Vini Vijayan

Chikungunya Virus Disease: An Emerging Challenge for the Rheumatologist.

AbstractChikungunya is caused by an alphavirus that is transmitted to humans via the Aedes species mosquito. Chikungunya is endemic to tropical Africa and South and Southeast Asia, but over the past decade, the geographic distribution of the virus has been expanding rapidly. The disease is characterized by fever and severe polyarthritis, and although symptoms typically resolve within 7 to 10 days, some patients experience persistent arthritis and arthralgias for months to years.In December 2013, the first local transmission of chikungunya virus in the Americas was identified in the Caribbean Island of Saint Martin. Since then, the number of afflicted individuals has spread throughout the Caribbean and Central America, as well as into South America. The United States reported 2788 chikungunya virus disease cases among travelers returning from affected areas in 2014. In addition, 11 locally acquired cases were reported in Florida. Further spread and establishment of the disease in the Americas are likely considering the high levels of viremia in infected individuals, widespread distribution of effective vectors, lack of immunity among people living in the Americas, and the popularity of international travel.Considering the prominent rheumatic manifestations of chikungunya, rheumatologists are likely to encounter patients with the disease in their practice. We recommend that rheumatologists consider chikungunya in their differential diagnosis when evaluating patients presenting with fever and joint pain following travel to a chikungunya endemic area. Early diagnosis would ensure timely management and reduction of polypharmacy and its associated complications. In this article, we briefly describe the epidemiology of chikungunya, the clinical features, laboratory testing, prevention, and treatment of disease.

Evaluation of diagnostic and therapeutic approaches for suspected influenza A(H1N1)pdm09 infection, 2009-2010.

Variations between practice and national recommendations could inform clinical education in future influenza seasons.

Acute-onset opioid-induced hyperalgesia in a child with juvenile idiopathic arthritis.

We describe a child with polyarticular juvenile idiopathic arthritis (JIA) presenting with severe diffuse pain refractory to nonsteroidal anti-inflammatory agents and high-dose opioids. Her JIA involved her knees and ankles and was mildly active on etanercept and nonsteroidal anti-inflammatory agents. At presentation, she complained of hip pain progressing to severe diffuse pain and allodynia involving her extremities. No abnormalities were seen in her laboratory parameters and imaging of her lower extremities. After appreciating no substantial benefit by increasing her opioids, her opioids were tapered and discontinued, and this was followed by significant alleviation in her pain, and a diagnosis of opioid-induced hyperalgesia (OIH) was made. Despite reports in adults, the phenomenon of OIH has been reported infrequently in children. To our knowledge, OIH has not been described in children with rheumatologic conditions. We recommend investigating the possibility of OIH when treating a child with JIA and severe refractory pain.

Hemophagocytic Lymphohistiocytosis Secondary to Ehrlichiosis in a Child

Hemophagocytic lymphohistiocytosis (HLH) is a distinct life threatening clinical entity characterized by fever, pancytopenia, splenomegaly, and hemophagocytosis in bone marrow, liver, or lymph nodes. It is a syndrome of excessive inflammation and tissue destruction due to abnormal immune activation and prompt initiation of treatment is essential for the survival. HLH may be (a) primary due to a familial inheritance of autosomal recessive genes encoding for perforin, Munc 13-4, Munc 18-2, and syntaxin 11 proteins or (b) secondary to infections, malignancy, autoimmune conditions. The association between HLH and infections are important because HLH may mimic infectious illnesses and HLH may obscure the diagnosis of a precipitating, treatable infectious illness. We present a child with secondary HLH but whose illness was triggered by infection with Ehrlichia chaffeensis. The child was treated with doxycycline and for HLH and fully recovered. Genetic testing revealed that child had a compound heterozygous mutation of the PRF-1 and UNC13D, which encode for perforin and Munc 13-4 genes. This case emphasizes the importance of a considering ehrlichiosis as a potential trigger of HLH in children.

Mycobacterium simiae Infection of the Parotid Gland in an Immunocompetent Child

Mycobacterium simiae is a multidrug-resistant, slowgrowing, nontuberculous mycobacterium (NTM) that has been rarely reported as a cause of pulmonary infections and disseminated disease in immunocompromised hosts, especially in patients with advanced AIDS [1]. Nontuberculous mycobacterium infections caused by M simiae have increasingly been reported as a cause for cervical lymphadenitis in immunocompetent children [2, 3]; however, infection of the parotid gland secondary to M

Pelvic Abscess Secondary to Mycoplasma Hominis after Vaginal Laceration

BACKGROUND Mycoplasma hominis frequently colonizes the urogenital and respiratory tracts of healthy individuals. It has also been associated with genitourinary tract and extragenital syndromes. CASE We present a 14-year-old girl who developed a pelvic abscess secondary to M. hominis after a vaginal laceration during sexual intercourse. Despite drainage and broad-spectrum antimicrobial therapy, the patient remained symptomatic until M. hominis was identified and specific therapy instituted. SUMMARY AND CONCLUSION Health care providers need to be aware of the potential for M. hominis as a causal agent in patients who present with pelvic abscesses after vaginal trauma. This case highlights the challenges that exist in the diagnosis and treatment of M. hominis, because bacterial cultures are often negative and empiric antimicrobial agents do not provide adequate antimicrobial coverage.

Obstetrical Healthcare Personnel's Attitudes and Perceptions on Maternal Vaccination with Tetanus-Diphtheria-Acellular Pertussis and Influenza

Objectives. To assess perceptions of obstetrical healthcare personnel (HCP) regarding routine delivery of Tdap and influenza vaccines to pregnant and postpartum women and identify perceived barriers to vaccination. Methods. Anonymous Web-based survey of obstetricians and nurses caring for pregnant and/or postpartum women. Results. We contacted 342 HCP and received 163 (48%) completed surveys (33/142 (23%) obstetricians, 130/200 (65%) nurses). Among obstetricians, 72% and 63% thought it was “beneficial” to immunize postpartum women against influenza and pertussis, respectively. Only 8% reported vaccinating >75% of pregnant women in their care against influenza. Similarly, <1% of obstetricians reported vaccinating against pertussis. Of all HCP surveyed, 92% and 58% were familiar with ACIP recommendations for influenza and pertussis, respectively. Reported perceived barriers included patient refusal to be vaccinated, reimbursement difficulties, and discomfort in providing vaccine education. Ninety-four percent of respondents agreed that standing orders would be helpful to ensure postpartum vaccination. Conclusions. HCP were less familiar with ACIP recommendations for Tdap compared to influenza vaccines. Substantial discrepancy existed between perceived benefit of vaccination and reported immunization practices. Most identified barriers could be addressed with provider training; however, other barriers require review and changes in systematic policies related to vaccine reimbursement.

Infantile-Onset Fever and Urticaria

A 5-year-old white girl presented with a history of recurrent fevers and urticaria since 2 months of age. The child had fevers (maximum temperature, 40°C) that lasted 3 to 5 days. Her mother reported that the fevers resolved spontaneously but continued to recur almost every month. The fever symptoms were associated with bilateral conjunctivitis, arthralgias, and irritability. The hivelike, nonpruritic urticaria did not improve with antihistamine medication and there were no known precipitating or aggravating factors. The child did not attend day care. Family history was noncontributory and her parents denied consanguinity. The child was hospitalized on multiple occasions during infancy for the fevers, and she had comprehensive sepsis evaluations, including lumbar punctures, with negative results. Findings from chest and abdominal imaging and bone marrow aspiration with biopsy were negative for a malignant process. Despite extensive evaluation, a definitive source for the fevers was not identified, and the patient was referred to our institution. On physical examination, the patient was febrile (temperature, 39°C) and appeared fussy. Growth measure findings were normal. Skin examination confirmed nonpruritic, macular and urticarial lesions on the face, back, and lower extremities (Figure). Bilateral conjunctival hyperemia without drainage was noted. There was neither swelling nor redness of the joints. Her right ankle and knee examination showed limited active and passive range of motion secondary to pain symptoms. Findings from the remainder of physical examination were normal.