Updates-By Carol A. Kemper, MD, FACP
Updates-By Carol A. Kemper, MD, FACP
Histoplasmosis for Spring Break?
Source: CDC. MMWR Morb Mortal Wkly Rep. 2001;50:359-360.
An outbreak of suspected acute histoplasmosis in college students returning from spring break in Acapulco, Mexico has authorities searching for the source of the infection. As of May 1, 229 students from 44 colleges throughout the United States have become ill after traveling to Acapulco during the first 2 weeks of March. Students typically experienced an acute febrile illness lasting ~3 days associated with dry cough, chest pain, shortness of breath, and headache. The laboratory investigation is ongoing but histoplasmosis is strongly suspected.
An investigation of the students’ activities have narrowed the focus to one hotel in Acapulco—the Calinda Beach Hotel—that was significantly associated with the development of illness in univariate analysis. Further investigations at the site have not been able to pinpoint a source within the hotel or adjacent grounds. Interestingly, the CDC was recently notified by California authorities about 2 cases of histoplasmosis in a couple who had stayed at the same hotel in early April.
VISAs, GISAs and VTSPs
>Source: Normark BH, et al. Clin Infect Dis. 2001;32:552-558.
Just as clinical practice has adapted to the emergence of penicillin-tolerant Streptococcus pneumoniae and the necessity of administering vancomycin for cases of invasive pneumococcal infection, consider this: a Swedish study of 116 clinical isolates of pneumococci identified 3 strains (3%) with tolerance to vancomycin. Eight percent of the isolates were tolerant to penicillin. The 116 isolates were collected from various countries between 1987 and 1997, and most were from cases of invasive disease or pneumonia, although a few isolates were nasopharyngeal in origin. One of the strains of vancomycin-resistant S pneumoniae (VISP) was from blood and the other 2 were obtained from nasopharyngeal swab specimens. All 3 isolates had high MBC:MIC ratios of 32, compared with 15 vancomycin-sensitive strains with a ratio of 1 to 2. While all 3 strains had reduced susceptiblity to PCN, only one was tolerant. All 3 strains were serotype 9V and had almost identical fingerprints, suggesting a common origin, although 1 of the isolates had come from Spain and the other 2 were Swedish (40% of PCN-resistant S pneumoniae isolates in the United States are believed to have arisen from a single Spanish clone).
Eradication of this organism requires a prolonged course of antimicrobial therapy with concentrations of drug well above the MIC. Patients with invasive disease due to this organism, especially those lacking effective bactericidal function, are at high risk for treatment failure. A recent report documents treatment failure in a patient with recrudescent meningitis due to VTSP infection.
Exotic’ Dancers Transmit TB
Source: CDC. MMWR Morb Mortal Wkly Rep. 2001;50:291-293.
Public health authorities in Kansas report a cluster of 18 cases of tuberculosis (TB) including a number of women who worked at local clubs as exotic dancers. Of the 18 cases, 14 were confirmed by culture. Eight of the patients were women, including 7 dancers, all of whom had cavitary pulmonary disease. The dancers worked at 6 different clubs in the area. Of the 11 nondancers, 3 of whom were children, 6 had been exposed to the dancers. Nine isolates received for DNA analysis had matching fingerprints, including isolates from 6 of the dancers.
Contact investigation identified 344 contacts, 302 of whom had tuberculin skin testing. One-fourth of those skin tested were positive. Fourteen of 32 contacts who had follow-up skin testing done had evidence of conversion, consistent with recent TB infection. About three-fourths of those eligible for treatment of latent TB infection have initiated prophylaxis.
Unfortunately, the 18 cases were identified over a 7-year period from 1994 to 2000, and the significance of the cluster was only belatedly recognized. Twelve of the 15 adult cases reported using various illicit drugs, and 10 (67%) had been incarcerated at various times during the 7-year period. This cluster shares many similarities with that which recently occurred in several transsexual communities on the East Coast that hosted large "balls," or dance contests, resulting in the facilitated transmission of TB within an isolated "community" that is otherwise fragmented and difficult to trace (Kemper CA. Infectious Disease Alert 2000; 19:144). The difficulty in tracking and identifying cases in situations like these, where participants may be reluctant to be identified or name contacts, and contacts often prove elusive, makes the job of the public health department TB control staff extremely difficult, especially in times of limited resources. This outbreak emphasizes the continued need for adequate resources for TB control, even in a place like Kansas with a lower case-incidence of TB that may not have the usual resources and staffing to allocate to outbreaks such as these.
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