Updates
By Carol A. Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, Section Editor, Updates; Section Editor, HIV, is Associate Editor for Infectious Disease Alert.
Honeymoon Meningitis?
Agouridakis P, et al. "Honey Moon" Meningitis. Emerg Med J. 2005;22:803-804.
These authors report on the unique presentation of a 17-year-old previously healthy woman who developed acute onset fever, headache, nausea, and vomiting. Lumbar puncture confirmed a cerebrospinal fluid pleocytosis, and blood and CSF (but not urine) cultures yielded Group B streptococcus (S. agalactiae). Further investigation for a possible source found no evidence of intraabdominal abscess, endometritis, or endocarditis. Tests for HIV antibody and serum immune globulins were unremarkable.
The young woman admitted to having had vaginal intercourse for the first time only 2 days before the onset of symptoms. Vaginal cultures yielded a Group B streptococcus with a similar susceptibility profile to the blood and CSF isolates, suggesting the vaginal flora may have been the source for her bacteremia and meningeal seeding. (No comment was made regarding the type of sexual activity or whether there was any trauma). The organism was resistant to ceftriaxone. The patient fully recovered with 15 days of vancomycin therapy.
Group B strep rarely causes meningitis in otherwise healthy non-pregnant adults. In a review of 50 patients with Group B strep meningitis, 20% had endometritis, 8% had endocarditis, and 6% had urinary tract infection; 60% had no identifiable source.
Sharing HCV With Your Best Friend
Daniel AR, Sheha T. Transmission of Hepatitis C Through Swapping Body Jewelry. Pediatrics. 2005;116:1264-1265.
This author reports the unique presentation of a previously healthy 17-year-old with newly diagnosed HCV infection. The patient was a regular blood donor, along with her mother, and tested negative for HCV antibody on several prior occasions. At the age of 17, with the permission of her mother who accompanied her to a reputable salon, she got a single umbilical piercing. Six months later, she again tested negative for HCV. However, 16 months following her body piercing, blood tests revealed evidence of HCV antibody, with confirmation of an uncommon genotype (genotype 3c), found in only 3-5% of those with HCV infection.
The young woman denied any high risk activities. She had a single sexual partner who tested negative for HCV. It turns out that many young teenagers and college-aged women commonly swap body jewelry. The young woman had frequently swapped her umbilical ring for a friend’s jewelry. Unfortunately, the friend had several risk factors for HCV infection (including the use of intranasal cocaine, sharing straws, and multiple sexual partners) and tested positive for HCV genotype 3a. This case report suggests that transmission of HCV (and presumably other blood born pathogens, such as HIV and HBV) can occur when swapping body jewelry. While some umbilical, nipple, and eyebrow rings are semi-permanent and can not be easily removed, young people with removal rings should be counseled to avoid sharing.
The Hazards of Adult Sex Filming
CDC. HIV Transmission in the Adult Film Industry—Los Angeles, California. MMWR Morb Mortal Wkly Rep. 2005;54:923-926.
This article is a surprise to read for no other reason than that the Division of Occupational Health and Safety (Cal/OSHA) now monitors the adult film industry as part of its responsibilities under the California Department of Industrial Relations (no pun intended). The adult film industry encompasses about 200 production companies in Los Angeles County with an estimated 1200 actors and actresses who engage in sex acts for the camera. As can be imagined, many of these individuals engage in high risk sexual activity with multiple partners for prolonged periods of time, without the use of condoms or other protection. The Adult Industry Medical Health Care Foundation, a private not-for-profit organization, located in Los Angeles, has provided HIV and STD testing for adult film workers since 1998. The service is entirely voluntary, and many of the actors/actresses pay for the screening tests out of pocket, although the practice is encouraged by their production companies and the test results are generally shared among employees and employers.
In April 2004, the Los Angeles County Department of Health Services requested Cal/OSHA assistance in the investigation of 4 newly diagnosed cases of HIV infection in heterosexual adult film industry workers. The index case was a 40-year-old male who tested HIV negative on 2/12/04 and 3/17/04, but tested positive on 4/9/04 (using the Amplicor™ HIV-1 Detection Kit, Roche Diagnostics). Between the 2 negative tests, he traveled to Brazil, where he participated in a number of unprotected sexual acts during movie production. He also developed flu symptoms while working in Brazil. Upon returning to LA, he continued to work, engaging in sex with 13 different female partners. During this period, the index case denied any sex partners outside of work (an interesting twist on the usual desire to avoid taking your work home).
Three of the 13 women, each of whom had tested HIV negative within the previous 30 days, subsequently tested HIV-positive, for an attack rate of 23%. All 3 had engaged in sexual acts with an increased risk of mucosal tears, 2 on the same day and within 7 days of his final negative test. One of the women had just arrived in Los Angeles and was barely 20 years old, and had just started working in the adult film industry weeks earlier. Specimens from the index case and 2 of the women were available for HIV DNA sequencing of regions of the gag and env genes, which convincingly demonstrated that the index patient was the source of infection for at least 2 of the women. Following identification of these cases, 25 first-generation sex partners and 36 second-generation sex partners received counseling and HIV testing; none have thus far tested HIV-positive.
Clearly the index case, who tested negative only a week before contact with 2 of the women, was able to transmit virus before the PCR test was able to detect it. Although the PCR test is highly sensitive, it is not as specific, and is not approved for diagnostic testing. The lesson learned from this case is that individuals engaging in frequent high risk sexual activity, who may have been depending on a potential sex partner’s negative test result, should be aware of the small risk that recent infection may escape detection, at least for a few days. The eclipse period between exposure and a positive PCR plasma test is estimated to average 10-15 days (but may be longer in some), and the window period, which is the time to a positive antibody test, may be an additional 10-15 days.
Cal/OSHA responded to this event by issuing citations to 2 production companies for failing to provide prompt reporting of a serious work-related injury, by failing to provide a written policy for occupational injury and illness prevention to workers, and by failing to adhere to Cal/OSHA Bloodborne Pathogens Standards. Apparently, if the adult film production companies encouraged testing and were aware of the results, then they should also be responsible for appraising employees of the risks, and encourage barrier protection to prevent exposure to hazardous or infectious substances, just like another California employer. The film industry is appealing the ruling. Somehow the State electing to fine the adult film industry at this juncture, just as they are making attempts to encourage screening for HIV and STDs and reduce exposure risks, seems a bit like a double-bind.
Raw Camel Liver Plague
Bin Saeed AA. Plague From Eating Raw Camel Liver. Emerg Infect Dis. 2005;11:1456-1457.
Four residents of Goriat, in a desert area of Saudi Arabia, were admitted with fever and severe pharyngitis and tonsillitis. Three had dysphagia and tender submandibular lymphadenitis. The initial presumptive diagnosis was diphtheria. Two died, one with hemorrhagic manifestations. Blood cultures were positive for Yersinia pestis.
Investigators found that members of 11 families, comprising 106 individuals, had shared the meat of a camel that had been butchered. The camel had been ill. The man who had slaughtered the camel (not one of the 4 cases above) subsequently developed plague with cellulites of his arm (which he had cut) and axillary buboes. Six individuals ate the raw liver of the camel and 4 developed plague pharyngitis. None who ate only cooked meat or liver were affected (except for the butcher). Y. pestis was isolated from leftover camel meat, from nearby jirds, small desert rodents related to gerbils, and from fleas combed from the jirds.
Of interest, the possibility of plague as the cause of the pharyngitis was first considered by a local preventive medicine specialist who had seen similar cases in years before. It is also of interest that almost one-half of domestic plague-infected cats in New Mexico, who presumably acquired the disease by eating infected prey, had submandibular lymphadenitis. This episode contains 2 lessons. First—plague may result from ingestion of meat or viscera removed from infected animals. Second—do not eat raw liver removed from the carcasses of sick camels.
These authors report on the unique presentation of a 17-year-old previously healthy woman who developed acute onset fever, headache, nausea, and vomiting. Lumbar puncture confirmed a cerebrospinal fluid pleocytosis, and blood and CSF (but not urine) cultures yielded Group B streptococcus (S. agalactiae).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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