With a membership of a little more than 300, the AAN's Neuro-infectious Disease Section is one of its smallest Sections — but the need it serves is significant.
Elsewhere in the world, the burden of neuro-infectious diseases such as bacterial meningitis, viral encephalitis, toxoplasmosis, rabies, tetanus, and cerebral malaria is high. The World Health Organization has ranked neuro-infectious diseases as the second leading cause of healthy years of life lost to disability among neurologic disorders.
The picture in higher-income countries is quite different: neuro-infectious diseases don't even make the top five among causes of years lost to disability attributed to neurologic disorders. As a result, neuro-infectious disease neurologists are few and far between. AAN surveys have found that only about 10 percent of US neurologists list infectious disease as one of the focuses of their practice, compared with more than 16 percent of international neurologists.
“You'd be hard pressed to find a neurology department in academic medicine, or a private practice in neurology, that doesn't have a stroke neurologist or an epileptologist,” Section Webmaster Cheryl Jay, MD, a, clinical professor of neurology at the University of California, San Francisco, told Neurology Today. “But a lot of places don't have a neuro-infectious disease specialist. Even at many big academic centers, if you're trying to train in this field as a resident, it's more likely than not that there isn't a neurologist with these particular interests to educate you.”
THE NEED FOR MORE TRAINING
Neuro-infectious disease is not yet an United Council for Neurologic Specialties-accredited subspecialty, noted Dr. Jay. Only a few leading centers, such as Johns Hopkins and Massachusetts General have full-fledged neuro-infectious disease fellowships, although that number is slowly increasing. Most of today's experts in the field, like Dr. Jay, came up through neurovirology or other related subdisciplines.
“If you were interested in this area years ago, you studied neurovirology or prion diseases,” she said. “And then the era of AIDS came along. I was a neuro-AIDS fellow, and when you come out of fellowship with any experience in a sub-discipline related to neuro-infectious disease, all the patients with neurologically related infections come to you. My practice started with a focus on patients who had neurological complications of AIDS, but I wound up with many patients who had other neurologic infections.”
And that, she said, underscores the need for expanded training opportunities, new programs, and other resources in neuro-infectious disease. “I always tell my fellows, when you're looking for a position you'll hear, ‘I don't think we really need a neuro-infectious disease specialist.’ Well, any center of any size that has a cancer program, a transplant program, or a significant population of patients with HIV probably could keep a neuro-infectious disease specialist very busy — although they might not appreciate that until you get there. These patients are often treatable and time is of the essence, so having someone available who can take on an expedited workup quickly becomes very valued.”
A main focus for the Section has been on developing educational resources to help guide institutions that want to expand their neuro-infectious disease training. Several years ago, they released core curricula in neuro-infectious diseases for medical students, residents, and fellows, with specific references.
“In some cases, the curricula point out that you may need to go outside neurology to teach this,” Dr. Jay said. “Programs may need to ask neurosurgery, infectious disease, or internal medicine departments to help teach these courses. That's unusual, but it reflects the very multidisciplinary focus of what we do.”
Those curricula are now becoming dated, and at the most recent Academy meeting, Dr. Jay said the group put plans into place to update them in order to reflect advances in the field, the emergence of new neuro-infectious diseases, and new references. “People were assigned to prepare that update, and between now and next year's meeting, it will be circulated through the Section for comments.”
The curricula interlock with courses in neuro-infectious disease presented at the Academy's Annual Meeting. In past years, neuro-infectious education included an eight-hour, daylong course. Although well attended, Dr. Jay says that some meeting attendees found it difficult to devote that much time in a solid block to neuro-infectious disease. So at the most recent meeting, for the first time, the content was split in half, with basic subjects in the morning and more advanced topics in the afternoon.
CONSENSUS STATEMENT ON PML
Another recent achievement from the Section was the publication of a consensus statement on diagnostic criteria for progressive multifocal leukoencephalopathy (PML), which appeared in Neurology last April and included clinical, imaging, pathologic, and virologic standards; histopathological and clinical pathways for PML diagnosis; and diagnostic algorithms. Section members have also been very active in helping to organize specialty meetings devoted to PML and natalizumab therapy.
“The story of PML a complication of natalizumab therapy for multiple sclerosis really represents a convergence of two related neurologic subspecialties,” said Dr. Jay. “There have always been people in neuro-infectious disease whose background is neuroimmunology — there's a clear and obvious overlap there. But it's remarkable to see how quickly this has come together — from recognizing PML as a serious complication, to having tools to risk stratify patients, to being able to counsel them with evidence if natalizumab therapy is being considered.”
The Section's strategic goals are largely focused on patient care and education. “We have a fairly significant international membership, and we'd like to help encourage some of the fellowship programs to have neurologists who are based in other parts of the world come to this country to learn specialized techniques — and to take those home — in hopes of improving public health,” Dr. Jay said.
She noted that the Section is also working on organizing an endowment through the American Brain Foundation for a prize in neuro-infectious disease to be presented through the Academy at the Annual Meeting.
Dr. Jay cautions US neurologists against dismissing some neuro-infectious diseases as not relevant to their practice.
“This year, as India and other countries have been declared polio-free, we've seen recurrences of polio in other parts of the world because of political instability and war. It may be easy to think of these as remote problems, but the meningitis outbreak on college campuses in New Jersey and California and the fungal outbreaks associated with contaminated methylprednisolone, underscore that these conditions do happen here. And people travel a lot. So, where someone has been, and the kind of work they do, may be an important key to figuring out what's going on if someone has a suspected infection of the nervous system.”