Blending Stool into Chocolate Milk

Clostridium difficile has become a scourge in hospitals and is beginning to be viewed as a Medicare "no pay" condition. This infection is fundamentally the result of a disruption of the microbiome making the human colon hospitable to C.diff. When antibiotic treatment, which further disrupts the microbiome, is insufficient, few options exist.

The option with the most promise--which is almost per se unpalatable--is a fecal transplant. This involves reconstituting the microbiome of the patient and crowding out C.diff. When used, often as a last resort, it works. The stool can be administered via a nasal feeding tube or via colonoscopy.

A story in The New York Times is focused on a stool bank (Openbiome) that offers donor stool for use in these infections. The advantage of a stool bank is that it provides a source of donor stool that has been screened for the presence of pathogens and is safe to instill. This innovative thinking by Openbiome is admirable.

My favorite quote from the article: "a technician blended the donor’s stool into preparations that looked like chocolate milk."

Bet Your Bottom Dollar that Tomorrow There'll Be Pus and Infection

Today, working as infectious disease physician (as opposed to my other roles), I rounded on 38 inpatients--quite a lot for me. I anticipate the next few days will bring the same sort of volume. 

It wasn't one particular infection I was seeing; influenza has diminished in activity and there are no outbreaks. I think that the higher number of consultations is reflective of the growing appreciation of the value of an infectious disease physician in improving outcomes in those with severe infections, as has been shown. 

What I did see today was a cornucopia of infections that challenged me intellectually and reinforced my passion for the field. Cytomegolovirus (CMV), Nocardia, and Staphylococcal prosthetic valve endocarditis were some of today's stars. Antibiotic resistance and C.diff always has an overshadowing supporting role in all I do. 

The beauty and allure of infectious disease is that after all that today, I can't wait to see which bugs I get to battle with tomorrow.

Anthrax Guest Starring on House of Cards

On one of the episodes in the 2nd season of House of Cards there is a white powder incident at the US Capital, causing a lockdown. In the episode, the lockdown lasts for hours while the powder is tested and ultimately revealed to be a mixture containing flour (wheat) and talcum powder. It was stated that pesticide on the wheat caused a false positive on initial tests, requiring the longer lock down of the area while confirmatory tests were performed.. There were several references to anthrax, which was actually released from an envelope in the Capital in 2001, in the dialogue. 

White powder incidents abounded after the events of 2001 and still continue to this day--witness the Super Bowl's corn starch incident. What is often overlooked is the amount of law enforcement, public health, and clinical resources that are absorbed--and diverted from other functions--in the response to these incidents. Much like a bomb threat, a white powder incident can't be ignored as both anthrax and ricin have been sent in the mail. 

TB: Treating Humans as Matter

The biopic of brilliant Nobel Prize winning physicist Richard Feynman, Infinity, not only portrays the awesome power of his genius, but also the struggles he faced dealing with the fatal illness of his wife.

In the 1930s and 40s, the diagnosis and treatment of infectious diseases was very rudimentary--in some ways, it still is--and Arline Feynman's illness was sequentially labeled typhoid fever and Hodgkin's Disease, before the final diagnosis of tuberculosis was made.

It was not until 1946 that the first trials in humans of streptomycin--the discovery of which generated much controversy (see Experiment Eleven)--took place.  In the pre-antibiotic era in which the events of the movie take place, tuberculosis was a major killer that literally consumed the bodies of its victims, hence its alias "consumption". In the absence of treatment, or with highly resistant forms of the illness, it can still kill in its original manner. 

I can't imagine how someone of Feynman's ability and intelligence must have felt watching this simple microbe kill his wife. 

Speaking of the power of the atomic bomb in the movie, Feynman quotes fellow physicist Isidor Rabi as saying the bomb treated humans like matter--a description equally fitting for tuberculosis. 

The Real Crazy Train: Measles

Yet another large measles exposure occurred in this country as the result of an unvaccinated individual contracting the illness while in Asia. 

The patient, who is a college student in California, rode a public transportation train and potentially exposed thousands of individuals to the virus, which can be deadly in select cases.

This incident has several aspects that worth highlighting:

• Though measles has been nearly eradicated from the US that is not the case in the rest of the world
• Unvaccinated individuals, who may have a relatively low (but not zero) risk of contracting the disease in the US, are at a high risk of infection when traveling to areas in which measles is still present and human populations are not immunized to a high degree, i.e. herd immunity has not been achieved
• Measles is extremely contagious and if exposed individuals were not adequately vaccinated, for personal reasons or because they are less than 1 year of age, they may contract measles

The bottom line: Measles is too contagious of a disease for the human population to become lax about.