Clinical Capsules

Pneumococcal Vaccine Safety

Receiving three or more doses of pneumococcal polysaccharide vaccine does not appear to increase the risk of serious adverse events, a retrospective study has shown.

Only 1 of 179 persons who received three or more doses of 23-valent pneumococcal polysaccharide vaccine, and 4 of 181 controls who received one or two doses, had a medically attended adverse event, reported Frances J. Walker and colleagues at the Centers for Disease Control and Prevention, Atlanta.

Adverse events included tachycardia and arm redness, tenderness, rash, or swelling. No severe adverse events occurred, the investigators noted (Clin. Infect. Dis. 2005;40:1730–5).

The findings are important because data on the safety and effectiveness of revaccination have been lacking, and routine revaccination is therefore not generally recommended, except in certain high-risk patients, the investigators reported. However, pneumococcal antibody levels have been shown to decline to prevaccination levels within 6–10 years after vaccination.

Dengue Infection

A total of 77 cases of travel-associated dengue infection were confirmed in the United States from 2001 to 2004, according to the CDC.

Commonly reported symptoms of the infection included fever, headache, myalgias, chills, and rash. Additionally, 25% of patients had at least one hemorrhagic symptom, 16% had elevated liver transaminase levels, and 27% required hospitalization; one of the hospitalized patients died (MMWR 2005;54:556–8).

Travel destinations of affected patients in the 2 weeks prior to the onset of the illness included a Caribbean island (30% of patients), a Pacific island (21%), Asia (17%), Central America (15%), South America (15%), and Africa (2%).

Mosquito repellant, protective clothing, and remaining in well-screened or air-conditioned areas can help prevent infection. Health care workers should consider dengue in patients presenting with fever and a recent history of travel to tropical and subtropical areas. Patients should receive supportive treatment, with only acetaminophen for pain and fever, and should be monitored for dengue hemorrhagic fever with provision of fluids as necessary, according to the CDC.

Purpura Fulminans

Five recent cases of purpura fulminans associated with Staphylococcus aureus strains that produce high levels of superantigens suggest that this is a newly emerging clinical entity, Gary R. Kravitz, M.D., an infectious disease specialist in group practice in St. Paul, Minn., and his colleagues reported.

These patients represent the first known cases of purpura fulminans directly associated with S. aureus strains that produce high levels of toxic shock syndrome toxin-1, S. enterotoxin serotype B, or S. enterotoxin serotype C. One patient had a methicillin-resistant strain, and only two of the five patients survived, the investigators reported (Clin. Infect. Dis. 2005;40:941–4).

The clinical presentations were identical to those for patients with fulminant meningococcemia, which is much more common. Patients presenting with purpura fulminans should receive antibiotic therapy active against Neisseria meningitidis and streptococci, as well as methicillin-resistant S. aureus, the investigators advised.

Early administration of activated protein C to minimize purpuric skin injury may be indicated, as well as intravenous immunoglobulin therapy (which contains significant antibodies against the causative exotoxins), they noted.

Spread of HIV

The CDC estimates that 63% of new cases of HIV infection are in men who have sex with men, 50% are in blacks, 32% are in whites, and 16% are in Hispanics.

A recent report based on data from 5 cities (Baltimore, Los Angeles, Miami, New York, and San Francisco) of 17 participating in the National HIV Behavioral Surveillance System further suggested that 25% of the 1,767 surveyed men who have sex with men have HIV, and 48% of those were unaware of their infection (MMWR 2005;54:597–601).

Men under 30 years who are nonwhite and not living in San Francisco accounted for the highest proportion of those who were unaware of their HIV status, according to the report, which was presented at the 2005 National HIV Prevention Conference in Atlanta.

Men who have sex with men should be encouraged to have HIV testing at least annually, and prevention programs should focus on reaching those who are unaware of their HIV status, the report concluded. Men who have sex with men were more likely to be tested for HIV during the previous year if a health professional they visited had recommended such testing.