Updates: Mosquitoes and Patients with HIV; Pneumococcal Vaccination in SLE and RA; Highly Resistant GC Marches Toward U.S.
May 15, 2002 4 minutes read
Source: Greub G, et al. Clin Infect Dis. 2002;34:288-289.
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Greub and colleagues were quick to listen to their HIV-infected patients complaining that they seemed to get bitten more often by mosquitoes now than before they were HIV-positive. Intrigued, they administered a questionnaire and performed additional testing. Multivariate analysis of risk factors and disease status revealed that lipoatrophy, possibly as the result of long-term administration of antiretroviral therapy, was indeed associated with a greater risk of more frequent mosquito bites. The loss of subcutaneous fat may result in greater exposure of the underlying capillary network—in turn, resulting in a greater loss of heat and volatiles from the skin surface. A similar mechanism may occur in pregnant women, who also appear to be more attractive to mosquitoes. HIV patients, especially those with lipoatrophy, are therefore preferred mosquito targets! While this is probably more of a nuisance to patients in Northern America and Europe, it may have important implications for HIV-infected patients undergoing treatment in Africa and Asia, especially as we contemplate how to best administer antiretrovirals to patients in these countries.
Pneumococcal Vaccination in SLE and RA
Source: Elkayam O, et al. Clin Infect Dis. 2002;34:147-153.
The immunogenicity and safety of pneumococcal vaccination in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) remains controversial—the administration of tetanus and hepatitis B vaccine has reportedly preceded the development of SLE in certain cases—and concerns exit that superantigen production or other molecular mechanisms triggered by vaccination could exacerbate existing disease. Elkayam and associates administered the current 23-valent polysaccharide vaccine (Pneumovax, Merck) to 42 patients with RA and 24 patients with SLE. Clinical signs and symptoms of disease were assessed before and 2 months following vaccination. Anti-IgG levels to a panel of 7 pneumococcal polysaccharides were measured 1 month postvaccination. Seroresponse was defined as a 2-fold increase in antibody levels or an absolute increase > 1 µg/mL.
Most patients had mild disease activity before vaccination. The dosages of prednisone were similar between the 2 groups (62-69%), although the median daily dose for patients with RA was < 10 mg/dL and greater for patients with SLE.
While there was no appreciable change in disease activity post-vaccination, one third of patients with RA and 21% of patients with SLE failed to adequately respond to vaccine (response to none or one antigen). The proportion of patients responding to individual polysaccharides varied from 34% to 71% for patients with RA, and from 36% to 86% for patients with SLE.
These data suggest that, while vaccination of patients with RA and SLE is important and should be attempted, the adequacy of the response should be assessed postvaccination. For those patients who fail to mount an adequate response, repeat vaccination with either the 23-valent polysaccharide vaccine or the 7-valent conjugate vaccine may be possible within 1 year, although the relative merits of these approaches should be prospectively assessed. Whether pneumococcal vaccine is adequately immunogenic in such patients receiving higher dosages of corticosteroids require further investigation.
Highly Resistant GC Marches Toward the United States
Source: ProMED-mail post, May 10, 2002; [email protected]; MMWR Morb Mortal Wkly Rep. 2002;51(RR-6);1-80.
Multidrug-resistant strains of Neisseria gonorrhea—prevalent in East Asia for years—have finally reached Hawaii and the Mainland—resulting in a change in current treatment guidelines. The Gonococcal Isolation and Surveillance Project (GISP), coupled with similar programs in Asia and Australia, have been documenting the increasing prevalence of these MDR strains, and their march toward the US mainland for years. Fluoroquinolone strains were first detected in San Francisco in 2000, and had increased to 4.1% of cases by the end of 2001. Fluoroquinolone-resistant strains now make up 20% of cases in Hawaii. Fortunately these isolates remain sensitive to ceftriaxone, but clinicians should be aware that 3 cases of gonorrhea highly resistant to quinolones and with intermediate resistance to a cephalosporin have just been identified in San Francisco.
As a result, the CDC now cautions that fluoroquinolones should not be used to treat gonorrhea acquired in Hawaii, the Pacific, or Asia. In addition, Public Health Experts in San Francisco are recommending that GC in California be treated with agents other than fluoroquinolones. Even if patients are presenting for treatment outside of California and Hawaii, a good travel history is necessary to determine where the infection may have been acquired.
Dr. Kemper, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, is Associate Editor of Infectious Disease Alert.
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