Updates

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

Atypical hand, footand mouth disease

Atypical Hand, foot and mouth disease (HFMD), California Update for clinicians, July 24, 2012; San Mateo County Public Health Advisory (1); MMWR Notes from the field: Severe hand, foot, and mouth disease associated with Coxsackievirus A6 – Alabama, Connecticut, California, and Nevada, November 2011- February 2012. March 30, 2012; 61(12); 213-214 (2); ProMEDmail alert, August 14, 2012 (3).

Health alerts in our area warn of local cases and small outbreaks of atypical hand, foot and mouth disease (HFMD) due to a novel strain of Coxsackievirus (1). A genetically similar strain was reportedly responsible for international outbreaks in northern Europe and Taiwan in 2008, but is now being reported in several states in the United States (2). Washoe County in Nevada has logged more than 400 self-reported cases atypical HFMD in the past few months, prompting an alert to school systems as the new school year starts (3).

Although Coxsackie viruses generally cause high fever and painful oral aphthi, with a rash on the palms and soles, most often in children, this strain seems to result in more severe and more generalized skin lesions, and has been affecting adults. From November 2011 to February 2012, 63 persons with HFMD with severe, atypical rash were reported to the CDC. Cases were reported from Alabama ( n = 38) and Nevada ( n = 17), California (n= 7), and one from Connecticut. Two-thirds of the cases occurred in children < 2 years of age, and one-fourth occurred in adults. Eight of the fifteen affected adults had exposure to an ill child, a contact of an ill child through day care, or had provided medical care to a sick child. While three-fourths of the patients were described with a rash on the hands, feet or mouth, 46% developed rash on the arms and legs, 41% had facial involvement, 25% had buttocks involvement, and 19% had rash on the trunk. Vesicles were reported in 70%, sometimes quite large or confluent, resembling bullae or blisters, and some of the lesions were hemorrhagic. Skin desquamation was common, and 2 patients shed their nails (onychomadesis). Nineteen percent of the patients required hospitalization, primarily for dehydration and/or pain control.

The rash may be so atypical that authorities caution it may be mistaken for Kawasaki's, varicella, disseminated HSV, eczema herpeticum, or vasculitis.

While most HFMD is due to Coxsackie A16, this strain has been identified, by molecular means, as a Coxsackievirus A6 (CAV6). Based on partial sequencing of the VP1 gene at the CDC and the California Department of Public Health laboratories, all 25 CVA6 strains tested appear closely related to strains identified in international outbreaks.

Public Health authorities recommend home isolation of suspect cases for at least 24 hours after fever resolution and once all lesions have healed or scabbed. Current monoclonal assays may miss this particular strain (commonly done for CAV16). Your local or state public health department laboratory may be prepared to do PCR testing or other specialized testing of throat or vesicle swabs (using a Dacron swab). People with active infection should avoid kissing or sharing utensils till lesions scab over and no lesions have appeared for 2 days.

Homelessness and TBa bad combination

Tuberculosis – USA: (Florida) fatal, homeless shelter. A ProMED-mail post, July 8, 2012; http://www.promedmail.org.

According to this ProMED-mail posting from July 2012, officials have expressed concern that an ongoing outbreak of tuberculosis in Jacksonville, Florida remains uncontained – and now threatens to spread to other parts of the state. This outbreak, which stemmed from a single individual with MTb in 2008, has now affected 99 individuals with active MTb, including 6 children, and resulted in 13 deaths. Hundreds to thousands of homeless and mentally ill in the Jacksonville area may have been infected.

Although not unusual for some parts of the world, this outbreak, which began in 2008, and was believed to have been contained at that time, and then obviously was not by 2011-2012, is emblematic of the degree to which one highly contagious individual, with unrecognized or poorly managed active MTb can infect hundreds of individuals. It is also no surprise this outbreak occurred coincident with the decline in public health funding. It is also a reminder that managing cases of active MTb in the homeless, mentally ill or drug addicted is not only especially challenging but of critical importance —and is exactly the circumstance where public health dollars are requisite.

The outbreak began in 2008, when a single patient with schizophrenia was diagnosed with active MTb. A cough was documented in various charts for 8 months — but unfortunately he was variously admitted to jail, repeated psychiatric hospitalizations, homeless shelters, and an assisted living facility before his MTb was recognized and he was effectively quarantined at a State Tuberculosis Hospital (which has since been closed for lack of funding). From August 2008 — May 2009, 15 of the mentally ill residents of the assisted living facility and 3 other individuals at the psychiatric facility developed active MTb, 2 of whom died. Nine of the 18 isolates were available for testing; genotyping using spoligotyping and 12-locus mycobacterial interspersed repetitive unit typing (MIRU) showed the isolates to be identical (named FL046).

Investigation at the assisted living facility revealed that of the 75 residents, 88% had positive PPDs consistent with exposure. This rate of positivity suggests a high level of exposure in the facility. Based on this information, it has been estimated that up to 3000 to 4000 people at homeless shelters may have been additionally infected. Unfortunately, this report indicates that only 253 of those persons were ever identified and tested. The CDC provided Duval County with a grant ($USD275K) to facilitate the investigation, but once the funds ran out, personnel were apparently assigned to other duties.

It was not until an additional 30 cases were reported from Duval County in 2011 that authorities recognized the contagion had not been stemmed. Eleven of those cases were subsequently sent to the State TB hospital; and one remains quarantined at Jacksonville Memorial Hospital. These 30 cases also appear to be due to the same strain type. Fortunately none of the cases have demonstrated resistance to TB medications. Many of the subsequent cases have occurred in the homeless or mentally ill, who are undernourished, have poor and inconsistent access to medical care, and are especially hard to track. This report suggests that several of the deaths have occurred in poor black men, who simply presented with wasting, and were "too far gone" by the time their TB was recognized.

Chagas in Newborns

Congenital transmission of Chagas Disease – Virginia, 2010; MMWR July 6, 2012; 61(26): 477-479.

Awareness of Chagas in the blood supply in the United States — and in organ transplantation — as possible modes of transmission of this infection is increasing. Thus far only a handful of transfusion-related cases have been reported in the U.S. Data collected by the CDC suggests these cases are related to transfusion of fresh and not frozen blood products. Congenital transmission of Chagas in the U.S. seems to be similarly rare, in part because it is difficult to diagnose, there is a lack of awareness of the possible risk of infection, as well as a lack of classical signs and symptoms of neonatal infection.

This report documents the first case of congenital transmission of Trypanosoma cruzi in the U.S. A 31-year old mother from Bolivia required cesarean section for fetal hydrops at 29 weeks gestation. The baby weighed 1840 grams and had ascites, and pleural and pericardial effusions. An echocardiogram was normal, and no arrhythmias were noted. Studies for toxoplasmosis, malaria, cytomegalovirus, rubella, HSV, and enterovirus were negative, and the baby received empirical antibacterials and acyclovir.

The mother subsequently revealed she had been diagnosed with Chagas infection in Bolivia and had received antitrypanosomal treatment. The child's blood smear was positive for T. cruzi trypomastigotes. He responded well to a 60-day course of benznidazole, and by 10 months of appeared to developing normally.

Based on current epidemiological data, the numbers of at-risk women living in the U.S., and estimates of congenital transmission of 1%-5%, approximately 65 to 315 cases of congenital T. cruzi transmission may be occurring every year in the U.S. Signs or symptoms of infection may be deceptive, varying from asymptomatic or subclinical infection to low birth weight, hepatosplenomegaly, anasarca, cardiac failure and respiratory distress, to meningoencephalitis. Treatment is usually curative in > 90% of cases if administered in the first weeks of life.