Voices in the Band: Immersion in an American Epicenter of the HIV Pandemic

Because of my irregular schedule, I don't do outpatient infectious disease work anymore. There are times that I am thankful I made that decision, especially when a "chronic" Lyme patient happens to stumble upon my name online and wants to see me, and times I think about finding a way to do some outpatient work. Those positive thoughts are usually triggered by remembering my experiences treating HIV in an outpatient setting. It's not that I don't see HIV patients in the hospital and don't keep up with HIV anymore -- I am on Pittsburgh's HIV commission -- there's just something I miss about taking care of HIV patients in the outpatient setting. Outpatient care, I think, is much more personal allowing the physician to truly know a patient and the ups and downs of an illness over a longer period of time than during acute and brief episodes in the hospital. The satisfaction of seeing medications work or strategizing with a patient over the best long-term plan of care are all hallmarks of outpatient care that I sometimes miss.

It may seem odd that someone misses HIV clinic, but if you have ever practiced in one you would know exactly what I mean. I just finished Dr. Susan Ball's Voices in the Band: A Doctor, Her Patients, and How the Outlook on AIDS Care Changed from Doomed to Hopeful a memoir of her day-to-day work at the renowned HIV clinic at Cornell in New York City the Center for Special Studies, and all my own memories are becoming vivid again. 

Dr. Ball's tenure, which is ongoing, spans an important epoch in HIV history that saw HIV metamorphose, through the development of antiretroviral therapies, from a death sentence to a chronic illness and her narrative is therefore uniquely positioned to tell this important story.

Voices in the Band is a poignant, emotion-evoking story of one dedicated physician's experience of being literally immersed in a plague in which people died, orphans abounded, and myriad social calamities compounded the destruction wrought by a virus. As she puts it, "HIV existed as an addendum" in many patient's lives. Dr. Ball's vignettes of patients, their stories, and their coping mechanisms coupled with her own mind's analysis of how to provide the best care possible was, to me, the best feature of this book. Understanding her perspective and how she integrated each patient's individual context, some of which were endlessly complex, was, to me, the best aspect of this book. 

While the unique situations faced by an HIV physician in one of the epicenter's of the pandemic during its heyday may be appear, at first glance, to be very different to what a clinician treating HIV today may face, many of the same issues -- save the lack of effective therapies -- persist.

Dr. Ball's resilience and unequivocal commitment in being the best physician to her patients shines through the book and is exemplary. When she describes writes of her practice, "So much I’ve seen and so much more still to see" one is glimpsing the standing order of an active mind engaged passionately in a productive activity that it loves.

One of my favorite descriptions is her view of the role of an HIV (or infectious disease physician) as "trekking on another planet, exploring unknown territory where few wanted to go...where we shared a sense of being alive, of doing something brave and important."

Concussion: A Testament to the Power of Reason

When I talk about what draws me to medicine and infectious disease in particular, it is the solving of puzzles with real-life import that is always at the top of my list. Because of that attraction, I am drawn to any and all puzzle-solving stories in medicine, even outside my field. 

I recently saw the movie Concussion which details the discovery of a new brain disease, Chronic Tramautic Encephalopathy (CTE) which develops as the result of multiple blows to the head. This type of trauma is exemplified by the head trauma experienced by football players. This movie was excellent in its portrayal of Dr. Bennet Omalu's relentless quest to understand the inexplicable deaths of several professional football players. 

That the movie and Dr. Omalu's pioneering work occurred in my hometown of Pittsburgh made the film all the more engrossing as I recognized not only buildings, but the names of Pittsburgh medical royalty such as former Allegheny County Corner and Medical Examiner Dr. Cyril Wecht as well as Dr. Joseph Maroon (whose portrayal, I hope, was the result of cinematic hyperbole). 

I also found a kinship to the movie for other more superficial reasons including working (at the time, as a resident) at the hospital legendary Pittsburgh Steeler Mike Webster died at, taking Tae Kwon Do as a child with Pittsburgh Steeler Terry Long, having a pivotal scene filmed at the restaurant in which I am a limited partner, and also being a Carnegie Mellon University alumunus like Dr. Omalu.

The best aspects of the movie are that it continually emphasizes the American nature of Omalu's quest, his desire to be the best version of himself, and his affinity for the world class pathologist Dr. Wecht--all very admirable traits in anyone. His intransigent pursuit of the scientific truth, no matter the consequences, is something all physicians should emulate even if they do not possess the genius, the courage, the independence, or the ability to make the inductive and deductive conclusions on the scale of Dr. Omalu. 

The movie is a great inspiration that provides emotional fuel. It's theme concretizes something a great philosopher once wrote:  "America is the land of the uncommon man. It is the land where man is free to develop his genius—and to get its just rewards." 

The world--and Pittsburgh--owes Dr. Omalu thanks for identifying a heretofore unknown disease and showing how the inexplicable is no match for the faculty of reason.

Vaccine Efficacy: A Fact, Not Just Something to Believe In

As I like to keep my hand slightly in emergency medicine yesterday I worked one of my (infrequent) shifts in the emergency department of my hometown hospital. Throughout the course of the shift at this medium-sized community hospital, I took care of several cases of pneumonia and likely influenza.

One patient encounter particularly struck me. I took care of a girl of about 6 years of age who had upper respiratory complaints such as cough, sore throat, and fever. I make a point of asking every parent of a child with a potential infectious disease the vaccination status of the child because it is an important piece of information to know for diagnostic purposes and, if found to be lacking, an important opportunity for education. This particular child was fully vaccinated except against influenza. The mother stated "we don't believe in flu shots." Her reason was that the shots, she alleged, make her entire family sick immediately upon receipt. I tried to debunk this "belief" but really didn't get anywhere. I left the room and went back to the nurse's station and vented to the nurse who said she didn't "believe" in flu shots either!

I find the nurse's position really untenable as she is well educated on the efficacy of vaccines and the role they play in controlling infectious diseases and preventing the worst complications of infections such as influenza. This is something taught in nursing schools and written about in nursing journals; it is a well established part of nursing practice. I suppose this nurse is someone that will unfortunately prove recalcitrant to any mandatory influenza vaccine campaign which the major academic medical center for whom I primarily work introduced this year.

What I think is interesting is both the mother and the nurse used the concept of "belief" when it came to the efficacy influenza vaccine. The definition of belief is "a state or habit of mind in which trust or confidence is placed in some person or thing" and I do have confidence and trust in the influenza vaccine but I would never put it that way. The efficacy of a vaccine, about 60% (which could be much better) in the case of the flu vaccine, is an established fact dependent only on the immunological phenomenon elicted by the vaccine. The immunological effects of the vaccine occurs whether someone "believes" in it or not. In other words, it is a fact independent of anyone's recognition of it. 

A fact can be evaded, but it will still be a fact. Reality has primacy and vaccines work.

Putting Zika Virus into Context

Now that a case of Zika virus was recently confirmed in one of the 50 states (Texas), I expect a lot of domestic media attention to be focused on this virus that heretofore was not considered a major public health threat. Indeed only 1 in 5 people infected with this mosquito-borne virus actually experience symptoms.

What changed the perception? The correlation of its appearance in Brazil and the increase in fetal microcephaly cases, which number in the thousands. Fetal microcephaly refers to an abnormally small-sized head on a developing fetus. This condition has myriad causes and Zika virus has not been definitively proven to be an etiologic agent in any of the cases -- though the data is very suggestive. Microcephaly is a devastating diagnosis that can lead to abnormal brain functioning and a shortened lifespan. Thus far just 3 deaths of been reported, including one microcephalic newborn who died within 5 minutes of life. There are 2 deaths in El Salvador from the autoimmune neurologic disorder Guillan-Barre-- a rare complication of Zika and many other infections -- being investigated for possible linkages to Zika (something also being investigated in Brazil).

What is most significant, to me, about Zika virus is that it is spread by Aedes mosquito which also serve as the vector for the much more dangerous dengue and chikunguna viruses that are relatively neglected and haven't claimed international headlines as forcefully as the benign-in almost-cases Zika has (the subject of a blog post by another infectious disease physician). Societal has little tolerance for infections that target developing fetuses (witness the rubella elimination campaigns) even if they do not incur much damage to adult hosts. (Inappropriate aside that I can't resist -- Beetlejuice didn't like his own microcephaly either). 

With the attention on Zika however, there should be a renewed push to optimize Aedes mosquito vector control -- which should include the use of GMO Aedes mosquitoes to decrease population sizes -- as well as draw attention to the GSK Dengue vaccine (approved in Brazil, Mexico, and the Philippines -- but not yet the US). 

One last thing, though this Texas Zika case may capture headlines, Zika has been here before (confirmed cases and likely undiagnosed mild cases that escaped notice). What remains to be seen is if this virus will be successful like its forebears dengue and chikungunya in setting up foci of autochthonous transmission within the United States.

Salmonella, Swollen Glands, and other Cool Stuff

When someone is sick with an infection they often experience swelling of their lymph nodes, or lymphadenopathy. This is colloquially referred to as having "swollen glands" and is usually apparent in the neck region. What is going on when this phenomenon occurs is that immune cells are basically congregating in the lymph nodes and undergoing something akin to a pep rally before they face the invader. These conglomerations occur at sites known as follicles in which germinal centers are formed. The result of this process is an army of elite soldiers armed to the teeth with antibodies exquisitely targeted to the microbe that set off the immune system alarms. When your "glands" feel sore it's basically because the equivalent of troop mobilization is occurring. This massive oversimplification is the standard text book version of the events.

I recently listened to a fascinating lecture by Pitt's immunology chairman, Dr. Mark Shlomchik on this topic -- specifically when it doesn't occur quite as is written in the textbook. The infection that his research group has described an alternate pathway of immune response for is Salmonella. Salmonella is a major infectious disease threat that is responsible for thousands of cases of foodborne illness yearly. One of the intriguing facets of Salmonella is that it can, in certain contexts, turn humans into carriers who chronically shed the bacteria (this is well known with the typhoid species of Salmonella but can occur with the gastroenteritis causing members of the group as well).

The papers describing this work (in mice) conducted by Shlomchik and other groups are quite technical, but really really neat. Here's my attempt to drill it down to the basics:

It had been known that Salmonella infections produce what is known as an extrafollicular immune response with germinal center formation delayed by one month. This response produces antibodies that are directed against Salmonella. These antibodies are specific to Salmonella but are not the sharpest tools and have a lower affinity than a full-fledged graduate of the germinal center.  

Another interesting event that occurs is the germinal centers form only when the bacterial load falls through progression of the infection or via antibiotic therapy.

What could be the purpose of this alternative pathway? What is the evolutionary driver here?

A couple of hypotheses: if Salmonella "wants" to have us as its carriers it has to do two things: 1) not kill us and 2) not be killed by us. Could the suppression of germinal centers -- keeping the immune system's schools closed -- be a way to accomplish that by prompting a less elite team of the immune system to respond? This 2nd string team could keep the bacteria out of the bloodstream and somewhat in check (but not completely).

So cool.