DID YOU MISS US? Did you notice that there was no NEWSLETTER in the November and December 2012 issues of the journal? Since the inception of the journal in 1982 we have prepared 338 newsletters and some of you may remember that for about 5 years before starting The PIDJ we wrote and personally mailed the NEWSLETTER to many of you. Perhaps our greatest pleasure was hearing from you with suggestions or complaints and receiving items that we often used in the publication. Alas, in recent years we have heard less frequently from you and wondered whether you have become overwhelmed by the volume of printed material crossing your desk or whether we have become stale. Hopefully, it is not the latter. Please let us hear from you.
WHAT IS A SYNDEMIC? The title of an article, “CDC Grand Rounds: the TB/HIV Syndemic” (MMWR 2012; 61: 484) caught our eye because of the word “syndemic”. We could not find the word in 2 medical dictionaries or in standard dictionaries. The word is not defined in the article. Perhaps it is common parlance in epidemiologic circles. Perhaps our dictionaries are out of date. We first speculated that whoever coined the term was combining “synthetic” and “epidemic”, but that did not seem likely since neither TB nor HIV is synthetic. The combination of “synergistic” with “epidemic” seems to be more likely. Can anyone out there in readerland provide us with the etymologic history of this neologism? Has it been accepted by the OED?
CALL FOR A BETTER PERTUSSIS VACCINE We recommend to you a “Perspectives” piece by James D. Cherry that appeared in the August 30, 2012 issue of The New England Journal of Medicine on page 785. Dr. Cherry has studied pertussis and vaccines for many years and can be counted on for sage analysis and advice. Many issues confound the accuracy of numbers of reported cases of pertussis such as public awareness, physician awareness, changing diagnostic tests, changing vaccines, decreased use of vaccines, genetic changes in the pertussis organism that affect virulence, and so forth. Dr. Cherry concludes that the recent increased prevalence in the United States is real and that our current DTaP vaccines are not as good as the previous DPT vaccines. In the commendable search for a safer vaccine we appear to have substituted a less effective one. Development of a better vaccine should be a goal. Meanwhile, better use of the current vaccines including immunizing pregnant women, starting vaccination schedules earlier and giving doses at shorter intervals should improve protection of young infants, the most vulnerable to complications and death from the disease.
PERTUSSIS VACCINE AND PREGNANCY On October 24, 2012 the vaccine advisory panel recommended that pertussis vaccine be given to pregnant women, preferably during the last trimester. This decision was in response to increases of reported pertussis cases in several places in the United States. For many years the issue of giving any vaccine during pregnancy has been controversial. Influenza vaccine was the first to be recommended for pregnant women. That was in the 1990s.
PARASITES AND DIARRHEAL ILLNESS Cryptosporidiosis is a reportable disease in all 50 states and giardiasis is reportable in all but Texas, Mississippi, Kentucky, Tennessee and North Carolina. (Why the difference? We do not know.) The CDC recently reported on trends of those diseases during 2009 and 2010 (MMWR 2012; 61:1-12. No. 5, pp1-23). About 9000 cases of cryptosporidiosis and 20,000 cases of giardiasis were reported annually. Much of the information came from investigations of outbreaks, so the numbers are the proverbial tip of the iceberg of the total number of cases in uninvestigated outbreaks and sporadic cases. The main feature that arose from the analysis is the increased cases during summer months that are blamed on exposure to recreational water pools. These parasites are not killed by chlorine and parents cannot be relied on to keep children with diarrhea or those who recently had diarrhea out of the pools.
WEST NILE VIRUS INFECTION IN DALLAS Over the years we have seen only a few children with West Nile (WN) central nervous system infection despite documentation of viral activity in mosquitoes and in adults with febrile illnesses. Dr. Ana Rios, a former fellow and ID physician at Cook Children’s Medical Center, Fort Worth, TX told us of a neonate she managed in July 2012. This was a previously healthy 11 day old girl that was delivered at 39 weeks by normal spontaneous vaginal delivery. On the second day the mother developed a febrile illness associated with severe headache, neck pain and body aches and she required hospitalization for 5 days. The diagnosis was uncertain. The baby was seen in an emergency room on day 11 of life with a 3 day history of intermittent right-sided jerking movements, each lasting for less than one minute. The infant was fussy and had decreased oral intake and low grade fever. Her physical examination was unremarkable. Spinal fluid was turbid and had 475 white blood cells with 30% neutrophils, 10% lymphocytes and 60% monocytes. The glucose was 32 mg/dl and protein 197mg/dl. The culture was negative as were the CSF HSV and enterovirus PCRs. She received antimicrobials including acyclovir for 48 hours. MRI of the brain revealed abnormal signal on the diffusion sequence in the left posterior parietal and occipital regions. The CSF WN IgM was positive, 5.46 (negative, < 0.89) and the IgG was negative, 0.28 (positive > 1.29). The baby was discharged without medications and has done well on follow up. The mother’s WN titers in the convalescent stage were 3.34 (IgG) and 33.09 (IgM). This infant’s illness occurred during the time that there were many cases of WN infection in Dallas County. Dr. Wendy Chung, a former fellow and currently the Director of Epidemiology, Dallas County Health Department provided us with the following information. The total number of WN infections reported in Dallas County from June 19 through November 5, 2012 was 391 (173 were WN neuroinvasive cases and 218 had WN fever). Of these, only 10 (2.6%) were younger than 18 years of age and 2 of these had WN neuroinvasive infection, a 3 year old with mild meningitis and a 16 year-old with encephalitis. Because most WN infections are asymptomatic or associated with a mild flu-like illness, only a small proportion of cases are reported to the health department.
LONG-TERM FOLLOW UP OF GBS MENINGITIS There are very few studies of the long-term outcome of infants with group B streptococcal (GBS) meningitis. Physicians from Texas Children’s Hospital, Houston, TX and Monroe Carrell Jr. Children’s Hospital, Nashville, TN (Pediatrics 2012;130: e8-15) evaluated 43 children who survived their illness and were thoroughly assessed at a mean age of 6.8 years (range 3-12 years). Twenty-four (56%) children had age-appropriate development and normal vision and hearing, whereas 11 had mild-to-moderate and 8 had severe impairment. As the authors noted these long-term outcomes are similar to those from their own institution (i.e. Texas Children’s Hospital) more than 25 years ago although the case fatality rates are lower now. Of note was the observation that abnormalities on computed tomography or magnetic resonance imaging early in the illness were not predictive of outcome whereas abnormalities on cranial imaging at the time of discharge were associated with severe impairment on follow up. Although cranial imaging is performed in most infants it appears that it is most useful to clinicians in counseling parents about long-term prognosis. This is another valuable contribution from these investigators.