Chandra's corner - August 2018

Dr PH Chandrasekar

Have you heard of Robert H. Rubin, M.D.? If you’re an ID clinician, the name should ring a loud bell, or you must have seen his name in some of the seminal ID publications. An ID Professor in the Harvard system, Dr. Rubin is considered the “Father of Transplant Infectious Diseases”. He passed away in early June of this year after battling a long illness.

I had the privilege of listening to Dr. Rubin on numerous occasions. He is an icon. His characteristic nasal twang and Bostonian accent are easy to identify anywhere. He was a brilliant and intuitive clinician with his contributions transformative of clinical practice. You may not know him, but were I to mention some key concepts he introduced, you would instantly recognize them. Some of them are: 1) predictable time line for infections after transplant, 2) net state of immune suppression; 3) preemptive treatment (for example in CMV management). These have become mundane, deeply entrenched in transplant infectious diseases, taught regularly as biblical truths. Dr. Rubin did not like to define a specific length of antimicrobial therapy at the start of treatment-“treat long enough”, he’d say. His idea of steroids? “They are like credit cards. Patients and doctors get immediate satisfaction, but the bill comes at the end of the month”. Very apt, right? Dr. Rubin, as the creator of the field of transplant infectious diseases, has authored countless publications and trained many astute academic clinicians. One needs to have good fortune to be exposed to such giants.

Each of us has idols that we discover in our career path, and yearn to accomplish at least a fraction of what they did. Our idols may arise from any pool-teachers, friends, parents, colleagues, mentors. We stand on their shoulders in awe of their ability and contributions. Among these, you find one essential ingredient pulsating through their veins. They care to teach and impart their knowledge and desire to see the younger generation flourish. Frequently, they take the critical initial extra step of encouragement in a silent non obtrusive way, only to bask in the glory of the juniors’ success down the road. This quality, I believe, is innate, defining a true mentor, a gift, not something one can pretend to have. Think about your idol, enjoy the warmth.

Well, summer is just arriving here with a lot of hiccups of cold and rainy days. I was in Mexico as a guest of the ID Society at their annual meeting. It was a large gathering. My topic was “Role of Amphotericin B in the Management of Invasive Fungal Infections”. Amazingly, while use of this potentially toxic polyene has declined in the US, conventional amphotericin B and its lipid forms continue to play a very significant role in the management of diseases like cryptococcosis, mucormycosis, endemic mycoses and, of course, leishmaniasis. Inexplicably, a drug older than 50 years, is still not available in many developing nations, leading patients to succumb to eminently treatable infections. An avoidable tragedy.

At our recent ID Grand Rounds, a case of advanced HIV/HHV8 infection in a non-adherent patient with lymphoma and Castleman’s disease was presented. The patient had severe pneumonia; the bronchoalveolar lavage showed pneumocystis and cytomegalovirus. Despite aggressive therapy against the former, his condition failed to improve until treatment with IV ganciclovir for CMV infection/disease was introduced. The two learning points: a) establishing a pathogenic role for CMV requires judgement and careful bedside interpretation and b) CMV pneumonitis is not always a fatal disease, patients do respond to appropriate aggressive management. Our patient walked out of the hospital in good condition, perhaps only to return with another challenge. I will not give up, would you?

For the first time, am missing the Annual CIDS meeting this August. It happens to be at my Alma Mater. Am sorry to miss it, sure all of you will enjoy Vellore, enjoy the fine program!