Risk assessment for healthcare workers after a sentinel case of rabies and review of the literature.

BACKGROUND: After a case of rabies, healthcare workers (HCWs) had fear of contagion from the infected patient. Although transmission of rabies to HCWs has never been documented, high-risk exposures theoretically include direct contact of broken skin and/or mucosa with saliva, tears, oropharyngeal secretions, cerebrospinal fluid, and neural tissue. Urine/kidney exposure posed a concern, as our patient's renal transplant was identified as the infection source. METHODS: Our risk assessment included (1) identification of exposed HCWs; (2) notification of HCWs; (3) risk assessment using a tool from the local health department; (4) supplemental screening for urine/kidney exposure; and (5) postexposure prophylaxis (PEP) when indicated. RESULTS: A total of 222 HCWs including diverse hospital staff and medical trainees from university affiliates were evaluated. Risk screening was initiated within 2 hours of rabies confirmation, and 95% of HCWs were assessed within the first 8 days. There were 8 high-risk exposures related to broken skin contact or mucosal splash with the patient's secretions, and 1 person without high-risk contact sought and received PEP outside our hospital. Nine HCWs (4%) received PEP with good tolerance. Due to fear of rabies transmission, additional HCWs without direct patient contact required counseling. There have been no secondary cases after our sentinel rabies patient. CONCLUSIONS: Rabies exposure represents a major concern for HCWs and requires rapid, comprehensive risk screening and counseling of staff and timely PEP. Given the lack of human-to-human rabies transmission from our own experience and the literature, a conservative approach seems appropriate for providing PEP to HCWs.

Evaluating a decade of exposures to blood and body fluids in an inner-city teaching hospital.

OBJECTIVE: To analyze a decade of hospital staff and student exposures to blood and body fluids (BBF) and to identify risk factors relevant to prevention strategies. DESIGN: Retrospective review of a 1999-2008 data set of BBF exposures. The data, maintained by occupational health staff, detailed the type of exposure, the setting in which the exposure occurred, and the occupational group of the BBF-exposed personnel. SETTING: Washington DC Veterans Affairs Medical Center (VA-DC), an inner-city tertiary care hospital. PARTICIPANTS: All healthcare workers and staff at the VA-DC. METHODS: Review of database. RESULTS: A review of 10 years of data revealed 564 occupational exposures to BBF, of which 66% were caused by needlesticks and 20% were caused by sharp objects. Exposures occurred most often in the acute care setting (which accounted for 39% of exposures) and the operating room (which accounted for 22%). There was a mean of 4.9 exposures per 10,000 acute care patient-days, 0.5 exposures per 10,000 long-term care patient-days, and 0.35 exposures per 10,000 outpatient visits. Housestaff accounted for the highest number of all exposures (196 [35%]). There were, on average, 15.2 exposures per 100 housestaff full-time equivalents. An average of only 1 exposure per year occurred in the hemodialysis center. CONCLUSIONS: Occupational exposures to BBF remain common, but rates vary widely by setting and occupational group. Overall rates are steady across a decade, despite the use of various antiexposure devices and provider education programs. Targeting occupational groups and hospital settings that have been shown to have the highest risk rates should become foundational to future preventative strategies.

Stauffer's syndrome variant associated with renal cell carcinoma.

Cholestasis, as a paraneoplastic syndrome, has been well described in patients with malignant lymphohyperplastic diseases and renal cell cancer. Non-metastatic nephrogenic hepatic dysfunction syndrome without jaundice has often been described in patients with Stauffer's syndrome. Paraneoplastic cholestatic jaundice is extremely uncommon. We report, a patient who presented with pruritus and cholestatic jaundice and was diagnosed with renal cell carcinoma (RCC) in the right kidney. Liver malfunction and cholestatic icterus was attributed to RCC. Jaundice and liver dysfunction gradually restored to normal after surgical resection of the tumor. Malignancies may cause cholestatic jaundice through well-recognized mechanisms. Paraneoplastic syndromes associated with malignancy, can induce a reversible form of cholestasis through an unclear pathogenetic mechanism.