From 'ID Curse' to 'ID Karma'

My favorite conference to attend is by far the conference on retroviruses and opportunistic infections (CROI). I deeply enjoy the company of my colleagues working in HIV medicine and it’s always a formidable place to learn about the latest breaking developments in the field. Last year, I was unable to attend on site, but I was eager to participate virtually. Unfortunately, my father’s diagnosis of lymphoma decided otherwise and I cancelled everything to be with him as much as possible. He passed away on April 25th, 2023, at the age of 69. I won’t lie, I had a tough year. I had to stop a lot of work-related things to make it through. In the end, I’m glad I did, but now that I felt better, going back to CROI 2024 (Denver, March 3-6) was the first thing I had in mind.

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Punta Cana & my ‘ID Curse’.

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On February 10th, I left for Punta Cana on vacation with my wife (also a medical microbiologist and infectious disease physician at the same hospital as me) and my 2 kids. People who know me also know that I’m usually a victim of the ‘ID Curse': the stereotypical ID physician who goes crazy and overthinks everything in certain contexts. Punta Cana was doing the trick. We all received the vaccine for cholera/LT-producing ETEC diarrhea and of course we were already protected against hepatitis A. We were taking malaria prophylaxis even though the risk is very low at that time of year and region. We were using DEET and other mosquito precautions for arboviruses. Even so, if a pathogen was going to get us, it had to be Dengue… Right? I even took pictures of an Aedes aegypti flying around in our hotel room as a proof that I was not overreacting. Nevertheless, I managed to get a grip of my obsession with infectious disease risks and we enjoyed the week in a ‘very fine resort’ with splash pads and wading pools for the kids.

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Not so fast.

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Remember Hand-foot-and-mouth (HFM) disease? That mild, contagious viral infection that’s common in young children and caused by enteroviruses (mostly coxsackievirus). Well, let’s just say that I had forgotten the ‘not so chlorinated and poop contaminated’ splash pads and wading pools in my ‘ID Curse’ madness. Thankfully, my kids only had one day of fever and a painless, typical HFM rash. On the other hand, I ended up having the opportunity to experience ‘la totale’, as we say in French; fever, chills, sweats, myalgias, very painful blister-like rash on the hands, feet and mouth/lips. Quite interestingly, and luckily, I also had a painless blister-like rash on the thighs, arms, head & ‘private’ parts. Then, on the day we left (February 18th), the worst thing happened: just before boarding the plane, I realized that my father’s wedding ring was missing. The only material object I had left from him, always on the 4th finger of my right hand, was gone. A nightmare.

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My ‘ID Karma’.

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During the next week, all the HFM lesions were healing except a little one hiding in my moustache, on my upper right lip, near my nose columella (Google this word if needed). This lesion slowly started to look like a pimple / crusted pustule. Of course, as a good ID physician, when I see pus, I want it to come out. So, I removed the crust and started to press quite a few times. In a matter of 2 or 3 days, oedema of the lip and columella became prominent, and the pain was increasing. On the night of February 25th, I had had enough. I went to my hospital’s emergency department thinking there was a need for an incision and drainage, but no fluctuant area suggestive of an abscess was palpated. I left with Cefadroxil (we love Cefadroxil here) and I was instructed to apply warm compresses (also one of my favorite tricks) and use NSAIDs. The next two days were not so bad. The oedema stabilized and the pain stayed bearable. On Tuesday February 27th morning, the MRSA result came out (yes, of course I had personally collected a wound culture at that point!). Did I get MRSA at Punta Cana, or was I simply a colonized healthcare worker? Statistically speaking, probably the latter. Regardless, I was immediately started on TMP-SMX (susceptible). In the afternoon, the pain was increasing and my lip had taken an exaggerated lip filler gone bad aesthetic look. On my way home, I was feeling feverish, I had chills and sweats. So, I went back to the hospital. Once there, I was afebrile but hypertensive, tachycardic, pale, and weak. I was hospitalized and started on Vancomycin (no need to specify IV...). Blood cultures collected (was there really a blood culture indication?), were eventually negative (my prolapsed mitral valve was grateful). The initial CT scan showed a phlegmonous lip abscess extending into the columella, not organized enough to be amenable to drainage. On February 29th, progression was noted both clinically and radiologically, so the ENT specialist decided to attempt a drainage. I was thrilled. The end was coming! Finally achieving source control so I could switch to oral antibiotics and go to CROI. Little did I know… The ENT specialist appropriately talked me out of it. She reminded me of the ‘danger triangle of the face’ (you know, little things like meningitis, brain abscess, etc.), and of all the problems I could have outside country (you know… money!). I love CROI. I really do. But at this point, I had to accept my ‘ID Karma’ and let it go. My flight was scheduled on March 2nd. I cancelled everything. I cried; I truly did, it hurt badly.

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I left the hospital after the first ‘incomplete’ drainage with 2 packing strips in place: one in the columella, and one in the right upper lip. The decision of the ID specialist on call was to continue Vancomycin (OPAT) instead of switching to oral, because the source control wasn’t perfect. Talking about ID on call, of course you know who it was... My wife! How weird could it be? Because it was both medically and legally tricky, we asked our last available colleague at the time to see me and to make the decision. It was a good call. But I can imagine what you’re wondering at this point: why not Daptomycin? Why not Dalbavancin? Why not oral? They would have been options, but a decision was made and I’m the patient here. Also, at some point during my misadventure, my colleague even called another ID from another hospital just to be certain that he himself was formulating an unbiased opinion! Moving on…

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On March 2nd, the day I was supposed to leave for CROI, I already had had 2 subsequent drainages in outpatient ENT clinic, but then things went from bad to worse. I decided to go back to ED because I couldn’t tolerate the excruciating pain. Once there, the first ENT procedure was performed. Basically, they opened my lip from inside my mouth and made their way into multiple loculated areas then packed it. Because of the atypical progression, Linezolid was added to Vancomycin as an anti-toxin (PVL-producing strain?) adjuvant.

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From March 2nd to March 6th, I was hospitalized on the surgical unit, which happens to be a giant tent where most of the rooms have no ceiling, that was ‘gifted’ to us by the provincial government during the pandemic… but that’s a story for another time. At the request of my local ENT specialist, I had another ENT procedure at a tertiary center, followed the next day by another drainage with Penrose drain installed. I was discharged on Linezolid with daily ENT follow up and daily packing changes for about a week. The final duration of antibiotics was not worthy of Dr Spellberg ‘shorter is better’ mantra. However, it respected the 7 rules of Dr Sax and we avoided a PICC line for many weeks of IV as recommended by others. A small victory.

So, that’s my story.

But besides my ‘ID Curse’ and ‘ID Karma’, a few things are worth discussing. For the entirety of my hospital stays, I was placed in MRSA isolation rooms. Evidently, as ID, the ‘Holy Knights of Infection Prevention & Control’, we all undoubtedly know the purpose of MRSA isolation precautions, what it implies and what it means. But has your perspective ever been challenged? Should contact precautions really be used for patients with MRSA infections and/or colonizations in acute care settings at all? Here is not the place to debate it in detail, but I can give you my perspective as a patient.

First, the stigma. Well, that escalated quickly (please think about the Will Farrell meme). As soon as I was tagged as an MRSA patient, healthcare workers around me started to act differently, to be somehow afraid of me, and said things that didn’t make any sense. I can recall a pregnant nurse saying to a colleague: ‘Please take care of M. Poulin for me, I wouldn’t want to get his disease during pregnancy’. I can remember the moment where I was denied a shower by a patient care attendant, because ‘I could transmit my bacteria to others’ (in reality, I was allowed to take a shower, but they needed to clean it afterward and my IPC nurse colleagues made sure to correct the situation).

Then, there was the quality and frequency of care. It’s hard to describe how difficult this was. Every time I had to ask for help, for any reason, the delays were ridiculously longer than they were for patients without isolation precautions. The nurses and/or patient care attendants were also coming less frequently inside my room during their rounds than for the latter. Days were long. Nights were scary and filled with anxiety. I can think of many moments where I had to ring the bell to remind nurses that it was past the time for my Vancomycin (ID loves good Vancomycin PK) and/or other medications (including pain killers because yes, it was extremely painful). Were they keeping me last on their run because of the isolation precautions? And how can I forget the wait time to fix my ringing IV pump (at 2AM, it’s a ton of fun). So yes, I hated the MRSA isolation and my view on it has forever changed. We must please always include patient perspective in our discussions and/or debate about it.

Finally, another interesting thing I learned during my hospitalization is that I’m a "Hard stick" patient, which comes with a fair amount of anxiety. Please never order an unnecessary blood draw (looking at you CRP trenders). And yes, in case you were wondering, being a doctor hospitalized in his own hospital is really strange. Although I made sure that I always had a pair of pants on, I noticed that the staff behaved differently around me and that some appeared to be overly stressed. Why? I mean, it’s not like I was going to write something about it, right?

So what’s next? Well, for what it’s worth, MRSA decolonization of course5! You know… back to the ‘ID Curse’. Also, out of pathological curiosity, my MRSA stain was sent for PVL toxin detection and typing (Canada vs Dominican Republic strain?). Follow me on X or ask me directly if you want to know the results.

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To end on a positive note, do you believe in small miracles? My father’s ring was in the safe of my hotel room (I had removed it before going to the beach), and a trustworthy employee kept it safe for me. Then, as luck would have it, a colleague was staying at the same resort and brought it back to me. It’s been back on my hand since March 5th one day before my discharge from the hospital.

See you at CROI 2025 San Francisco (maybe) ?