UTIs Can Really Drive You Crazy

When a person with a known psychotic disorder has an exacerbation of their illness one often tries to determine hear the inciting cause might be. Did the person stop their medications, experience a major life stressor, or use an illicit substance? Is their condition progressing?

A new study identifies a potential cofactors that may have been overlooked: urinary tract infections. 

In a study published in the Journal of Clinical Psychiatry, 21% of those presenting with a psychotic episode who were admitted to the hospital had evidence of a urinary tract infection (as determined by their urinanalysis). By comparison only 3% of controls displayed evidence of infection.

I think that this finding is very intriguing and has the potential to change practice. It is well established that urinary tract infections can induce delirium and exacerbate dementia, so it is not surprising that they may have the same effect in psychotic disorders. Whether the generalized inflammatory response induced by the infection or some other factor is responsible remains to be determined.

At the least, awareness and screening for urinary tract infection should be considered in the evaluation of psychotic patients presenting with worsening symptoms. 

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.