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Editor’s Note: In this feature, brief items, primarily gleaned from abstracts or articles in journals and other resources not commonly perused by most US infectious disease physicians, will be presented, usually without comment. — Stan Deresinki, MD, FACP
|Pathogenesis & Host Defense|
Twitching Prevents Biofilm Formation
Lactoferrin, at subinhibitory concentrations, blocks biofilm development by P aeruginosa, by chelation of iron and consequent stimulation of bacterial twitching, a form of surface motility, thus causing the bacterial cells to travel across a surface rather than forming clusters and biofilm (Singh PK, et al. Nature. 2002;417:552-555).
Leptin and Host Defense
Relative to normal mice, leptin-deficient mice had reduced bacterial clearance and defective alveolar macrophage phagocytosis as well as increased mortality following intratracheal challenge with K pneumoniae (Mancuso P, et al. J Immunol. 2002;168:4018-4024).
CFTR Is a Pattern Recognition Molecule and a Component of the Innate Immune Response to P aeruginosa Infection
The cystic fibrosis transmembrane conductance regulator (CFTR) specifically recognizes P aeruginosa lipopolysaccharide which is then extracted from the surface of the organism and endocytosed by epithelial cells with subsequent activation of NF-kB (Schroeder TH. PNAS(USA) 2002;99:6907-6912).
S aureus Peptidoglycan Induces Procoagulant Activity
S aureus peptidoglycan, in addition to inducing proinflammatory cytokine production by monocytes, also activates the extrinsic pathway of coagulation by inducing the expression of tissue factor in these cells (Mattson E, et al. Infect Immun. 2002;70:3033-3039).
Invasive GAS Disease: Host or Bacterial Factors?
Examination of M serotypes 1, 3, and 28 of S pyogenes from both invasive and uncomplicated infections found no evidence of virulent clones accounting for more serious infection, suggesting that it is host, rather than bacterial factors that account for severe infection due to this organism (Johnson DR, et al. J Infect Dis. 2002;185:1586-1595).
|Respiratory Tract Infections|
No Benefit from Dexamethasone in Severe RSV Infection
Dexamethasone administration was not associated with clinical benefit in children with RSV infection requiring mechanical ventilation in a randomized placebo controlled trial (Buckingham SC, et al. J Infect Dis. 2002;185:1222-1228).
Classification of Community Acquired Bacteremia: Not All "Communities" Are the Same
A total of 1028 bloodstream infections were placed into one of 5 categories: true community-acquired infection (36%), infections in recently discharged patients (11%), infections associated with invasive procedures performed just before or at the time of admission (5%), infections in patients admitted from nursing homes (7%), and nosocomial (41%) (Siegman-Igra Y, et al. Clin Infect Dis. 2002;34:1431-1439).
Antibiotic Resistance Reports and Misidentification of S pneumoniae
In a study of nasopharyngeal carriage, only 9 (30%) of 30 isolates identified as S pneumoniae by standard techniques (optochin susceptibility and bile solubility) were confirmed by DNA probes. While the probe positive isolates had antibiotic susceptibility patterns similar to bloodstream isolates of S pneumoniae, the probe-negative isolates (probably truly organisms such as S mitis or S oralis) were more antibiotic resistant. This observation suggests there penicillin resistance rates in S pneumoniae may be overstated (Wester CW, et al. Diagn Microbiol Infect Dis. 2002;42:263-268).
Azithromycin vs Placebo for Acute Respiratory Infection
Jordanian patients 8 years of age or older with acute respiratory infection without pneumonia alternately received azithromycin or placebo. No benefit from antibiotic therapy was detected (Batieha A, et al. Scand J Infect Dis. 2002;34:243-247).
Simkania nevegensis & Acute Exacerbations of COPD
The seroprevalence of antibody to Simkania nevegensis was 63% among 120 patients with COPD, a prevalence similar to that of the general community in Israel. Serological evidence of acute infection with this organism during acute exacerbations of COPD was detected in 5 patients requiring hospitalization, 4 of whom had evidence of acute infection with at least one other respiratory pathogen (Lieberman D, et al. Eur J Clin Microbiol Infect Dis. 2002;21:307-309).
Erythromycin Resistance Zooms Among PNSP in Finland
Between 1996 and 2000, the prevalence of resistance to erythromycin among penicillin non-susceptible S pneumoniae increased from 32% to 62%, with 72% having the MSLB (erm), 25% the M (mefA), and 3% the MS (ribosomal mutation) phenotype (Pihlajamaki M, et al. J Antimicrob Chemother. 2002;49:785-792.
Potential for Fluoroquinolone Resistance in Chlamydia spp.
Serial passage of C trachomatis in subinhibitory concentrations of antibiotic was associated with a > 256-fold increase in MIC to both ofloxacin and ciprofloxacin. In contrast, no increase in either the moxifloxacin or ofloxacin MIC of C pneumoniae was seen after 30 passages (Morrissey I, et al. J Antimicrob Chemother. 2002;49:757-761).
|Central Nervous System Infections|
Low-Voltage EEG During Acute Encephalitis and Postencephalitic Epilepsy
Retrospective analysis of 19 children with acute encephalitis found that the presence of low-voltage EEG activity during the acute phase was highly predictive of the occurrence of postencephalitic epilepsy, which occurred in all 9 patients with this finding (Hosoya M, et al. Brain Dev. 2002;24:161-165).
Viral Meningitis—Perhaps Not So Benign After All
When evaluated 12 months after apparent complete recovery from viral meningitis, neuropsychological testing of 21 adults detected persistent mild cognitive impairment (Sittinger H, et al. J Neurol. 2002;249:554-560).
Chronic Meningitis and Coeliac Disease
A 56-year-old woman with chronic meningitis was subsequently found to have coeliac disease. Cartalat-Carel and colleagues suggest testing for anti-gliadin antibodies as part of the evaluation of patients with chronic meningitis (Cartalat-Carel S, et al. Revue Neurologique. 2002;158:467-469).
Recurrent Neurologic Symptoms After HSV-2 Meningitis
A retrospective analysis of 40 patients with HSV-2 meningitis and/or myeloradiculitis found that within 1 year 8 (20%) had at least 1 recurrence of meningitis, 3 had new episodes of myelitis or radiculitis, and 4 had attributable attacks of headache. Eleven patients had concurrent or separate episodes of recurring mucocutaneous and neuralgic symptoms, 7 had neurologic recurrences only, and 5 had only mucocutaneous recurrences (Aurelius E, et al. Scand J Infect Dis. 2002;34:278-283).
Nipah Virus Infection & Late-Onset & Relapsing Encephalitis
Twelve (7.5%) of 160 survivors of Nipah virus encephalitis followed for 24 months had encephalitic relapses. In addition, 3.4% of patients whose initial Nipah virus infection was asymptomatic or non-encephalitic had late-onset encephalitis. MRI showed patchy area of confluent cortical lesions (Tan CT, et al. Ann Neurol. 2002;51:703-708).
|Gastrointestinal & Intra-abdominal Infections|
Reactive Arthritis & Salmonella
Seventeen of 91 (19%) individuals exposed to Salmonella enteritidis in an outbreak subsequently reported symptoms of reactive arthritis/arthralgia (Locht H, et al. J Rheumatol. 2002;29:767-771).
The Pancreas & the Pneumococcus
S pneumoniae was isolated from intra- or peripancreatic samples from 9 patients with complications of chronic pancreatitis and was the sole bacterial isolate in most (Thege MK, et al. Microb Drug Resist-Mech Epidemiol Dis. 2002;8:73-76).
An Environmental Niche for H pylori?
H pylori lives quite happily within the free-living amoeba, Acanthamoeba castellani. (Winiecka-Krusnell J, et al. Scand J Infect Dis. 2002;34:253-256).
Metronidazole Resistance in C difficile
In a study in Spain, 6.3% of 415 isolates of C difficile were resistant to metronidazole; 3.1% had intermediate levels of susceptibility to vancomycin (Pelaez T, et al. Antimicrob Agents Chemother. 2002;46:1647-1650).
Risk Factors for Salmonella Bacteremia in Children
The independent risk factors for bacteremia in Taiwanese children with nontyphoidal Salmonella bacteremia were fever duration of 5 or more days and infection with group D1 Salmonella, particularly S panama (Yang YJ, et al. Eur J Clin Microbiol Infect Dis. 2002;21:290-293).
Ertapenem vs Pip-Tazo in Skin & Skin-Structure Infections
In a randomized trial, ertapenem (1 g q24h) and piperacillin-tazobactam (3.375 g q6h) had equivalent efficacy and safety in the treatment of adults with complicated skin and skin-structure infections (Graham DR, et al. Clin Infect Dis. 2002;34:1460-1468).
Streptococcus viridans Bacteremia During Prophylaxis with Levofloxacin
Six of 37 (16.2%) patients undergoing autologous peripheral blood stem cell transplantation developed viridans group streptococcal bacteremia while receiving levofloxacin prophylaxis; 3 developed septic shock. The 6 isolates were distinct but had reduced susceptibility to levofloxacin, 5 to gatifloxacin and 4 to moxifloxacin (Razonable RR, et al. Clin Infect Dis. 2002;34:1469-1474).
Treatment of VRE Prosthetic Valve Endocarditis
A patient with prosthetic valve endocarditis due to vancomycin-resistant E faecium was successfully treated with chloramphenicol plus minocycline after failure of treatment with quinupristin-dalfopristin (Safdar A, et al. Clin Infect Dis. 2002;34:E61-E63).
Brain MRI Findings in Infective vs Noninfective Endocarditis
Diffusion-weighted brain MRI found that patients with stroke syndromes due to nonbacterial thrombotic endocarditis had numerous small (< 10 mm) and medium or large (> 30 mm) lesions in multiple territories, while those with infective endocarditis exhibited a range of stroke patterns, including single lesions, territorial infarction, and disseminated punctate lesions, as well as the pattern seen in the noninfectious cases (Singhal AB, et al. Stroke. 2002;33:1267-1273).
Surfactant Administration in Septic Shock with ARDS
Surfactant administration via bronchoscope to 27 patients with ARDS and septic shock was associated with improvement in surface tension-lowering properties of BAL fluid, as well as improvement in oxygenation in most (Gunther A, et al. Eur Resp J. 2002;19:797-804; Wallmrath D, et al. Eur Resp J. 2002;19:805-810).
Treatment of Acute Adenoviral Keratoconjunctivitis
In a randomized trial, administration of cidofovir 1% eye drops reduced the frequency of severe corneal opacities, but its use was limited by local toxicity. Topical cyclosporin had no effect on the course of the infection (Killenkamp J, et al. Ophthalmol. 2002;109:845-850).
A retrospective analysis of 154 patients with active ocular toxoplasmosis found that recurrences developed in 79% of those followed for at least 5 years and these usually occurred in the originally affected eye. Legal blindness in 1 or both eyes occurred in 24%. Risk factors for visual loss included congenital infection, ocular infection manifesting during the acute phase of systemic infection, central location and/or extensive retinal lesions, and the administration of corticosteroids without concomitant antiparasitic drugs (Bosch-Driessen LE, et al. Ophthalmol. 2002;109:869-878).
Recurrent Anterior Uveitis & CMV
Two cases of recurrent anterior uveitis with sectorial iris atrophy and ocular hypertension, generally thought to be almost pathognomonic of HSV infection, were demonstrated to be the result instead of CMV infection by detection of viral DNA in aqueous humor by PCR (Markomichelakis NN, et al. Ophthalmol. 2002; 109:879-882).
A 1-day point prevalence study of 35 pediatric ICUs found that 11.9% of the children had a PICU-acquired infection, with 41% affecting the bloodstream, 23% the lower respiratory tract, 13% the urinary tract and 8% skin/soft tissue. Coagulase-negative staphylococci were recovered from 21% of those infected, Candida spp. from 17%, enterococci from 13%, S aureus from 12%, and P aeruginosa from 7% (Grohskopf LA, et al. J Ped. 2002;140:432-438).
Fungemia From the Pharmacy?
An outbreak consisting of 19 cases of fungemia due to Exophiala jeanselmei was associated with recovery of the organism from deionized water from the hospital pharmacy (Nucci M, et al. Clin Infect Dis. 2002; 34:1475-1480).
Linezolid vs Vancomcyin for MRSA Infections
In an open-label randomized trial, vancomycin and linezolid had equivalent efficacy in the treatment of infections with MRSA, most involving skin and soft tissue (Stevens DL, et al. Clin Infect Dis. 2002;34:1481-1490).
M Chelonae & Liposuction
Forty-one percent of 82 patients undergoing liposuction developed cutaneous abscesses with M chelonae isolated from 12 of the patients. M chelonae was isolated from biofilm in the piped water system in the surgeon’s offices and was genetically similar to the clinical isolates (Meyers H, et al. Clin Infect Dis. 2002;34:1500-1507).
Mupirocin Resistance Among Staphylococci
The prevalence of resistance to mupirocin among S aureus isolates from North America, Latin America and Europe ranged from 1.9% to 5.6% while among coagulase-negative staphylococci ranged from 12.8% to 39.9% (Deshpande LM, et al. Diagn Microbiol Infect Dis. 2002;42:283-290).
Amikacin Pharmacokinetics After Unilateral Nephrectomy
Unilateral nephrectomy was associated at 1 month with an 81% increase in amikacin AUC and, at 12 months, a 63% increase. Total body clearance of amikacin was reduced by 53% at 1 month and 45% at 12 months (Drozdzik M, et al. J Pharm Pharmacol. 2002;54:509-514).
Vancomycin and IgA Bullous Disease
A case of linear IgA bullous disease caused by vancomycin was reported (Neugehebauer BI, et al. Am J Med Sci. 2002;323:273-278).
Levofloxacin & CVVH
Levofloxacin blood levels are highly variable and unpredictable in patients undergoing continuous veno + venous hemofiltration using polysulfone membrane hemofilters (Bellmann R, et al. Internat J Clin Pharmacol Ther. 2002;40:142-149).
The Achilles Heel of Fluoroquinolones?
The relative risk of Achilles tendon disorders among current fluoroquinolone users was 3.2 (2.1-4.9) among those 60 years of age and older, but only 0.9 (0.5-1.6) among those younger. In this large UK study, corticosteroid use was also a significant risk factor (van der Linden, PD et al. BMJ. 2002;324:1306-1307).
|Geographic & Travel Medicine|
Respiratory Manifestations of Malaria
Altered pulmonary function, including airflow obstruction, impaired gas exchange, and increased pulmonary phagocytic activity, is commonly present in patients with both uncomplicated falciparum and vivax malaria and is frequently accompanied by coughing (Anstey NM, et al. J Infect Dis. 2002;185:1326-1334).
Evaluation of residents of onchocerciasis endemic areas in West and East Africa found that 42% of adults complained of pruritus and that associated skin lesions were present in 28% of those in endemic villages with chronic popular onchodermatitis, depigmentation, and acute popular onchodermatitis being most frequently detected (Murdoch ME, et al. Ann Trop Med Parasitol. 2002;96:283-296).
Transeverse Myelitis After JBV Vaccination
A 4-year-old girl developed acute transverse myelitis 14 days after Japanese B encephalitis virus vaccination (Matsui M, et al. Brain Dev. 2002;24:187-189).
Japanese B Encephalitis
Of 144 Vietnamese patients with Japanese B encephalitis, 12% died and 23% had severe neurological sequelae. Seizures and/or raised intracranial pressure were associated with a significantly increased risk of death (Solomon T, et al. Brain. 2002;125:1084-1093).
Walrus Meat & Trichinellosis
A program involving preconsumption testing of walrus meat at a regional laboratory has markedly reduced the incidence of trichinellosis in Inuit communities in Nunavik, Canada (Proulx JF, et al. Clin Infect Dis. 2002; 34:1508-1514).
HAM in Brazil
The mean age at onset of HTLV-1-associated myelopathy (HAM) in a Brazilian cohort was 43.2 years, with spastic paraparesis being the dominant abnormality. CSF examination revealed mild mononuclear pleocytosis and protein elevation, while MRI showed areas of high signal intensity in one third and cord atrophy in 5.6% (Milagres AC, et al. Neuroepidemiology. 2002;21:153-158).
Chronic Hepatosplenic Brucellosis
Abdominal CT in 7 patients with chronic hepatosplenic brucellosis showed large poorly defined lesions with heterogeneous attenuation and thick central calcifications surrounded by areas of hypointensity. Histologic examination revealed granulomas with central necrosis and a neutrophilic infiltrate (Colmenero JD, et al. Diagn Microbiol Infect Dis. 2002;42:159-167).
Travelers Diarrhea & EAEC
A prospective study of US travelers to Guadalajara, Mexico, found that diarrhea due to enteroaggregative E coli (EAEC) occurred as frequently as diarrhea due to enterotoxigenic E coli (Adachi JA, et al. J Infect Dis. 2002;185:1681-1683).
Mediterranean Visceral Leishmaniasis in Non-HIV Infected Children.
Of 111 consecutive non-HIV infected children (mean age, 1.7 years) admitted to a single hospital in Sicily, all had fever and splenomegaly and 90% had hepatomegaly, while 70% were thrombocytopenic and 42% leukopenic. Amastigotes were detected on bone marrow aspirate in 80%. Only 2 relapses occurred after treatment with meglumine (Cascio A, et al. Eur J Clin Microbiol Infect Dis. 2002;21:277-282).
|Sexually Transmitted Disease|
Bacterial Vaginosis and Women Having Sex with Women
Frequent concordance of bacterial flora was consistent with the hypothesis that sexual exchange of vaginal secretions may account for acquisition of bacterial vaginosis in women who have sex with women (Marazzo JM, et al. J Infect Dis. 2002;185:1307-1313).
Environmental Contamination By HPV DNA
Human papillomavirus (HPV) DNA was detected on multiple surfaces, including toilets, at 1 of 2 GU clinics but not at a staff leisure and fitness center (Strauss W, et al. Sex Trans Infect. 2002;78:135-138).
Treatment of HCV Infection in Patients with Normal or Near Normal ALT
Interferon-alpha 2b monotherapy was superior to placebo in a randomized trial in patients with chronic HCV infection with normal or near normal (< 1.5 times the upper limit of normal) ALT levels (Krown SE, et al. J Interferon Cytokine Res. 2002;22:365-369).
Chronic HCV Infection & Fatigue
The level of fatigue reported by patients with chronic HCV infection strongly correlated with findings of depression, anxiety, somatization, interpersonal sensitivity, and hostility, but not with measures of activity of hepatitis (McDonald J, et al. J Gastroenterol Hepatol. 2002;17:171-176).
Hepatic Iron & HCV Rx
Increased hepatic iron concentration did not adversely affect treatment of chronic HCV infection with interferon alpha plus ribavirin (Pianko S, et al. J Interferon & Cytokine Res. 2002;22:483-489).
Inactive HbsAg Carriers
Biopsy evaluation of "inactive carriers," patients who were HbsAg+/HbeAg- with persistently normal ALT and undetectable serum HBV DNA (< 100,000 copies/mL), found that histologic lesions were mild in all cases and viral load remained stable on follow-up (Martinot-Peignoux M, et al. J Hepatol. 2002;36:543-546).
HHV8 Seroconversion After Solid Organ Transplantation
HHV8 seropositivity increased from 5.3% to 15.8% after solid organ transplantation; seroconversions were not related to an organ donor source (Jenkins FJ, et al. J Infect Dis. 2002;185:1238-1243).
Artesunate Inhibits CMV
The antimalarial drug artesunate has potent in vitro activity against CMV, including strains resistant to ganciclovir, possibly as the consequence of inhibition of host cell kinase cascades (Efferth T, et al. J Molec Med. 2002;80:233-242).
Adoptive Immunotherapy of CMV Infection
Infusion of CMV-specific T cells in stem cell recipients with CMV infection but lacking CMV specific T-cell proliferation was associated with enhanced immune response and an antiviral effect (Einsele H, et al. Blood. 2002;99:3916-3922).
Two Kinds of Blastomycosis?
In contrast to North American cases, examination of tissue sections from patients who acquired B dermatitidis infection in Africa, hyphal forms of the fungus were found in 12 of 14 cases. This is consistent with other findings suggestive of the existence of 2 types of B dermatitidis (Huerre M, et al. J Mycol Medicale. 2002;12:5-11).
Enteral Administration of Fluconazole to Critically Ill Surgical Patients
In a trial of preventive therapy, enteral administration of fluconazole to critically ill surgical patients yielded mean trough fluconazole levels above the highest MIC of C albicans and C parapsilosis isolates from the patients in 96%. However, levels were below the MIC for C glabrata in 77%. There was no significant correlation between fluconazole levels and the risk for fungal infection (Pelz RK, et al. Surgery. 2002;131:534-540).
Boosting Ambisome with Fungizone
The efficacy of liposomal amphotericin B was enhanced by the administration of a single dose of conventional amphotericin B at the start of treatment in an experimental model of aspergillosis in neutropenic rodents (Becker MJ, et al. J Antimicrob Chemother. 2002;49:813-820).
Sulfas & Pentamidine Inhibit Aspergillus
Sulfamethoxazole, sulfadiazine, and pentamidine were each active in vitro against Aspergillus species (Afeltra J, et al. Antimicrob Agents Chemother. 2002; 46:2029-2031).
Susceptibility of Candida in Biofilms
C albicans exhibited resistance to fluconazole, nystatin, terbinafine, amphotericin B deoxycholate, voriconazole, and ravuconazole when the organism was grown as a biofilm, but they remained susceptible to amphotericin B lipid complex, liposomal amphotericin B, caspofungin, and micafungin (Kuhm DM, et al. Antimicrob Agents Chemother. 2002;46:1773-1780).
Nonsurgical Management of Tuberculous Spondylodiscitis
Nonsurgical management of lumbar or lumbosacral tuberculous spondylodiscitis was successful in 55 of 66 (83%) of adults and none were left with persistent instability, radiculopathy, or neurological compromise (Bhojraj S, Nene A. J Bone Joint Surg Br. 2002;84:530-534).
Moxifloxacin & TB
Moxifloxacin was bactericidal in a murine model of tuberculosis (Yoshimatsu T, et al. Antimicrob Agents Chemother. 2002;46:1875-1879).
|HIV Infection & Complications|
Civil Strife & HIV Infection
In contrast to the experience in much of the rest of Uganda, the prevalence of HIV-1 infection among pregnant women in rural areas of the Gulu district in the north of the country, an area where civil strife resurfaced since 1996, has increased significantly (Fabiani M, et al. AIDS. 2001;15:2330-2331).
HIV-2 Infection Does Not Protect Against HIV-1 Infection
Data from 2 prevalence surveys separated by 9 years in Guinea-Bissau found no evidence that prior HIV-2 infection protects against subsequent HIV-1 infection (VanderLoeff MF, et al. AIDS. 2001;15:2303-2310).
HIV-1 Subtypes and Disease Progression
Infection with HIV-1 subtype D was associated with lower CD4 count at follow-up as well as faster progression to death than was infection with subtype A in Uganda (Kaleebu P, et al. J Infect Dis. 2002;185:1244-1250).
Methadone & CCR5
Methadone increased CCR5 expression on human lymphocytes in vitro (Suzuki S, et al. FEBS Lett. 2002;519:173-177).
HLA-Restricted Immune Responses Drive HIV-1 Evolution
At a population level, selection of HIV-1 genome sequence as the consequence of viral adaptation allows escape from HLA allele-specific host immune responses (Moore CB, et al. Science. 2002;296:1439-1443).
Diagnosis of Primary HIV Infection
The sensitivity and specificity, respectively, for the diagnosis of primary HIV-1 infection for p24 antigen detection were 79% and 99%, while that of a third generation ELISA were 79% and 97%, HIV RNA by DNA were 100% and 95%, and HIV RNA by PCR 100% and 98%. False-positive HIV RNA tests were not reproducible and had values < 3000 copies/mL (Hecht FM, et al. AIDS. 2002;16:1119-1129).
Active source tracing and HIV testing significantly reduced the need for post-exposure prophylaxis in individuals with potential non-occupational exposures (Greub G, et al. AIDS. 2002;16:1171-1176).
The Thymus & HAART-Associated Immune Reconstitution
A significant increase in naïve CD4+ and CD8+ T cells, T-cell receptor excision circles (TRECs), and thymic volume was observed 12 weeks after initiation of HAART, suggesting a thymic role in immune reconstitution (Franco JM, et al. Blood. 2002;99:3702-3706).
Growth Hormone Increases Thymic Mass and Naïve T Cells
Administration of human growth hormone to 5 HIV infected patients for 6 to 12 months was associated with a marked increase in thymic mass as well as in circulating naïve T cells. (Napolitano LA, et al. AIDS. 2002;16:1103-1111).
Dr. Deresinski, Clinical Professor of Medicine, Stanford; Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center, is Editor of Infectious Disease Alert.
Readers are Invited
Readers are invited to submit questions or comments on material seen in or relevant to Infectious Disease Alert. Send your questions to: Rob Kimball, Reader Questions, Infectious Disease Alert, c/o American Health Consultants, P.O. Box 740059, Atlanta, GA 30374.