Updates-By Carol A. Kemper, MD, FACP
Updates-By Carol A. Kemper, MD, FACP
Med Students With a Bad Headache?
Source: ProMED-mail postings May 4, 5, & 11, 2000; www.promedmail.org.
Eight people, including five first-year medical students from Northwestern University, have been hospitalized with eosinophilic meningitis due to Angiostrongylus cantonensis. The pa-tients were part of a larger group of 22 first-year medical students and their relatives and friends who traveled to Jamaica in early April, 10 of whom developed symptoms of meningitis within 5-20 days of returning stateside.
This report was a surprise to me—A. cantonensis, commonly known as the rat lungworm, had been endemic to Southeast Asia, the Western Pacific, and Hawaii.
As the result of rats hitching free rides on cargo transport ships, the parasite has since spread to Africa, India, Australia, North America, and the Carribean. Human cases have been reported in Puerto Rico and Cuba, as well as in New Orleans, and 20% of the wharf rats in New Orleans are apparently now infected. The parasite is transmitted to humans via snails or slugs, which act as intermediate hosts for larvae excreted by an infected rat, or through raw or undercooked vegetables or leafy lettuces contaminated by slugs or mollusks. Fish, prawns, and crabs that eat infected snails can also be infectious. Of note, the only shared meal for the group of students was a large caesar salad at an exclusive restaurant in Montego Bay.
While the infection is generally self-limited, symptoms can be severe, with a duration of up to several weeks. Severe infections can occasionally result in permanent neurologic deficits or death. Symptoms include altered mental status, weakness and paralysis, visual symptoms and optic atrophy; 5% of cases are reported to cause Bell’s palsy. CSF eosinophilia can range from 25-100%. While A. cantonensis, like other helminths, is susceptible to mebendazole (and presumably albendazole), it is not clear whether the acute inflammatory response in response to treatment may worsen the outcome. The third world just seems to get closer to home every day.
Paris is Burning: Part II
Source: MMWR Morb Mortal Wkly Rep 2000;49:317-320.
Some of you may have seen the documentary "Paris is Burning" about groups of transgender males who form closely knit social networks, or "houses" (although they do not necessarily live together), and who participate in runway fashion competitions called "balls." Public health investigators are reporting an outbreak of tuberculosis (TB) within such transgender networks in Baltimore and New York City, with the potential for spread to similar networks in other major urban areas.
Beginning in May 1998, active TB was diagnosed in four young black transexual men, all of whom were HIV-positive and worked as prostitutes in the Baltimore area. Further investigation revealed that the men were part of a network of transgenders in Baltimore, many of whom traveled to New York and other cities to compete in balls. By identifying members of the network, 22 additional cases of TB in Baltimore and New York were eventually identified. Twenty-four of the 26 cases were confirmed by culture, and 23 had an identical DNA fingerprint.
Remarkably, standard contact tracing, whereby case-patients named contacts, was insufficient, resulting in the identification of only 14 individuals at risk. Rather, health officials were able to identify and screen an additional 91 contacts by developing profiles of the social networks, tracking individuals and their activities, doing home-based investigation, and by attending some of the actual balls and social events. Through these more intensive efforts, it was also determined that several case-patients had traveled to New York, as well as other cities on the East Coast, to compete in balls. DNA fingerprinting of TB organisms from young black men in New York City found four additional cases that matched the Baltimore strain. Because all TB isolates in New Jersey are typed, an additional case matching the Baltimore cases was identified. That patient was a young transexual who had traveled frequently to Baltimore to participate in balls.
Several points can be made regarding this outbreak. It occurred among a group of young, highly mobile men who exist within a poorly understood, but closely knit social network of other transgenders. Many were HIV-infected, increasing the risk for active TB and transmission of disease. Many were commercial sex workers, raising the potential for wide-spread transmission of infection. Finally, standard case identification was inadequate in determining the extent of the outbreak. Instead, a sophisticated blend of laboratory investigation through DNA strain typing in concert with psychosocial/behavioral investigation necessitating a greater understanding of the social behaviors of this community was required.
There is a parallel between this investigation and the current investigation in San Francisco of an internet-based outbreak of syphilis among anonymous sex contacts. How do you trace potential contacts who exist in the demimonde, known only by their call-name or internet handle? Successful investigations like these are increasing requiring an understanding of behaviors of these groups of individuals, which requires time-consuming and costly efforts on the part of individuals in local health departments manning the front lines of public health. State officials should keep these outbreaks in mind when evaluating public health budgets.
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