrombocytopenia (appendix). The patient was transferred to the Brownlee Centre for Infectious Diseases, Glasgow, and isolated in a negative-pressure room. Formal viral haemorrhagic fever risk assessment was implemented according to the 2012 guidelines published by the Advisory Committee on Dangerous Pathogens (ACDP); the patient reported no contact with ticks (the vector of Crimean-Congo haemorrhagic fever [CCHF]) or with animals and was therefore classifi ed as “possibility of viral haemorrhagic fever” (appendix). Infection control measures were applied in line with ACDP guidance. He was discussed with the Rare and Imported Pathogens Department (RIPD) of the Health Protection Agency, Greater Glasgow and Clyde Public Health Department, and the High Security Infectious Diseases Unit at the Royal Free Hospital, London. Samples of blood and urine were sent by courier to the RIPD laboratory at Porton Down, UK, for rapid CCHF virus testing by PCR: laboratory con fi rmation of the diagnosis of CCHF was made within 36 h of the patient’s presentation. After diagnosis, the patient’s wife discovered that during the Afghan wedding ceremony her husband had been close to a slaughtered calf, the probable source of infection. Despite intravenous ribavirin, the patient’s condition deteriorated, with fl uctuating Glasgow Coma Scale scores, and rising respiratory rate and pulse. 60 h after initial presentation, in keeping with national guidelines, he was transported to Glasgow International Airport by the Scottish Ambulance Service Special Operations Response Team and a dedicated RAF Air Transport Isolator team, and then transferred to the Royal Free Hospital High Security Infectious Diseases Unit in an RAF Hercules and dedicated ambulance where he was managed in a modi fi ed Trexler isolator (Putlock Chimney Systems Ltd, Whitchurch, UK) which provided a sealed environment and pro tection for the staff caring for him. During the fl ight further clinical deterioration was evident including anuria, vascular leak, and a decerebrate response to pain suggesting an intracerebral haemorrhage. Over the subsequent 24 h, he deteriorated further and developed pulmonary haemorrhage. The patient died 96 h after initial presentation. Viral haemorrhagic fever is a rare diagnosis in nonendemic areas and we report the fi rst confi rmed case of CCHF in the UK. Caused by a tick-borne virus, CCHF virus is endemic to more than 30 countries in Central and south western Asia, south eastern Europe, and Africa. Human beings can be infected from tick bites, contact with body fl uid, or, as suspected in the present case, contact with tissue from viraemic livestock. After a variable incubation period (average 2–7 days), fever and myalgia develop; haemorrhagic features start around the fourth day of illness, with mortality rate up to 30%. With increasing international travel to viral haemorrhagic fever endemic areas, clinicians in all countries must maintain a high index of suspicion for cases. In this instance, following infectious diseases consultant assessment, the possibility of viral haemor rhagic fever was recognised within 6 h of presentation, and the diagnosis of CCHF confi rmed rapidly. Consequently, the patient was promptly isolated. Surveillance has not identifi ed any onward transmission. This situation contrasts with multiple previously reported incidences of CCHF where late diagnosis and gaps in infection control procedure have been associated with nosocomial outbreaks. The case also highlights the value of a collateral history and asking about contact with blood from animal carcasses. Our patient is the fi rst confi rmed case of viral haemorrhagic fever in the UK since the 2012 guidelines for management of human infectious diseases of high consequence were published.

Hospitalised adult patients with Suspected 2009 H1N1 Infection at Regional Infectious Diseases Units in Scotland – Most had alternative final diagnoses

The misdiagnosis of serious illness during the current flu pandemic has been highlighted in your journal by Payne et al, and others have raised their concern. We have reviewed 110 cases of ‘‘query H1N1’’ presenting to our Infectious Diseases service and have found a variety of alternative diagnoses, some of which required significantly different management. Human pandemic Influenza A (H1N1) virus has spread globally during 2009. On the 25th April the first 2 cases confirmed in Europe were in our region, the West of Scotland, United Kingdom. Subsequently suspected and confirmed cases surged throughout the UK. Information regarding the clinical spectrum and risk factors for severe illness are still emerging. The clinical case definition, indications for hospital admission and therapeutic intervention are continually being refined as more experience in managing these patients is gained. In order to add to the growing body of clinical experience in managing this novel infection worldwide, this case series describes the clinical presentation and outcome of all adult patients admitted to the Infectious Diseases units in the West of Scotland with suspected H1N1 infection, during the first three months of the global pandemic. In the West of Scotland, the two regional infectious diseases units at Gartnavel General Hospital in Glasgow and at Monklands District General hospital in Airdrie, serve the populations of Lanarkshire, Forth Valley, and Greater Glasgow and Clyde Health Boards (population approx 1.9 million). Between April and July 2009, all adult patients in the West of Scotland requiring hospitalization for confirmed or suspected H1N1 infection were transferred to one of these two Regional Infectious Diseases unit for isolation and treatment, unless their condition merited direct admission to intensive care. The case definition was a pyrexia 38 C or history of fever AND two or more of the following symptoms: cough, sore throat, headache, rhinorrhoea, limb/ joint pain.

Improvement is needed in the documentation and HIV testing of children of HIV-positive women

We assessed our units documentation of the HIV status of 146 identifiable existing children of 146 women audited, out of our total cohort of 329 HIV-positive women. For 23 women (16%) there was no documentation of the presence or absence of children. For 81 children of 43 (29%) women the HIV status was unknown. Of these children, at least eight (5.5%) reside in the UK and could be accessed for testing. It is essential that documentation and testing of children of HIV-positive women takes place to prevent potentially fatal late-stage presentations of AIDS and onward transmission of HIV as young people become sexually active.

Efavirenz use and contraceptive methods in HIV-positive women in a large urban cohort

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

The use of enfuvirtide-based HAART regimens in HIV patients undergoing chemotherapy for lymphoma

of results The five patients studied were all male, median age of 30 yrs (range 28–42), with no significant co-morbidities. Median baseline HIV viral load (VL) was 90,000 copies/ ml (range 11,759–3,035,664). Patients 1 and 2 with Burkitts Lymphoma, and Patient 3 with HIV-assoc DLBCL of anus (stage 1E) were treated with CODOX-M/IVAC; Patient 4 had high grade B cell lymphoma and received rCHOP. Each of these patients were treated with tenofovir/ emtricitabine and enfuvirtide. Patient 5 had plasmablastic high grade B cell NHL of the pancreas, which recurred in the leg. He received ESHAP/Ifosphamide/Cytarabine and his HAART regimen was zidovudine/lamivudine/tenofovir with enfuvirtide. Initial virological response was excellent in four patients, with all having more than 2 log drop in VL within the first 3–7 weeks of treatment. VL was undetectable within 12 weeks in Patients 1 and 2. Patient 4 initially did very well, followed by virological relapse. He subsequently admitted to poor compliance and resistance testing revealed lamivudine resistance. Patient 5 had an initial excellent virological response but the lymphoma progressed despite therapy and he died 8 weeks into treatment. Patient 3 had a 0.9 log drop in VL at week 5 and undetectable VL at week 19 which was then sustained throughout treatment. Two patients developed severe mucositis due to methotrexate, but none of the patients required dose reductions in their chemotherapy regimens. Two patients developed injection site reactions with enfuvirtide but continued to tolerate it for the duration of the chemotherapy. No patients developed renal dysfunction.

Experience of myocardial infarction in a Glasgow HIV cohort

of results Of 947 HIV-positive patients in the database, 19 (2%) had experienced an MI. Case notes for three patients were unobtainable, leaving 16 cases and 32 controls for review. All cases were male, with a median age of 45 yrs at the time of MI. Fourteen cases (87.5%) were of white UK origin and 13 cases (81%) were MSM. Median CD4 count was 322 cells/cmm and median HIV viral load (VL) was 36,500 copies/ml at HIV diagnosis in the MI group. Myocardial infarction occurred before HIV diagnosis in one case and within a year of diagnosis in three cases. Median time from HIV diagnosis to MI was 9 yrs in the remaining 12 cases. Eleven cases were on HAART at the time of MI, with a median treatment length of 6.7 yrs. Abacavir was included in the treatment regimen of four cases (25%) at the time of MI and by seven controls (22%) at the corresponding time point. Didanosine was used by four cases (25%) at the time of MI and by three controls (9%). Current smoking was more common amongst the MI cases (81% vs. 37%). Diabetes mellitus was also more frequent in the MI group (25% vs. 15%). Whilst median total cholesterol was similar between the cases and controls (5.9 vs. 5.05 mmol/l), median total triglyceride was higher in the MI group (2.95 vs. 1.85 mmol/l). Hypertension was recorded in 31% of the MI group and in 28% of controls. Insufficient data were recorded on family history. Eightyseven percent of MI cases take regular aspirin at present. Currently, 69% of MI cases are prescribed a statin and an ACE-inhibitor. There have been no MI-related deaths, however, three MI cases (19%) have required coronary artery by-pass grafting.

Regular audit can lead to changes in practice and better outcomes for pregnant women with HIV

Methods Over a 3-year period from 1 July 2005 to 30 June 2008, there were 50 deliveries of pregnant mothers who were HIV-positive and looked after by a joint team from the Brownlee Centre and Princess Royal Maternity, Glasgow. Each year an audit meeting reviewed all the pregnancies with a view to improving the care pathway. The audit focused on two areas which were measurable and had the potential to change practice. Changes to practice were reaudited in subsequent years.

Managing HIV in pregnancy in Glasgow

Methods Data were collected on all pregnancies occurring between 1 July 2005 and June 2008. Women already attending the Brownlee Centre for their HIV care who became pregnant and pregnant women found to be HIVpositive following antenatal screening were included in the study. Antenatal care was centralised mainly at Princess Royal Maternity, Glasgow, and HIV care provided at the Brownlee Centre, Glasgow. Monthly case management meetings were held between centres. All cases were reviewed at annual audit meetings.