Joshua D. Hartzell

Invasive fungal infections following combat-related injury.

Invasive mold infections are a rare complication of traumatic wounds. We examined the incidence and outcomes of these infections in combat wounds. A retrospective chart review from March 2002 through July 2008 of U.S. soldiers returning from Iraq and Afghanistan with traumatic wounds was performed. A confirmed fungal wound infection was defined as growth of a known pathogenic mold and visualization of fungal elements on histopathology. Six cases were identified for an incidence of 0.4 cases/1,000 admissions. The incidence of invasive mold infections increased over time (p = 0.008) with a peak of 5.2 cases/1,000 admissions in 2007. Isolated molds included Aspergillus (n = 4), Bipolaris (n = 2), and 1 each Mucor and Absidia. All patients were male with a mean age of 22. Blast (n = 5) and gunshot wound (n = 1) were the sources of injury. All patients had fever (mean 39.4 degrees C) and leukocytosis (mean white blood cell count 25 x 10(3)/microL). The average acute physiology and chronic health evaluation II score was 22. All patients received antifungal agents, surgical debridement, and 3 required amputation revision. Average length of stay was 97 days. There were no deaths. Invasive mold infections are a rare complication of combat wounds but are associated with significant morbidity and may be increasing in frequency.

Phase 1/2a Trial of Plasmodium vivax Malaria Vaccine Candidate VMP001/AS01B in Malaria-Naive Adults: Safety, Immunogenicity, and Efficacy

Background A vaccine to prevent infection and disease caused by Plasmodium vivax is needed both to reduce the morbidity caused by this parasite and as a key component in efforts to eradicate malaria worldwide. Vivax malaria protein 1 (VMP001), a novel chimeric protein that incorporates the amino- and carboxy- terminal regions of the circumsporozoite protein (CSP) and a truncated repeat region that contains repeat sequences from both the VK210 (type 1) and the VK247 (type 2) parasites, was developed as a vaccine candidate for global use. Methods We conducted a first-in-human Phase 1 dose escalation vaccine study with controlled human malaria infection (CHMI) of VMP001 formulated in the GSK Adjuvant System AS01B. A total of 30 volunteers divided into 3 groups (10 per group) were given 3 intramuscular injections of 15μg, 30μg, or 60μg respectively of VMP001, all formulated in 500μL of AS01B at each immunization. All vaccinated volunteers participated in a P. vivax CHMI 14 days following the third immunization. Six non-vaccinated subjects served as infectivity controls. Results The vaccine was shown to be well tolerated and immunogenic. All volunteers generated robust humoral and cellular immune responses to the vaccine antigen. Vaccination did not induce sterile protection; however, a small but significant delay in time to parasitemia was seen in 59% of vaccinated subjects compared to the control group. An association was identified between levels of anti-type 1 repeat antibodies and prepatent period. Significance This trial was the first to assess the efficacy of a P. vivax CSP vaccine candidate by CHMI. The association of type 1 repeat-specific antibody responses with delay in the prepatency period suggests that augmenting the immune responses to this domain may improve strain-specific vaccine efficacy. The availability of a P. vivax CHMI model will accelerate the process of P. vivax vaccine development, allowing better selection of candidate vaccines for advancement to field trials.

Transient blindness due to posterior reversible encephalopathy syndrome following ephedra overdose.

Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy syndrome (RPLS), is most often associated with hypertensive emergencies and is characterized by seizures, mental status changes and visual disturbances. We report a case of a previously healthy young man who developed multiorgan failure and transient cortical blindness following ingestion of a performance-enhancing ephedra-based supplement. Neuroimaging findings confirmed the clinical suspicion of PRES. Radiographic abnormalities and neurologic dysfunction subsequently resolved with correction of his systolic blood pressure. This case emphasizes the need for prompt treatment and consideration of toxic ingestions in patients presenting with hypertension-related end-organ dysfunction.

Whooping Cough in 2014 and Beyond: An Update and Review

Pertussis, or whooping cough, has had a dramatic resurgence in the past several years and is the most common vaccine-preventable disease in the world. The year 2012 marked the most cases in the United States in > 50 years. Large outbreaks have occurred in multiple states, and infant deaths have drawn the attention of not only health-care providers but also the media. Although the disease is theoretically preventable by vaccination, it remains a challenge to control. New vaccination strategies have been implemented across different age groups and populations of patients, but vaccine coverage remains dismally low. Acellular vaccines, although safe, do not afford the same long-lasting immunity as the previously used whole-cell vaccine. Ultimately, improvements in the development of vaccines and in vaccination coverage will be essential to decrease the burden of pertussis on society. This article provides a review of pertussis infection and discusses advances related to the epidemiology, diagnosis, treatment, and prevention of infection, as well as continued areas of uncertainty.

Practice Guidelines for the Diagnosis and Management of Patients With Q Fever by the Armed Forces Infectious Diseases Society

This issue in the series Current Topics in Military Tropical Medicine focuses on Q Fever. Q fever is a zoonotic infection caused by the bacterium Coxiella burnetii. Over 150 confirmed cases have occurred among U.S. military personnel deployed to Iraq since 2007. Acute Q fever is underdiagnosed because of a myriad of possible clinical presentations but typically presents as a flu-like illness. The most common chronic manifestation is endocarditis. Most providers are not familiar with the diagnosis, treatment, or appropriate follow-up of this disease. In order to facilitate the care of patients infected with C. burnetii, the Armed Forces Infectious Diseases Society convened a panel of experts in the field to develop practical guidelines for those caring for infected patients. The recommendations and rationale are reviewed in this article.

Multimodality imaging of multivalvular endocarditis after transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgery for severe aortic stenosis in non-operable and high surgical risk patients. While endocarditis following TAVR is rare, the significant co-morbidities commonly found in this patient population can complicate evaluation and management. A case of TAVR endocarditis initially diagnosed by cardiac computed tomography angiography and confirmed with transesophageal echocardiogram is presented. In addition to demonstrating the appearance of vegetations and perivalvular involvement in endocarditis complicating TAVR, this case illustrates the utility of cardiac CT techniques in imaging suspected TAVR endocarditis.

Tdap Coverage in a Military Beneficiary Population: Room for Improvement

Pertussis has had a resurgence in recent years. Women of child-bearing age and adults with infant contact are important reservoirs of infection because of waning immunity. Recent infant deaths and outbreaks led to new tetanus, diphtheria, and acellular pertussis (Tdap) vaccine recommendations, but vaccination rates remain low. A performance improvement project was started at Walter Reed Army Medical Center to target women of child-bearing age. Women treated in Gynecology had their electronic medical record screened for Tdap during their vital signs assessment. Those eligible for vaccination were directed to the Immunization Clinic. The intervention was considered successful if the patient received the vaccine within 30 days of the visit. Data were compiled on vaccination rates 1 month before and 1 and 3 months after the start of the performance improvement project. Only 13.9% of all patients had a documented Tdap at any time. During the first month following the intervention, vaccination rates within 30 days of the appointment increased from 0.38% to 6.5% (p < 0.005). The effect waned at 3 months following intervention, with only 1.1% of patients vaccinated within 30 days of the appointment. Overall vaccination rates remain low, and future studies should focus on barriers to vaccination to prevent morbidity and mortality.

Role of the Battalion Surgeon in the Iraq and Afghanistan War

The battalion surgeon is an invaluable asset to a deploying unit. The primary role of a battalion surgeon is to provide basic primary care medicine and combat resuscitation. Other expectations include health care screening, vaccinations, supervision of medics, and being a medical advisor to the units commander. As many physicians who fill this role previously worked at medical treatment facilities or medical centers without prior deployment experience, the objective of this article is to highlight some of the challenges a battalion surgeon may encounter before, during, and following deployment.

Gluteal Abscess and Bacteremia Following Promethazine Injection in a Marine

Intramuscular injection is routinely used and rarely leads to adverse events such as abscess or tissue necrosis. Intramuscular promethazine has been documented to cause these problems. We discuss the case of a previously healthy 19-year-old U.S. Marine, who was diagnosed with methicillin sensitive Staphylococcus aureus bacteremia and abscess formation after receiving intramuscular promethazine for vomiting. After confirmation of abscess formation via magnetic resonance imaging, he underwent percutaneous drainage. He improved and was treated with 6 weeks of cefazolin. This case demonstrates an unusual and severe adverse reaction associated with intramuscular promethazine administration. Additionally, this case highlights the importance of proper antiseptic technique before promethazine administration and calls into question the utility and safety of intramuscular promethazine when oral dissolving antiemetic medications are available.

A Major Cause of Pertussis Resurgence: Gaps in Vaccination Coverage

TO THE EDITOR—We read with great interest Plotkin’s excellent article, “The Pertussis Problem,” and we agree wholeheartedly that there is an obvious need for improvements in the acellular pertussis vaccine if we are to ultimately prevent what was once believed to be a completely preventable disease [1]. However, we believe his article misses on the second half of the story, which is the dismally low use of available vaccines. A significant vaccination gap exists, and new vaccinations alone will not solve the challenges of pertussis unless adequate vaccination coverage is ensured. Vaccine coverage in both developed and developing countries remains remarkably low, and there have been multiple updates in the past several years that may elude some providers [2]. Ensuring adequate vaccination coverage remains a major challenge. Several studies have demonstrated substantial gaps in pertussis vaccination coverage (eg, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap] coverage ranging from 5.9% to 45.5%) and in adherence with recommendations, including by patients with free access to medical care and those with adequate insurance coverage [3–5]. Despite a record number of pertussis cases in 2012, data suggest that only 14% of all adults and 26% of those living with infants had received Tdap [6].The problem is amplified worldwide where an estimated 22.6 million children did not complete the appropriate pertussis vaccination series (3 doses in the first year of life) [7].Unfortunately, this leaves the most vulnerable patients at risk. Additionally, it is very disappointing that healthcare workers have demonstrated low rates of vaccination as well [8]. In order to improve vaccination, healthcare organizations need to think outside the box and consider a multipronged approach to vaccination (Table 1) [9]. Plotkin correctly recognizes that such strategies as depicted would be a costly public health strategy. However, a growing body of literature suggests that