Patrick W. Hickey

Trichosporon mycotoxinivorans, a Novel Respiratory Pathogen in Patients with Cystic Fibrosis

ABSTRACT This report describes the molecular epidemiology, in vitro susceptibility, colonial and microscopic morphologies, and biochemical features of Trichosporon mycotoxinivorans, a newly recognized pathogen that appears to have a propensity for patients with cystic fibrosis. The index patient died with histologically documented Trichosporon pneumonia complicating cystic fibrosis. This is also the first report of disease caused by a Trichosporon species in a nontransplant patient with cystic fibrosis. As T. mycotoxinivorans has not previously been recognized as a respiratory pathogen, the significance of its recovery from sputum samples was not initially appreciated. Genetic analysis of archived clinical samples found three additional cases of T. mycotoxinivorans infection which had previously been identified as other members of the genus. An additional isolate of T. mycotoxinivorans was identified from a clinical sample on initial testing. Three of these four cases were also patients with cystic fibrosis. All isolates had MICs at 48 h of amphotericin B of ≥1 μg/ml and of echinocandins of ≥16 μg/ml, but they displayed various susceptibilities to the triazoles. In summary, Trichosporon mycotoxinivorans is a newly recognized human pathogen that is associated with cystic fibrosis.

Rotavirus-Induced Seizures in Childhood

Rotavirus infection is a frequent cause of gastroenteritis in children and accounts for significant morbidity and mortality, especially in the developing world. Less well recognized is the association of rotavirus-induced central nervous system dysfunction, which has been associated with seizure, encephalopathy, and death. Symptoms may vary widely, however, and children can experience short afebrile convulsions as the only manifestation of rotavirus encephalopathy. We report 4 further cases of rotavirus-induced seizures with mild neurologic manifestations. The condition is reviewed and practical management strategies are suggested.

A local, regional, and national assessment of pediatric malaria in the United States.

BACKGROUND Imported malaria remains a public health concern in the United States, but the health impact on children and the financial costs to society have not been well defined. METHODS Inpatient and outpatient malaria cases diagnosed at Childrens National Medical Center (CNMC) in Washington, DC over an 8-year period are retrospectively reviewed. Cases are mapped against Census Bureau population data. These observations are compared with the national burden of pediatric malaria, including both disease severity and cost, by reviewing inpatient malaria cases in the Pediatric Health Information System (PHIS), January 2003 to June 2008. RESULTS At CNMC, malaria most commonly affects children who traveled to West Africa to visit friends and relatives. Poor adherence to prophylaxis and self-treatment with antimalarial medications were commonly identified. Mapping demonstrates case clustering in communities with large sub-Saharan African populations. The cumulative incidence (CI) of malaria at CNMC of 9.0 per 10,000 admissions is 7.6 times the national average. The CI of malaria at PHIS hospitals is 1.2 per 10,000 admissions with an average cost of

Adult Malaria Chemoprophylaxis Prescribing Patterns in the Military Health System from 2007-2011

17,519. CONCLUSIONS Malaria is a preventable disease for which the risk to life and costs of treatment are significant. Patterns of risk can be used by health planners to target prevention strategies at the community level. In regions with a high density of immigrants, particularly from sub-Saharan Africa, physicians must be aware of the risk, understand recommended prophylaxis and treatment regimens, and advocate for their appropriate use in the community.

Preparing Families With Children for International Travel

The Military Health System (MHS), with 9.7 million beneficiaries, represents an enormous pool of potential travelers requiring malaria prevention measures. A systematic search of the MHS electronic pharmacy record was performed for prescriptions of atovaquone-proguanil (AP), chloroquine (CQ), doxycycline (DC), mefloquine (MQ), primaquine (PQ) to adult patients from 2007 through 2011. Over 1,000,000 were identified, including 161,341 primary prophylaxis prescriptions originating from civilian facilities. Military facility prescription volume rose from 50,128 (PQ < 1%, AP 4%, CQ 6%, DC 53%, MQ 36%) in 2007 to 166,649 (PQ < 1%, AP 3%, CQ < 1%, DC 94%, MQ 2%) in 2011. Mefloquine use diminished in all clinics over time. The majority of military facility prescriptions originated from primary care clinics (83%); primary care clinics predominantly and increasingly prescribed DC, whereas specialty travel clinics predominantly and increasingly prescribed AP. Prescribing patterns in the MHS varied by time, practice setting, beneficiary status, and provider specialty. These changes, including among non-active duty military patients, are temporally associated with policy changes intended for the active duty force.

Select Clinical Recommendations for Military Medical Practitioners Conducting Humanitarian and Civic Assistance Activities

ra “T veling is a brutality. It forces you to trust strangers and to lose sight of all that familiar comfort of home and friends. You are constantly off balance. Nothing is yours except the essential things—air, sleep, dreams, the sea, the sky...” (Cesare Pevase). This romanticized statement from the early 1900s still captures the essence of many peoples’ approach to international travel, that is, until they or their children develop traveler’s diarrhea and wish that at some point they had made better preparations for their trip. Pre-travel medical care can play a crucial and often overlooked role in preventing illness and injury. With the globalization of society, this role has become increasingly important. Although we do not have vaccines or therapies for every risk that can be encountered, we have compiled a massive amount of evidence-based research that can help the traveler to minimize their risks. As stated in the introductory article, there are over 1 billion airplane trips involving international travel annually to the U.S. Although generalizations can be made, advice is more pertinent when tailored to the traveler. The majority of patients presenting for a travel appointment are preparing for vacation. Identifying high-risk groups such as patients with chronic illnesses, visits to friends and relatives (VFR), relief workers, and adventure seekers is important because they have unique risk factors associated with their travel plans.

A “Syndromic” Approach for Diagnosing and Managing Travel-Related Infectious Diseases in Children

Training and planning for stability, security, transition, and reconstruction, to include humanitarian and civic assistance activities, has taken on new importance for todays military forces. Deployed medical forces providing medical care to local populations are presented with the challenge of limited resources, complex public health needs, and complex cultural and linguistic barriers to care. In this article, we review some of the clinical situations commonly encountered during these operations and provide an evidence-based rationale for proposed courses of action. This report is timely given expanding operations in Afghanistan and the stand-up of the U.S. African Command (AFRICOM).

Knowledge, Attitudes, and Practice Regarding HIV Testing Among Female Military Family Members of Childbearing Age in Honduras

ri P mary care physicians practicing in the United States are often less familiar with many of the common as well as more exotic diseases that children can acquire when traveling abroad. This review will focus mainly on infectious diseases specifically associated with travel-related exposures. While having access to reference material to help guide diagnostic resources and therapy is useful, it is most useful to have a consistent well-organized approach to help identify specific risk factors associated with both the most common and the most severe illnesses potentially occurring in a child who has recently traveled internationally. According to the National Travel and Tourism Office the number of Americans traveling abroad increased to more than 61.9 million in 2013. The main areas of travel included Europe at 34.6%, the Caribbean at 24.8%, Asia at 18.8%, South America at 7.3%, Central America at 6.9%, Africa at 3.1%, the Middle East at 5.9%, and Oceania at 1.9%. Nearly 27% of travel was to visit friends and families. This category accounts for a significant portion of the travel in the pediatric age groups. Although travel to Asia and Africa accounted for only 21.9% of US traveler the majority of travelrelated illnesses were acquired from Asia (32.6%) and sub-Saharan Africa (26.7%) according to a recent geosentinel-illness surveillance of returned international travelers presenting to the GeoSentinel Network. As

DoD-Supported Overseas Training Rotations in Tropical Medicine and Global Health, 2000–2015

This is a survey of knowledge, attitudes, and practice regarding HIV testing among 187 female family members affiliated with the Honduran Armed Forces and civilian controls. Prior HIV testing was reported by 45%, and 94% expressed willingness to be tested in the future. Pregnancy was the reason for 73% of prior tests, but only 49% of the 149 women with prior pregnancies reported prior tests. Although most women tested for HIV did so during pregnancy, there appears to be a gap in understanding that the rationale is to help prevent maternal-child transmission at birth or through breast-feeding. Military-affiliated women were more likely to describe themselves as being knowledgeable of HIV/AIDS, 95% versus 82% (p < 0.01), but there were few differences in knowledge between groups. Positive perceptions of confidentiality, test accuracy, and self-awareness of HIV were associated with prior testing. Although these differences may point to HIV/AIDS educational areas that should be emphasized for a particular population, the overall content that should be provided to military or civilian families is the same.

Predicting Risk of Imported Disease with Demographics: Geospatial Analysis of Imported Malaria in Minnesota, 2010–2014

In 1999, the Department of Defense developed a tropical medicine training program (TMTP) to train military physicians, medical students, and scientists in performing surveillance activities in an overseas environment. This review describes the competencies, educational approach, program participants, institutional collaborations, and process outcomes of the TMTP from 2000 to 2015. TMTP-sponsored rotations addressed a wide variety of interdisciplinary competencies, many of which have military-unique applications. Rotations consisted of both didactic and experiential (overseas) components. The program provided 282 rotations for 260 trainees between 2006 and 2015, the years for which data were available. The Department of Defense accrues benefits from this training program in three main ways: (1) building a cadre of health care professionals who will go on to work at the overseas research laboratories, (2) supporting force health protection and readiness through experiential tropical medicine training, and (3) engaging in global health collaborations and partnerships. The primary challenges include funding, health and security, trainee and site heterogeneity, supervision, trainee engagement, and burden on the host institution. The program will continue to focus on improvement in these areas, with special attention to trainee preparation, communication with both trainees and host sites, and increasing reciprocity with host sites and their faculty.