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Vital statistics birth certificate data are an important source of information for researchers, policy makers, and state officials to evaluate the quality of care delivered to pregnant women. The purpose of this study was to assess the validity of data elements being reported by the hospitals on the birth certificate record when compared to the medical record. This study used a random sample of birth certificates from two upstate and two downstate counties, in New York State, comprising a total of 100 records per county. The review assessed data elements from seven major categories: prenatal care, maternal medical risk factors, risk factors related to pregnancy, lifestyle risk factors, method of delivery, complications of labor and delivery, and infant information. Sensitivity, specificity, the positive predictive value and the negative predictive value assessed level of agreement between the birth certificate and the medical record. Overall, the birth certificate data reflected high specificity, because most conditions are rare. The sensitivity of the data was more varied, ranging from 0 to 100%, reflecting that if a rare condition was present it often was not documented on the birth certificate. Many of the data elements are reported accurately. However, caution should be used for data elements that are poorly reported. [ABSTRACT FROM AUTHOR]

Two boys with the clinical and radiographic picture of acute tropical pyomyositis of the short external rotators of the hip were treated surgically followed by parenteral antibiotics (Figure 1). Intraoperatively, no pus was found. Histopathology specimens from 1 patient demonstrated small foci of degenerative changes and necrosis without evidence of infection (Figure 2). Prior to decompressing the muscle in the second patient, intramuscular pressure was measured and found to be significantly elevated. Surgical decompression was performed and both patients fully recovered after a course of intravenous antibiotics. Tropical pyomyositis' clinical presentation is often insidious with a variable course accounting for its frequent missed or late diagnosis. Often the illness progresses through three stages - invasive, suppurative, and late. Patients progress from a diffuse muscle inflammation to abscess formation and sepsis. Staphylococcus aureus is responsible for the infection in >75% of the cases. The quadriceps, iliopsoas, and gluteal muscles are most commonly affected. Multiple reports addressed the optimal treatment of tropical pyomyositis. Traditionally, surgical treatment was advocated. However, there are reports of successful nonsurgical or minimally invasive treatment. Based on our experience, it is suggested that the sequence of events in the development of tropical pyomyositis is an initial insult such as vigorous exercise, leading to elevated compartment pressure, resulting in a compartment syndrome. If simultaneous bactermia occurs, the vulnerable muscle is seeded with the infectious organism and abscess formation follows. That may explain other authors' findings that early aspiration, combined with antibiotic treatment, may be sufficient to decompress the muscle, prevent abscess formation and result in full recovery. [ABSTRACT FROM AUTHOR]

Two siblings aged 5 and 15 years from Connecticut were hospitalized with petechial rash, oral mucositis, and severe thrombocytopenia approximately 10 days after they played with a jar of elemental mercury they found in their home. Before the mercury exposure was disclosed, the siblings were treated with platelet transfusions, intravenous immune globulin (IVIG) for possible immune thrombocytopenic purpura, and antibiotics for possible infectious causes. When their conditions did not improve after 6 days, poison control facilitated further questioning about toxic exposures including mercury, testing for mercury, and chelation with dimercaptosuccinic acid. The older sibling soon recovered, but the younger child required a prolonged hospitalization for severe thrombocytopenia, ultimately receiving repeated doses of IVIG, steroids, and romiplostim, a thrombopoietin receptor agonist. Close collaboration among multiple agencies was required to identify the extent of mercury contamination, evaluate and treat the other family members, and decontaminate the home. These cases demonstrate the importance of ongoing public health outreach to promote early detection of elemental mercury toxicity, and the need to evaluate for environmental exposures when multiple close contacts experience similar signs and symptoms., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

The role that microorganisms might have in the development of Alzheimer disease is a topic of considerable interest. In this article, we discuss whether there is credible evidence that Lyme disease is a cause of Alzheimer disease and critically review a recent publication that claimed that Borrelia burgdorferi sensu stricto infection, the primary cause of Lyme disease in the United States, may cause Lewy body dementia. We conclude that no convincing evidence exists that Lyme disease is a cause of either Alzheimer disease or Lewy body dementia., Competing Interests: Potential conflicts of interest. G. P. W. reports receiving research grants from the Institute for Systems Biology for exploring biomarkers for the outcome of Lyme disease; Pfizer, Inc for developing Lyme diagnostics for a Lyme vaccine trial; NIH/Tufts for Xenodiagnosis to assess persistence of Borrelia; and Colorado State University/NIH. He has been an expert witness in malpractice cases involving Lyme disease and was an expert witness regarding babesiosis; is employed by New York Medical College; and is an unpaid board member of the non-profit American Lyme Disease Foundation. He reports no money paid to anyone for US Patent 10,669,567 B2 (High Sensitivity Method for Early Lyme Disease Detection, issue 2 June 2020). A. M. has a patent for compositions and methods for screening for Lyme disease (US 8,926,989 B2 and 9310367) and is an unpaid scientific advisor to the Global Lyme Alliance and to the American Lyme Disease Foundation. I. S. has been on the External Advisory Committee for Oklahoma idea networks biomedical research excellence. All remaining authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Competing Interests: Declaration of interests We declare no competing interests.

Dermatologists reported an outbreak of pernio (red to purple swollen painful toes) during the COVID-19 pandemic. Most subjects lacked positive CoV-19 polymerase chain reaction (PCR) or antibodies or a preceding illness. The dermatologists termed the illness "COVID toes." Pernio usually affects adults versus "COVID toes" usually children. Pernio is preceded by a clear history of exposure to wet and cold. Patients with "COVID toes" lack this history. Also, it is not unusual for multiple family members to have "COVID toes." Our case report describes "COVID toes" in an 18-year-old with no preceding illness, a negative SARS-CoV-19 PCR, and an initially negative SARS-CoV-19 antibody, and also his 2 siblings also developed "COVID toes." In our index case, repeat SARS-CoV-19 antibodies were positive. Seroconversion has rarely been reported in patients with "COVID toes." Why most "COVID toes" patients lack a clinical history of COVID-19 and are SARS-CoV-19 PCR and antibody negative is a mystery., Competing Interests: The author has no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Powassan virus (POWV) is a tick-transmitted pathogen that may cause severe encephalitis; experimentally, it can be transmitted within just 15 minutes following a tick bite. The deer tick virus subtype of POWV (DTV) is transmitted by the deer tick and is the likely cause of the increase in the number of POWV cases reported in the United States. However, DTV has only been definitively documented in 6 patients by molecular analysis of the virus., Methods: Two patients from Connecticut with encephalitis, who had a recent deer tick bite, were evaluated by the relevant serologic tests to determine if they had been infected with POWV. Evaluation also included molecular testing of an adult deer tick that had been removed from one of the patients., Results: We documented neuroinvasive POWV infection in 2 children from Connecticut. Based on the results of testing the tick removed from case 2, this patient was infected by DTV, representing the 7th reported case and the first documented case of DTV infection in a child. Of note, the duration of the tick bites in both cases was very short., Conclusions: We provide the first clinical and epidemiologic evidence that POWV/DTV can be rapidly transmitted to a human host, that is, within hours of tick attachment, which is distinctive when compared to other deer tick-transmitted infections such as Lyme disease., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children. The disease appears to cluster in families, but the pathogenesis is unknown. We queried two European-American cohorts and one Turkish cohort (total n = 231) of individuals with PFAPA for common variants previously associated with two other oropharyngeal ulcerative disorders, Behçet's disease and recurrent aphthous stomatitis. In a metaanalysis, we found that a variant upstream of IL12A (rs17753641) is strongly associated with PFAPA (OR 2.13, P = 6 × 10 -9 ). We demonstrated that monocytes from individuals who are heterozygous or homozygous for this risk allele produce significantly higher levels of IL-12p70 upon IFN-γ and LPS stimulation than those from individuals without the risk allele. We also found that variants near STAT4 , IL10 , and CCR1-CCR3 were significant susceptibility loci for PFAPA, suggesting that the pathogenesis of PFAPA involves abnormal antigen-presenting cell function and T cell activity and polarization, thereby implicating both innate and adaptive immune responses at the oropharyngeal mucosa. Our results illustrate genetic similarities among recurrent aphthous stomatitis, PFAPA, and Behçet's disease, placing these disorders on a common spectrum, with recurrent aphthous stomatitis on the mild end, Behçet's disease on the severe end, and PFAPA intermediate. We propose naming these disorders Behçet's spectrum disorders to highlight their relationship. HLA alleles may be factors that influence phenotypes along this spectrum as we found new class I and II HLA associations for PFAPA distinct from Behçet's disease and recurrent aphthous stomatitis., Competing Interests: Competing interest statement: F.D. is a consultant to Novartis and receives royalties from UpToDate. K.M.E. is on the Data Safety and Monitoring Board for Seqirus, Pfizer, Sanofi, Moderna, and X4 Pharma, and serves as an advisor to Bio-Net and Merck. P.F.W. is on the scientific advisory boards for GlaxoSmithKline, Sanofi-Pasteur, and Meissa Vaccines., (Copyright © 2020 the Author(s). Published by PNAS.)

Human granulocytic anaplasmosis (HGA) is a tick-borne infection, characterized as an acute and sometimes severe febrile illness which may be associated with leukopenia and thrombocytopenia. Most case reports of HGA have been in adults, with only 8 case reports of HGA in children. We add a ninth case of HGA, which occurred in a 5-year-old. The paucity of pediatric HGA case reports maybe because publication bias, or HGA in children is a mild illness and children with HGA are less likely than adults to seek medical care, or the diagnosis of HGA requires a blood draw and adults (versus children) are more likely to get diagnostic testing. The 9 case reports in children suggest that pediatric HGA is usually a mild infection and that doxycycline and rifampin are effective therapies. Like adults, children with HGA frequently present with fever, headache, and malaise; however, children are more likely than adults to have abdominal pain as a prominent complaint., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A previously well infant aged 9 months presented with an acute, self-limiting illness characterised by high fever and a papular eruption that started on the face. Although fever subsided within 3 days, the rash worsened and extended over the whole body, with some papules evolving into vesiculobullous lesions. The infant had been exposed to children with a similar illness 1 week before onset. PCR of vesicular swabs and stool samples taken on day 6 of illness showed Coxsackie virus A6. The illness resolved within 10 days of onset, although onychomadesis was seen on both big toes at follow-up 5 weeks later. Our case exemplifies the severe, atypical cases of hand, foot, and mouth disease that have been reported worldwide since 2008, and in the USA since the 2011. Atypical hand, foot, and mouth disease is caused by a new lineage of Coxsackie virus A6 and is characterised by high fever and vesiculobullous eruptions on the calves and backs of the hands. Infants with eczema might be predisposed to severe disease., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Kikuchi disease is a self-limited disorder of unknown etiology characterized by focal painful lymphadenitis, fever, and weight loss that can be mistaken for malignancy. Diagnosis is established by node biopsy. Kikuchi disease is endemic in Asia; 10 cases have been reported in the US to date. We report 3 cases and review other US cases., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Overall, 3% to 19% of travelers to the developing world will return to the United States with fever or will develop fever within weeks of their return. When evaluating the returning traveler with fever, it is important to know which pretravel immunizations the patient received; which medications he or she took during travel; the likely pathogen exposures during travel; and the incubation interval between travel and onset of fever. A physical examination that includes a search for focal findings may narrow the list of possible infections. Fever compatible with a common illness that occurs in the United States (e.g., mononucleosis) should always be considered. If the patient has fever without a focus and a tropical infection is suspected, malaria, dengue fever, and typhoid fever are common causes. These infections may appear clinically similar, with symptoms of fever, headache, muscle pain, joint pain, and malaise, and decreased white blood cell and platelet counts. Malaria can usually be diagnosed with a thin blood smear. Dengue fever is a clinical diagnosis. Serologic testing for dengue virus immunoglobulin M and G and virus detection tests can be performed to confirm the diagnosis, but are not immediately available. Typhoid fever can usually be diagnosed with a blood, urine, or stool culture.

Rabies has the highest case fatality of any infectious disease. Pathobiological and clinical insights have questioned the assertion that death is inevitable after onset of acute encephalomyelitis. Relying upon national laboratory-based surveillance, we reviewed records of human rabies acquired in the United States during 1960-2009. Changes in the epidemiology of human rabies were notable, due to improved animal management, safer and more efficacious biologics, and revisions in prevention guidelines. Historically, domestic animals were the most important source of infection. Since the 1990s, more human cases were associated with rabid bats. Prior to 1980, postexposure prophylaxis failures were reported. After development of modern rabies immune globulin and vaccines, none occurred. Of 75 human cases identified, only four patients survived. Rabies remains an extremely high consequence zoonosis, but the disease is not uniformly fatal, per se. Rabies is essentially preventable when primary exposures are averted, or appropriate prophylaxis occurs before illness.

Unlabelled: There is paucity of data regarding tick-borne diseases during pregnancy. Here, we report a case of human granulocytic anaplasmosis during pregnancy with successful treatment and a favorable neonatal outcome. We also review diagnosis, treatment, and outcomes of published case reports from 1983 to 2010 of human granulocytic anaplasmosis, Lyme disease, babesiosis, and human monocytic ehrlichiosis in the United States., Target Audience: Obstetricians and Gynecologists and Family Physicians., Learning Objectives: After the completing the CME activity, physicians should be better able to diagnose tick-born diseases, implement best treatment options during the pregnancy, and assess the neonatal outcomes.

The most common clinical manifestation of Lyme disease is the characteristic rash, erythema migrans (EM). In the 1980s EM-like eruptions were reported in Missouri and other southeastern states. The EM-like eruptions, which were of unknown etiology, often followed the bite of the Lone Star tick (Amblyomma americanum) and the rash is called STARI (southern tick-associated rash illness). Although the Lone Star tick is found in the Lyme disease-endemic areas of New England and Mid-Atlantic regions of the United States, STARI has been reported only once from the Northeast and Mid-Atlantic regions. We report a child from Connecticut who visited Long Island, New York, and developed a rash that was thought to be EM. Because the patient failed to respond to antibiotics used to treat Lyme disease, an investigation ensued, and the diagnosis of STARI was established.

Sediment-dwelling macrofauna, polycyclic aromatic hydrocarbons (PAH), and abiotic parameters were monitored annually in benthic marine sediments from 1989-2007 in Port Valdez, a period of declining routine discharge of treated marine ballast water containing residual PAH from a major crude oil loading facility. The resulting dataset was used to evaluate associations between macrofauna and environmental characteristics including PAH concentrations. The influences of natural abiotic gradients on macrofauna were stronger than associations between macrofauna and sediment PAH. Though overall associations of PAH with macrofaunal community structure were weak, effects were greater for the tube-dwelling polychaete worms Galathowenia oculata and Melinna cristata which responded negatively to low PAH values near sediment quality criteria (threshold effects concentration: TEC and field-based sediment quality criterion: fb-SQG: ∼300 ng g( -1)). Effects of PAH on benthic fauna may be strongest through poor survival of juveniles and failed recruitment over multiple years. Comparison of measured PAH concentrations to the TEC and field-based fb-SQG suggest that the observed levels of change in Port Valdez are minor and the criteria are ecologically appropriate for environmental monitoring. By demonstrating positive responses of sensitive fauna to reduction of PAH concentration, this study contributes to understanding the temporal change, ecological importance, and size of effects expected on benthic fauna in the presence of continuous exposure to low levels of hydrocarbons.

Objective: To determine how frequently Connecticut primary care physicians are diagnosing and treating patients with chronic Lyme disease., Study Design: A survey was mailed to a random 33% sample of primary care physicians in Connecticut, which asked how many cases of Lyme disease and chronic Lyme disease they diagnosed and treated in the last 3 years., Results: The survey had a response rate of 39.1%. Physician respondents (n = 285) fit in one of 3 groups. Group 1 included 6 of 285 (2.1%) physicians who diagnose and treat patients with chronic Lyme disease. Group 2 included 137 of 285 (48.1%) physicians who are undecided on the existence of chronic Lyme disease, but did not diagnose or treat any patients with chronic Lyme disease. Group 3 included 142 of 285 (49.8%) physicians who do not believe in the existence of chronic Lyme disease., Conclusion: A small percentage (2.1%) of primary care physicians diagnose and treat patients for presumed chronic Lyme disease., (Copyright © 2010 Mosby, Inc. All rights reserved.)

Temporal trends of deep-subtidal macrofauna in Port Valdez, Alaska, were assessed with respect to multiple environmental stressors. Effects from a magnitude 9.2 earthquake in Prince William Sound, Alaska, 1964, were reflected in recolonization of the basin of the fjord, increased abundance and number of taxa over time, and moderately increased variability in abundance through 1990, stabilizing 26years after the earthquake. Long-term climatic variability and local physical processes were important sources of spatial and temporal variability. Correlative evidence suggests that indirect effects of juvenile salmon from a shoreline salmon hatchery and deposition of adult salmon carcasses moderately enhanced deep-basin benthic communities. Effects on the deep benthos from a marine oil terminal were negligible. Overall, faunal trends deviated from the stability expected for benthic communities in other fjords. Physical characteristics of the fjord were important in mediating the effects of stressors and in delaying the readjustment process., (Copyright 2009 Elsevier Ltd. All rights reserved.)

We describe a case of polyoma virus hemorrhagic cystitis in a nonimmunosuppressed child. Polyoma virus infection was suspected because of abnormal urine cytology. Polyoma virus cystitis in nonimmunosuppressed children is self-limited, resolving spontaneously within 2 weeks.

This article reviews pediatric Lyme disease in the United States. The agent of Lyme disease includes three pathogenic species (Borrelia burgdorferi, B afzelii, and B garinii), but only B. burgdorferi strains are found in the United States. The article's discussion is limited to the single species B burgdorferi.

Methicillin-resistant Staphylococcus aureus (MRSA) infections have become more common over the last decade. Recently, severe MRSA infections including necrotizing pneumonia, purpura fulminans, and rapidly progressive skin abscesses have been reported. These severe infections frequently have been associated with the virulence factor Panton-Valentine leukocidin (PVL). Two unusual cases of occult deep tissue abscesses in children who had family members with a history of severe MRSA skin abscesses are presented in this article. Both children initially presented with fever without a focus. Deep tissue MRSA (PVL positive) abscesses evolved. Empiric antibiotic therapy for MRSA should be considered for infants and children who are hospitalized with occult fever and who have a family member with a history of MRSA infection.

Most patients with erythema migrans, the pathognomonic rash of Lyme disease, do not recall a deer tick bite. The rash is classically 5 to 68 cm of annular homogenous erythema (59%), central erythema (30%), central clearing (9%), or central purpura (2%). Serologic testing is not indicated for patients with erythema migrans, because initially, the result is usually negative. Successful treatment of a patient with erythema migrans can be accomplished with 20 days of oral doxycycline, amoxicillin, or cefuroxime axetil. Patients with Lyme arthritis usually present with a mildly painful swollen knee. Patients with Lyme arthritis have markedly positive serology and can usually be successfully treated with 28 days of oral doxycycline or amoxicillin. Some patients may have persistent effusion despite 4 to 8 weeks of antibiotics and may need synovectomy. Persistent effusion is not due to persistent infection. Antibiotic therapy for more than 8 weeks for patients with Lyme disease is not indicated. Chronic Lyme disease due to antibiotic resistant infection has not been demonstrated.

Objective: Patients and families searching the Internet about Lyme disease may find conflicting information. Our purpose was to review the accuracy of information on Lyme disease easily available on the Internet., Methods: We used 15 search engines to find general information about Lyme disease. We found 251 Lyme disease websites, which we reviewed. Of these 251 websites, 19 gave general Lyme disease information and were analyzed. We evaluated the accuracy of information concerning 8 Lyme disease topics., Results: Ten of the 19 websites gave accurate information and 9 of the 19 websites provided inaccurate information. There were 8 websites with the word "Lyme" in the domain name, and 7 of the 8 sites gave inaccurate information. There were 2 ".gov" websites, and both gave accurate information., Conclusions: Patients and families searching the Internet for medical information about Lyme disease may encounter inaccurate information.