{"id":8277,"date":"2017-01-16T09:39:45","date_gmt":"2017-01-16T14:39:45","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=8277"},"modified":"2017-01-17T05:53:00","modified_gmt":"2017-01-17T10:53:00","slug":"oddly-delightful-piece","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/oddly-delightful-piece\/2017\/01\/16\/","title":{"rendered":"Two Case Reports Worth Reading, and Enlisting Pro-Vaccine Support"},"content":{"rendered":"

\"levels-of-evidence\"<\/a>Case reports are pretty low down on the “levels of evidence” pyramid. This low status notwithstanding, when\u00a0they are well done they can illustrate\u00a0important clinical lessons, including these two:<\/p>\n

    \n
  1. A Las Vegas woman died after infection with a pan-resistant strain of Klebsiella.<\/em>\u00a0<\/a><\/strong>While CDC receives many isolates of carbapenem-resistant enterobacteriaceae (CRE), 80% are\u00a0susceptible to at least one aminoglycoside and 90% to tigecycline — not this one, which retained susceptibility only to fosfomycin (a drug not available in this country for systemic use). One critical\u00a0detail in this case was her\u00a0multiple recent hospitalizations in India related to a right femur fracture and osteomyelitis of the right femur and hip. As with this case of metronidazole-resistant Bacteroides<\/em>,<\/strong><\/a> the travel appears to be the critical exposure history. Question for those who\u00a0practice in a Travel Clinic — do you now counsel patients\u00a0about their risks of acquiring highly\u00a0resistant organisms during\u00a0travel to certain countries? Seems this risk is particularly high\u00a0with travel to Southern Asia<\/a>\u00a0— <\/strong>probably higher than many of the more exotic conditions that get more attention.<\/li>\n
  2. A man experienced a delayed diagnosis of TB meningitis due to a false-positive multiplex PCR.<\/a><\/strong>\u00a0A 75-year-old man presented\u00a0with mental status changes, and the BioFire FilmArray on the CSF was positive for HSV-1. Herpes encephalitis, case closed, right?\u00a0However, the ultimate diagnosis was tuberculous meningitis, and the HSV-1 was not\u00a0confirmed by additional PCR testing using another FDA-approved assay. Of course in hindsight, it seems clear that this wasn’t\u00a0clinically<\/em> consistent with HSV-1 encephalitis, FilmArray result notwithstanding — onset of confusion and speech difficulties was gradual, not acute; an MRI showed\u00a0no parenchymal abnormalities, unusual in someone with HSV-1 encephalitis of this duration and severity; there was a neutrophilic pleocytosis and markedly elevated CSF protein; he developed\u00a0hydrocephalus. Individually, several of these\u00a0could rarely be seen\u00a0with HSV-1 encephalitis, but together along with his clinical worsening they appropriately raised the concern that the diagnosis was\u00a0incorrect. Of course hindsight is 20-20, and the most important message in this case is not to succumb to “premature closure”<\/a><\/strong> if the clinical picture does not fit the lab test result — an especially important lesson with new testing modalities.<\/li>\n<\/ol>\n

    Now, to enlist your support for vaccines, for which there is the highest<\/em> level of evidence for efficacy and safety. At the kind invitation of Carey Goldberg<\/a>, the skillful editor of WBUR’s CommonHealth blog, I wrote a piece about the possible appointment of Robert F. Kennedy Jr. by Trump to lead\u00a0a\u00a0commission on vaccine safety and scientific integrity<\/a>.<\/p>\n

    Kennedy, you may be aware, has a\u00a0lengthy history of pushing anti-vaccine propaganda.<\/a><\/p>\n

    To you, loyal\u00a0readers of an\u00a0ID\/HIV blog, I am going to state with 99.9% confidence that you will agree with my views — but please read the piece anyway.<\/a> This debate about the risks and benefits of childhood immunizations is still (amazingly), a thing — just read the comments if you can stand it — and we need all the support we can get.<\/p>\n

    But I have a query. Here’s the NPR Facebook page<\/a>\u00a0on the piece, with one section highlighted for discussion:<\/p>\n

    \"npr<\/a><\/p>\n

    Not sure exactly what\u00a0they meant by “oddly delightful”, but I’m pretty sure it’s better than the converse\u00a0— “delightfully odd.”<\/p>\n

    Happy MLK Day.<\/p>\n

    [youtube https:\/\/www.youtube.com\/watch?v=cuAl5cMTJ7A&w=560&h=315]<\/p>\n","protected":false},"excerpt":{"rendered":"

    Case reports are pretty low down on the “levels of evidence” pyramid. This low status notwithstanding, when\u00a0they are well done they can illustrate\u00a0important clinical lessons, including these two: A Las Vegas woman died after infection with a pan-resistant strain of Klebsiella.\u00a0While CDC receives many isolates of carbapenem-resistant enterobacteriaceae (CRE), 80% are\u00a0susceptible to at least one […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3],"tags":[1149,1150,967],"class_list":["post-8277","post","type-post","status-publish","format-standard","hentry","category-health-care","tag-cre","tag-multiplex-pcr","tag-vaccines"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8277","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=8277"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8277\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=8277"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=8277"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=8277"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}