BackgroundThe term severe acute respiratory infection (SARI) encompasses a heterogeneous group of respiratory illnesses. Grading the severity of SARI is currently reliant on indirect disease severity measures such as respiratory and heart rate, and the need for oxygen or intensive care. With the lungs being the primary organ system involved in SARI, chest radiographs (CXRs) are potentially useful for describing disease severity. Our objective was to develop and validate a SARI CXR severity scoring system.MethodsWe completed validation within an active SARI surveillance project, with SARI defined using the World Health Organization case definition of an acute respiratory infection with a history of fever, or measured fever of ≥ 38 °C; and cough; and with onset within the last 10 days; and requiring hospital admission. We randomly selected 250 SARI cases. Admission CXR findings were categorized as: 1 = normal; 2 = patchy atelectasis and/or hyperinflation and/or bronchial wall thickening; 3 = focal consolidation; 4 = multifocal consolidation; and 5 = diffuse alveolar changes.Initially, four radiologists scored CXRs independently. Subsequently, a pediatrician, physician, two residents, two medical students, and a research nurse independently scored CXR reports. Inter-observer reliability was determined using a weighted Kappa (κ) for comparisons between radiologists; radiologists and clinicians; and clinicians. Agreement was defined as moderate (κ > 0.4–0.6), good (κ > 0.6–0.8) and very good (κ > 0.8–1.0).ResultsAgreement between the two pediatric radiologists was very good (κ = 0.83, 95 % CI 0.65–1.00) and between the two adult radiologists was good (κ = 0.75, 95 % CI 0.57–0. 93).Agreement of the clinicians with the radiologists was moderate-to-good (pediatrician:κ = 0.65; pediatric resident:κ = 0.69; physician:κ = 0.68; resident:κ = 0.67; research nurse:κ = 0.49, medical students: κ = 0.53 and κ = 0.56).Agreement between clinicians was good-to-very good (pediatrician vs. physician:κ = 0.85; vs. pediatric resident:κ = 0.81; vs. medicine resident:κ = 0.76; vs. research nurse:κ = 0.75; vs. medical students:κ = 0.63 and 0.66).Following review of discrepant CXR report scores by clinician pairs, κ values for radiologist-clinician agreement ranged from 0.59 to 0.70 and for clinician-clinician agreement from 0.97 to 0.99.ConclusionsThis five-point CXR scoring tool, suitable for use in poorly- and well-resourced settings and by clinicians of varying experience levels, reliably describes SARI severity. The resulting numerical data enables epidemiological comparisons of SARI severity between different countries and settings.

BackgroundPrimaquine is the only drug available for preventing relapse following a primary attack by Plasmodium vivax malaria. This drug imposes several important problems: daily dosing over two weeks; toxicity in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency; partner blood schizontocides possibly impacting primaquine safety and efficacy; cytochrome P-450 abnormalities impairing metabolism and therapeutic activity; and some strains of parasite may be tolerant or resistant to primaquine. There are many possible causes of repeated relapses in a patient treated with primaquine.Case descriptionA 56-year-old Caucasian woman from New Zealand traveled to New Ireland, Papua New Guinea for two months in 2012. One month after returning home she stopped daily doxycycline prophylaxis against malaria, and one week later she became acutely ill and hospitalized with a diagnosis of Plasmodium vivax malaria. Over the ensuing year she suffered four more attacks of vivax malaria at approximately two-months intervals despite consuming primaquine daily for 14 days after each of those attacks, except the last. Genotype of the patient’s cytochrome P-450 2D6 alleles (*5/*41) corresponded with an intermediate metabolizer phenotype of predicted low activity.DiscussionMultiple relapses in patients taking primaquine as prescribed present a serious clinical problem, and understanding the basis of repeated therapeutic failure is a challenging technical problem. This case highlights these issues in a single traveler, but these problems will also arise as endemic nations approach elimination of malaria transmission.

To better understand the natural history, management, and outcome of pneumothoraces in HIV-infected patients, we reviewed hospital charts and chest radiographs of HIV-infected adults discharged from the University of Maryland Medical Center over a 6-year period. Sixty pneumothoraces occurred in 39 patients. Twenty-three pneumothoraces resulted from trauma and 37 were spontaneous. Thirty-two (86%) of the spontaneous pneumothoraces occurred in patients with Pneumocystis carinii pneumonia (PCP). Eight percent of the traumatic pneumothoraces in patients who did not have PCP resolved. Patients who had pneumothorax as well as PCP were more difficult to manage and had a poorer outcome (50% mortality) than those who did not have PCP (25% mortality).

Two cases of endocarditis caused by Neisseria mucosa are reported, and the literature on N. mucosa endocarditis is reviewed. N. mucosa is a rare but serious cause of endocarditis that is associated with a high rate of embolic complications and high mortality and is not always highly sensitive to benzylpenicillin. Most patients with N. mucosa endocarditis have been treated with combined therapy with penicillin and an aminoglycoside, although the optimal regimen has not been defined.

We compared 40 patients taking lomefloxacin 400 mg once daily for 5 days in a double blind trial with 44 placebo takers with proven community acquired bacterial diarrhoea (85% due to Campylobacter spp.). Lomefloxacin eradicated Campylobacter spp. in 75% but did not alter clinical outcome. Twenty-eight per cent of the campylobacter isolates developed resistance. Thirty-three per cent developed side-effects. Lomefloxacin is not recommended for community-acquired bacterial diarrhoea when Campylobacter spp. predominate.