Top Associations in Clinical ID

Paul Sax: [00:00:00] Hi, this is Paul Sax. I'm the editor-in-chief of Clinical Infectious Diseases. And this is the Let's Talk ID podcast brought to you by the Infectious Disease Society of America, or IDSA. Now joining me today is my longtime friend and colleague, Dr. Rebeca Plank. Rebecca, welcome.

Rebeca Plank: [00:00:20] Thanks, Paul.

Paul Sax: [00:00:21] Now, Rebeca has been on these podcasts with me before and each time she's come on, we've drafted things and she's really a good, good person to do this because she has such a broad background. She's an HIV doctor, she's an ID doctor. She currently works on HIV treatment and prevention trials at Merck, and she continues to see patients with me here at the hospital. And today we're going to draft ID associations, just idea associations. And when I invited her, I was deliberately vague about what I meant. I gave her only like one example. I said it was Rose Thorns and Sporotrichosis. That's it. And I didn't say anything else. So now we're going to see what she came up with. And she not only happily accepted, but said that one morning she woke up and she came up with a great idea for her first one. So, Rebeca, take it away. You go.

Rebeca Plank: [00:01:09] First. I hope that people in their own minds are thinking about their associations, you know, which ones they would draft first. Because one of the things I really love about infectious disease is that it's often related to a narrative, right? So where did you go? What did you do while you were there? Those are the things I often ask in my consults, and sometimes I even start off by saying, what's the most exotic place you've been? People show me photos, they tell me about their trip, but always in my questions, I include, did you have any contact with animals and or do you have any pets? So my number one draft pick is poker players pneumonia.

Paul Sax: [00:01:46] Ah, poker players pneumonia. Yes, very good.

Rebeca Plank: [00:01:50] The thing about ID and associations is that sometimes infections become associated with place names and sometimes they become associated with people's names, people who have discovered them or identified the agent. But when they're associated with activities, I think it's the most fun for me. And poker players pneumonia,as most people will remember, I'm sure it turned out to be a Coxiella infection that was associated with not really playing poker, but with a parturient cat. And as it turns out, parturient animals have long been associated with Coxiella infection and that's all over the world. You can call it poker players pneumonia, you can call it an abattoir workers pneumonia, you can call it sheep farmers pneumonia, and of course, it also has a myriad clinical presentations. Coxiella, because it is associated with so many locations, so many activities and so many routes of infection, it's kind of the perfect venn diagram with culture negative endocarditis, because that also can be anything. And depending on your exposure history, you can go down a lot of rabbit holes, so to speak. But yes, so poker players pneumonia is my number one ID association.

Paul Sax: [00:02:57] That's a great choice, Rebeca. And actually, you know, I had thought you might choose Coxiella infection because as I recall, you appeared in a very prestigious journal discussing Coxiella infection in a case of culture, negative endocarditis yourself. And you might remember the name of that journal. What was it, Rebecca playing?

Rebeca Plank: [00:03:17] Gosh, it was a local publication - the New England Journal of Medicine.

Paul Sax: [00:03:21] They're very good. Okay. So that's a that's a great choice. And I also want to say that as a poker player myself, I've often thought about poker players pneumonia, especially during these pandemic years, because one of the the great disappointments of the social isolation part of the pandemic was cessation of our twice monthly poker game, which, by the way, poker is illegal in Massachusetts. So don't share that. The fact that I play poker with anybody.

Rebeca Plank: [00:03:47] Did you resume your game?

Paul Sax: [00:03:49] Remember it's illegal in Massachusetts.

Rebeca Plank: [00:03:52] Would you feel safe resuming a poker game at this point?

Paul Sax: [00:03:54] I think we would. Yes, we have honor code about not playing while sick and we utilize, liberally, the rapid tests. Okay. That's that was a great first choice. I'm going to go with a much more prosaic first choice, one that's very commonly known, known even to medical students, but I think really illustrates the cool aspects of our field. And I'm going with strep bovis and colon cancer.

Rebeca Plank: [00:04:20] Oh, great. Yeah, I love it.

Paul Sax: [00:04:22] So there is not an ID doctor in the world doesn't know it. And I decided to bring it up for a few reasons. First, everyone knows it. Second, it gives us a chance to nod to the microbiology nerds and pedants out there who don't think we should say strep bovis anymore, but think we should say strep bovis streptococcus equinus complex, but I'm never going to say that. I'm going to say strep bovis. I might say strep gallolyticus, because that's actually the one that really counts here. Turns out that's the species of strep bovis that really is associated with colon cancer. And it also gives me a chance to give a shout out to an amazing clinical teacher, Dr. Tony Breu, from the VA, and he has these remarkable things on Twitter where he does these long threads describing pathogenesis in internal medicine and one of the ones he did recently, in fact, just in January of this year, was describing why, you know, asking why is strep bovis associated with colon cancer? You know, you think about there are all these other enteric bacteria. If it's just a break down of the mucosal barrier from colon cancer, it should be all kinds of other strep species or gram negatives or who knows, there's lots, obviously, of colonic bacteria. Well, it turns out that strep gallolyticus grows better when colon cancer is present in it and it outcompete other bacteria. Who knew? It also enters the bloodstream more easily than other bacteria by evading the host immune response. And then the third one, which I never anticipated at all, is that there are some data that strep gallolyticus might actually promote tumor growth. So it turns out to be the perfect storm that leads to this invasive streptococcal infection and causing endocarditis because there's no doubt that there's this association. What do you think about that for my number one association?

Rebeca Plank: [00:06:15] That is a very high bar, Paul. Very high bar.

Paul Sax: [00:06:19] Although I can't say that it's really teaching people something they didn't know because everybody knows about that association.

Rebeca Plank: [00:06:26] Especially the three factors that are thought to contribute to that.

Paul Sax: [00:06:30] To quote Dr. Breu, "strep gallolyticus is both a passenger and a cancer-promoting bacteria."

Rebeca Plank: [00:06:37] That's really fascinating. Thank you. I like that.

Paul Sax: [00:06:41] All right, choice number two, Dr. Plank.

Rebeca Plank: [00:06:43] Well, I'm going to teach people something that is not necessarily about infectious disease, but it does talk about how environmental changes are impacting health. And that has to do with the association between mowing lawns on Martha's Vineyard and getting tularemia.

Paul Sax: [00:07:02] Ah, yes.

Rebeca Plank: [00:07:03] So that is a long standing association, right? When people come with community acquired pneumonia in this part of the world, did they run over any rabbits with their lawnmower? And it turns out that there is a true association. And one of the reasons I believe that tularemia is so prevalent on Martha's Vineyard and the islands, and more in a concentrated way than the rest of the state of Massachusetts, is because tularemia seems to really like rabbits. The Eastern cottontail, I'm not kidding, was imported from the Midwest at the end of the 1800s to the islands for sport so that people could hunt them. Most of the cases of tularemia in the United States come from Oklahoma, Kansas, Missouri, and that's where those rabbits were imported from to Massachusetts for sport. And so now it turns out that we have, I'm not going to say they're common, but they're famous, outbreaks in this part of the country that involve tularemia. And it really does appear to be associated with rabbits and other wildlife. That's what happens when you introduce a non-native species into your environment. And they've outcompeted the New England Cottontail rabbit. And so now we have a lot more tularemia in this part of the country.

Paul Sax: [00:08:14] You know, certainly have a lot of rabbits all over New England. You might say that they breed like rabbits.

Rebeca Plank: [00:08:20] Yes. And the eastern cottontail actually outcompete the New England cottontail because they can live out in the open. They are better at spotting predators, maybe from their life out on the prairies. So they actually survive better than the native ones. 

Paul Sax: [00:08:34] Tularemia as a cause of severe community acquired pneumonia is much discussed, but it causes another illness, too. And I'm going to actually talk about it in my choice number two.

Rebeca Plank: [00:08:46] Oh, all right.

Paul Sax: [00:08:47] You've gone from parturient animals and poker players pneumonia, to mowing over rabbits and causing another form of pneumonia. I'm going to go with just cats and infections.

Rebeca Plank: [00:09:01] Love it.

Paul Sax: [00:09:01] You know, for years, I was an owner of both a cat and a dog. The cat was a very nice cat named Otto and may Otto rest in peace. The two pets of the two pets, I was always much more fond of the dog, Louie, still still with us. And I have to say, several years ago I wrote in my blog about dog-related infections really is just an excuse to put a picture of my dog Louie on the New England Journal of Medicine website. And then my friend had recently gotten a puppy, I got to put his picture up there too. So now I'm going to talk about cat-related infections because cat-related infections, the associations are vast. They're vast. They include a partial list, obviously Pasteurella multocida. Everybody knows about this rapid onset cellulitis after a cat bite. It includes Bartonella henselae, the cause of cat scratch disease or cat scratch fever. And this could be the first time that there's been a Ted Nugent citation on an IDSA podcast. I don't know. Could be. Politically, I think it's the first time. Yes? Do you know about Ted Nugent and his politics?

Rebeca Plank: [00:10:09] Oh, I don't know about his politics, but I do know that song.

Paul Sax: [00:10:11] Okay. Let's just say that that Ted Nugent's politics are polar opposite of the typical infectious disease doctors politics. There's, as you mentioned, Coxiella burnetii, which is due to placental exposure. There's Toxoplasma gondii, which, you know, the definitive host is the cat. Although to be fair, most people get toxoplasmosis from ingestion of steak tartare, or poorly cooked lamb, like they have in France. Yuck. Or, you know, from poorly cooked pork, but they don't get it from their cats. But still, the definitive host is a cat. And I learned recently that actually kangaroos can also have toxo, but cats are the definitive host. It includes Francisella tularensis, which you mentioned already, so I can't really count that, but I do want to give a shout out to the late great Arnie Weinberg, who in one of his last New England Journal of Medicine CPCs, discussed a case of tularemia from a cat bite. It was a cat that had wandered off and then came back and was very sick. And before it...

Rebeca Plank: [00:11:15] It probably had tangled with a rabbit.

Paul Sax: [00:11:16] ...and before it died, it bit its owner and its owner developed tularemia, the ulcer glandular, form of tularemia. And then the last one I'm going to mention, just because I learned this from a colleague of mine who specializes in fungal infections, is that cat scratches can transmit sporotrichosis. Because when cats walk through gardens, especially gardens that have sphagnum moss on them, their claws can get contaminated with sporotrichosis and cause sporotrichosis that way. So my number two choice is cat-related infections and the whole grab bag of them to choose from.

Rebeca Plank: [00:11:53] Wow. I couldn't agree more. I think cats are very dangerous.

Paul Sax: [00:11:57] Yeah. Watch out.

Rebeca Plank: [00:11:58] Well, you know, you left out rabies, and I'll just add a personal anecdote, because when I was small, I was bitten by a cat, and it was back in the day when the rabies vaccine was intraperitoneal.

Paul Sax: [00:12:09] Oh, no.

Rebeca Plank: [00:12:09] I had to get vaccinated. To this day, I am deathly afraid of cats.

Paul Sax: [00:12:13] Yeah. No, clearly, that was not a good vaccine. I completely understand your PTSD.

Rebeca Plank: [00:12:20] I don't think I'll ever get rabies. That's the good news.

Paul Sax: [00:12:22] That's the good news. All right, choice number three.

Rebeca Plank: [00:12:25] Okay, so my third choice actually has to do with sports, which although generally thought to be healthful, once in a while, people get out of the water at their triathlon and they develop fever. And this is another one of my favorites, which is association between freshwater exposure and leptospirosis.

Paul Sax: [00:12:45] Good one.

Rebeca Plank: [00:12:46] This is something I also frequently cited in the differential diagnosis, but rarely successfully diagnosed. But there are outbreaks and in fact, there are also locations where these are more likely to happen. I think Hawaii, for example, there are certain places with fresh water there where they have signs saying, you know, be careful, this is leptospirosis. Another place where it happens a lot is in megacities in the developing world with flooding, because as everybody knows, leptospirosis is associated with animal urine. And lastly, although this is less commonly cited, but it is documented in the literature, if you fall down in a Baltimore alleyway, you also are at risk for contracting leptospirosis. And there was some very careful work done by, I think this person was a resident at the time at Hopkins, and they actually not only tested people who were had spent time or got injured in those alleyways, but they also trapped the rodents. And there was a very strong association between those alleyways and leptospirosis.

Paul Sax: [00:13:41] Yeah, well, that's a really great choice. And we always mention leptospirosis and anyone who has that systemic illness associated with hepatitis and conjunctival effusion. How often do you get to say conjunctival effusion?

Rebeca Plank: [00:13:55] Only when talking about leptospirosis.

Paul Sax: [00:13:57] Exactly. The last case we actually saw at this hospital was someone who crossed the border from Mexico into Texas through some fresh water, made his way somehow up to here to Boston. It's not easy to get from there to here when you're crossing the river. But he had actually quite severe leptospirosis, and fortunately, it's treatable and he did really well. So that's a terrific choice.

Rebeca Plank: [00:14:21] And again, I will also add another personal anecdote, which is there is post-exposure prophylaxis for leptospirosis. Recently, I was involved in a canoeing incident that also involved some scrapes and bruises, and so I did take doxycycline prophylactically because it does appear to be very effective after freshwater exposure in cases where there's a concern.

Paul Sax: [00:14:42] And were you taking a canoeing trip to play your poker game?

Rebeca Plank: [00:14:47] Yes. I won't say which border I was crossing because it's illegal.

Paul Sax: [00:14:51] Okay. My choice number three is another oft-cited association. You notice I'm going with mainstream associations so they can be practical and useful. And this one is soft cheeses and listeria.

Rebeca Plank: [00:15:04] Oh, yep.

Paul Sax: [00:15:05] You know, now it's almost unfair to the soft cheeses to blame them, because if you follow the news, you realize that it's not just Camembert and brie and queso fresco, but it's also deli meats and cantaloupes and ice cream and packaged salads. And there's enoki mushrooms. You know, those enoki mushrooms? Enoki mushrooms are these long, skinny mushrooms you find in bundles. There have been outbreaks from listeria associated with all of those things. I feel like the soft cheese lobby should get together and sort of protest and say they're being, you know, I don't know, "isolated" is being too dangerous, but it's true. All of these things can cause listeriosis. Every person who goes through pregnancy is counseled about avoiding soft cheeses and deli meats. And I also want to bring this one up because listeria has always had a special place in medical school education. Is that something that you recognize? When you were talking to a medical student about bacteria, it's ironic to me they often know more about listeria monocytogenes than they do about Staphylococcus aureus. I think there's like an entire course in medical school about listeria. And it has always struck me as quite, quite remarkable. They know that it's a gram positive rod, that it's got a dietary source, that it's bad in pregnant women and can cause meningitis in the immunocompromised and it's treated with ampicillin. After that, what else is there to learn?

Rebeca Plank: [00:16:38] Staph aureus, I guess.

Paul Sax: [00:16:41] I do actually think that those dietary recommendations are appropriate. And I will also say that listeria is always case conference worthy. Don't you think? When it shows up in case conferences?

Rebeca Plank: [00:16:54] Definitely. Yep.

Paul Sax: [00:16:56] Dr. Plank, number four?

Rebeca Plank: [00:16:57] My number four, actually, I want to add to, I want to make a Venn diagram with your listeria number three. My number four is actually salmonella...like oh, raw eggs. No, it's just like listeria. The outbreaks are associated with absolutely everything.

Paul Sax: [00:17:15] True. True. So your choice is salmonella and contaminated food?

Rebeca Plank: [00:17:19] No, actually, my choice is salmonella and owning a reptile. But I just want to do the tie in because salmonella is associated with all kinds of food outbreaks, not just raw eggs. But I want to bring us back to the case of like a baby turtle, right? Because it's these pet shop animals. It's these pets. And one of my favorites. I feel like we're really doing a free plug for the New England Journal of Medicine here. But one of my favorite cases about salmonella and reptiles was published in the New England Journal many years ago, and it was actually two people who had gotten platelet transfusions and they both got salmonella like fulminant salmonella bacteremia. And they traced it back to the guy who had donated platelets and he was perfectly well. But, you know, they asked him about his exposures, his history, and it turns out he had a boa constrictor at home. And he had been sick many days before he donated platelets, but he was perfectly fine. So they went to his house and they collected excrement from the boa constrictor. And they did gel electrophoresis with the boa's excretions and the patient's blood and the platelet tubing, and it was all the same salmonella. So even though you think that like ok salmonella and reptile ownership, and like these people who had salmonella bacteremia had no contact with reptiles, if you go back far enough, you may be able to make the association with pet reptiles.

Paul Sax: [00:18:39] I think that's a sensational one. The association of reptiles and salmonella and snakes, etc. There is, of course a very strong dietary association too, and it allows me to bring up a case report that occurred with one of our colleagues, Dr. Ken Kay, who's a translational virologist, and the son of a famous ID doctor, Donald Kay, and the brother of another famous ID doctor, Keith Kay. Well, Ken Kay, as a little baby, contracted salmonella from ingesting something contaminated and ended up being a case report, I think, published in the New England Journal of Medicine? So, yeah. So anyway, a little trivia fact about the the K dynasty in infectious diseases. Very good. Okay. My next choice in this draft of ID associations is limb edema, so arm or leg, and beta strep infections. And here's one that everyone should know. Anyone who's like maybe caring for patients who have had a lymph node dissection in their axilla from breast cancer, or they have saphenous vein harvest because it gives them edema, or they're just overweight and they have leg edema, they are predisposed to getting staph aureus cellulitis, but the dominant pathogen by far are beta streptococci. Not just Group A, but also group B, C, G, and F. Remember, not group D, because that's strep Bovis, I've already covered that and not group E, because who on earth knows what happened to group E strep? I have no idea. But those beta straps cause a very stereotypical illness of like a flu like syndrome and then sudden onset of shaking chills, high fevers, and then sometimes very severe cellulitis. Recognition of this entity has also led to a really practical, wonderful clinical trial which showed that chronic suppressive treatment with penicillin or chronic preventive treatment with penicillin reduces the incidence of this complication substantially. An I have a very low threshold for recommending that to people, especially if their cellulitis has been severe enough to be hospitalized. So that's my choice number four, which is limb edema and beta strep cellulitis. So you see, I'm going all over the place.

Rebeca Plank: [00:21:02] I appreciate that because I'm sticking on the straight and narrow here. So now I'm going to go back to nothing to do...

Paul Sax: [00:21:08] Wait, this is your last choice. But then you get some honorable mentions.

Rebeca Plank: [00:21:11] ...Oh, I have a few honorable mentions here that I do want to get to. But my last one, actually, you know, you mentioned that I have trained an ID and an HIV. I also used to travel clinic, which I really loved,

Paul Sax: [00:21:22] Ah.

Rebeca Plank: [00:21:23] And it was so interesting and fun and exciting to talk to people before they were setting off to their much anticipated travel. I want to talk about swimming in Lake Malawi and getting schistosomiasis.

Paul Sax: [00:21:37] Beautiful. I was so sure you were going to choose this one.

Rebeca Plank: [00:21:41] Really?

Paul Sax: [00:21:41] Yes, I when I when I actually thought of inviting you to be on this association's podcast, I said we are going to get schisto from swimming in freshwater lake or river.

Rebeca Plank: [00:21:52] Oh yeah. Let's just put aside leptospirosis for now, let's focus on acute schistosomiasis.

Paul Sax: [00:21:57] Wait, how, how often have you said that to your friends? Let's put aside leptospirosis and just talk about schistosomiasis. It happens all the time.

Rebeca Plank: [00:22:05] You know what, I do want to say. Sometimes I think I'm no fun to travel with because people are like, well, here's the destination, and I'm like, already making a list in my mind about the different things that are endemic in that part of the world. So it's no fun to travel...actually, it is fun to travel with me, but beware that I may make a list of things that we could get while we're there. So Lake Malawi, full disclosure, I did go, I did swim. One of the beautiful things about Lake Malawi, is it's incredibly inviting. It's in a very hot part of the world. And it's the most diverse lake on the planet, it has the most different numbers of species of fish. So I wanted to go in and I wanted to make myself feel better about not getting acute schistosomiasis there. What I found out is that the schistosoms are most likely to be in the water and active, ready to infect you around noon. So you've got to go in the water early in the morning or late in the day, preferably, I'd say early. And then the other thing is that the life cycle depends on the snails that depend on the reeds that are on the lakeshore. There is a smaller population of snails that can live in the sand, but the greatest risk to you is swimming near the shore after noon. So if you go in the deep part of the lake, you should be fine. So people should be aware that people come back from traveling to that part of the world and they have acute fever, headache, etc, to think of Katayama fever, which is the acute form of schistosomiasis, and at the same time, have in mind what a beautiful place that is, and that you should just maybe practice harm reduction and go in the water.

Paul Sax: [00:23:38] Well, you know, I should say that you are a world traveler. And despite your infectious disease fears, I will say that you've traveled way more than I have. So the fears haven't kept you from from leaving the country. I think that's a great choice. And it also reminds me that the person who figured out the life cycle of schistosomiasis was a pretty smart person because... 

Rebeca Plank: [00:24:06] It's the circadian rhythm of the schistosomiasis.

Paul Sax: [00:24:08] How do you think they did it? I mean, it's like it involves, if I can recall correctly, some sort of copulation within the mammalian host, doesn't it? 

Rebeca Plank: [00:24:19] That's how the eggs. Yeah. That's how the eggs get regenerated. Yes.

Paul Sax: [00:24:22] All I can say is amazing. Amazing. I'm not going to be the person who discovers the lifecycle of a parasite. There's just no way. I can say that pretty confidently.

Rebeca Plank: [00:24:31] Okay, well, there's still time, Paul.

Paul Sax: [00:24:33] All right. My last choice. I wanted to cover the bases of all infectious disease associations. And my last one is going to start with just rifampin and orange urine and tears. And that is a way of introducing what I think is one of our weirdest drugs and its various challenges. And that's rifampin. Rifampin, obviously, this critical drug in mycobacterial infections, in particular TB, you know, this critical drug and prosthetic joint infections and penetrating biofilms. But what a pain. What a pain. And the orange urine and tears is the easiest part, as long as you counsel your patient and you tell them you're going to get it and that it's reversible and not harmful, otherwise they're going to page you panicking in the middle of the night. But the other aspects of rifampin, boy, are they hard. The drug interactions, Oh my goodness. It's like, I always think of rifampin as like Pac-Man gobbling up all the other drugs in your body as it moves around, inducing your cytochrome P450 enzymes and your p glycoprotein. Basically you cannot find many drugs that don't interact with rifampin. And then there's the hepatitis, and the hypersensitivity reactions, and the bone marrow suppression. And all I can tell you is rifampin, you could be better. You could be better, rifampin. So that's my fifth choice.

Rebeca Plank: [00:26:00] That's the take home lesson to rifampin.

Paul Sax: [00:26:02] Exactly. I hope rifampin is listening to this podcast. All right. So finish up with some quick honorable mentions. I have some quick ones, too.

Rebeca Plank: [00:26:11] All right, Paul, this one is for you. Civets and respiratory infections.

Paul Sax: [00:26:15] I remember civets very well. Yeah, okay.

Rebeca Plank: [00:26:19] Home canned asparagus and botulism.

Paul Sax: [00:26:24] Ah, you know what? This is the first time we've overlapped. I have a botulism one, too. I'll get to it.

Rebeca Plank: [00:26:27] Okay. I just want to say two more things. One is the church picnic and whatever salad is made with mayonnaise.  That's always the culprit.

Paul Sax: [00:26:35] Sure. And it's staph aureus food poisoning. It's so interesting because no one has ever made that diagnosis definitively. Never. Because it's a toxin mediated food poisoning. And you just basically, church picnic, middle of the day mayonnaise, potato salad. That's what is.

Rebeca Plank: [00:26:54] Yeah, well, it's on every, you know, example of how to do an outbreak investigation. So it's always the mayonnaise salad. We talk about these associations, and I talked a lot about travel and, you know, things that you get different places, doing different things and contact with animals. But there's also the fake out, right? And I just want to say an honorable mention was one time we saw someone who came back from a hallucinogenic, kind of cathartic tour in the rainforest, and they had every exposure in that part of the world. And what they actually had was Lyme disease that they had gotten in Western Mass.

Paul Sax: [00:27:22] Yeah, of course.

Rebeca Plank: [00:27:22] So, yeah, although we talk about all these associations, and I certainly do, and they're fun to think about, sometimes there is the fake out.

Paul Sax: [00:27:29] Yeah, absolutely. You know, I have seen someone who traveled to the farthest reaches of the planet, collecting mammalian urine in the rainforests of Asia. And he came back to the United States and he had fever and apathy and pharyngitis. And he ended up having group A strep pharyngitis.

Rebeca Plank: [00:27:52] Yeah.

Paul Sax: [00:27:52] All right. My honorable mentions raspberries and Cyclospora cayetanensis. Absolutely. First time I saw that, I couldn't believe it. There was an outbreak of cyclosporiasis after a wedding here in Boston at a very fancy place. Apparently, like 30-40% of the wedding party got got slammed. And the thing that I remember about it was that people were sick for a long time. And the other thing was that the investigation found that you can't really wash raspberries very well because they're so fragile. So that's one. Spelunking and histoplasmosis. Two things about that - one is spelunking is a really cool word. And the other thing is that I don't want to go into caves. Why would anyone want to go into a cave? I have no desire to do that. My next one is a rustic cabin and Borrelia hermsii for tick-borne relapsing fever. The one time I saw this case, person came back from Colorado. He said he was having fever and shaking chills, and he had just been in Africa. And so we thought he had malaria and we did a careful examination of his smear and it was negative. And then we sent him home because he looked really well. And then a few days later, he came back with fever again. And this time we looked at his smear and the spirochetes were outside the cells.

Rebeca Plank: [00:29:18] Amazing.

Paul Sax: [00:29:19] I know, I know. And then cruise ships and norovirus. If you haven't seen the movie "Triangle of Sadness," it's actually quite amusing. There is actually a way too long and very vivid display of a norovirus outbreak on a cruise ship that I do not recommend you watch. In fact, I recommend you walk out of the room during it, but it's a very, very good movie. And then the one I was going to mention, I just have to mention, bamboo rat and Talaromyces. I know that's on the top of your list, but Talaromyces marneffei, formerly Penicillium marneffei, the definitive host is the bamboo rat in Asia.

Rebeca Plank: [00:30:00] Right? Right. Yeah, that slipped my mind. But now that you're saying it sounds familiar.

Paul Sax: [00:30:06] Anyway, we could go on all day. As someone responded to me when I said I was going to be doing this podcast on Twitter, someone responded to me and said, this is you know, this is the doctor's bread and butter. And I said, yeah, that's what we have to have a draft. Well, Dr. Rebecca Plank, I got to say, it's been absolutely delightful having you on again drafting these top ID associations. I do hope you'll come back and join me again.

Rebeca Plank: [00:30:29] Thank you. Thank you. Bye bye.

Paul Sax: [00:30:31] Bye bye.