Arti Barnes

A fatal central nervous system enterovirus 68 infection.

The anticipated eradication of poliovirus emphasizes the need to identify other enteroviral causes of severe central nervous system disease. Enterovirus 68 has been implicated only in cases of respiratory illness. We therefore report a case of fatal meningomyeloencephalitis caused by enterovirus 68 in a 5-year-old boy, which required neuropathology, microbiology, and molecular techniques to diagnose.

Current Diagnosis and Management of Peripheral Tuberculous Lymphadenitis

Peripheral tuberculous lymphadenitis accounts for ~10% of tuberculosis cases in the United States. Epidemiologic characteristics include a 1.4:1 female-to-male ratio, a peak age range of 30-40 years, and dominant foreign birth, especially East Asian. Patients present with a 1-2 month history of painless swelling of a single group of cervical lymph nodes. Definitive diagnosis is by culture or nucleic amplification of Mycobacterium tuberculosis; demonstration of acid fast bacilli and granulomatous inflammation may be helpful. Excisional biopsy has the highest sensitivity at 80%, but fine-needle aspiration is less invasive and may be useful, especially in immunocompromised hosts and in resource-limited settings. Antimycobacterial therapy remains the cornerstone of treatment, but response is slower than with pulmonary tuberculosis; persistent pain and swelling are common, and paradoxical upgrading reactions may occur in 20% of patients. The role of steroids is controversial. Initial excisional biopsy deserves consideration for both optimal diagnosis and management of the otherwise slow response to therapy.

Symptomatic Trichomonas vaginalis infection in the setting of severe nitroimidazole allergy: successful treatment with boric acid

This report describes a patient with symptomatic Trichomonas vaginalis infection who was unable to tolerate nitroimidazole drugs because of severe hypersensitivity, for which desensitisation was not possible. Use of intravaginal clotrimazole, intravaginal paromomycin, intravaginal furazolidone, povidone-iodine douches, and oral nitazoxanide were unsuccessful in eradicating the patients T. vaginalis infection. A 2-month course of intravaginal topical boric acid subsequently achieved a complete symptomatic cure and the patient remained T. vaginalis wet prep- and culture-negative 60 days after treatment.

Healthcare Provider Attitudes, Practices, and Recommendations for Enhancing Routine HIV Testing and Linkage to Care in the Mississippi Delta Region

The Mississippi Delta region is one of the communities most heavily impacted by HIV/AIDS in the United States. To understand local provider attitudes and practices regarding HIV testing and care, we conducted 25 in-depth qualitative interviews with local primary care providers and infectious disease specialists. Interviews explored attitudes and practices regarding HIV testing and linkage to care. Most providers did not routinely offer HIV testing, noting financial barriers, financial disincentives to offer routine screening, misperceptions about local informed consent laws, perceived stigma among patients, and belief that HIV testing was the responsibility of the health department. Barriers to enhancing treatment and care included stigma, long distances, lack of transportation, and paucity of local infectious disease specialists. Opportunities for enhancing HIV testing and care included provider education programs regarding billing, local HIV testing guidelines, and informed consent, as well as telemedicine services for underserved counties. Although most health care providers in our study did not currently offer routine HIV testing, all were willing to provide more testing and care services if they were able to bill for routine testing. Increasing financial reimbursement and access to care, including through the Affordable Care Act, may provide an opportunity to enhance HIV/AIDS services in the Mississippi Delta.

Addressing Mississippi’s HIV/AIDS crisis

We appreciate Talha Burki’s World Report (June 11, p 1994)1 regarding the Human Rights Watch report2 on Mississippi’s HIV/AIDS policies. Although Mississippi’s AIDS rates plateaued in recent years, racial disparities in HIV infection widened: African Americans represent 37% of the population, but account for 78% of new infections.3 Mississippi’s HIV/AIDS and reproductive health policies warrant scrutiny and improvement. However, we note that individuals who qualify for treatment generally receive it; unlike many other American states, Mississippi currently has no waiting list for its AIDS Drug Assistance Program. Complex social and structural factors that contribute to Mississippi’s racial disparities in HIV infection also deserve more nuanced discussion. Many individuals, particularly African Americans, underestimate their risk of sexually transmitted diseases, including HIV. This phenomenon is compounded by the overwhelming stigma associated with HIV/AIDS among African Americans in southern USA; many individuals forego testing not only because of limited access to health services, but because of paralysing stigma.4 Additionally, complex sexual networks and a high prevalence of HIV within networks perpetuate high rates of HIV infection;5 50% of those who tested positive in 2010 had no identified risk behaviours.3 A comprehensive, culturally appropriate response to HIV/AIDS in Mississippi should focus not only on fully funding Medicaid and providing comprehensive testing and treatment services, but on social marketing and media campaigns designed to address HIV/AIDS stigma and raise awareness about the risks of HIV and sexually transmitted diseases. These steps would help normalise and stimulate more demand for HIV testing and treatment services and are crucial components of any policy to address racial disparities in HIV infection.

Fatal case of macrophage activation syndrome (MAS) in a patient with dermatomyositis and cytomegalovirus (CMV) viraemia

We describe a case of an adult with dermatomyositis (DM) who presents with a rash, high fevers, tachycardia and hypotension, initially concerning for an infectious aetiology or a DM flare. She was found to have cytomegalovirus viraemia which improved after starting valganciclovir. After extensive workup and lack of improvement with broad-spectrum antimicrobial therapy, intravenous immunoglobulin and steroids, the patient was diagnosed with macrophage activation syndrome after bone marrow biopsy and levels of soluble CD25 (soluble interleukin (IL)-2 receptor) and IL2 were obtained. Unfortunately, despite therapy with dexamethasone, anakinra and etoposide, the patient decompensated and the patient’s family opted for comfort care. The patient subsequently expired in the intensive care unit.

Cervical Cancer Burden and Opportunities for Prevention in a Safety-net Healthcare System

Background: The high prevalence of cervical cancer at safety-net health systems requires careful analysis to best inform prevention and quality improvement efforts. We characterized cervical cancer burden and identified opportunities for prevention in a U.S. safety-net system. Methods: We reviewed tumor registry and electronic health record (EHR) data of women with invasive cervical cancer with ages 18+, diagnosed between 2010 and 2015, in a large, integrated urban safety-net. We developed an algorithm to: (i) classify whether women had been engaged in care (≥1 clinical encounter between 6 months and 5 years before cancer diagnosis); and (ii) identify missed opportunities (no screening, no follow-up, failure of a test to detect cancer, and treatment failure) and associated factors among engaged patients. Results: Of 419 women with cervical cancer, more than half (58%) were stage 2B or higher at diagnosis and 40% were uninsured. Most (69%) had no prior healthcare system contact; 47% were diagnosed elsewhere. Among 122 engaged in care prior to diagnosis, failure to screen was most common (63%), followed by lack of follow-up (21%), and failure of test to detect cancer (16%). Tumor stage, patient characteristics, and healthcare utilization differed across groups. Conclusions: Safety-net healthcare systems face a high cervical cancer burden, mainly from women with no prior contact with the system. To prevent or detect cancer early, community-based efforts should encourage uninsured women to use safety-nets for primary care and preventive services. Impact: Among engaged patients, strategies to increase screening and follow-up of abnormal screening tests could prevent over 80% of cervical cancer cases.