{"id":9955,"date":"2021-01-11T13:25:50","date_gmt":"2021-01-11T18:25:50","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=9955"},"modified":"2022-02-11T14:01:06","modified_gmt":"2022-02-11T19:01:06","slug":"after-ivermectin-controversy-a-covid-19-free-id-link-o-rama","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/after-ivermectin-controversy-a-covid-19-free-id-link-o-rama\/2021\/01\/11\/","title":{"rendered":"After Ivermectin Controversy, A COVID-19-Free ID Link-o-Rama"},"content":{"rendered":"<div id=\"attachment_9959\" style=\"width: 258px\" class=\"wp-caption alignright\"><a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2021\/01\/field-cricket.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-9959\" class=\"size-medium wp-image-9959\" src=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2021\/01\/field-cricket-248x300.jpg\" alt=\"\" width=\"248\" height=\"300\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2021\/01\/field-cricket-248x300.jpg 248w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2021\/01\/field-cricket.jpg 660w\" sizes=\"auto, (max-width: 248px) 100vw, 248px\" \/><\/a><p id=\"caption-attachment-9959\" class=\"wp-caption-text\">Field Cricket, from Fabre\u2019s Book of Insects (1921)<\/p><\/div>\n<p>Wow, quite the week for this country of ours. We&#8217;re all deeply saddened by the events, very hopeful that the transition in leadership will be peaceful.<\/p>\n<p>And also an eventful week for this little blog. When I wrote &#8220;<a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/ivermectin-for-covid-19-breakthrough-treatment-or-hydroxychloroquine-redux\/2021\/01\/04\/\" target=\"_blank\" rel=\"noopener noreferrer\">Enter ivermectin &#8212; and let the controversy begin<\/a>,&#8221; little did I know.<\/p>\n<p>Amazingly, this is <em>already<\/em> the second-most widely read post on this site over the past 365 days, and it&#8217;s been out less than a week. It&#8217;s closing in on number one, which came in early March &#8212; that&#8217;s when I not-so-boldly predicted we&#8217;d see a <a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/as-testing-ramps-up-diagnoses-of-coronavirus-disease-in-the-u-s-will-soon-increase-substantially-how-will-we-respond\/2020\/03\/08\/\" target=\"_blank\" rel=\"noopener noreferrer\">big increase in COVID-19 cases.<\/a> Quite the visionary, wasn&#8217;t I?<\/p>\n<p>(That was a rhetorical question.)<\/p>\n<p>Anyway, who knew this obscure antiparasitic agent would capture so much attention?<\/p>\n<p>With that controversy out of the way (ahem), allow me to return to non-COVID-19 ID\/HIV for a brief time. I&#8217;ve been doing inpatient ID consults quite a bit recently, and here are a few of the interesting things that popped up:<\/p>\n<ul>\n<li><a href=\"https:\/\/cmr.asm.org\/content\/32\/3\/e00001-19\"><strong>Hypervirulent <em>Klebsiella<\/em> <em>pneumoniae<\/em> is a nasty, nasty bug.<\/strong><\/a> In addition to liver abscesses, it frequently causes metastatic infection elsewhere, including septic arthritis, meningitis, and endophthalmitis.<\/li>\n<li><strong><a href=\"https:\/\/journals.lww.com\/ajsp\/Fulltext\/2010\/05000\/Endocervical_Adenocarcinomas_With_Prominent.18.aspx?casa_token=anyGyS3umN4AAAAA:4nK8bANlYu9ofwU-1Ei5cGNbq_J6QQrGZPu2yY8Gpij6sLvyrUqtt0Z8SdLlyVz5WUmgU3vvZkkVyckvoeFxTw\" target=\"_blank\" rel=\"noopener noreferrer\">Nodular &#8220;granulomatous&#8221; pneumocystis pneumonia is an unusual radiographic presentation of PCP<\/a>.<\/strong> Not all PCP presents with diffuse ground-glass infiltrates &#8212; and yes, I still abbreviate it PCP (<strong>P<\/strong>neumo<strong>C<\/strong>ystis <strong>P<\/strong>neumonia). Note that sputum induction and BAL may have lower sensitivity in granulomatous PCP, which will warrant other diagnostic strategies. For example &#8230;<\/li>\n<li><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC4181577\/\" target=\"_blank\" rel=\"noopener noreferrer\"><strong>A markedly elevated beta-glucan in a person with HIV and respiratory symptoms is PCP until proven otherwise.<\/strong><\/a> Disseminated <em>Talaromyces marneffei<\/em> and histoplasmosis can also greatly increase beta-glucan in people with HIV, but PCP is way more common. <em>(Should I change to saying PJP? It&#8217;s <strong>P<\/strong>neumocystis <strong>J<\/strong>irovecii <strong>P<\/strong>neumonia, after all.)<\/em><\/li>\n<li><strong><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC6763633\/\">This is also true with non-HIV related immunosuppression, where a high beta-glucan and a compatible clinical syndrome are all but diagnostic.<\/a><\/strong> Many of the &#8220;false positive&#8221; beta-glucan results are not very high, or represent testing done in low pre-test probability settings. ID fellows will recognize that fact instantly! <em>(Seems that switching to PJP is just a matter of time. Oh well. I&#8217;ll live.)<\/em><\/li>\n<li><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/19280622\/\" target=\"_blank\" rel=\"noopener noreferrer\"><strong>Prior treatment failure of hepatitis B with lamivudine may induce entecavir cross-resistance. <\/strong><\/a>This is why it&#8217;s so critical that our heavily treatment-experienced patients with HIV\/HBV receive tenofovir-based regimens &#8212; many received lamivudine for years before we knew about this issue of HBV cross-resistance.<\/li>\n<li><a href=\"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmicb.2015.00893\/full\"><strong>The preferred treatment of <em>Stenotrophomonas maltophilia<\/em> is TMP\/SMX.<\/strong><\/a> Optimal dosing is unclear, though our crack ID pharmacy team recommend 12 mg\/kg\/day of the TMP component. (12? Not 10 or 15?) And yes, this is one of those fabulous ID tongue-twister bugs &#8212; one of the more common ones.<\/li>\n<li><a href=\"https:\/\/onlinelibrary.wiley.com\/doi\/full\/10.1111\/hiv.12402\"><strong>TMP\/SMX is probably as effective as pyrimethamine plus sulfadiazine for CNS toxoplasmosis.<\/strong> <\/a>Certainly it&#8217;s <em>way<\/em> less expensive (pyrimethamine, ouch), and much easier to take. It&#8217;s already standard of care in most of the rest of the world. Will <strong><a href=\"https:\/\/clinicalinfo.hiv.gov\/en\/guidelines\/adult-and-adolescent-opportunistic-infection\/toxoplasma-gondii-encephalitis?view=full\" target=\"_blank\" rel=\"noopener noreferrer\">our HIV opportunistic infection guidelines<\/a><\/strong> make this the case here in the USA as well? At least list it side-by-side with pyrimethamine and sulfadiazine, rather than listing it as an alternative?<\/li>\n<li><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3111523\/\" target=\"_blank\" rel=\"noopener noreferrer\"><strong>Intramedullary spinal cord abscess is a rare CNS infection that may be complicated by spinal artery occlusion.<\/strong> <\/a>This review notes that 40% are cryptogenic, 20% come from a dermal sinus, and 20% from bacteremia. High incidence of permanent neurologic sequelae.<\/li>\n<li><a href=\"https:\/\/www.acpjournals.org\/doi\/10.7326\/0003-4819-123-5-199509010-00006?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub%20%200pubmed\" target=\"_blank\" rel=\"noopener noreferrer\"><strong>Hair loss is a well-recognized complication of prolonged fluconazole use. <\/strong><\/a>Anecdotally I&#8217;ve seen this most commonly in those being treated for candida endocarditis, cryptococcal meningitis, and osteomyelitis. I&#8217;m sure it&#8217;s true for coccidioides, too, but we don&#8217;t see much of that in Boston. It slowly improves after stopping therapy, or decreasing the dose. In a similar theme &#8230;<\/li>\n<li><a href=\"https:\/\/link.springer.com\/article\/10.2165\/00002018-199818060-00004\" target=\"_blank\" rel=\"noopener noreferrer\"><strong>Blue skin is a well-recognized complication of prolonged minocycline use.<\/strong><\/a> Most cases do resolve over time after cessation of the drug, but sometimes it can be permanent. And it&#8217;s not just the skin &#8212; here&#8217;s a <strong><a href=\"https:\/\/academic.oup.com\/ofid\/article\/2\/4\/ofv129\/2460293?searchresult=1\">blue aorta!<\/a><\/strong><\/li>\n<li><a href=\"https:\/\/www.bmj.com\/content\/364\/bmj.l525?ijkey=3cb303a54a094c06532c4dfd4bf995fd13a785fc&amp;keytype2=tf_ipsecsha\" target=\"_blank\" rel=\"noopener noreferrer\"><strong>While UTIs in older adults no doubt are overdiagnosed (and overtreated), this paper hints that undertreatment may be a problem too.<\/strong><\/a> The problem is that assessing whether positive urine cultures are symptomatic &#8212; especially in older adults with cognitive impairment and multiple comorbidities &#8212; is an enormous challenge.<\/li>\n<li><a href=\"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2771521\" target=\"_blank\" rel=\"noopener noreferrer\"><strong>Oral beta-lactam antibiotics might be a reasonable option for treating gram-negative bacteremia after all.<\/strong> <\/a>The dogma has always been to use a fluoroquinolone or TMP\/SMX. This study suggests beta-lactams may be a good option, provided it&#8217;s a urinary source and that initial treatment is parenteral.<\/li>\n<li><a href=\"https:\/\/academic.oup.com\/jac\/article\/68\/8\/1894\/867974\"><strong>Penicillin-susceptible <em>Staph aureus<\/em> can be treated with penicillin &#8212; provided the microbiology laboratory confirms it&#8217;s truly sensitive.<\/strong><\/a> The critical thing is that the lab does this testing &#8212; some don&#8217;t. Anecdotally, penicillin is better tolerated than nafcillin and oxacillin, too.<\/li>\n<li><strong><a href=\"https:\/\/academic.oup.com\/cid\/article\/68\/2\/338\/5050260\">Should osteomyelitis complicating sacral pressure ulcers be treated with antibiotics?<\/a><\/strong> Generally no, argues this persuasive paper. And this question comes up <em>all the time<\/em> on inpatient ID services.<\/li>\n<li><a href=\"https:\/\/academic.oup.com\/jid\/advance-article\/doi\/10.1093\/infdis\/jiaa669\/5940424\" target=\"_blank\" rel=\"noopener noreferrer\"><strong>Certain clinical and laboratory features are predictive of immune reconstitution inflammatory syndrome (IRIS) due to <em>M. avium<\/em> complex (MAC) in people with HIV.<\/strong><\/a> This contemporary series cites low body mass, low hemoglobin, and elevated alkaline phosphatase as readily available predictors. Note that the literature on management of HIV-related MAC IRIS is badly out of date. When should steroids be started? How long should they be continued? What are the side effects? A good project for a large cohort study.<\/li>\n<\/ul>\n<p>Many thanks to ID fellows Drs. Susan Stanley, Alex Tatara, and Zach Nussbaum for providing some of these references. And remember all you fellows out there, you&#8217;re more than halfway done with your first year of fellowship!<\/p>\n<p>For next week? Maybe I&#8217;ll write about albendazole. Or praziquantel. Or nitazoxanide. Or some other antiparasitic agent. They seem to be quite popular!<\/p>\n<p>Or maybe I&#8217;ll just watch this baby bear playing on this golf green.<\/p>\n<p><iframe loading=\"lazy\" title=\"Baby Bear Circus Act on Golf Course - At Fairmont Hot Springs Resort, BC\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/kMkWuXk11Uk?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Wow, quite the week for this country of ours. We&#8217;re all deeply saddened by the events, very hopeful that the transition in leadership will be peaceful. And also an eventful week for this little blog. When I wrote &#8220;Enter ivermectin &#8212; and let the controversy begin,&#8221; little did I know. Amazingly, this is already the [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,4,5,8],"tags":[565],"class_list":["post-9955","post","type-post","status-publish","format-standard","hentry","category-health-care","category-hiv","category-infectious-diseases","category-patient-care","tag-link-o-rama"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/9955","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=9955"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/9955\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=9955"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=9955"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=9955"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}