An ongoing dialogue on HIV/AIDS, infectious diseases,
November 25th, 2011
Childhood Meningitis Terrifying, Fortunately Very Rare
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.
November 20th, 2011
Who Should Care For The Aging HIV Patient? Everything Old is … Oh You Know
Over in Journal Watch AIDS Clinical Care, Carlos Del Rio reviews a couple of remarkable studies on HIV and aging. From one of them:
Compared with the controls, the HIV-infected patients had a higher prevalence of renal failure, bone fracture, and diabetes in every age range evaluated, as well as a higher prevalence of cardiovascular disease and hypertension at age 60… Of note, the HIV-infected patients appeared to develop polypathology at a younger age than controls, such that a 40-year-old HIV-infected patient had a risk similar to that of a 55-year-old HIV-uninfected person.
Wow, I bet that last fact gets quoted a lot.
Carlos concludes by suggesting “Now may be the time for many of us to take a refresher course in primary care for the HIV provider.”
A reasonable proposal — but one which prompted a reader to comment:
I fear this may reflect the common misperception that primary care is easier than disease specific care, especially with a disease like HIV… Perhaps we should focus on educating primary care doctors so that they feel more comfortable with HIV patients rather than HIV clinicians so that they feel more comfortable with primary care.
I completely agree — being an excellent primary care doctor has got to be one of the hardest jobs in all of medicine. I could never do it, which is why I chose to memorize all the cephalosporins, non-pathogenic intestinal protozoa, and the thymidine-associated mutations instead.
But what I find particularly interesting about this exchange is that it raises — again — the question about who should be caring for people with HIV. This has been an area of debate going way back to when the disease was first described, and the funny thing is that the perspectives keep flipping back and forth.
Back in the 1980s, it was argued that all PCPs should learn to manage common HIV-related complications because “the small number of subspecialists and other interested physicians now caring for most patients with AIDS will be overwhelmed” by the rapidly growing numbers of patients. Plus, some ID doctors (especially those spending the bulk of their time doing hospital-based consults) wanted little to do with a progressive, incurable infection that placed a premium on longitudinal outpatient and palliative care.
San Francisco was always a vanguard in the “HIV is a primary care disease” approach. In this paper from the 1990s, the authors state that the general medicine residents at UCSF rotated through the continuity HIV clinic, but the ID fellows didn’t. Amazing.
Then along came effective prevention and treatment strategies for opportunistic infections, followed by multiple advances in antiretroviral therapy, lipodystrophy, lactic acidosis, viral load monitoring, the mind-boggling complexity of resistance testing, the drug-drug interactions, and so on. With all that, HIV became the quintessential specialty disease. This was the pervasive view back in 2006, the last time we covered the topic in AIDS Clinical Care.
But today? The vast majority of people in care for HIV are virologically suppressed (especially true among those who show up for office visits), and they’re on stable HIV regimens — usually regimens that have been, and likely will remain, stable for years. That’s the good news.
Of course if you decrease deaths, you increase survival, and people get older, with older-people problems. We heard this summer at IAS that more than half the HIV population of San Francisco is now older than 50. One afternoon last week only one of the patients I saw was younger than 50, and she was 48.
(50. That’s positively ancient. Ha ha.)
All were virologically suppressed, rock-solid stable from the HIV perspective. I didn’t change a single HIV regimen, or do a single ID-related task that isn’t comfortably within the repertoire of a generalist.
So what did I do? Talked about PSA (pros/cons), bone density screening, lipid abnormalities, diabetes, various aches and pains — plus the struggles they are having with their aging parents, or the flip side, the joys of having grandchildren.
And if that sounds to you a lot like general primary care, you’re absolutely right.
So who should be providing the bulk of care for our aging HIV patients? ID/HIV specialists? Primary care providers? Some combination?
November 14th, 2011
Here Are Two Things You Don’t Hear Together Very Often: Walmart and HIV
As the parent of teenagers (and having been one myself many years ago), I’m acutely aware that everyone wants to think that he or she is special in some way.
And while that is literally true (that is, no two people are exactly alike), as anyone will tell you who looks up a Sunday Times crossword puzzle clue on Google, there are a whole lot of people out there very much like us — no matter how special we think we are.
But here are four things about me that, cumulatively, probably put me into a very small percentage of Americans my age in 2011:
- I have seen every episode of “Seinfeld” (several multiple times), but never watched a single “Friends”.
- I have never eaten at an Olive Garden restaurant. (Would love to try — how is it?)
- Despite half of my family being huge fans, I have never read any of the Harry Potter series — not a chapter.
- I have never shopped at a Walmart — in fact, I’ve never even been inside one.
This last one (a Walmart-less life) is not a conscious move, not a politically/ethically driven avoidance. It just so happens that the places I spend most of my time are not conducive to shopping at Walmart, even though there are seven of them within 15 miles of where I live.
Which is why this news, from NPR, came as something of a surprise:
Wal-Mart wants to be your doctor… The nation’s largest retailer is planning to offer medical services ranging from the management of diabetes to HIV infections, NPR and Kaiser Health News have learned.
If you don’t believe me, it’s right here on page 7, “HIV management and monitoring”, along with more than a dozen other conditions that Walmart will manage as part of the proposal to become “the largest provider of primary healthcare services in the nation.”
Walmart later backed off this claim, but still — you have to imagine they’re planning something for 2014 when the federal health law kicks in. Could this be the “disruptive” idea that helps relieve an already bursting-at-the-seams primary care system?
And as the treatment for HIV gets better and better, and our patients live longer and longer, we should start expecting to see HIV along side of many other chronic medical diseases managed by all sorts of caregivers in all sorts of ways.
Will MinuteClinic — the rhyme that’s not a rhyme — be next?
November 9th, 2011
HCV Treatment Studies at AASLD: Wow … and I Mean WOW!
I didn’t attend “The Liver Meeting” (the nickname for the annual meeting of the American Association for the Study of Liver Diseases, AASLD), but the studies presented there this week on HCV treatment were absolutely mind-boggling.
“Breathtaking!” said one of my HCV-oriented colleagues. “Hopeful is an understatement,” said another.
An example:
Dual Oral Combination Therapy with the NS5A Inhibitor Daclatasvir (DCV; BMS-790052) and the NS3 Protease Inhibitor Asunaprevir (ASV; BMS-650032) Achieved 90% Sustained Virologic Response (SVR12) in Japanese HCV Genotype 1b-Infected Null Responders
Mind you, this was only 10 patients, but 9/10 is no fluke — especially when all the responders had HCV RNA below detection by week 8, and all 9 who completed 24 weeks were cured!
Want a larger study?
PROTON: PSI-7977 & Peg/RBV in Treatment-naïve Patients with HCV GT1: Sustained Virologic Response
Here, in nearly 100 patients, the addition of 12 weeks of the nucleotide analogue polymerase inhibitor PSI-7977 to Peg/RBV led to a cure rate of over 90%, regardless of baseline IL-28B status (13/13 cured with genotype TT). Works with other HCV genotypes, too.
I chose these two studies in particular because the companies developing these drugs — BMS and Pharmasset — are working together on a prospective study that features all-oral, interferon-less strategies lasting only 12 weeks.
But there’s plenty more. Don’t take my word for it — go over to NATAP, click on the “Hepatitis C” link on the left, and start reading.
And if you have limited time, and want a glimpse of the future of HCV therapy, limit your search to studies that say “interferon-free”.
November 7th, 2011
Can We All Agree That This Is Stupid? Thank You.
If this report isn’t an urban legend, then it’s pretty clear some people need a brain transplant:
The Facebook group is called “Find a Pox Party in Your Area.” According to the group’s page, it is geared toward “parents who want their children to obtain natural immunity for the chicken pox.” …On the page, parents post where they live and ask if anyone with a child who has the chicken pox would be willing to send saliva, infected lollipops or clothing through the mail.
One topic I’ve tended to steer clear from is whole vaccine controversy.
How could I be rational? I’m an Infectious Diseases specialist married to a pediatrician! I believe that the benefits of vaccines — especially for childhood diseases — so overwhelmingly outweigh the risks that I can’t really engage in a polite debate about it.
So each time I’m about to write something about the vaccine issue, I hear Dana Carvey’s voice saying, “Not gonna do it … Wouldn’t be prudent.”
And I write nothing.
But sending infected lollipops in the mail? Some things just deserve open ridicule, and this is one of them.
November 5th, 2011
A Mysteriosis about Listeriosis
For obvious reasons, listeriosis has been much in the news recently. The latest information from CDC on the Colorado cantaloupe outbreak cites 139 cases and 29 deaths.
The recent outbreak aside, however, actual cases of listeriosis are pretty rare. We easily could go months in our hospital without seeing a single case, and we have the largest obstetrical service in New England.
Which brings me to the mystery part: Why is medical student knowledge about listeria so high?
I meet with the medical students to review basics of antibiotics at the beginning of every rotation. Depending on the time of year and the number of prior clinical rotations they’ve done, they have variable amounts of ID knowledge before they get here.
But all of them know about listeria. And they know a lot about it.
- Causative organism? (Listeria monocytogenes — check)
- Dietary risk factors? (deli meats, soft cheeses, now cantaloupes — check)
- Population at risk? (pregnant women, transplant patients, and the elderly — check)
- Clinical manifestations? (meningitis, sepsis, gastroenteritis — check)
- Antibiotic of choice? (ampicillin — check)
They seem to know way more about listeria than they do about far more common infections, such as Strep pneumoniae or Epstein-Barr virus.
It’s the oddest thing. Any proposed explanations for this remarkable expertise would be most welcome.
October 29th, 2011
Will An Antiretroviral Patch Help Adherence? Doubtful …
This little nugget came up recently, found by our Journal Watch Executive Editor:
Preliminary research suggests that a patch could deliver an AIDS drug to patients … The researchers successfully used transdermal patches to administer 96 percent of an AIDS drug to simulated skin over a week. “Still, the important limitation of pills, regardless of how few there are or even how minimal the side effects, is adherence,” Johnston [the investigator] noted. Research has shown that many patients, if not most, don’t take their pills all the time.
Setting aside for a moment the fact that most patients actually do take their medications just fine, thank you — and that this particular transdermal HIV drug delivery system hasn’t even been tested on animals, let alone humans — I have always wondered about the assumption that novel drug delivery systems would improve adherence.
Seems to me that the major problem with non-adherent patients isn’t that they can’t take pills.
It’s that they won’t take them.
And I strongly suspect that most would make the same choice when it comes to putting on a patch every day (or even every week).
October 26th, 2011
Xigris is Gone — Not That Many ID Docs Will Notice
From the FDA comes this news:
FDA notified healthcare professionals and the public that on October 25, 2011, Eli Lilly and Company announced a worldwide voluntary market withdrawal of Xigris [drotrecogin alfa (activated)]. In a recently completed clinical trial (PROWESS-SHOCK trial), Xigris failed to show a survival benefit for patients with severe sepsis and septic shock.
Some quick (and non-scientific) thoughts on these perhaps no-so-surprising turn of events:
The use of various adjunctive therapies in acute sepsis has a long and mostly checkered history. ACTH-directed glucocorticoids, mineralocorticoids, intensive insulin therapy, disparate antibody treatments (most famously anti-endotoxin antibodies) — none has really worked very well. Now we can add recombinant human activated protein C — Xigris — to the list of disappointing (and sometimes dangerous) therapies. In failure there may be opportunity, but treatment of sepsis is one tough nut to crack.- I know trade names are frowned upon in academic medicine, but is there anyone who actually said, “drotrecogin alpha (activated)”? What kind of word is “drotrecogin”? Is there a “Drotrecogin Beta (Activated),” and is it a space ship? The use of the parenthetical post-name word — “(activated)” — is particularly cumbersome.
- Finally, how many ID doctors ever literally prescribed this drug? In our institution, the use of drotecogin alpha … oh you know, Xigris … was overwhelmingly in the hands of the intensivists. They would consult us sometimes after giving it to their critically-ill patients for advice on the usual ID issues (choice of antibiotics, source of fever, whether to change the lines). I only remember being specifically asked, “should we give it” a few times, and am certain I never ordered it.
Meanwhile, “Xigris” happens to be a terrific name. Kudos to whatever advertising brainiac thought of that one.
I’m sure he/she cashed the check for these services many years ago.
October 25th, 2011
Important Reminder: Don’t Eat Raw Garden Slugs
From the pages of the New York Times, courtesy of ProMED, comes this case report:
An Australian man has been hospitalized for more than a month in serious condition as a result of eating two garden slugs on a dare…The 21-year-old Sydney man apparently contracted a rat lungworm parasite from the slugs, which pick it up from rodent droppings. The parasite, a nematode called Angiostrongylus cantonensis, can cause fatal brain swelling.
From the perspective of an Infectious Diseases doctor, the surprising thing isn’t that a person would actually eat a raw garden slug — or even, as in this case, eat two raw garden slugs. After all, in our field one regularly hears of risk-taking behavior that, to quote a particular novel, “… runs to Z and beyond!”
Nope — my favorite part of the case report is this line:
“We hope this will help to remind others to avoid eating raw slugs,” the moderator, Eskild Petersen, said.
And with that, Public Health Crisis averted.
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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