Hemophagocytic Lymphohistiocytosis Secondary to Unknown Underlying Hodgkin Lymphoma Presenting with a Cholestatic Pattern of Liver Injury.

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon disease that often presents with nonspecific findings. A high index of suspicion is necessary to make a prompt diagnosis and prevent fatal disease. A 45-year-old man presented with fever, hypotension, abdominal pain, nausea, and vomiting. Imaging showed hepatosplenomegaly and laboratory tests revealed pancytopenia, increased ferritin, and a cholestatic pattern of injury with elevated alkaline phosphatase and total bilirubin. Due to a history of Crohn disease, systemic lupus erythematous, and rheumatoid arthritis, the patient was on immunosuppressants, including infliximab. After multiple negative cultures, persistent fever, and days of empiric broad spectrum antibiotics, our differential shifted to fever of unknown origin. A liver wedge biopsy revealed areas of sinusoidal dilatation with enlarged, activated macrophages containing erythrocytes and intracytoplasmic iron, consistent with hemophagocytosis due to HLH. The portal tracts showed mixed lymphoplasmacytic inflammation, a prominent bile ductular reaction, periportal fibrosis, and scattered large cells with occasional binucleation and prominent nucleoli. These cells stained positive for Epstein-Barr virus encoding region in situ hybridization, PAX5, CD15, and CD30, and hepatic involvement by classic Hodgkin lymphoma was diagnosed and determined to be the cause of the HLH and cholestatic pattern of injury. Simultaneously, a bone marrow biopsy showed diffuse involvement by Hodgkin lymphoma with a similar staining pattern. Aggressive treatment failed and the patient succumbed to multiorgan failure. HLH is a rare, potentially fatal disease, with nonspecific signs and symptoms, and should be considered in any patient presenting with fever and pancytopenia, especially if they are immune compromised.

Disease surveillance and emergency services at the 1982 World's Fair.

We designed a special surveillance system to detect health complaints of visitors to the 1982 World's Fair. Heat-related illness occurred during the first month of the Fair but was substantially reduced by public education, environmental modification, and provision of additional water fountains. There was no disruption of emergency health services in the communities surrounding the Fair. Advance planning and the provision of on-site medical services can minimize the public health impact of large gatherings.

Survey of tampon use and toxic shock syndrome, Tennessee, 1979 to 1981.

Thirty-eight cases of toxic shock syndrome were reported in Tennessee between January 1, 1979, and March 31, 1981. Thirty-one of these cases (82%) occurred in white women less than 30 years of age; none occurred in black women. We suspected that age and racial differences in tampon use could contribute to the relatively high risk of toxic shock syndrome in young white women. In March, 1981, we surveyed 1,136 Tennessee women regarding their past and current used of tampons. Age and race were related, not only to whether or not tampons were used but to the way tampons were used. "Continuous" tampon use during the most recent menstrual period was most common among young white women (61%), less common among older white women (42%), and least common among black women (23%). On the other hand, the brands, absorbency types, numbers, and usage patterns did not vary greatly with respect to age or race. Comparing each woman's tampon habits in March, 1981, with her usual habits in June, 1980, suggested a striking effect of publicity about the toxic shock syndrome. We estimate that 23% to 39% of the women surveyed changed their tampon habits in an attempt to reduce their risk of toxic shock syndrome.

A statewide characterization of hospital infection control practices and practitioners.

Selected features of infection control programs among the 163 general hospitals in Tennessee were surveyed in 1976 and 1979. Each hospital but one had a designated infection control practitioner. Three-fourths of the hospitals had fewer than 200 beds and most were in rural areas. The practitioners in these small hospitals worked in an isolated professional milieu: few (4%) had attended a basic training course or were members of a national (11%) or local (16%) infection control association. They also had significantly less access to standard infection control resource publications than did practitioners in large hospitals. Use of aqueous quaternary ammonium compounds for disinfection was reported by 37% of all hospitals in 1979; 68% of hospitals routinely performed bacteriologic cultures of personnel or the environment. In contrast, only 3% of hospitals did not have a policy specifying the use of sterile closed-system drainage of indwelling bladder catheters. Although these practices varied somewhat by hospital size, the differences were not statistically significant. Modest improvement in each parameter was noted since 1976. Pathology was the most common medical specialty (34%) among chairman of infection control committees; internal medicine and pediatrics accounted for only 13%. The practice of routine microbiologic monitoring was significantly more common among hospitals with chairmen who were pathologists. The implications of these findings for national priorities in hospital infection control are discussed.