The edition · Infectious Diseases
Steroids in herpes encephalitis: 209 patients, and still no answer
A meta-analysis finds the randomised evidence for adjunctive corticosteroids too thin to support routine use; testing every admitted patient with HIV for tuberculosis did not beat symptom-based testing; and dihydroartemisinin-piperaquine holds vivax at bay while primaquine waits.
The edition in brief
The infectious diseases desk opens with a meta-analysis of adjunctive corticosteroids in herpes simplex encephalitis: four comparative studies, only 209 patients, two of them randomised. Pooled randomised estimates showed no difference in unfavourable outcome (RR 1.00, 95% CI 0.68-1.47) or mortality (RR 0.92, 0.35-2.40), with intervals wide enough that meaningful benefit or harm remains possible. The EXULTANT trial randomised 1,172 adults with HIV admitted to 11 hospitals in Tanzania and Mozambique to expanded Xpert Ultra testing of sputum, stool and urine plus urine LAM irrespective of symptoms, or to WHO symptom-based testing; 16.0% against 15.3% started tuberculosis treatment within 72 hours and eight-week mortality was 25.8% against 28.8%, neither significant. An Indian phase 2/3 trial in 643 infants found an adjuvanted dose-sparing inactivated polio vaccine with a quarter of the antigen content non-inferior to full-dose IPV across all three serotypes. A phase 2 trial in Kampala of the hexavalent GBS6 vaccine in 300 pregnant women found comparable safety and antibody responses in women living with and without HIV. A pearl covers the returning traveller with fever. The edition closes with Curavivax, in which dihydroartemisinin-piperaquine without immediate primaquine gave a 42-day recurrence rate of 2.4% against 27.3% for chloroquine alone.
The evidence on steroids in herpes encephalitis is 209 patients deep
Do not give corticosteroids routinely in herpes encephalitis; if cerebral oedema forces your hand, record it as a decision outside the evidence.
Testing every admitted patient with HIV for TB did not beat testing the symptomatic ones
Fix sputum collection and use urine LAM in advanced HIV disease before adding stool and urine Xpert to the panel.
A quarter-dose polio vaccine matched the full dose in Indian infants
Nothing changes in clinic today, but expect a quarter-dose intramuscular IPV to become an option in national schedules.
Group B strep vaccine in pregnancy worked as well with HIV as without
Note that HIV status did not blunt the response — a future group B strep programme would not need to treat these women differently.
Fever after travel: malaria first, everything else second
Send the malaria test first, and repeat it at 12 and 24 hours if the fever persists.
For vivax, the schizontocide buys the time that primaquine needs
If primaquine cannot start on the same day, treat vivax with dihydroartemisinin-piperaquine rather than chloroquine.
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