Raw Milk: A Return to the Primitive?

It’s unfortunate that in the 21st Century the American Academy of Pediatrics has to release a policy statement regarding the danger of consuming raw milk. Over 100 years ago, Louis Pasteur discovered that heating wine could prevent it from souring by killing the bacteria responsible. The process was named pasteurization in honor of Pasteur (but the use of heat to preserve food stuffs had been practiced before). It seems that the ongoing fad of raw milk consumption represents a return to the primitive.

During my critical care fellowship, I took care of a patient who consumed raw milk who developed Campylobacter gastroenteritis and subsequent paralysis secondary to Guillan-Barre Syndrome. Though the patient knowingly consumed the raw milk, he subsequently filed a lawsuit labeling the product he consumed “defective”.

To me, the consumption of raw milk represents a dangerous return to a pre-industrial practice that needlessly increases risk. Though I believe it is each adult’s right to consume this—by definition and design—defective product, I find it highly questionable. 

Breast Milk vs. Hepatitis C: Breast Milk Wins

An interesting paper published in the Journal of Infectious Diseases details the discovery that human breast milk has antiviral activity against the hepatitis C virus (HCV). 

Approximately 5-10% of deliveries by HCV positive women result in perinatal transmission of HCV to the child. Transmission is related to HCV viremia, HIV co-infection, prolonged membrane rupture, and intrapartum exposure to maternal blood. Breast milk, though it contains the virus, is not thought to be a major risk.

This paper adds further weight to the safety of HCV positive mothers breastfeeding their children. In this study, researchers incubated HCV--at concentrations 1000x higher than that found in breast milk--with breast milk from HCV uninfected women. Infectivity after incubation with breast milk was reduced 2-3 fold for all genotypes of the virus. Further experimentation confirmed that the mechanism underlying the antiviral effect was due to free fatty acids that disrupt the viral envelope (see graphic).

In an accompanying editorial, Ravi Jhaveri of UNC writes: "After reading this article, when we clinicians next encounter an HCV-infected patient that just delivered a healthy infant and wants to breastfeed, we have yet another reason to say 'Breast is Best'."

Elite HIV Controllers: The Exceptions that Prove a Cure is Possible?

Today I saw a patient who was infected with HIV in the 1970s and is alive today. In the modern era of HIV treatment in the US, seeing people survive long term with HIV is commonplace. In fact, it is projected that in a few years individuals over 50 will comprise half the cases in the US (as I was quoted saying in this article).

The interesting thing about this patient, however, is that the patient remains alive without the benefit of drugs. HIV has been held at bay by the patient's immune system. The patient is what we refer to as a long-term non-progressor. These individuals exhibit no overt signs of immune destruction by HIV despite years of infection.

The terminology defining long-term non-progressors can get confusing as they are divided into one of two types:

1. Elite controllers: no measurable virus detected using routine test
2. Viremic controllers: viral loads < 2000 copies/mL

The patient I saw today is an elite controller, with no measurable virus in the blood. 

Studying the mysteries of how elite controllers control HIV replication is thought to be key to developing a cure (see great graphic from amFAR) for HIV. Most current hypothesis are currently focused on what immune responses are operative in these patients (it is not thought that the HIV virus is defective in these patients nor the CD4 cells immune from infection). 

Disproportionate pneumonic cases in Madagascar plague outbreak

The African island nation of Madagascar is reporting an outbreak of plague which has infected 86 people, killing 39. The more deadly--and contagious--pneumonic form of the disease represents 90% of cases.

Madagascar is a well known focus of plague and has recently led the world in cases. Madagascar is also the site where a naturally occuring multi-drug resistant strain of plague was discovered.

The United States reports a few cases per year, the great majority of which are of the bubonic form. These cases are almost exclusively from the western half of the country as the rodent populations which serve as the reservoir for the plague bacillus (Yersinia pestis) seem not to move east of an artificial plague line which falls roughly on the 100th meridian. 

A few months ago, when a squirrel in Los Angeles County tested positive for plague, I was interviewed by Erin Burnett on CNN on this topic.

What is most interesting about the current cases in Madagascar is that they are of the pneumonic form and not the much more common bubonic form. It is crucial to understand the reason behind the disproportionate number of the pneumonic cases.

Botulism aka "sausage fever" in Texas

Coincidentally on the same day that I delivered a lecture on various bioterrorism topics, four cases of botulism were reported in Amarillo, Texas. During my lecture, I reminded the audience that botulism was once known as "sausage fever", provoking snickering in the crowd.

Remembering that botulus is the Latin word for sausage helps reinforce the fact that many botulism cases in the US are food-borne, often linked to home-canned substances (as these cases will likely turn out to be). Learning several important pieces of information regarding the  4 cases, who are all known to each other and 3 of whom have household contact, will be essential. Answers to the following questions will be crucial in the investigation:

• Has confirmatory testing been done?
• Is the same toxin type responsible in all cases? 
• Why did only 2 of the 4 meet criteria for antitoxin administration?

Another recently reported development with botulism was the discovery of a new of an 8th toxin type, for which no anti-toxin is currently available.