Wednesday, December 14, 2016

Syphilis: resistance and epidemiolgy

Instapundit linked to this article on the resistance of syphillis to antibiotics... i.e. Zithromax/azithromycin.

The advantage of Zithromax is that it is a few pills, whereas Penicillin means a shot (and if you have ever seen an allergy to penicillin you know why the pills are preferred). And Zithromax will also cure Gonorrhea and Chlamydia, which often are also present in these patients but may not show up in tests or give symptoms.

But the article wonders what is behind this:

They found that the two current clades (categories) of syphilis infections had a common ancestor in approximately the 18th century. One of these clades, called SS14, has a particular strain (SS14-Ω) that seems to have split from the others sometime in the middle of the twentieth century. (italics mine)....
It’s not clear why SS14-Ω is so successful. There could be a biological explanation, like it having an increased transmission rate, says Arora. But it could also be social or demographic reasons: “Perhaps there’s a strain type that circulates among networks of people more easily.” Isolates of both strains show up with resistance to azithromycin, but resistance is far more prevalent in SS14

 middle of the 20th century? As in "time of the sexual revolution"? Or a bit later, as in after the Gay liberation movement stopped all attempts to close disease spreading bathhouses and bars:?

People with hundreds of sexual contact are more likely to catch HIV and other STD's than a monogamous person, but to say that out loud will get you accused of homophobia or rigidity/moralism.

and since syphilis is more common in HIV positive white men practicing MSM, could the problem be that Azithromycin, which only discourages and doesn't kill the germ, might not be killed by the body's defenses?

Zithromax belongs to a class of antibiotics called macrolides, which are bacteriostatic – meaning they treat infections by preventing bacteria from multiplying and producing the proteins that are essential for their growth. Eventually, the remaining bacteria die or are killed by the immune system, not by the drug itself. This is in contrast to bactericidal antibiotics, which kill bacteria.

we saw a lot of syphilis, including neonatal syphilis, when I worked in Africa. Men worked in town but were forced by company policies and tribal customs (where if you don't have someone working your land, it will be deeded to someone else) to let their wives in the country to tend the farm. Prostitutes spread various STD's and we saw cases after each holiday.

I always wondered why the mines didn't bother to check the local gals and treat their STD's (as the US Army usually did to stop STD's in the good old days).

and don't say: "condoms"... they aren't used in Africa, mainly due to tribal custom, but also the heat and humidity mean that the latex deteriorates so may be useless.

the presence of "male dormitories" at mines and factories in South Africa etc. is one of the big reasons for the spread of heterosexual HIV, along with no circumcision. And it is probably one of the reasons for South Africa's problem with drug resistant TB.

and in Asia, including China, Iran, and parts of Russia, most of the HIV was related to to injection of heroin etc.

But as a whole, in the West, it is same sex male sexual practiccs that spread Syphilis, HIV and other STD's.


The HIV/AIDS epidemic in the 1980s was associated with general declines in the rates of syphilis among the general population in the US and Western Europe, including MSM [1, 8, 9]. The decline continued into the early 1990s and was concurrent with the adoption of safer sex behaviors and the effectiveness of sexual education and HIV/AIDS prevention programs [10, 11].
However, around 1999, intermittent outbreaks of syphilis were reported in many urban areas in the US and Western Europe [8–13]. These outbreaks occurred almost exclusively among MSM and were attributed to increases in risky sexual behaviors such as condomless anal sex (CAS), exchange sex, illicit drug use before sex, multiple sexual partners, and high-risk anonymous sexual contacts [14].
Syphilis outbreaks continue to occur sporadically in the US and Western Europe [3]. Given the continued risk of syphilis transmission, its close association with HIV infection, and the disproportionate disease burden among MSM in the US and Western Europe, there is a need to examine and understand syphilis trends among MSM in both geographic areas.

to check why, you need an x rated investigation, This article is a good place to start, but is probably quite shocking to the general population.

but we docs already know what is going on: not just drug use, and not just a very large number of different sexual partners, but a lot of practices that a normal woman or an ethical prostitute would reject.

read this and weep..

and then tell the damn Pope that his going along with this "who am I to judge" and condemnation of rigid/moral ideas rather than the condemnation of sin is a major reason that this epidemic spreads.

Yes, in the good old days, we had gays sneaking out once in awhile to have sex, but at least we could use shame and fear (of hell, of disease, or being picked up by the cops) to limit their disease spreading behavior.

being judgment free only means they refuse to recognize the reality behind all those rigid moralisms was not hatred of women/ hatred of sex, or  homophobia, but based on experience.

Warniing people of danger is not hatred, but a form of love...

Tuesday, December 13, 2016

Orange Babies and blue men

I had written a previous post about the Rose Madder herb being fed to horses to make their hooves pink.

That is not the only dye/foodstuff that can change the colour of skin or nails:

Wholesome baby food website discusses the question: Why is my baby orange.

Image: keeleymorris on Twitter

Carotenemia is a medical term for a condition that causes the skin to turn orange-ish due to increased blood carotene levels. In the vast majority of cases seen, it is associated with large consumption of carotene in the diet; as in too many carrots or sweet potatoes. Read more at

more at Wikipedia 

we see this a lot in kids, and the way you can tell it's not jaundice is that their eyes are not yellow. The treatment is to reassure the parents.

I've only seen it once in an adult: It she admitted that she had a craving for carrots.

People who are anemic often have similar cravings: although ice eating and starch/clay eating are more common. (The technical term for this is pica).

I tested her, and sure enough, she was anemic and low in iron.

but carrots are not the only food that can cause problems: tomatoes can do it also, from the lycopene in them.

argyria is from silver in the skin (benign). One of the problems for "preppers" who use AgNO3 for medical problems.

and Iron overload (from a genetic defect, hemochromatosis or from being given too much iron for severe anemias,) can also discolor the skin.

It's not hemochromatosis per se, but there is a well known problem of dark black skin in Bantus in Africa.

We saw a lot of very dark skin in our heavy native-beer drinkers in Africa: it is because the local beer is brewed in iron kettles, but also because some people carry a gene that makes them vulnerable to the condition.


Dietary iron overload is the consumption of large amount of home-brewed beer with high amount of iron content in it. Preparing beer in iron pots or drums results in high iron content. The iron content in home-brewed beer is around 46–82 mg/l compared to 0.5 mg/l in commercial beer

we didn't treat it as such (often these patients also had cirrhosis from alcohol, and/or viatmin B deficiency, so mainly we would feed them up and tell them to stop drinking).

The Wikipedia article also suggests this might be behind the high rate of liver cancer in Africa, but I have also read that mold in certain foods might be another reason for this, or maybe Hepatitis C.

finally, there was a book of medical mysteries that included a story about 11 blue men.

usually when patients are blue, it is due to lack of oxygen from heart or lung problems.

For example: we docs separate lung disease in smokers into pink puffers (pure emphyesema) and blue bloaters (Chronic Bronchitis...Bloaters is British slang for a person who coughs up lots of phelgm). Because the mucus causes CO2 retention, they tend to have a high CO2 level and tend to be a bit cyanotic.(blue)

But the classic story "11 Blue Men", this was due  someone accidentally putting sodium nitrate into salt shaker.

Full story HERE

quite a few medicines can cause methhemoglobinemia, but most of these medicines are used in doses too small to cause problems unless you overdose, or unless have a genetic problem. this long medical article discusses the problem.

and then there is a rare congenital form of methhemoglobinemia that runs in families... one example is the Blue Fugates of Kentucky.

------a shorter version is on my FKCLINIC blog.

Friday, December 9, 2016

Zika and microcephaly

Long report on the CDC website about cases in Colombia.

The rate of microcephaly in women who were diagnosed with Zika was 4 times that of those without the virus.

But the "natural" rate is low so that means the actual number of case was low.

. Peak prevalence of microcephaly was registered in July 2016, when the prevalence was ninefold higher than in July 2015 (PR = 9.0). In 2016, among all microcephaly cases, 432 (91%) occurred in live born infants, and 44 (9%) occurred among pregnancy losses; in 2015, among 110 reported cases of microcephaly, 90 (82%) occurred in live born infants, and 20 (18%) occurred among pregnancy losses.

So all the hysteria was about a couple hundred cases of microcephaly out of tens of thousands of births.

Although the microcephaly prevalence in 2016 among infants likely exposed to Zika virus in utero (9.6 per 10,000 live births) in Colombia was not much higher than the median of microcephaly prevalence (6.6 per 10,000 live births) reported by passive surveillance in 17 U.S. states during 2009–2013 (4), the comparison with 2015 Colombia data indicates the magnitude of the increase.
Tranlation: chance of microcephaly was low, and higher among those affected but still the risk was low (6 out of ten thousand).

now, the question Why was the risk higher in Brazil than in Colombia?

In 2015, microcephaly prevalence in Brazil was 5.5 per 10,000 live births, representing an approximate ninefold increase over the average prevalence during the previous 14 years (5,6). 
In Colombia, the relative increase has been smaller (fourfold); however, the baseline microcephaly prevalence was 2.1 per 10,000 live births in 2015, at least three times higher than Brazil’s reported baseline.
Ah, so even the baseline was different. So does this mean that microcephaly was being missed in Brazil before the epidemic, making the statistics higher? or did altitude have something to do with it (Colombianos live mainly in the high plateaus).

 There are several possible reasons for differences between the reported baseline microcephaly prevalences in Brazil and Colombia, as well as the differences in increases of microcephaly in the context of the Zika virus outbreaks in the two countries. 
First, 50%–75% of the population of Colombia reside at altitudes above 2,000 meters, in areas without active, vectorborne Zika virus transmission (7). 

or maybe the difference is how the measurement is done

Second, microcephaly is a difficult birth defect to monitor because there are inconsistent definitions, obtaining accurate measurements is challenging, and terminology is inconsistent. Because of these challenges, prevalence estimates vary widely among countries and among surveillance systems within the United States (4). 

finally, how many women were frightened by the kerfuffle and either postponed pregnancy or aborted their babies in fear?

Third, the reports of microcephaly from Brazil might have served as an early warning. As evidence was emerging about the link between Zika virus infection and microcephaly, the Colombian Ministry of Health issued a recommendation in February 2016 advising women to consider delaying pregnancy for 6 months, which might have affected subsequent birth rates.§ The number of live births in Colombia during epidemiologic weeks 5–45 decreased by approximately 18,000 from 2015 to 2016.

and the dirty little secret: not all the cases of microcephaly were from Zika. Other viruses etc were also to blame: 476 cases, 306 tested for Zika but only half of them had blood tests positive for Zika. Toxoplasmosis was found in one fifth, and CMG, herpes simplex and syphillis were found in other cases.

Among the 476 infants and fetuses with microcephaly reported during epidemiologic weeks 5–45 in 2016, a total of 306 (64%) were tested for Zika virus infection; 147 (48%) had laboratory evidence of Zika virus infection by RT-PCR or immunohistochemistry on any placental, fetal, or infant specimen, and five of six tested had serologic evidence of infection by MAC-ELISA. Among 121 infants tested for other pathogens, 26 (21%) had evidence of infection with other pathogens, including toxoplasmosis (15 infants), herpes simplex (six), cytomegalovirus (four) and syphilis (one); among these 26 infants, 17 (65%) had evidence of coinfection with Zika virus (14 of 15 with toxoplasmosis, two of six with herpes, and one of four with cytomegalovirus). Neuroimaging results were available for 32% of all microcephaly cases. Among 476 infants or fetuses with microcephaly, mothers of 164 (34%) reported having symptoms compatible with Zika virus infection during pregnancy.

I am not saying this is not a serious disease: What I am saying is that the risk of malformation is low, compared to women infected with other diseases e.g. rubella in the first trimester.which is associated with an 80 percent chance of one of several devesstating problems.

Rubella infection in pregnant women may cause fetal death or congenital defects known as congenital rubella syndrome (CRS). Worldwide, over 100 000 babies are born with CRS every year. There is no specific treatment for rubella but the disease is preventable by vaccination.

usually rubella vaccine is given with measles and mumps vaccine as the MMR.

So compare the hysteria on Zika and the outcry to rush to get a vaccine, while everyone is ignoring the 100 thousand cases of fetal rubella syndrome, where there actually is a vaccine that will prevent babies from being born deaf, blind and/or retarded.

my sarcasm is twofold:

One, because the outbreak occured shortly before the Olympics, there was a chance that rich American yuppies might catch it, so hysteria.

Two: Zika can be used to push the abortion/population control agenda on poor women.

Is Smallpox a new disease?

tech times:

new analysis of smallpox DNA from the 17th century suggests smallpox might have recently evolved and does not date into prehistory as many had thought.

The disease had long been believed to have emerged among humans thousands of years ago, afflicting people in India, Egypt, and China. Some historical accounts even suggest the Egyptian pharaoh Ramses V, who passed away in 1145 B.C., had been struck by smallpox.

For the study that involved the genetic analysis of the viral DNA taken from the partially mummified remains of a child dating back from the 17th century, researchers found that the smallpox could be just some hundreds of years old.

measles is considered to be a "new" disease also, so questions if ancient plagues were measles are also at question. Measles evolved from the animal disease Rinerpest in the 11th century.

so what caused earlier plagues?

One problem is that diseases sort of change with time.

Often they are very virulent when they first hit humans, then because killing one's host is not very beneficial for your evolution, the variation of the germ that doesn't kill quickly (and hence, spreads to more people) wins the evolutionary battle.

DNA has helped to identify ancient diseases: there is some evidence that Justinian plague was actually Bubonic plague, and some studies of the plague of Athens suggest it might have been typhoid.

and they are still debating what caused the Antonine plague (which weakened the Roman Empire and killed Marcus Aurelius, the emperor in Gladiator). Since the soldiers caught it from "Parthia", a dry climate, one suspects it could be bubonic plague or a similar zoonosis.

but it also does mention the Chinese in 1000 AD devised innoculation with smallpox scabs to stop the disease from spreading (other stories insist it was Africans or the Arabs who did this. A lot of the Africans brought to the Americas were from Muslim areas and the Arabs were in touch with China so maybe the idea spread? The English started to use it from the Ottoman empire contacts.

on the other hand,

Until the 18th century, inoculation was a practice largely confined to China, India, Turkey, and other eastern countries. 
Lady Mary Montagu, an aristocrat and the wife of England’s ambassador to Turkey, is credited as being the first to bring attention to the practice in the Western world. In 1715, Montagu had gone through her own bout of smallpox, and had been disfigured as a result. After learning about inoculation during her time in Turkey, she was determined to protect her six-year-old son from the disease through inoculation.

One possible reason for the confusion is that there are two variations of smallpox: One with a very high mortality, and one with a lower mortality.

the latest case that suggested a recent evolution of the virus ignores non DNA evidence from the past

So is smallpox old or new, or something that just pops up now and then?  LINK and LINK (these are long MEGO type articles that I will have to read in detail later).

but this is one puzzle:

As variola virus lacks a known non-human animal reservoir, its origin as a human pathogen has been concealed under a veil of mystery. The evolutionary history of this virus can be dated based on either the assumed dates of variola virus subtypes diverging from the ancestors, or the dates of isolated samples that contain variola virus.
the problem with the smallpox family of viruses is that they mutate quickly, and humans can catch pox viruses from animals: The most famous example of this is Jenner's observation that milkmaids who caught cowpox never caught smallpox, and devised vaccination.

but other animal pox could cause problems: in recent years, there have been reported cases of monkeypox in humans.

and then there is camelpox:

Phylogenetic reconstructions suggest that camelpox virus, taterapox virus and variola virus emerged from a common progenitor almost simultaneously. Additionally, these viruses are strictly specific for their hosts, and both variola virus and camelpox virus cause diseases with high case fatality rates.

However, the real puzzle about human smallpox is that so far they haven't discovered an animal who carries it, i.e. a reservoir where it hides.

sow what does this mean?

It means a new outbreak could pop up from animals, mutate and kill thousands of people

Recent oubreaks of "new" diseases like SARS (in China), MERS (in the Middle East) and cases of avian flu in humans so far haven't killed millions mainly due to old fashioned ways of stopping the spread of the virus, e.g. washing hands, isolation, and stopping travelers.

 and of course outbreaks of known diseases like Zika and Ebola are also a worry.
But small pox? Spread via the air to people nearby, long incubatio perios, and no one except some of the military and first responders who have had immunity suggest a problem.

But at least with smallpox, there is a vaccine.

And the real worry: What if a newer variation, such as weaponized monkeypox or camelpox that evolves ?

again, the bad old days of quarrentine will return.

Plague in the news: Here, kitty kitty kitty

CDC report of domestic cats in Idaho who were diagnosed with the plague.

Cat-associated human plague cases, including fatalities, have been reported in the western United States since 1977 (3). Compared with dogs, cats are highly susceptible to plague illness and can transmit disease to humans directly through exposure to respiratory droplets and infectious body fluids associated with bites or scratches (1). Cats could also carry infected fleas into households.

no human cases, but it can be spread to humans so the pet owners are being put on alert.


related item: Plague carrying squirrels.

PJMedia has an article remembering how children were urged to kill plague carrying squirrels during World War I... \

George H. Hecke, commissioner of California's State Horticulture Commission, created what would be known as the "Squirrel Army." The effort was presented as an extension of the United States' declaration of war on Germany, which was made the previous year.
“We have enemies here at home more destructive, perhaps, than some of the enemies our boys are fighting in the trenches," said Hecke. By organizing “a company of soldiers" in their classes or in schools, children were encouraged to help annihilate their ultimate foe—the ground squirrel.
The rodents were a source of bubonic plague back then, and the cause of an estimated $30 million in crop devastation. That's equivalent to $480 million today. Hecke called for "Squirrel Week," which ended up being seven days of murder and mayhem.