Spinal Tap!

No, not the parody English heavy metal band, but the procedure to help identify infectious and auto-immune diseases effecting the central nervous system. Below is a summary of the expected CSF findings in a variety of conditions:

Routine CSF constituents in different CNS disorders
  Normal Viral infection Bacterial infection Fungal infection TB infection GBS Multiple sclerosis
Appearance Clear Clear or opaque Turbid Clear Clear/opaque Clear Clear
White cells (per mm3) 0–5 10–2,000 100–60,000 20–500 50–5,000 Normal >15 atypical (>50 very rare)
Protein (g/l) <0.5 0.5–0.9 >0.9 >0.5 >1.0 >1.0 Normal
Glucose (% serum glucose) >60–75% Normal <40% <80% <50% Normal Normal

Adapted from Clarke et al.

Case Challenge #9

  • History
    • A 52 year old female presents with fever, new-onset weakness, and dyspnea on exertion. This is associated with weight loss and a rash. She denies current or previous drug use. No pets or recent travel.
  • Physical Exam
  • Labs
    • WBC 12k, ESR 75, CRP 8.5.
    • Blood cultures negative ngtd.
  • Imaging
    • Brain MRI shows multifocal acute CVA in different vascular distributions.

(Note: this post contains an audio clip, so it must be listened to on the website! Click on the title above)

“What’s that syndrome with erythema nodosum and sarcoidosis?”

Lofgren syndrome! Below is a quick 101 cheat sheet on Lofgren syndrome, check it out!

  • Lofgren syndrome is a form of acute sarcoidosis (not to be confused with Loffler’s syndrome)
  • Initially described in 1953 by Sven Halvar Lofgren, a Swedish clinician
  • More common in Scandinavian, Irish and African populations
  • The syndrome is comprised of the combination of
  • Erythema Nodosum
  • Hilar adenopathy
  • Migratory polyarthralgia
  • Fever
  • In men, more common to have bilateral ankle arthritis instead of EN
  • The combination of all features of Lofgren syndrome has a 95% specificity for sarcoidosis, allowing for clinical diagnosis without pathology
  • However, consider the ddx for EN and hilar adenopathy: primary TB, sarcoid, coccidiodomycosis, histo, blasto, yersiniosis and chlamydia
  • The syndrome is associated with a good prognosis
  • Some patients have spontaneous remission and others require only NSAIDs to control their symptoms
  • In one retrospective study of 80 patients, 67% were treated with NSAIDs and 41% with steroids and only 17% had a recurrence

“Cancer: The Emperor of All Maladies” Documentary Coming Soon!

On March 30th, PBS will air the documentary “Cancer: The Emperor of All Maladies” based on the Pulitzer prize winning book “Emperor of All Maladies: A Biography of Cancer” written by Dr. Siddhartha Mukherjee, an oncologist at Columbia University. It is a six-part, 3-hour documentary with the following synopsis below from the film’s website:

This ‘biography’ of cancer covers its first documented appearances thousands of years ago through the epic battles in the 20th century to cure, control and conquer it, to a radical new understanding of its essence. The series also features the current status of cancer knowledge and treatment —the dawn of an era in which cancer may become a chronic or curable illness rather than its historic death sentence in some forms.”

Check out the film’s trailer and a link to the book on Amazon below by clicking the picture:


emperor of all maladies

How vaccines change the way we think about disease

Elena Conis, Emory University

The news on the current measles outbreak contains plenty of reminders that measles causes brain damage, pneumonia, hearing loss and death. A few lone voices have spoken up to say measles isn’t that serious, including an Arizona doctor who said it’s “really just a fever and a rash” – and soon found himself under investigation by his state’s medical board.

Back in the 1960s, it wasn’t controversial to call measles benign. Though the disease killed about 400-500 Americans a year, it was considered a normal part of childhood. It was so common, in fact, that to this day, people born in the pre-measles vaccine era are considered immune. But the introduction of the measles vaccine, and efforts to promote it, fundamentally changed things. In the five decades since we’ve been immunizing against it, measles has become increasingly known as a deadly killer.

This transformation in perception, from relatively benign to a serious disease, isn’t unique to measles. As I have discovered in my research, it’s a pattern that’s been repeated over and over again in the modern history of immunization. This is not to say that measles is now considered a mild infection, or to suggest that risk from the virus, or other vaccine-preventable diseases, is overestimated. The point I want to argue is that the introduction of a vaccine reframes our perception of the disease it prevents.

Vaccines change our perception of risk

How does this happen? New vaccines simultaneously drive down the number of people getting the disease and increase our awareness of the risks of the disease.

Vaccines shine a spotlight on their target infections and, in time, those infections — no matter how “common” or relatively unimportant they may have seemed before — become known for their rare and serious complications and defined by the urgency of their prevention.

A spotted vaccine delivery van labeled ‘Measles must go.’
CDC

This certainly happened to measles, whose first vaccine was uneventfully released in 1963.

At the time, many parents saw measles as a common and relatively harmless part of childhood – even though it infected three to four million people a year and caused roughly 48,000 hospitalizations annually. Many doctors felt as parents did, especially when comparing measles to such worrisome disease threats as smallpox and polio. Even the head of the Centers for Disease Control described measles as a disease “of only mild severity” which caused “infrequent complications.”

But the very development of the vaccine focused new scientific attention on the disease. Within a few years, scientists had compared measles to polio — the previous decade’s public health priority — and found it a much more serious threat to children’s health. Inspired by this finding, and frustrated by the public’s lack of enthusiasm for the vaccine, federal health officials launched a national campaign to publicize measles’ dangers.

The campaign officially spread the word, for the first time, that measles was “a serious disease that sometimes causes pneumonia, deafness, encephalitis and even death.” Public figures ranging from the Surgeon General to Ann Landers announced that measles could leave children blind, deaf and mentally impaired. And the campaign employed a poster child — disabled ten-year-old Kim Fisher — to illustrate the idea that measles immunization was necessary because “one death, one brain-damaged child, or even one child who needs hospitalization is one too many,” as one campaign supporter put it.

A new picture of measles emerges

As the campaign wore on, scientists continued to study the disease more closely than ever. Doctors began to report measles cases to health departments at unprecedented rates. And together, doctors and scientists began to pay more attention to the disease’s risks than even before. As a result, a new picture of the disease began to form: it appeared to cause more deaths than previously thought, brain damage in even mild cases, even harm to fetuses.

As the public continued to respond to the national campaign with “general apathy,” however, health officials redoubled their efforts to publicize measles’ “dramatic aspects,” and states began passing laws requiring the vaccine for schoolchildren. Within just over a decade, the country saw an all-time low of measles cases — and the disease had solidly acquired its new reputation as a deadly infection worthy of prevention at any cost.

A measles immunization campaign poster display at the Eradicate Measles Exhibit in 1972.
CDC/Don Lovell

We used to think mumps and chickenpox were ‘mild’ too

In the decades that followed the introduction of the measles vaccine, vaccine makers and health officials duplicated this approach with one new vaccine after another.

Mumps, often the butt of jokes in its pre-vaccine days, was no laughing matter within a decade of its vaccine’s introduction in 1967. Hepatitis B was considered an obscure infection of little import to most Americans when its vaccine first came out in 1981, but soon after it evolved into a “cousin” of AIDS known for lurking in nail salons, piercing parlors and playgrounds.

Since the development of the chickenpox vaccine in the 1990s, the virus has been transformed in the public imagination from an innocuous if uncomfortable rite of childhood to a highly contagious infection that can cause pneumonia, sepsis and sometimes death. And in just the last decade, human papillomavirus (HPV) has morphed from a little-known sexually transmitted infection to a widely known cause of multiple forms of cancer. Each of these transformations in perception was triggered by a new vaccine.

Each new vaccine invited deliberation on how it should be used. That, in turn, focused increased scientific attention on the disease. Often, as federal health officials and other scientists accumulated new information about the disease’s risks and complications, the vaccine maker did its part to market its vaccine. As talk of each disease and its more dramatic aspects spread, public and scientific perception of the disease gradually transformed.

In this country, high vaccination rates rest on a consensus about the diseases prevented by vaccines. When doctors, health officials and, in particular, parents view a disease as serious, they view its vaccine as one worth getting.

The recent increase in the number of philosophical objectors to measles vaccine shows that historical consensus about the disease itself has eroded in recent years. But history also shows that one surefire route to consensus about a disease is fear of that disease. And fear often spreads like wildfire during disease outbreaks, much like what is happening once again now with measles.

The Conversation

This article was originally published on The Conversation.
Read the original article.