HIV and ID Observations

Back in fellowship, we used to discuss the various reasons why we’d be called back into the hospital at night when we were on call.

Mind you, this was a fairly rare event, since unlike gastroenterology fellows doing emergency endoscopy for bleeding and cardiology fellows coming in to do the urgent cath, what were we supposed to do — the emergency 6-page consult note? Plus, given the inherently-OCD nature of our field, often we were in the hospital pretty late to begin with.

(You don’t need to get called back to the hospital when you’re already there.)

But when it did happen, it often seemed to be one of the 3 M’s — meningitis, malaria, and mad surgeons.

• Meningitis — because these cases were so darn scary, and bacterial meningitis is the very definition of an ID emergency. One sometimes wondered what additional added value we were providing in the middle of the night above antibiotic recommendations (which were given over the phone way before we got back to the hospital) — but I certainly understood, given the gravity of the cases, that those consulting us needed all the support they could get.
• Malaria — because who else would interpret a blood smear in a febrile returning traveler? Of course working in New England, and not Malawi, it wasn’t as if we were seeing dozens of cases a month and could really consider ourselves experts. But compared to your typical Boston clinician, I guess we had something to offer.
• Mad Surgeons — because they were often “mad” in both senses of the word, meaning that a bad outcome on one of their patients had left them both angry and crazy. And you can’t reason with an angry and crazy person over the telephone, especially when they are the size of most orthopedic surgeons. Remember that most ID docs (myself included) consider ear irrigation to be about the limits of our “invasive” procedures, so we are in awe of what actual surgeons do. Plus they carry sharp objects around with them.

I was thinking of these meningitis cases because here in Boston, a 12-year-old girl recently died of suspected bacterial meningitis. There has been no micribiologic confirmation, but there’s enough clinical evidence for meningococcal disease that the Department of Public Health recommended that close contacts receive antibiotic prophylaxis.

This is a horrible, tragic case — arguably worse than bacterial meningitis in adults, for obvious reasons, not the least of which is that she was apparently healthy the day before. Like all meningitis cases, it has received a lot of media attention, and a fair amount of panic.

Last week I was interviewed on WBUR (our local public radio station) about bacterial meningitis, and during the course of the interview — a part not aired or published — the interviewer made a great point, namely:

The case is all the more disturbing because fatal infectious diseases of children have pretty much disappeared.

She’s right, of course:  Childhood immunizations have been nothing short of miraculous (see here for a recent example), and for that, we can be incredibly grateful — even as we are saddened by the loss of this poor girl.