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Quick Update: Recent Reports on MMWR (December 2018 - January 2019)

Black Tar Heroin With a Side of Botulism

  • January 4, 2019 / 67(5152);1415–1418

  • September 29–October 6, 2017 in County of San Diego

  • Two patients with suspected wound botulism and a history of using black tar heroin

  • Baseline only one a year

  • Typical signs and symptoms: muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, difficulty breathing, loss of facial expression, or descending paralysis

  • By April 2018: identified 9 patients, all hospitalized and one died

  • All 9 with history of injected drugs

  • 7 used black tar heroin

  • 6 practiced “skin popping”

  • Skin popping: injection of drugs into the skin with goal of achieving slower absorption, decreased risk of overdose, and easier administration than IV

  • All treated with heptavalent botulism antitoxin (BAT)

  • What public health labs can do per LRN (check with your jurisdiction)

  • Specimens to submit: serum, stool, gastric aspirate, tissue, environmental or food, culture isolates

  • What we do

  • Mouse bioassay

  • Culture and enrichment followed by PCR to detect toxin gene

  • More sensitive technologies being developed at the CDC

Forearm with round, depressed, hyperpigmented papules and plaques (arrows) indicative of skin popping

Human Rabies

  • January 4, 2019 / 67(5152);1410–1414

  • May 2017: Virginia Department of Health was notified regarding a patient with suspected rabies

  • History of dog bite 6 weeks before symptom onset while traveling in India

  • CDC confirmed that rabies virus from patient was the same as circulating dog strain in India

  • 9th rabies death in US since 2008

  • Post-exposure prophylaxis in healthcare workers was very costly

  • Lesson: International travelers should consult with travel health specialists and get vaccinated when suggested

  • How we test for rabies: DFA on specimens (animals, humans), PCR is being launched by the CDC

  • A significant subset of bats we tests are positive for rabies: don’t hang out with them!

Mycobacteria chimaera in the OR

  • January 4, 2019 / 67(5152);1428–1429

  • Mycobacteria chimaera: member of MAC group, challenging to diagnose since infection develops very, very slowly

  • December 2016: a hospital in Los Angeles County, California (home!) reported two Mycobacterium avium complex infections, later identified as Mycobacterium chimaera, in patients with a recent history (<5 years) of cardiopulmonary bypass surgery

  • Both procedures used Sorin Stöckert 3T (Sorin Group, Munich, Germany) heater-cooler unit brand (currently LivaNova PLC, London, United Kingdom), which have been linked to outbreaks of M. chimaera infections among patients with similar surgical histories in Europe and the United States

Don’t Get Unlawfully Marketed Stem Cell Injections!

  • December 21, 2018 / 67(50);1397–1399

  • Background: the FDA ONLY granted approval to umbilical cord blood-derived stem cells ONLY for hematopoietic and immunologic reconstitution

  • There is also no validated process for sterilization of these cells so manufacturers need to be SUPER CLEAN

  • September 2018: Texas Department of State Health Services received notification of Enterobacter cloacae and Citrobacter freundii bloodstream infections in three patients

  • All had received injections or infusions of non-FDA–approved umbilical cord blood-derived stem cell products processed and distributed by a private company for other than hematopoietic or immunologic reconstitution at an outpatient clinic

  • E. cloacae had identical PFGE patterns

  • Also in September 2018: Florida Department of Health received notification of Escherichia coli, Enterococcus faecalis, and Proteus mirabilis joint infections in four patients

  • All had received injections of these same products at an orthopedic clinic during also for other than hematopoietic or immunologic reconstitution. SURPRISE!

  • More cases in TX, FL, AZ presenting as bloodstream infections, joint infections, and epidural abscesses

  • Cultures of unopened vials demonstrated presence of these bugs

  • Suggesting pre-distribution contamination

Conjunctivitis After a Visit to an Eye Clinic

  • December 7, 2018 / 67(48);1347–1349

  • June 2017: Los Angeles County Department of Public Health (home, again!) was notified of seven patients seen at an eye care clinic earlier that month and developed epidemic keratoconjunctivitis

  • Contagious, severe form of viral conjunctivitis

  • Identified 17 patients with EKC (15 patients and 2 household contacts)

  • Found deficiencies!

  • Improper disinfection of tonometers (70% isopropanol wipes instead of soaking in chlorine or ethanol)

  • Improper use of eye drop administration among multiple patients (touching eyes or surrounding areas)

  • Human adenovirus (HAdV) type D53 (HAdV-53) identified from patient specimens

  • First report of EKC outbreak caused by HAdV-53

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