Polio in Kabul: The Polio Hydra in Pakistan Strikes Again

The news that a polio case has occurred in Kabul is another setback for the eradication program. While Afghanistan has cases of polio annually--14 last year--none have occurred in Kabul since 2001. Almost all cases from 2013 were linked to Pakistan. Similarly, in this case, members of the patient's family reportedly travelled to the polio-endemic nation of Pakistan where the virus was contracted. 

To date this year, 2 cases of polio have occurred in Afghanistan while 7 have occurred in Pakistan. No other nations have reported cases. 

A case in the highly populated capital city is concerning because of the potential for the virus to spread and spark further cases. Accordingly, an immunization campaign in Kabul has been launched. 

This case illustrates the fact that Pakistan, an area rife with murderous violence against polio vaccinators, is the head of the hydra that must be severed to control this disease.

Antibiotic Resistance, the End of Precision Medicine, & Job Security

Today I came across an interesting perspective on antimicrobial resistance, a phenomenon that, as an infectious diseases physician, commands a great deal of my attention. In The Innovator's Prescription, the diagnosis of many infectious diseases is described as having moved from a stage in which diagnosis and treatment was intuitive, expert-led, and hypothesis-driven to a more precise stage in which diagnoses is largely exact and response to therapy predictable (think strep throat). 

The book goes on to make the point that antimicrobial resistance, by rendering our standard treatments obsolete, may reverse this trend relegating us back to a stage in which response to treatment is not predictable and treatment regimens may require a lot of expert-led contemplation and hypothesis testing (think multi-drug resistance Acinetobacter). 

At least this fascinating and dire analysis predicts job security for my colleagues and me. 

When it Comes to Tamiflu 48 Hours is just the Title of a Movie

One thing that I really annoys me is the common misconception that Tamiflu should only be used within 48 hours of symptom onset and is only able to diminish symptoms. While the strongest data supports the above two claims, there is evidence that Tamiflu confers additional--and potentially lifesaving--benefits.

What must be kept in mind is that when Tamiflu received FDA approval it was studied in uncomplicated influenza cases and was shown to be maximally (not exclusively) beneficial when administered within 48 hours of symptom onset. Severe cases were not included in those randomized controlled trials and, consequently, strong data regarding pneumonia and other severe complications of influenza do not really exist. 

The other element of this story is that because severe influenza is unequivocally life-threatenening it is not possible to conduct a placebo-controlled trial as withholding antiviral treatment from a severely ill individual can not be justified. 

While strong data (i.e. prospective, randomized, placebo-controlled) may not exist that does not mean no data exist. Retrospective data has shown Tamiflu to be beneficial in severe cases, especially when given early. 

M y practice is to use Tamiflu (or Relenza) for influenza cases irrespective of how long symptoms have occurred, especially in those at high risk of a severe course.

A Fever Without a Cause

Today one of my friends told me about a mother of one of her friends having an ongoing fever for 2 weeks. I immediately thought that this is likely not the result of an infectious disease, but of a malignancy of some sort.

What this person has is a fever of unknown origin (FUO). FUOs almost always require infectious disease consultation, represent a challenging aspect of infectious disease, and a problem I relish tackling. 

Usually an FUO is the result of an infection,  an autoimmune disease, or a malignancy. In those under the age of 65, infections make up the majority of cases. As one ages, however, infection becomes less likely as malignancy becomes more common. 

A fever is best understood as a warning sign and adaptation from the immune system that can be caused by a myriad of different processes. Nevertheless, they  prompt extensive work-ups in order to find the inciting cause, especially when present for two weeks.

Could Spock Have Been Infected With a Fungi?

Actor Leonard Nimoy, of Star Trek fame, recently announced that he has chronic obstructive pulmonary disease (COPD), a lung disease that comprises emphysema and chronic bronchitis. COPD is usually thought to be almost exclusively caused by smoking tobacco. 

While smoking is clearly a major etiologic factor responsible for the development of this condition, fascinating work--much of it done by Dr. Allison Morris at Pitt, has shown that a fungal infection may also play an important--and independent--role. This fungus, Pneumocystis jiroveci, usually headlines as the most common opportunistic infection that US HIV patients contract. However, this fungus also has the ability to colonize non-HIV infected individuals.

Colonization rates of this fungus are higher in COPD patients and the higher the colonization density, the more severe the COPD. 

Hypotheses regarding how this infection might be involved with COPD are centered on the inflammation its presence may trigger and the subsequent lung damage that occurs.

If COPD is indeed proved to be an infectious disease, it may translate into novel treatments that could decrease the considerable burden of this disease.