Sarah L McGuinness

Nocardiosis in the Tropical Northern Territory of Australia, 1997–2014

Background. Nocardia is an opportunistic pathogen that can cause life-threatening disease. We aimed to characterize the epidemiological, microbiological, and clinical features of nocardiosis in the tropical north of Australia. Methods. We conducted a retrospective cohort study of nocardiosis diagnosed between 1997 and 2014. Population-based incidences were calculated using district population data. Results. Clinically significant nocardiosis was identified in 61 patients. The unadjusted population-based annual incidence of nocardiosis was 2.02 (95% confidence interval [CI], 1.55–2.60) per 100000 people and was 1.7 (95% CI, .96–2.90) fold higher in Indigenous compared with non-Indigenous persons (P = .027). Of 61 patients, 47 (77%) had chronic lung disease, diabetes, and/or hazardous alcohol consumption; 22 (36%) were immunocompromised; and 8 (13%) had no identified comorbidities. Disease presentations included pulmonary (69%; 42 of 61), cutaneous (13%; 8 of 61), and disseminated nocardiosis (15%; 9 of 61). The most commonly identified species were Nocardia asteroides and Nocardia cyriacigeorgica (each 11%). Linezolid was the only antimicrobial to which isolates were universally susceptible; 89% (48 of 54), 60% (32 of 53), and 48% (26 of 54) of isolates were susceptible to trimethoprim-sulfamethoxazole, ceftriaxone, and imipenem, respectively. Eighteen patients (30%) required intensive care unit (ICU) admission, and 1-year mortality was 31%. Conclusions. The incidence of nocardiosis in tropical Australia is amongst the highest reported globally. Nocardiosis occurs in both immunocompromised and immunocompetent hosts, and it is associated with high rates of ICU admission, 1-year mortality, and resistance to commonly recommended antimicrobials. Diagnosis should be considered in patients with consistent clinical features, particularly if they are Indigenous or have chronic lung disease.

Management of dengue in Australian travellers: a retrospective multicentre analysis

Objectives: To describe the epidemiology, clinical and laboratory features and outcomes of dengue in returned Australian travellers, applying the revised WHO dengue classification (2009) to this population.

Murray Valley Encephalitis Virus: An Ongoing Cause of Encephalitis in Australia’s North

Murray Valley encephalitis virus (MVEV) is a mosquito-borne virus endemic to Australia and New Guinea. Encephalitis due to MVEV is potentially devastating, and no therapeutic interventions of proven value exist. Prevention relies largely on personal protective measures against mosquito bites. We present a case of MVEV encephalitis with a favourable outcome following intensive care management and prolonged rehabilitation, and the epidemiological features of a further 21 cases notified to the health department of Australia’s Northern Territory. As cases occur in travellers, and epidemics occur sporadically in south-eastern Australia, clinicians across Australia and further abroad should be familiar with the disease and its diagnosis and management.

Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review

Acute respiratory infections (ARIs) disproportionately affect those living in low‐ and middle‐income countries (LMICs). We aimed to determine whether hygiene interventions delivered in childcare, school or domestic settings in LMICs effectively prevent or reduce ARIs.

Spectrum of illness among returned Australian travellers from Bali, Indonesia: a 5-year retrospective observational study: Illness in Aust. travellers from Bali

Bali, Indonesia, presents significant infectious and non‐infectious health risks for Australian travellers. Understanding this spectrum of illnesses has the potential to assist clinicians in evaluating unwell returning travellers and guide provision of pre‐travel advice.

Protocol for a cluster randomised stepped wedge trial assessing the impact of a community-level hygiene intervention and a water intervention using riverbank filtration technology on diarrhoeal prevalence in India

Introduction Diarrhoea is a leading cause of death globally, mostly occurring as a result of insufficient or unsafe water supplies, inadequate sanitation and poor hygiene. Our study aims to investigate the impact of a community-level hygiene education program and a water quality intervention using riverbank filtration (RBF) technology on diarrhoeal prevalence. Methods and analysis We have designed a stepped wedge cluster randomised trial to estimate the health impacts of our intervention in 4 rural villages in Karnataka, India. At baseline, surveys will be conducted in all villages, and householders will receive hygiene education. New pipelines, water storage tanks and taps will then be installed at accessible locations in each village and untreated piped river water will be supplied. A subsequent survey will evaluate the impact of hygiene education combined with improved access to greater water volumes for hygiene and drinking purposes (improved water quantity). Villages will then be randomly ordered and RBF-treated water (improved water quality) will be sequentially introduced into the 4 villages in a stepwise manner, with administration of surveys at each time point. The primary outcome is a 7-day period prevalence of self-reported diarrhoea. Secondary outcomes include self-reported respiratory and skin infections, and reported changes in hygiene practices, household water usage and water supply preference. River, tank and tap water from each village, and stored water from a subset of households, will be sampled to assess microbial and chemical quality. Ethics and dissemination Ethics approval was obtained from the Monash University Human Research Ethics Committee in Australia and The Energy and Resources Institute Institutional Ethics Committee in India. The results of the trial will be presented at conferences, published in peer-reviewed journals and disseminated to relevant stakeholders. This study is funded by an Australian National Health and Medical Research Council (NHMRC) project grant. Trial registration number ACTRN12616001286437; pre-results.

Two forms of immunological recovery and immune reconstitution inflammatory syndrome in one patient.

TO THE EDITOR: A 38-year-old HIV-positive Somalian refugee with a past history of pulmonary tuberculosis (TB) and poor compliance with antiretroviral therapy (ART) presented with fever, lethargy and mediastinal lymphadenopathy. He was diagnosed with fully drug-sensitive lymph node TB. The CD4 lymphocyte count at TB diagnosis was 20/ L (reference interval, 350–2630/ L), and the HIV RNA viral load was 99 000 copies/mL. Standard anti-TB treatment was commenced, and ART was reinstated. Two weeks later, he re-presented with lethargy, cough and night sweats. He reported compliance with both ART and anti-TB therapy. His HIV viral load had dropped to 1460 copies/mL, and his CD4 count had increased to 30/ L. A chest x-ray showed changes indicating a worsening of his condition and suggesting TB immune reconstitution inflammatory syndrome (IRIS). Both anti-TB therapy and ART were continued. Seventeen days after restarting ART, he developed weakness in his left arm and leg. Magnetic resonance imaging (MRI) of the brain showed white matter lesions with oedema in the right frontoparietal region, suggesting possible progressive multifocal leukoencephalopathy (PML) IRIS (Box). JC (John Cunningham) virus was not detected on initial cerebrospinal fluid polymerase chain reaction testing, but the diagnosis of PML was confirmed 3 months later, when the patient presented with a symptom flare and worsening changes apparent on MRI. A brain biopsy showed a perivascular inflammatory infiltrate of lymphocytes, and JC virus was detected in oligodendrocytes by Simian virus 40/BK virus immunostain. Corticosteroids were added, after which his condition slowly improved. He was eventually discharged to supported accommodation. The beneficial immunological effects of ART result from the restoration of pathogen-specific immune responses.1 However, although recovery of immune function has substantial clinical benefits, it is sometimes accompanied by paradoxical adverse effects, including IRIS. The timing of initiation of ART in patients co-infected with TB and HIV poses a dilemma. On the one hand, there is an increased risk of IRIS when anti-TB therapy and ART are commenced concurrently.2,3 On the other hand, recent studies have shown that delaying ART leads to higher rates of mortality and morbidity, particularly with CD4 counts of less than 50/ L.1,4 Despite the potential for complications associated with immune restoration, prompt institution of ART was necessary in our patient, given the risks of severe prolonged immunodeficiency. Although ART unmasked PML, it was ultimately crucial in the patient’s survival from this infection.