Updates

By Carol A. Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, Section Editor: Updates; is Associate Editor for Infectious Disease Alert.

Prison brew

Source: ProMED-mail post 2011 Oct 10; Available at: www.promedmail.org.

In early October, 12 inmates from the Utah State Correctional Facility became acutely ill with nausea, vomiting, facial paralysis, and visual blurring.

All 12 were diagnosed with acute botulism, 8 of whom required hospitalization and botulism anti-toxin. Three remain hospitalized, requiring ventilatory support. Four others were well enough to be cared for as outpatients.

The culprit is believed to be the ingestion of jail house home-brewed liquor, which the men reportedly concocted out of potatoes, oranges, apples, and pineapples salvaged from their meals. Originally called "pruno" because a common ingredient was breakfast prunes, similar jail house concoctions go by a variety of names including juice, jump, hooch, and raisin jack. It can be "brewed" from such simple ingredients as cake frosting, bread, jelly, and milk. A proven recipe found on the web includes a Ziploc bag (or heavy duty garbage bag and rubber bands), 9 peeled oranges, an 18 oz can of fruit cocktail, 50 sugar cubes, 6 tsp of ketchup, and water — fermentation begins within 48 hours and the slop can be drunk within 9 days. Adding dinner rolls (with yeast) can cut the fermentation time in half. One taste-tester described the concoction as like drinking "thunderbird thru a dumpster of rotten garbage," which is a testament to how badly some inmates want to get drunk.

To keep the bag from exploding, it must be opened to let out the gases, maintaining an anaerobic environment, which is perfect for botulism toxin production. The use of potatoes may increase the risk of botulism. Similar outbreaks of jail house-brewed botulism occurred in 2004 and 2005 in prisons in Riverside and Monterey, Calif.

Transfusion-associated babesiosis in the United States

Source: Herwaldt BL, et al. Transfusion-associated babesiosis in the United States: A description of cases. Ann Intern Med 2011 Sep 5; Epub ahead of print.

Transfusion-associated babesiosis is an uncommon, poorly recognized, but serious complication that may be on the increase in the United States. These authors summarized all 159 recognized cases occurring between 1979-2009 in the United States. While babesiosis was not considered a reportable disease for many years, the authors went to great lengths to track down all known cases of transfusion-associated infection. Positive donors were identified in 136 (86%) of cases. All but four cases were associated with transfusion of red cell components. The cases occurred throughout the year and were reported from 19 states, although 87% of the cases occurred in just seven states: Connecticut, Massachusetts, New Jersey, New York, Rhode Island, Minnesota, and Wisconsin. While cases were reported from states other than these, many of these donors had visited or resided in states known to be endemic for the organism. Three cases of B. duncani infection were reported in 2004 and 2008 from California and Washington.

The median age of transfusion-related B. microti cases was 65 years (range, < 1 to 94 years). Most of the patients were either very young (18 were infants, 13 of whom were cluster-associated) or very old. However, a subset of about 25 patients were in the middle age group, 19 of whom had hereditary blood disorders, such as sickle cell anemia or transfusion-dependent thalessemia, and/or splenectomy. The all-cause mortality rate was 19%, although many patients were critically ill for other reasons.

During the period of study, only 7 (4%) cases occurred between 1979 and 1989, whereas 122 (77%) occurred between 2000 and 2009. These data suggest that either post-transfusion babesiosis may be occurring with increasing frequency or it is increasingly being recognized and reported. The authors report that many of the cases were only incidentally recognized. Many of the cases were detected by the laboratory during routine manual examination of a peripheral blood smear, and several cases were detected post-mortem. Several of the cases were misdiagnosed, as demonstrated by the fact that 14 of 20 cases were ring forms and initially received anti-malarial treatment. The authors argue that babesiosis should be considered in the differential of fever of unknown origin following transfusion, or any case of post-transfusion hemolysis with or without fever.

Increasing alarm over NDM-resistance

Source: ProMED-mail post 2011 Oct 5; Available at: www.promedmail.org.

Last year, Morbidity Mortality Weekly Report described the emergence of a novel resistance mechanism, called New Dehli metallo-beta-lactamase (NDM-1), which had been identified in three Enterobacteriaceae isolates in the United States between January and June 2010.1 The three isolates, including an Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae, all carried "blaNDM-1," which confers resistance to all beta-lactams and carbapenems, with the exception of aztreonam. These three isolates were, however, additionally resistant to aztreonam, presumably by an additional resistance mechanism. The organisms were isolated from 3 patients who received recent medical care in India. Similar isolates are being reported with increasing frequency in the United Kingdom, as well as Western Europe and Canada, generally in persons who have received recent medical care in India and Pakistan.

Since that report, alarm at the increase in these highly drug-resistant organisms in India, and their spread to the West, has prompted India to call for a global summit on antibacterial resistance. NDM and other drug-resistant mechanisms are contributing to an increased mortality in India, especially in infants. A West Bengal hospital recently described the deaths of 4 infants from these organisms. Drug resistance may contribute to at least 30% of the 190,000 annual infant deaths in India — either because of lack of access to antibiotics to which the bacterium is sensitive or due to extremely drug-resistant bacteria for which there is no treatment. Data from a well-known tertiary care hospital in New Dehli suggest that of 10,899 culture specimens collected in a 5-month period, more than 2,500 specimens from the ICU and 2,700 from the general ward yielded organisms containing NDM-resistance (usually patients with E. coli infection or pneumonia).

Reference

  1. CDC. Detection of Enterobacteriaceae isolates carrying metallo-beta- lactamase — United States, 2010. MMWR Morb Mortal Wkly Rep 2010;59:750.

Pedicure-associated furunculosis

Source: Stout JE, et al. Pedicure-associated rapidly growing mycobacterial infection: An endemic disease. Clin Infect Dis 2011;53:787-792.

Rapidly growing mycobacteria (RGM) have been increasingly identified with skin and soft-tissue infection, especially those associated with pedicures at nail salons. An outbreak of 110 pedicure-associated furunculosis cases (specifically due to Mycobacterium fortuitum) occurred in our area in 2000. I provided care for about a dozen "victims" when a second, larger outbreak involving 140 customers and 33 different salons occurred in our county in 2004. This second outbreak involved multiple different RGMs, including M. fortuitum and M. chelonae/asbscessus. One immunocompromised patient died of her infection. These can be difficult infections to diagnosis and treat, cultures are often negative, even when tissue cultures are obtained, and treatment frequently requires the administration of two or more antimycobacterial agents for months at a time. Patients are often left with residual scars.

Both of these outbreaks quietly ended just as mysteriously as they began. Interestingly, adjacent San Mateo County was not involved — only salons in Santa Clara County. Although the new-fangled whirlpool salon chairs were considered a suspect source, extensive evaluation of a number of implicated salons and chairs failed to demonstrate a consistent source. That investigation did reveal that extensive biofilm, matted hair, and debris can build up within the whirlpool pipes, couplings, and valves of the chairs, and recommendations were made for routine cleaning, using disinfectant and bleach.

A similar outbreak of 40 cases of pedicure-associated furunculosis occurred in two counties in North Carolina from 2005 to 2008, 55% of which were due to M. abscessus/chelonae group organisms. Again, extensive investigation failed to reveal a specific source. Although a number of RGM were recovered from tap water, footbaths, and biofilm samples from 11 of 13 implicated salons and 4 of 11 controls salons (P = 0.032), no specific relationship could be identified between specific salons and specific organisms. Nonetheless, the authors concluded that the heated whirlpool waterbaths are a likely source. Because many nail salons form "co-ops" and share supplies, some of which are imported, and given the local nature of these outbreaks, I have been suspicious that a contaminated lotion or nail product might be the culprit. Avoiding shaving your legs one to two days before getting a pedicure may decrease the risk of infection.