Keyur Vyas

Geographic distribution of endemic fungal infections among older persons, United States.

To the Editor: We read with interest the article by Baddley et al. (1) and appreciate their efforts to characterize incidence rates of mycoses. We agree that histoplasmosis, blastomycosis, and coccidioidomycosis are differential diagnoses for patients with consistent symptoms but who reside outside mycosis-endemic areas. However, we believe that the methods of Baddley et al. probably do not determine the true incidence of these mycoses in sparsely populated states such as Arkansas. Their estimates contrast markedly with surveillance data from the Arkansas Department of Health (Table) and with our clinical experience as infectious disease physicians. We characterize Arkansas as a state in which histoplasmosis and blastomycosis incidence is high and coccidioidomycosis incidence is low; however, Baddley et al. indicate that in Arkansas, incidence of blastomycosis is relatively low and incidence of coccidioidomycosis is high. Table Reported cases of fungal diseases in Arkansas, by year* To investigate whether this finding might be associated with their small 5% sample of Medicare beneficiaries, we used data from the Arkansas census to determine that in 2008 the population of adults >65 years of age was ≈407,014, and during 1999–2008, there were ≈3,840,896 person-years for persons in this age group. A 5% sample would account for ≈192,045 person-years. Using their rate ranges (7.84–12.3 cases/100,000 person-years for histoplasmosis, 3.97–6.71 for coccidioidomycosis, and 0.39–0.86 for blastomycosis), we calculated the approximate numbers of cases in their sample: 15–23 histoplasmosis cases, 7–12 coccidioidomycosis cases, and only 1 blastomycosis case. Compared with rates from surveillance averaged over the 10 years, the midpoints of the Baddley et al. estimates are ≈6-fold higher for histoplasmosis, ≈60-fold higher for coccidioidomycosis, and ≈0.4-fold lower for blastomycosis. Only their estimate for blastomycosis incidence falls within the 10-year 95% CIs from surveillance data. We believe that the small cell sizes require that the rate estimates of Baddley et al. be interpreted with care, especially with respect to less populous states.

Influenza A Outbreak in an Ambulatory Stem Cell Transplant Center

Background  In the era of cost-consciousness regarding healthcare , provision of medical services in an outpatient setting has become increasingly attractive. We report an influenza outbreak in an ambulatory stem cell transplant center in 2013 that highlights unique identification and infection control challenges in this setting. Methods  Nasopharyngeal swabs were performed on patients with suspected influenza-like illnesses (ILI), defined by subjective fever or measured temperature of ≥37.7°C (≥100°F) with cough or sore throat during July 25, 2013 through August 7, 2013. In addition, testing was triggered by an elevated C-reactive protein (CRP). Specimens were analyzed by using eSensor Respiratory Viral Panel. Clinical and epidemiologic information was collected in real time, and frequencies were calculated on demographics, baseline clinical parameters, treatment methods, comorbidities, and symptoms of affected persons. Results  Thirty-one patients had influenza A (H3N2) infection during July 25, 2013 through August 7, 2013. Only 7 patients (23%) met the Centers for Disease Control and Prevention and Council of State and Territorial Epidemiologists ILI case definition. Twenty-five patients (81%) had received ≥1 transplant, with 13 (42%) having occurred within 1 year before the outbreak. Twenty-five patients (81%) had received B-cell active chemotherapy <60 days before influenza diagnosis, 6 (19%) were neutropenic, and 25 (81%) lymphopenic. Among clinical and laboratory markers analyzed, abnormal CRP was the most sensitive screening tool for influenza. Twelve (39%) patients were hospitalized (median stay, 10 days; range, 2–20). No deaths occurred. Conclusions  Immunocompromised hosts with influenza have atypical presentations. Existing surveillance case definitions might be insufficient to reliably identify influenza outbreaks in such patients.

Autoimmune clustering: sweet syndrome, Hashimoto thyroiditis, and psoriasis.

Acute febrile neutrophilic dermatosis (AFND; Sweet syndrome) is characterized by a constellation of symptoms and findings: fever, neutrophilia, and tender erythematous skin lesions that typically show an upper dermal infiltrate of mature neutrophils. Whereas some cases are idiopathic, others have been associated with a variety of disorders. In this report, we describe the occurrence of AFND with chronic lymphocytic thyroiditis (Hashimoto thyroiditis) and preexisting psoriasis. This is the first case report of the association of chronic lymphocytic thyroiditis with AFND from the United States and only the third reported in the worlds literature. Because the coexistence of these disorders is rare, an underlying common pathogenic mechanism is a possibility. We postulate this to be CD4(+) T-cell dysfunction.

Treatment of endemic mycoses

The endemic mycoses are a diverse group of diseases caused by thermally dimorphic fungi. While they share many characteristics, each has unique aspects with regards to their clinical course, diagnosis and management. Diagnosis may be difficult and delayed owing to the varied manifestations and wide differential diagnosis. Historically, treatment has been with amphotericin B, which has been limited by its significant toxicity. The advent of the azole class of medications has allowed for safer alternatives to amphotericin B. The azoles have become the mainstay of treatment for many, if not most, forms of these diseases. Guidelines have been released for the management of each of the North American endemic mycoses; however, many questions remain as to the best strategies for the diagnosis and management of various manifestations of these diseases.

Adult immunization guidelines: challenges and opportunities.

Annually, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention issues a revised Adult Immunization Schedule that is approved by the major specialty soc...

Mobilizing a Statewide Network to Provide Ebola Education and Support.

BACKGROUND Healthcare providers require the latest information and procedures when a public health emergency arises. During the fall of 2014, when the Ebola virus was first identified in a patient in the United States, education about Ebola virus disease (EVD) and procedures for its identification and control needed widespread and immediate dissemination to healthcare providers. In addition, there was a need to allay fears and reassure the public and providers that a process was in place to manage Ebola should it arrive in Arkansas. The state health department engaged multiple interest groups and provided a variety of educational and management activities. The Arkansas Department of Health and the only academic medical center in the state began offering time-consuming, one-on-one education over the phone, which reached too few providers. A solution was needed to educate many providers across the state in the protocols for identification, isolation, and management of patients with EVD. In response, the Arkansas Department of Health and the University of Arkansas for Medical Sciences leveraged the interactive video and Webinar capabilities of the states telemedicine network to educate both providers and the public of this public health emergency. MATERIALS AND METHODS Six interactive video events were staged over 5 days in October 2014. RESULTS In six events, 82 individual healthcare facilities (67 of which were hospitals) and 378 providers attended via the Webinar option, whereas 323 healthcare professionals received continuing education credits. CONCLUSIONS A statewide videoconferencing infrastructure can be successfully mobilized to provide timely public health education and communication to healthcare providers and the public in multiple disciplines and practice settings.