Extragenital chlamydia infection among active-duty women in the United States Navy.

BACKGROUND: Pharyngeal and anorectal reservoirs of gonorrhea (GC) and chlamydia (CT) are increasingly recognized among heterosexual women. While a number of studies performed at sexually transmitted disease (STD) clinics have found a high prevalence of extragenital GC/CT infection, such screening is typically not offered during routine primary care visits for women. We sought to define the prevalence of and factors associated with extragenital GC/CT among women in the U.S. Navy. METHODS: We recruited servicewomen stationed in San Diego, California, between the ages of 18 and 25 who presented for an annual physical exam between January and September, 2017. Nucleic acid amplification testing was performed on swabs collected at endocervical, oropharyngeal and anorectal sites to assess the presence of GC/CT. An anonymous behavioral questionnaire was also administered to characterize sexual risk. Descriptive statistics were used to compare women with and without a prior history of any sexually transmitted infection (STI) (self-report) along with a current GC/CT diagnosis. This study was approved by the Institutional Review Board of the Uniformed Services University of Health Sciences. RESULTS: Of the 75 patients who were approached, 60 subjects were enrolled in the study, including white 20 (33.3%), black/African American 18 (31.0%), Hispanic/Latina 13 (21.7%) and Asian/Pacific Islander 9 (15.5%) women. Among all the women, six (10.0%) were diagnosed with CT infection, all via endocervical exam. Of these, five (8.3%) had concurrent anorectal infection, including two cases (3.3%) accompanied by pharyngeal infection. Of the subjects, 15 (25.0%) reported anal intercourse in their most recent sexual encounter, most of which was condomless (13/15, 86.7%). A high number of women who reported sex with a casual male partner (19/45, 42.2%) reported rarely or never using condoms; last, 41.7% consuming at least 3 drinks on a typical drinking day, and one-third of the reported drinking more than once per week. CONCLUSIONS: We found a high prevalence of anorectal CT infection, although no infections were detected without concurrent endocervical involvement. Nonetheless, the high prevalence of condomless anal intercourse reported by participants argues for further study and ongoing consideration of extragenital screening among high-risk patients. Behavioral interventions are also warranted given the high prevalence of sexual and related risk factors.

Primary Care of Men Who Have Sex With Men in the U.S. Military in the Post-Don't Ask, Don't Tell Era: A Review of Recent Progress, Health Needs, and Challenges.

BACKGROUND: With repeal of "Don't Ask, Don't Tell" (DADT) in 2011 and the Supreme Court decision regarding Section 3 of the Defense of Marriage Act (DOMA) in 2013, military providers are now able to openly address unique health needs of lesbian, gay, and bisexual (LGB) service members and their same-sex spouse beneficiaries. These federal laws created health care barriers, either real or perceived, between providers and patients and often limited medical research involving LGB patients in the Military Health System (MHS). Men who have sex with men (MSM), the largest proportion of LGB service members, represent a segment of the population with the highest risks for disparities in primary care with regard to sexual health and mental health disorders. We provide a review of available research about this military population, in addition to a review of specific health care needs of the MSM patient in order to aid the primary care provider with screening, testing, and counseling. METHODS: A structured literature search was conducted to identify recent literature pertaining to health needs of U.S. military MSM service members. In addition, a review of applicable clinical guidelines, Department of Defense policies, and expert opinion was used to identify areas of particular relevance. FINDINGS: There is little published to characterize the MSM population and their health needs as beneficiaries of the MHS. Only recently have directed assessments of the active-duty MSM patient population been pursued in the post-DADT, DOMA era. Unique needs of the MSM patient identified center around both sexual and mental health, disparities that are paralleled within the nonmilitary MSM population. Population-specific epidemiology driving risk for sexually transmitted illnesses, substance abuse, and mental health disorders are identified and used to inform preventive medicine recommendations for the MSM patient. In addition, resources on MSM health for the health provider are included. DISCUSSION/IMPACT/RECOMMENDATION: The MHS at large now openly serves the MSM population and is making progress toward addressing their unique health needs. Despite ongoing challenges to address remaining disparities, MSM patients, beneficiaries, and primary providers are now more able to have frank, open discussions about specific health needs of this minority segment of the U.S. military without fear of reprisal.

Self-administration of intranasal influenza vaccine: Immunogenicity and volunteer acceptance.

BACKGROUND: In outbreak settings, mass vaccination strategies could maximize health protection of military personnel. Self-administration of live attenuated influenza vaccine (LAIV) may be a means to vaccinate large numbers of people and achieve deployment readiness while sparing the use of human resources. METHODS: A phase IV, open-label, randomized controlled trial evaluating the immunogenicity and acceptance of self-administered (SA) LAIV was conducted from 2012 to 2014. SA subjects were randomized to either individual self-administration or self-administration in a group setting. Control randomized subjects received healthcare worker-administered (HCWA) LAIV. Anti-hemagglutinin (HAI) antibody concentrations were measured pre- and post-vaccination. The primary endpoint was immunogenicity non-inferiority between SA and HCWA groups. Subjects were surveyed on preferred administration method. RESULTS: A total of 1077 subjects consented and were randomized (529 SA, 548 HCWA). Subject characteristics were very similar between groups, though SA subjects were younger, more likely to be white and on active duty. The per-protocol analysis included 1024 subjects (501 SA, 523 HCWA). Post-vaccination geometric mean titers by vaccine strain and by study group (HCWA vs. SA) were: A/H1N1 (45.8 vs. 48.7, respectively; p=0.43), A/H3N2 (45.5 vs. 46.4; p=0.80), B/Yamagata (17.2 vs. 17.8; p=0.55). Seroresponses to A components were high (∼67%), while seroresponses to B components were lower (∼25%). Seroresponse did not differ by administration method. Baseline preference for administration method was similar between groups, with the majority in each group expressing no preference. At follow-up, the majority (64%) of SA subjects preferred SA vaccine. CONCLUSIONS: LAIV immunogenicity was similar for HCWA and SA vaccines. SA was well-tolerated and preferred to HCWA among those who performed SA.

Prevalence and factors associated with asymptomatic gonococcal and chlamydial infection among US Navy and Marine Corps men infected with the HIV: a cohort study.

OBJECTIVES: Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) can facilitate transmission of HIV. Men who have sex with men (MSM) may harbour infections at genital and extragenital sites. Data regarding extragenital GC and CT infections in military populations are lacking. We examined the prevalence and factors associated with asymptomatic GC and CT infection among this category of HIV-infected military personnel. DESIGN: Cross-sectional cohort study (pilot). SETTING: Infectious diseases clinic at a single military treatment facility in San Diego, CA. PARTICIPANTS: Ninety-nine HIV-positive men were evaluated-79% men who had sex with men, mean age 31 years, 36% black and 33% married. INCLUSION CRITERIA: male, HIV-infected, Department of Defense beneficiary. EXCLUSION CRITERIA: any symptom related to the urethra, pharynx or rectum. PRIMARY OUTCOME MEASURES: GC and CT screening results. RESULTS: Twenty-four per cent were infected with either GC or CT. Rectal swabs were positive in 18% for CT and 3% for GC; pharynx swabs were positive in 8% for GC and 2% for CT. Only one infection was detected in the urine (GC). Anal sex (p=0.04), male partner (OR 7.02, p=0.04) and sex at least once weekly (OR 3.28, p=0.04) were associated with infection. Associated demographics included age <35 years (OR 6.27, p=0.02), non-Caucasian ethnicity (p=0.03), <3 years since HIV diagnosis (OR 2.75, p=0.04) and previous sexually transmitted infection (STI) (OR 5.10, p=0.001). CONCLUSIONS: We found a high prevalence of extragenital GC/CT infection among HIV-infected military men. Only one infection was detected in the urine, signalling the need for aggressive three-site screening of MSM. Clinicians should be aware of the high prevalence in order to enhance health through comprehensive STI screening practices.

Postpartum herpes simplex virus endometritis and disseminated infection in both mother and neonate.

BACKGROUND: Herpes simplex virus (HSV) is an unusual cause of postpartum endometritis. We describe a rare case of primary disseminated maternal HSV in the postpartum period associated with endometritis. CASE: A previously healthy patient developed fundal tenderness and postpartum fevers after an uncomplicated vaginal delivery. Despite traditional broad-spectrum antimicrobial therapy, she had persistent fevers and systemic symptoms. Concurrently, her neonate developed fevers and a nonvesicular rash, with viral cultures ultimately returning positive for HSV. The patient developed active pharyngeal and genital herpetic lesions and was diagnosed with HSV endometritis and disseminated HSV. Symptoms and fevers in both the mother and neonate responded to antiviral therapy. CONCLUSION: Herpes simplex virus endometritis should be included in the differential diagnosis for postpartum fevers and fundal tenderness that are unresponsive to broad-spectrum antimicrobial treatment.

E. coli O157:H7 and other toxigenic strains: the curse of global food distribution.

It is estimated that there are approximately 76 million illnesses, 325,000 hospitalizations, and 5,200 deaths in the US each year attributed to foodborne outbreaks with a total cost of 10-83 billion US dollars a year. While the rates of foodborne disease have remained relatively constant over the last few years, there have been large outbreaks associated with either a component of commercially prepared food or outbreaks that span between states or even countries. With the world population expecting fresh produce year round, organic produce, and exotic foods, these global outbreaks have the potential to increase in number and severity. There needs to be a means to both rapidly identify these outbreaks, screen our food supply, as well as prevent these outbreaks. This article will discuss the global nature of this problem associated with our food and water supply as well as explain potential ways to solve this international problem.

Gonorrhoea or chlamydia in a U.S. military HIV-positive cohort.

OBJECTIVES: To investigate the epidemiology and risk factors of gonorrhoea (GC) or chlamydia (CT) coinfection in an HIV-positive US military cohort, focusing on the time after participants' knowledge of HIV diagnosis. METHODS: The authors analysed data from 4461 participants enrolled in the U.S. Military Natural History Study cohort for GC or CT infection ≥6 months after their HIV-positive test. RESULTS: During a mean follow-up of 7.08 years, 482 (11%) participants acquired a GC or CT infection. Of these, 283 (6%) acquired a GC infection, 278 (6%) acquired a CT infection and 123 (3%) had multiple GC or CT infections during follow-up. Risk of GC or CT infection was significantly greater in those younger, male, African-American and with a history of GC or CT infection. CONCLUSIONS: Frequent GC and CT diagnoses observed among members of this HIV-positive cohort indicate substantial ongoing risk behaviours that raise concerns for HIV transmission and underscore the need for continued screening to help identify and treat these sexually transmitted infections in this population.

Delayed lower urinary tract symptoms and erectile dysfunction after acute episode of coccidioidal meningitis.

We present an interesting case of a 27-year-old male with coccidioidal meningitis who developed permanent erectile dysfunction (ED) and lower urinary tract symptoms 3 months after initiation of therapy. The patient presented to the urology clinic with a complaint of a weak stream, urinary urgency and frequency, as well as enuresis which were only moderately controlled with anti-cholinergics. His ED responded well to phosphodiesterase-5 inhibitors. After an extensive review of the literature, this is the first report of delayed presentation of ED and lower urinary tract symptoms secondary to coccidioidal meningitis.

Hand infections.

Hand infections are commonly seen by orthopedic surgeons as well as emergency room and primary care physicians. Identifying the cause of the infection and initiating prompt and appropriate medical or surgical treatment can prevent substantial morbidity. The most common bacteria implicated in hand infections remain Staphylococcus aureus and Streptococcus species. Methicillin-resistant S aureus infections have become prevalent and represent a difficult problem best treated with empiric antibiotic therapy until the organism can be confirmed. Other organisms can be involved in specific situations that will be reviewed. Types of infections include cellulitis, superficial abscesses, deep abscesses, septic arthritis, and osteomyelitis. In recent years, treatment of these infections has become challenging owing to increased virulence of some organisms and drug resistance. Treatment involves a combination of proper antimicrobial therapy, immobilization, edema control, and adequate surgical therapy. Best practice management requires use of appropriate diagnostic tools, understanding by the surgeon of the unique and complex anatomy of the hand, and proper antibiotic selection in consultation with infectious disease specialists.

Escherichia coli O157: what every internist and gastroenterologist should know.

Infections with Escherichia coli O157:H7 have gained media attention in recent years because of cases associated with unusual sources (eg, produce and swimming pools). Although most adults recover without sequelae, children and the elderly are more likely to develop complications (eg, hemolytic uremic syndrome and death). The diagnosis typically has been made by culture; however, newer hand-held immunoassays and polymerase chain reaction technology have led to more rapid detection of this important pathogen in stools, food, and water. Treatment is largely supportive; nonetheless, new methods to neutralize or bind toxin, such as probiotics, monoclonal antibodies, and recombinant bacteria, are showing promise to treat patients infected with E. coli O157:H7. The role of antibiotics in relation to this condition remains unclear.

Unusual presentations of coccidioidomycosis: a case series and review of the literature.

Coccidioidomycosis is an emerging fungal infection of the southwestern United States. Although Coccidioides species infections are usually asymptomatic or result in a mild, flu-like illness, disseminated disease may occur in 1% of cases. While extrapulmonary disease usually involves the skin, central nervous system, bones, or joints, coccidioidomycosis is a great imitator, with the ability to infect any tissue or organ. Cases may be diagnosed outside of endemic areas, hence providers worldwide should be aware of the broad range of manifestations of coccidioidomycosis. We present a case series of unusual presentations of coccidioidomycosis including serous cavity infections with cases of pericarditis, empyema, and peritonitis, as well as unusual abscesses involving the retropharyngeal space and gluteal musculature. We provide a complete review of the literature and summarize the clinical presentations, diagnoses, and treatments of these rare forms of disseminated coccidioidomycosis.

History of U.S. military contributions to the study of rickettsial diseases.

Rickettsial diseases have affected the military throughout history. Efforts such as those of the Joint U.S. Typhus Commission near the beginning of World War II and of military researchers since have reduced the impact of these diseases on U.S. and Allied forces. Despite the postwar development of effective antibiotic therapies, the newly emerging antibiotic-resistant scrub typhus rickettsial strains of the Asian Pacific region mandate continued research and surveillance. Similarly, tick-infested training areas in the United States and similar exposure abroad render the spotted fevers and the ehrlichioses problematic to deployed troops. The military continues to work on countermeasures to control the arthropod vectors, as well as actively participating in the development of rapid accurate diagnostic tests, vaccines, and improved surveillance methods. Several rickettsial diseases, including epidemic typhus, scrub typhus, the ehrlichioses, and the spotted fevers, are reviewed, with emphasis on the military historical significance and contributions.

Neutropenic enterocolitis.

Neutropenic enterocolitis is an acute syndrome characterized by cecal and ascending colon inflammation that may progress to necrosis and perforation. It is most often associated with leukemia but has also been described in patients with solid tumors, multiple myeloma, aplastic anemia, AIDS, and cyclic neutropenia. Medical management usually suffices, but surgical intervention may be required.