Christina Schofield

Epidemiologic, clinical, and virologic characteristics of human rhinovirus infection among otherwise healthy children and adults: Rhinovirus among adults and children

Abstract Background human rhinovirus (HRV) is a major cause of influenza-like illness (ILI) in adults and children. Differences in disease severity by HRV species have been described among hospitalized patients with underlying illness. Less is known about the clinical and virologic characteristics of HRV infection among otherwise healthy populations, particularly adults. Objectives to characterize molecular epidemiology of HRV and association between HRV species and clinical presentation and viral shedding. Study design observational, prospective, facility-based study of ILI was conducted from February 2010 to April 2012. Collection of nasopharyngeal specimens, patient symptoms, and clinical information occurred on days 0, 3, 7, and 28. Patients recorded symptom severity daily for the first 7 days of illness in a symptom diary. HRV was identified by RT-PCR and genotyped for species determination. Cases who were co-infected with other viral respiratory pathogens were excluded from the analysis. We evaluated the associations between HRV species, clinical severity, and patterns of viral shedding. Results eighty-four HRV cases were identified and their isolates genotyped. Of these, 62 (74%) were >18 years. Fifty-four were HRV-A, 11HRV-B, and 19HRV-C. HRV-C infection was more common among children than adults (59% vs. 10%, P <0.001). Among adults, HRV-A was associated with higher severity of upper respiratory symptoms compared to HRV-B (P =0.02), but no such association was found in children. In addition, adults shed HRV-A significantly longer than HRV-C (P trend=0.01). Conclusions among otherwise healthy adults with HRV infection, we observed species-specific differences in respiratory symptom severity and duration of viral shedding.

Vaccine-associated reduction in symptom severity among patients with influenza A/H3N2 disease.

BACKGROUND The moderate level of protection conferred by influenza vaccines is well-known, but the vaccines ability to attenuate symptom severity among vaccinated individuals (i.e., vaccine failures) has not been established. METHODS We enrolled otherwise healthy adults who presented with influenza-like illness (ILI) at five US military hospitals between 2009 and 2014. Influenza was diagnosed and subtyped by PCR. Individual and composite severity scores were compared between those who had vs. had not received the seasonal influenza vaccine >14 days prior to enrollment. RESULTS A total of 155 cases of influenza (A/H1N1, n=69; A/H3N2, n=66; A/untyped, n=3; B, n=17) were identified, of whom 111 (72%; A/H1N1, n=44; A/H3N2, n=52; A/untyped, n=3; B, n=12) had been vaccinated. Women were significantly less likely to be vaccinated than men (49% vs. 89%; p<0.01). In multivariate analysis, vaccinated individuals were significantly less likely to report a fever >101°F (OR 0.24; 95% CI [0.10, 0.62]) and more likely to report myalgias (OR 3.31; 95% CI [1.22, 8.97]) than vaccinated individuals. Among patients with A/H3N2 infection, upper respiratory and total symptom severity scores were significantly lower for vaccinated patients during the first 2 days of illness, and differences in total symptom severity persisted over 7 days (p<0.05 for all comparisons). Differences across additional symptom categories (lower respiratory and systemic) were also observed throughout 7 days of illness in bivariate analyses. Differences in symptom severity were not observed between vaccinated and unvaccinated participants with A/H1N1 infection. CONCLUSIONS Among patients with A/H3N2 infection, receipt of seasonal influenza vaccine was associated with reduced symptom severity. Patient-centered discussion about the benefits of influenza vaccination should be expanded to include the possibility that the vaccine could attenuate symptoms.

Characterization of Infections With Extended-Spectrum β-Lactamase Producing Escherichia coli and Klebsiella Species at a Major Military Medical Center

This study represents a review of the incidence of extended-spectrum β-lactamase (ESBL) producing Escherichia coli and Klebsiella species causing infections over a 7-year period and provides a comparison of patient demographics, comorbidities, and ESBL subtypes between community-associated (CA) versus health care-associated (HA) infections. All ESBL-producing bacterial isolates between 2003 and May 2011 at Madigan Army Medical Center were evaluated and reviewed. Polymerase chain reaction (PCR) for ESBL subtypes TEM, SHV, and CTX-M was performed. Demographics and comorbidities associated with infection, ESBL subtype, and antibiotic susceptibility were compared for HA and CA infection. A total of 122 isolates were included in the analysis. From 2005 to 2010, incidence of ESBLs in E. coli increased from 0.13% to 1.0%, and incidence in Klebsiella species rose from 1.0% to 2.55%. CA infections were more likely in females (p < 0.01), age <60 (p < 0.01), urinary source (p < 0.01), and recurrent urinary tract infections (p = 0.02). 42% of CA infections had no associated comorbidity. CTX-M was the predominant subtype in CA infections. Coresistance was high in both HA and CA infection. These data emphasize the need for ongoing monitoring of local microbial epidemiologic trends as changes in prescribing practices may become necessary if resistance continues to spread.

Trimethoprim/sulfamethoxazole induced multiorgan dysfunction

A 22-year-old African-American man with AIDS who had recently started on trimethoprim/sulfamethoxazole daily for pneumocystis jirovecii pneumonia prophylaxis presented with an altered mental state, malaise and nausea was found to have hepatitis, pancreatitis, rhabdomyolitis, acute kidney injury and haemolytic anaemia. Cessation of Bactrim and supportive care with volume expansion resolved his clinical symptoms and laboratory abnormalities.

Type-specific clinical characteristics of adenovirus-associated influenza-like illness at five US military medical centers, 2009-2014.

Adenovirus is a recognized cause of influenza‐like illness (ILI). The proportion of ILI attributable to adenovirus is not known. Moreover, knowledge gaps remain with respect to the epidemiologic, virologic, and clinical characteristics of adenovirus‐associated ILI among otherwise healthy individuals.

Rituximab-Associated Inflammatory Progressive Multifocal Leukoencephalopathy

Progressive multifocal leukoencephalopathy (PML) is a rare disease of the immunosuppression that results from neurotropic invasion of the JC virus which leads to demyelination of oligodendrocytes. Immune reconstitution inflammatory syndrome (IRIS), on the other hand, is a condition of inflammation that develops as the immune system reconstitutes. This case report describes a case of a 35-year-old HIV-negative male who presented with three weeks of right lower extremity paresthesias as well as right upper extremity apraxia. He was diagnosed with PML complicated by IRIS secondary to Rituximab, which he had completed four months prior to presentation. Despite the conditions poor prognosis, the patient recovered with only minor deficits.

Neuraminidase inhibitor therapy in a military population

BACKGROUND Although neuraminidase inhibitors (NI) are the mainstay of treatment for influenza infection, prescribing practice for these agents is not well described. Additionally, benefit is contested. OBJECTIVES We examined provider prescriptions of NI during the 2009 pandemic and post-pandemic periods. We also evaluated the effectiveness of NI in reducing severity of influenza infection. STUDY DESIGN Data on NI prescription and severity of influenza infection were compiled in healthy pediatric and adult beneficiaries enrolled in a prospective study of influenza like illness conducted at five military medical centers over five years. Subjects underwent nasal swabs to determine viral etiology of their infection. Demographic, medication and severity data were collected. Subjects with positive influenza were included. RESULTS Two hundred sixty three subjects were influenza positive [38% [H1N1] pdm09, 38.4% H3N2, and 20.5% B); 23.9% were treated with NI. NI were initiated within 48h in 63% of treated subjects. Although NI use increased over the five years of the study, early use declined. Most measures for severity of illness were not significantly reduced with NI; adults treated within 48h had only a modest reduction in duration and severity of some of their symptoms. CONCLUSIONS NI use in our population is increasing, but early use is not. NI use resulted in no reduction in complications of illness. Resolution of symptoms and reduction in severity of some symptoms were slightly better in adults who were treated early. These modest benefits do not support routine treatment with NI in otherwise healthy individuals with influenza.

An End-of-Year Oral Examination for Internal Medicine Residents: An Assessment Tool for the Clinical Competency Committee.

BACKGROUND Comprehensive evaluations of clinical competency consume a large amount of time and resources. An oral examination is a unique evaluation tool that can augment a global performance assessment by the Clinical Competency Committee (CCC). OBJECTIVE We developed an oral examination to aid our CCC in evaluating resident performance. METHODS We reviewed tools used in our internal medicine residency program and other training programs in our institution. A literature search failed to identify reports of a similar evaluation tool used in internal medicine programs. We developed and administered an internal medicine oral examination (IMOE) to our postgraduate year-1 and postgraduate year-2 internal medicine residents annually over a 3-year period. The results were used to enhance our CCCs discussion of overall resident performance. We estimated the costs in terms of faculty time away from patient care activities. RESULTS Of the 54 residents, 46 (86%) passed the IMOE on their first attempt. Of the 8 (14%) residents who failed, all but 1 successfully passed after a mentored study period and retest. Less than 0.1 annual full-time equivalent per faculty member was committed by most faculty involved, and the time spent on the IMOE replaced regular resident daily conference activities. CONCLUSIONS The results of the IMOE were added to other assessment tools and used by the CCC for a global assessment of resident performance. An oral examination is feasible in terms of cost and can be easily modified to fit the needs of various competency committees.

Symptomatic hepatitis secondary to disseminated coccidioidomycosis in an immunocompetent patient.

A young man from California presented with acute onset of cough, fevers, night sweats and pruritus with dark urine. Laboratory studies were notable for moderate transaminitis with elevated bilirubin and eosinophilia. Hepatitis panel, HIV screen and heterophile antibodies were negative. CT scan showed multiple bilateral focal opacities with hilar and mediastinal lymphadenopathy with no ductal dilation or gallbladder stones. The patient had positive coccidioidomycosis serologies and he was started on fluconazole with resolution of symptoms and improvement in transaminitis over the next month. This article highlights a rare manifestation of disseminated coccidioidomycosis with symptomatic hepatitis. Although an increasingly prevalent infection found in southwest USA, dissemination is rare in immunocompetent hosts. Postmortem studies suggest hepatic involvement is common in disseminated infection. However symptomatic hepatitis is rare, with only three cases of symptomatic hepatitis found in the literature.

When occam's razor can fail– active mycobacteria infection and lung cancer: A case of neuroendocrine lung cancer diagnosed in the setting of refractory mycobacterium avium‐intracellulare

The link between Myobacterium avium‐intracellulare and lung cancer remains underemphasized in literature. Our objective is to increase awareness of Myobacterium avium‐intracellulare and coexisting lung cancer and to emphasize the need in establishing prevalence and specific testing guidelines in this patient population.