Shigella sonnei Outbreak Investigation During a Municipal Water Crisis-Genesee and Saginaw Counties, Michigan, 2016.

Objectives. To investigate a shigellosis outbreak in Genesee County, Michigan (including the City of Flint), and Saginaw County, Michigan, in 2016 and address community concerns about the role of the Flint water system.Methods. We met frequently with community members to understand concerns and develop the investigation. We surveyed households affected by the outbreak, analyzed Shigella isolate data, examined the geospatial distribution of cases, and reviewed available water quality data.Results. We surveyed 83 households containing 158 cases; median age was 10 years. Index case-patients from 55 of 83 households (66%) reported contact with a person outside their household who wore diapers or who had diarrhea in the week before becoming ill; results were similar regardless of household drinking water source. Genomic diversity was not consistent with a point source. In Flint, no space-time clustering was identified, and average free chlorine residual values remained above recommended levels throughout the outbreak period.Conclusions. The outbreak was most likely caused by person-to-person contact and not by the Flint water system. Consistent community engagement was essential to the design and implementation of the investigation.

Breakthrough Invasive Fungal Infections in Patients with Acute Myeloid Leukemia.

OBJECTIVES: We sought to determine the occurrence, risk factors, effect of antifungal prophylaxis, and outcomes of invasive fungal infections (IFIs) in patients with acute myeloid leukemia (AML). PATIENTS AND METHODS: We performed a retrospective analysis of all adult patients admitted to the University of Michigan Health System for AML over a 3-year period from 2010 to 2013. We determined comorbidities, hematopoietic cell transplant (HCT) status, antifungal prophylaxis, proven and probable IFI, and outcomes at 12 weeks after initiation of appropriate antifungal therapy. RESULTS: Of 333 patients in our cohort, 116 of whom had received a HCT, 98 (29%) developed an IFI. Of the 30 (9%) patients who had a proven or probable IFI, 18 had breakthrough infection while on micafungin (n = 5), voriconazole (n = 4), posaconazole (n = 5), or fluconazole (n = 4). Breakthrough IFIs were due to Aspergillus species (n = 11), other molds (n = 4), and Candida species (n = 3). Factors associated with breakthrough IFI were prolonged severe neutropenia (p = .05) and having received tacrolimus (p = .04). Antifungal therapy was successful in 7 of the 18 (39%) patients with breakthrough IFI and 8 of the 12 (67%) patients with non-breakthrough IFI, p = .13. Mortality at 12 weeks was 27%, 5 with breakthrough IFI and 3 with non-breakthrough IFI and was associated with prolonged severe neutropenia, p = .04. CONCLUSIONS: Patients with AML remain at risk for IFI despite the use of several different antifungal agents for prophylaxis. Mortality remains high in patients with AML who develop IFI.

Testing the performance of a prototype lateral flow device using bronchoalveolar lavage fluid for the diagnosis of invasive pulmonary aspergillosis in high-risk patients.

The diagnosis of invasive pulmonary aspergillosis (IPA) increasingly relies on non-culture-based biomarkers in bronchoalveolar lavage (BAL) fluid. The Aspergillus lateral flow device (LFD) is a rapid immunoassay that uses a novel Aspergillus monoclonal antibody to gain specificity. The objective of the study is to compare specificity and sensitivity of the prototype LFD and the galactomannan (GM) enzyme immunoassay in BAL fluid in high-risk patients. A total of 114 BAL samples from 106 patients at high risk for IPA were studied: 8 patients had proven/probable IPA, 16 had possible IPA and 82 did not have IPA. In patients with proven/probable IPA, specificity of LFD was 94% and GM was 89%; sensitivity of LFD was 38% and GM was 75%. Negative predictive value (NPV) for LFD was 94% and for GM was 98%; positive predictive value (PPV) was 38% for both tests. The use of anti-mould prophylaxis did not affect specificity but resulted in decreased NPV of both LFD and GM. Union and intersection analysis showed no improvement in the performance by using both tests. Among patients at risk for IPA, the diagnostic performance of LFD and GM in BAL fluid appears comparable; specificity is high, but sensitivity of both LFD and GM is poor.

Blastomycosis.

Blastomycosis is an endemic fungal infection due to Blastomyces dermatitidis that most commonly causes pneumonia; but the organism can disseminate to any organ system, most commonly the skin, bones/joints, and genitourinary tract. Both immunocompetent and immunocompromised persons can be infected, but more severe disease occurs in the immunocompromised. Blastomycosis can be diagnosed by culture, direct visualization of the yeast in affected tissue, and/or antigen testing. Treatment course and duration depend on severity of illness. For mild to moderate pulmonary disease the treatment is itraconazole. For severe blastomycosis, lipid formulation amphotericin B is given, followed by step-down therapy with itraconazole.

Detection of human pathogenic Ehrlichia muris-like agent in Peromyscus leucopus.

An Ehrlichia muris-like (EML) bacterium was recently detected in humans and Ixodes scapularis ticks in Minnesota and Wisconsin. The reservoir for this agent is unknown. To investigate the occurrence of the EML agent, groEL PCR testing and sequencing was performed on blood from small mammals and white-tailed deer that were collected in areas where human and tick infections were previously demonstrated. DNA of the EML agent was detected in two Peromyscus leucopus of 146 small mammals (1.4%); while 181 O. virginianus tested negative. This report provides the first evidence that DNA from the EML agent is found in P. leucopus, the same animal that is a reservoir for Anaplasma phagocytophilum in this region. The role of white-tailed deer remains inconclusive. Further sampling is warranted to understand the spatial and temporal distribution, transmission and maintenance of this pathogen.

Postoperative bowel herniation in a 5-mm nonbladed trocar site.

BACKGROUND: Incisional hernias are a rare complication of laparoscopic surgery, with a reported incidence of <1%. CASE REPORT: We describe a case of bowel herniation and strangulation involving a 5-mm trocar site. CONCLUSION: Although there is growing literature supporting fascial closure of abdominal port sizes ≥ 10 mm, there is sparse data to suggest closure of 5-mm port sites. Our case illustrates that in appropriate clinical scenarios, the possibility of a strangulated hernia involving a 5-mm port site warrants consideration.

Polycyclic aromatic hydrocarbons in the South American environment.

Pollution of the environment with polycyclic aromatic hydrocarbons (PAHs) should be a global concern, especially in urbanized areas. In South American countries, where notable increase in urban populations has been observed in the past few years, reliable information about the pollution status of these urban environments is not always easily accessible, and therefore an effort to collect updated information is required. This review attempts to contribute by analyzing the existing information regarding environmental levels of PAHs in some South American countries. A regional trend for environmental PAH information is an uneven contribution, because some countries, such as Bolivia, Peru, Paraguay, and Ecuador, have reported no information at all in the scientific literature, reflecting to a certain extent the different patterns of economic, technical, and scientific development. PAH air monitoring is one of the areas that has received the most attention during the last few years, mainly in Brazil, Chile, and Argentina, where data represent a few geographical areas within the region. PAH levels in air from some urban areas in Argentina, Brazil, and Chile, considered moderate to high (100-1000ng/m3), are probably among the highest values reported in the open literature. Urbanization, vehicle pollution, and wood fires are the principal contributors to the high reported levels. In more temperate areas, a clear distinction is observed between summer and winter levels. PAH monitoring in soils is very limited within the region, with few data available, and most information indicates widespread pollution. In Brazil, values for many representative ecosystems were found. In Chile, data from forestry and agricultural areas indicate in general low concentrations, in spite of a relatively high detection frequency. Pollution levels in soils are highly dependent on their closeness to PAH sources and certain cultural practices (agricultural burnings, forest fires, etc.). Water PAH levels are rarely reported in the scientific literature for South American countries. Few data were available, even though many regulatory agencies perform routine analysis of hydrocarbons in waters. No information was found specifically related to PAH compounds, which could indicate generally low PAH levels in waters. Regional PAH information for sediments also indicates higher levels. Overall, as observed for water, sediment data indicate a complex situation in densely populated areas affected by urban-industrial inputs where high PAH levels are found. In contrast, in remote areas a typical profile of diagenetic PAHs dominates. Concentrations are greatly variable and are principally related to several highly contaminated sites in Argentina and Brazil (hot spots) with levels four to five orders of magnitude higher. Even though PAHs have carcinogenic properties, little attention has been paid to the analysis of aquatic organisms except in the case of bivalves. As observed for other environmental receptors, the regional data distribution is uneven and is heavily centered in coastal environments and in a few countries (Argentina, Brazil, Chile, and Peru). The most comprehensive PAH monitoring program in the South American coastal environment is the Mussel Watch. Baseline PAH concentrations range from 200 to 700 microg kg(-1) lipids in unpolluted sites; from 1,000 to 3,000 microg kg(-1) in moderately contaminated sites; and from 4,000 to 13,000 microg/kg lipids in the most affected bivalves that come from areas of Río de la Plata (Argentine side), Recife (Brazil), and Punta Arenas (Chile). Critical data gaps exist with respect to PAH analysis in biota, including humans, in foodstuffs, and subsequent effects. Considering the high levels reported in the air compartment, risk assessment procedures in highly populated areas need to be performed. Additionally, few countries within the region have information on PAH levels. In these countries, this type of analysis needs to be performed, and the laboratory capacity needs to be built to assure the accomplishment of these objectives.