Guidelines to implement medical examiner/coroner-based surveillance for fatal infectious diseases and bioterrorism ("Med-X").

Medical examiners and coroners investigate deaths that are sudden, unexplained, and violent. Oftentimes these deaths are a consequence of infections, many of which have public health consequences. Additionally, because deaths from bioterrorism are homicides, they fall under the jurisdiction of medical examiners and coroners. Surveillance for infectious disease-related deaths can enhance the opportunities to recognize these deaths. Beginning in 2000, the New Mexico Office of the Medical Investigator developed and tested a medical examiner surveillance model for bioterrorism and infectious disease mortality ("Med-X") using a set of symptoms to determine which cases should receive an autopsy and a set of pathology-based syndromes for early reporting of cases to public health authorities. This model demonstrated that many of the symptoms had a high predictive value for infections and were useful criteria for autopsy performance. The causative organism was identified for 81% of infections of which 58% were notifiable conditions by public health standards. Uniform criteria for performing autopsies and reporting cases to public health authorities enhance surveillance for notifiable infectious diseases and increase the probability of recognizing fatalities related to bioterrorism. We have developed guidelines for medical examiners, coroners and their public health partners to use in implementing Med-X surveillance in their jurisdictions. These guidelines encompass definitions of symptoms and syndromes, specimen collection and storage procedures, laboratory diagnostic approaches, and processes for case flow, case reporting, and data collection. We also suggest resources for autopsy biosafety information and funding.

Undiagnosed cases of fatal Clostridium-associated toxic shock in Californian women of childbearing age.

OBJECTIVE: In 2005, 4 Clostridium sordellii-associated toxic shock fatalities were reported in young Californian women after medical abortions. The true incidence of this rare disease is unknown, and a population-based study has never been performed. Additional clostridia-associated deaths were sought to describe associated clinical characteristics. STUDY DESIGN: Population-based death certificate review and a clinical case definition for clostridial-associated toxic shock identified women with likelihood of dying from a Clostridium infection. Formalin-fixed autopsy tissues underwent immunohistochemical and polymerase chain reaction assays. RESULTS: Thirty-eight women were suspected of having C sordellii-associated death. Five tested positive for Clostridium species: 3 for Clostridium perfringens, 1 for C sordellii, and 1 for both. Deaths occurred after the medical procedures for cervical dysplasia (n = 2), surgical abortion (n = 1), stillborn delivery (n = 1), and term live birth (n = 1). None had a medical abortion. CONCLUSION: C sordellii and C perfringens are associated with undiagnosed catastrophic infectious gynecologic illnesses among women of childbearing age.

Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion.

OBJECTIVE: To better understand the risk of fatal toxic shock caused by Clostridium sordellii in women who had a recent medical abortion with mifepristone and misoprostol. METHODS: We performed active and passive surveillance for cases of toxic shock associated with medical or spontaneous abortion. To identify the cause of toxic shock, immunohistochemical assays for multiple bacteria were performed on formalin-fixed surgical and autopsy tissues. We extracted DNA from tissues, performed Clostridium species-specific polymerase chain reaction assays, and sequenced amplified products for confirmation of Clostridium species. RESULTS: We report four patients with toxic shock associated with Clostridium species infection after medical or spontaneous abortion. Two women had fatal Clostridium perfringens infections after medically induced abortions: one with laminaria and misoprostol and one with the regimen of mifepristone and misoprostol. One woman had a nonfatal Clostridium sordellii infection after spontaneous abortion. Another woman had a fatal C sordellii infection after abortion with mifepristone and misoprostol. All four patients had a rapidly progressive illness with necrotizing endomyometritis. CONCLUSION: Toxic shock after abortion can be caused by C perfringens as well as C sordellii, can be nonfatal, and can occur after spontaneous abortion and abortion induced by medical regimens other than mifepristone and misoprostol. LEVEL OF EVIDENCE: III.

A case of naturally acquired inhalation anthrax: clinical care and analyses of anti-protective antigen immunoglobulin G and lethal factor.

This report describes the first case of naturally acquired inhalation anthrax in the United States since 1976. The patient's clinical course included adjunctive treatment with human anthrax immunoglobulin. Clinical correlation of serologic assays for the lethal factor component of lethal toxin and anti-protective antigen immunoglobulin G are also presented.

Immunohistochemical evidence of Clostridium sp, Staphylococcus aureus, and group A Streptococcus in severe soft tissue infections related to injection drug use.

Severe soft tissue infections are caused by either single or multiple microorganisms. We performed a retrospective immunohistochemical (IHC) study on formalin-fixed, paraffin-embedded soft tissue samples from 20 injection drug users who were part of a cluster of severe illness and death after skin and soft tissue infections in Scotland and Ireland in 2000. The IHC assays used antibodies against Clostridium sp, Staphylococcus aureus, group A streptococci, and Bacillus anthracis. Intact bacilli and granular Clostridium antigen staining in areas with necrosis, edema, and inflammation were observed in skin, fascia, or muscle samples of 12 (60%) patients. A variety of clostridia were isolated from affected soft tissues in 10 IHC-positive cases. Staphylococcus aureus antigens were observed in 3 cases including 1 where S aureus was isolated, 1 with negative cultures, and 1 where mixed cultures were obtained. Group A streptococcal antigens were observed in 1 case in which Streptococcus pyogenes and S aureus were isolated. By using IHC, we detected different bacteria in archival soft tissue samples from patients with severe skin and soft tissue infections. Immunohistochemical assays can be of great diagnostic value, particularly for bacteria such as Clostridium sp, which are difficult to isolate because of their anaerobic fastidious growth requirements.

Diagnosis of invasive group a streptococcal infections by using immunohistochemical and molecular assays.

Invasive group A streptococcus (GAS) infections cause 1,100 to 1,300 deaths annually in the United States. Diagnosis is made when Streptococcus pyogenes is isolated from pus or body fluids; however, cultures are not always obtained, and antibiotic treatment can preclude bacterial growth. An immunohistochemical assay for GAS was applied to formalin-fixed tissue samples from 122 patients with suspect GAS infection. Immunohistochemical staining of well-defined cocci and small, granular antigen fragments was observed in 27 cases. S pyogenes was isolated in 18 cases, whereas in 8 cases, immunohistochemical staining was confirmed by amplification of the sepB gene of S pyogenes from paraffin-embedded samples in a heminested polymerase chain reaction (PCR) assay. A primary focus of infection (respiratory, mucocutaneous, or gynecologic) was present in 22 patients, whereas 5 had no identifiable primary focus of infection. Eighteen patients had systemic infection. Immunohistochemical analysis and PCR can be used for diagnosis of GAS infections in formalin-fixed, paraffin-embedded samples.

Myocarditis Outbreak among Adults, Illinois, 2003.

An outbreak of myocarditis occurred among adults in Illinois in 2003. Diagnostic testing of myocardial tissues from 3 patients and comprehensive tests for enterovirus and adenovirus of other specimens from patients were inconclusive. Appropriate specimen collection from patients with idiopathic cardiomyopathy and further enhancement of diagnostic techniques are needed.

Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion.

Endometritis and toxic shock syndrome associated with Clostridium sordellii have previously been reported after childbirth and, in one case, after medical abortion. We describe four deaths due to endometritis and toxic shock syndrome associated with C. sordellii that occurred within one week after medically induced abortions. Clinical findings included tachycardia, hypotension, edema, hemoconcentration, profound leukocytosis, and absence of fever. These cases indicate the need for physician awareness of this syndrome and for further study of its association with medical abortion.

SARS clinical features, United States, 2003.

We compared the clinical features of 8 U.S. case-patients with laboratory-confirmed severe acute respiratory syndrome (SARS) to 65 controls who tested negative for SARS coronavirus (SARS-CoV) infection. Shortness of breath, vomiting, diarrhea, progressive bilateral infiltrates on chest radiograph, and need for supplemental oxygen were significantly associated with confirmed SARS-CoV infection.

Surveillance for unexplained deaths and critical illnesses due to possibly infectious causes, United States, 1995-1998.

Population-based surveillance for unexplained death and critical illness possibly due to infectious causes (UNEX) was conducted in four U.S. Emerging Infections Program sites (population 7.7 million) from May 1, 1995, to December 31, 1998, to define the incidence, epidemiologic features, and etiology of this syndrome. A case was defined as death or critical illness in a hospitalized, previously healthy person, 1 to 49 years of age, with infection hallmarks but no cause identified after routine testing. A total of 137 cases were identified (incidence rate 0.5 per 100,000 per year). Patients' median age was 20 years, 72 (53%) were female, 112 (82%) were white, and 41 (30%) died. The most common clinical presentations were neurologic (29%), respiratory (27%), and cardiac (21%). Infectious causes were identified for 34 cases (28% of the 122 cases with clinical specimens); 23 (68%) were diagnosed by reference serologic tests, and 11 (32%) by polymerase chain reaction-based methods. The UNEX network model would improve U.S. diagnostic capacities and preparedness for emerging infections.