Updates
By Carol A. Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, Section Editor, Updates; Section Editor, HIV, is Associate Editor for Infectious Disease Alert.
Banana starch in Diarrhea
Source: Rabbani GH, et al. Green banana reduces clinical severity of childhood shigellosis. Ped Infect Dis J. 2009;28.
The role of amylase-resistant starches, which are not digested in the human small intestine, as dietary therapy of various bowel diseases, such as infectious diarrhea, is not well understood. Starch-based oral solutions have been found to be beneficial in inflammatory bowel disease, ulcerative colitis, as well as cholera and non-cholera diarrhea. Green banana, which is high in amylase-resistant starch, is used as a digestive aid for children in many parts of Asia, Africa, and Latin America, and turns up as a folk remedy for diarrheal illness in some parts of the world.
Rabbani et al examined the effects of a green banana-containing diet on 73 children (ages 6 to 60 months) with Shigellosis. In a double-blind, controlled study, children were randomized to receive a rice-based diet with or without green banana. Green banana was prepared by boiling the whole fruit for 7 to 10 minutes, removing the peel, and creating a paste from the inner pulp. Rice flour was added, so the total calories were similar, and vanilla and strawberry flavoring were added so the taste of the two diets was similar. All of the children received ciprofloxacin (15 mg/kg/day for five days). Oral rehydration solutions were available, and simple, soft foods, such as bread and potatoes, were allowed as tolerated.
The addition of green banana was associated with greater frequency of clinical success at five days of therapy compared with the control group (85% vs. 67%, p = .001). Stool frequency was reduced in those receiving green banana vs. the control group (70% vs. 50%, p < .01), and fecal volume was also reduced. Fecal blood was cleared in 96% vs. 60% of those with or without green banana, respectively. Clinical improvement was also observed at three days of therapy, but the results were not statistical significant. In addition, stool fatty acid concentrations were significantly higher in the GB group.
Amylase-resistant starches appear to stimulate colonic flora, which break down the starches into short-chain fatty acids. These fermentation by-products are a major source of energy for colonocytes, and may help to protect colonic mucosa, reducing fecal myeloperoxidase activity and diminishing invasion by bacteria. Though not part of the discussion here, certain kinds of rice may also have some beneficial effects on the digestive system, depending on the type of rice available for use. Rice starch is made up of both amylopectin and amylose, but the latter is less readily digested. That is why some rices, such as risotto rice (e.g., Arborio), which are higher in amylopectin and are more readily digested by salivary enzymes, taste sweeter and yield creamier foods with cooking. Others, such a longer grain rice (e.g., Jasmine) have higher amounts of amylose, which is less readily digested in the human mouth and intestine to sugars, and is, therefore, better for diabetics.
Tularemia of the Middle Ear
Source: Gukov R et al. Tularaemia of middle ear with suppurative lymphadenopathy and retropharyngeal abscess. J Laryngol and Otology. 2009;1 of 6.
This article describes a highly unusual presentation of otoglandular and oropharyngeal tularemia infection, resulting in hearing loss in a 37-year-old previously healthy German woman. The route of infection was not clear, but the woman reported contact with a friend's bunny rabbit and a cat (both of which were healthy), as well as "canyoning" in wild waters in France.
The patient presented with multiple suppurative lesions on the left neck, including pre-auricular, infra-auricular, and retropharyngeal abscesses, with extensive phlegmon in the lateral soft tissues of the neck, and mastoiditis. Studies confirmed impairment of hearing and conduction in the left ear, which persisted despite treatment. She failed to respond to initial courses of amoxicillin and cephalosporin. All cultures remained negative, and the diagnosis was finally made based on an aspiration of a lesion at day 41 of illness, with a positive PCR for Francisella tularensis subspecies holartica. She eventually responded to a more aggressive regimen of ciprofloxacin, doxycycline, and gentamicin and surgical debridement.
Tularemia can present in a number of different ways depending on the route of infection. Oropharyngeal infection is quite rare (1%-4% of cases), and is believed to occur from ingestion of contaminated water or meat. Oculoglandular disease occurs when contaminated hands or infectious material come in contact with conjunctiva. Ulceroglandular disease, which is probably the most familiar to many of us, occurs as the result of trauma, animal bites, or tick or mosquito bites, with inoculation of infectious material in the wound, resulting in an eschar and regional suppurative adenopathy. Finally, pneumonic tularemia occurs from airborne infection. Tularemia-involving lymph nodes is often unilateral, suppuration is common, and the infection generally progresses slowly and responds poorly to antibiotics. Clinicians are readily fooled into thinking it is TB adenitis, especially when cultures are negative. In addition, many patients with suppurative tularemic adenitis are not clinically ill and have normal white blood counts. The diagnosis is often made weeks after presentation and is usually based on serologic studies.
Francisella tularensis (Type A) is endemic to North America, although other strains (such as Francisella tularensis spp holartica) are present in other parts of the world. Environmental exposure accounts for some cases. A problem with molecular-based methods for bioterrorism environmental screening has been the frequency with which non-Type A F. tularensis spp are detected.
Post-operative Uveitis and Whipple Disease
Source: Drancourt M, et al. Postoperative panophthalmitis caused by Whipple Disease (letter). EID J. 2009,15.
The occurrence of post-operative endophthalmitis and uveitis in an elderly woman prompted further investigation. She had undergone intraocular lens implantation about 15 months earlier, followed by retinal surgery, and topical corticosteroid administration about three months earlier. She presented with a painful red eye and decreased visual acuity. Her sedimentation rate was 70, and eosinophils were present on peripheral smear. She had a remarkable history of polyarthropathy for two years that was poorly responsive to corticosteroids.
An aspirate of the anterior chamber fluid was tested using 16s rDNA sequencing for Tropheryma whipplei, demonstrating 99.9% homology with a banked organism. A specific PCR confirmed the result, and also was positive in saliva and stool, but not blood or cerebrospinal fluid. An outside lab also confirmed the result. Duodenal biopsy specimens were negative by PAS stain. She slowly responded to treatment, and follow-up PCR testing at eight months was negative.
A review of published reports of 19 individuals with uveitis due to T. whipplei found that 11 had a history of ophthalmic surgery within the few months prior to onset of symptoms and 13 had received topical or system corticosteroids. Drancourt et al speculate that reactivation of latent infection could be triggered by corticosteroid administration, especially in the setting of ophthalmic surgery.
Botox update — 2009
Source: Follow-up to the February 8, 2008, Early Communication about an Ongoing Safety Review of Botox and Botox Cosmetic (Botulinum toxin Type A) and Myobloc (Botulinum toxin Type B), www.fda.gov/cder/drug, May 1, 2009.
The FDA has strengthened its safety warning for the use of botulism toxins for both FDA and non-FDA approved purposes following a number of reported events of botulism-like symptoms and illness at sites distant from the injection site. A box warning has been added, and the FDA is requesting that physicians report unusual or unexpected side effects to the FDA's MedWatch Adverse Event Reporting Program (www.fda.gov/medwatch/report.htm).
Botox (Botulinum toxin Type A) is currently FDA-approved for use in the treatment of blepharospasm, cervical dystonia, and axillary hyperhidrosis, as well as for cosmetic purposes in adults (facial wrinkles). Myobloc (Botulinum toxin Type B) is approved for use in adults with cervical dystonia (severe neck spasms). However, these agents are increasingly being used for off-label purposes, such as for the treatment of dysphagia, ptosis, strabismus, and limb spasticity. There is concern that distant effects of the toxin, especially at higher doses in children, could result in serious impairment. Part of the problem may be due to the difference in effective unit doses for the two products.
Adverse events in children, all of whom were less than 16 years of age, have included botulism symptoms ranging from dysphagia to respiratory insufficiency, and have resulted in hospitalization, intubation, and death (the number involved was not specified). Reported Botox doses used in these cases ranged from 6.25 to 32 units/kg in these cases, and Myobloc doses ranged from 388 to 625 units/kg.
Adverse events in adults have been similar, ranging from weakness and numbness of the lower extremities, difficulty holding up heads, ptosis, and dysphagia. No respiratory failure events or deaths have been reported in adults. In those more severe adult cases, Botox doses ranged from 100 to 700 units, and Myobloc doses ranged from 10,000 to 20,000 units.
No serious adverse events or deaths have been reported with the use of Botox at either the labeled dose of 20 units for wrinkles or 100 units for axillary hyperhidrosis.
The role of amylase-resistant starches, which are not digested in the human small intestine, as dietary therapy of various bowel diseases, such as infectious diarrhea, is not well understood.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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