Microbiology Case Study: A 47 Year Old Woman with Three Day History of Fever

Case History

A 47 year old Caucasian female presented to her primary care physician with a three day history of fever (Tmax 102°F), chills and generalized body aches. Her rapid influenza test was negative, but she was treated with oseltamivir for suspected viral infection. Her past medical history was significant for severe mitral regurgitation for which she had had a prosthetic valve replacement two years prior, ischemic cardiomyopathy with recent pacemaker placement one month prior and an undifferentiated connective tissue disease. Her current medications included hydroxychloroquine (Plaquenil) and warfarin. Her symptoms persisted and upon return to clinic, a urinalysis was performed and blood cultures were collected. On physical exam, the pacemaker site was erythematous and tender to palpation. She was started on doxycycline and fluconazole for a presumed urinary tract infection. After 4 days of incubation on the automated instrument, the two aerobic blood cultures bottles were positive and the patient was admitted to the hospital for further workup and therapy.

Laboratory Identification

Microscopic examination from the positive blood culture bottle revealed slender, beaded Gram positive bacilli (Figure 1). No definitive branching was identified. Given the morphology on Gram stain, a Kinyoun stain was performed and revealed red-purple, beaded acid fast bacilli which were consistent with a Mycobacterium spp. (Figure 2). A Mycobacterial Growth Indicator Tube (MGIT), a Lowenstein Jensen slate and blood & chocolate agars were inoculated with specimen. Given that the organism grew after 2 days, a rapidly growing Mycobacterium spp. was suspected (Figure 3). High performance liquid chromatography (HPLC) identified the organism as M. fortuitum.

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Figure 1. Gram stain from the positive blood culture bottle showed slender, beaded Gram positive bacilli that were arranged in clumps (100x oil immersion).

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Figure 2. Kinyoun stain of the organisms was consistent with acid fast bacilli (100x oil immersion).

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Figure 3. Small, off-white colonies grew on chocolate agar after 3 days of incubation at 35°C in a CO2 incubator.

Discussion

M. fortuitum is a common rapid growing mycobacterial species that is ubiquitous in the environment and tap water. Most common infections due to M. fortuitum include post-traumatic or post-surgical wound infections and it can be associated with the insertion of prosthetic devices including heart valves, artificial joints and rods inserted after fractures. Of the rapid grower group (Runyon Group IV), which includes M. chelonae, M. abscessus and M. mucogenicum, it is M. fortuitum that accounts for approximately 60% of localized cutaneous skin infections and prosthetic device infections most frequently.

In the laboratory, M. fortuitum typically grows after two to five days incubation and appear as small, off-white colonies on a variety of different agars. The organism is typically slender, beaded Gram positive bacilli on Gram stain and positive for acid fast bacilli on a Ziehl-Neelsen or Kinyoun stain. As part of a traditional lab work up, M. fortuitum is arylsulfatase positive and is capable of reducing nitrates. Today a variety of methods, including HPLC, pyrosequencing, sequence analysis and matrix assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS), have become routine identification options. Susceptibility testing of isolates from clinically significant sites should be performed by broth microdilution and includes the following antimicrobials: amikacin, cefoxitin, ciprofloxacin, moxifloxacin, clarithromycin, doxycycline, linezolid, imipenem, meropenem, minocycline, trimethoprim-sulfamethoxazole and tobramycin.

In the case of our patient, it was discovered her pacemaker site was infected and upon further questioning it was discovered she wasn’t able to complete her antibiotic course after device placement due to nausea. A transesophageal echocardiogram showed no evidence of infective endocarditis and she was taken to the operating room for removal of the pacemaker and leads. The site was filled with pus and wound cultures obtained during surgery were consistent with M. fortuitum as well. Repeat blood cultures were negative and she was treated with intravenous amikacin and imipenem as well as oral levofloxacin for an anticipated 6-8 weeks before transitioning to oral therapy.

 

-Debbie Rigney Walley, MD, is a 1st year Anatomic and Clinical Pathology Resident at the University of Mississippi Medical Center.

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-Lisa Stempak, MD, is an Assistant Professor of Pathology at the University of Mississippi Medical Center in Jackson, MS. She is certified by the American Board of Pathology in Anatomic and Clinical Pathology as well as Medical Microbiology. She is the director of the Microbiology and Serology Laboratories.  Her interests include infectious disease histology, process and quality improvement and resident education. 

Leadership is WEadership

Leadership is all about the other person; it is about adapting your own behavior and communications styles to meet the needs of the people you are leading. However, in order to be able to adapt your own behavior, you first need to learn about yourself.  Discovering your natural leadership styles, communication and delegation preferences, views about conflict, and your strengths and weaknesses will improve your leadership abilities. This learning requires a deep-dive analysis through one (or preferably all) of these methods:

  • Self-reflection
  • Feedback from others
  • Coaching
  • Self-assessments

Personally I have always been drawn to constructive feedback so I can discover areas for growth. It’s not always pleasant to hear, but we all have blind spots, and feedback is a crucial first step in personal and professional development. In the last few years I have added another layer of self-discovery: self-assessments. In my experience, self-assessments give you 1) a sense that you are not alone; that your thoughts, behaviors, the ways in which you process information are not different than everyone else but that there are people who behave, think, and process in similar ways, 2) a deeper sense of understanding where your behavior or communication preferences come from, and 3) a practical understanding of people who act differently than you and how to approach them more effectively. In other words, self-assessments are a way to acknowledge one’s own behavior and that of others. So much of leadership is about acknowledging other people through adapting your own behavior.

When I got hired to create a Leadership Institute for ASCP members, I used self-assessments as the cornerstone of our curriculum. I want our members to have access to the same level of awareness and development that I have enjoyed throughout the years. Learning about your motivators and blind sides is crucial before you can truly turn leadership into WEadership.

 

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-Lotte Mulder earned her Master’s of Education from the Harvard Graduate School of Education in 2013, where she focused on Leadership and Group Development. At ASCP, Lotte designs and facilitates the ASCP Leadership Institute, an online leadership certificate program. She has also built ASCP’s first patient ambassador program, called Patient Champions, which leverages patient stories as they relate to the value of the lab.

Microbiology Case Study: A 73 Year Old Man with Back Pain

Case History

A 73 year old man with a history of multiple back surgeries presented with bilateral lower extremity back pain of over greater than one month duration. Prior surgeries included L4/L5 fusion with pedicel screws and a decompression laminectomy one year prior to presentation. Imaging of his spine showed a fluid collection in his lumbar spine and he underwent several tissue biopsies over the course of a month which consistently showed no growth. Despite negative cultures he was treated with doxycycline and levoquin for 30 days. He was transferred to University of Vermont Medical Center (UVMMC) for IR drainage and tissue biopsy of this lumbar abscess as he continued to complain of back pain and had begun to develop bilateral lower extremity weakness. Cultures grow the organism below and close inspection revealed the presence of small feet. The organism was confirmed to be Candida albicans.

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Discussion

Vertebral osteomyelitis due to Candida is rare, however, a review of the literature reveals that most patients have lower thoracic or lumbar spine involvement and over 80% present with >1 month of lower back pain. An elevated white blood cell count is not as sensitive as an elevated erythrocyte sedimentation rate and of all patients, less than a quarter have neurologic signs. Candida albicans was responsible for almost 2/3 of cases and the remaining cases were caused by Candia tropicalis or Candida glabrata.1 Risk factors include IV drug abuse for patients under 25 years old; for elderly patients a central venous catheter, antibiotic use and immunosuppression .1

 

Reference

Miller, D and Mejicano, George. Vertebral Osteomyelitis due to Candida species: Case report and review of the literature. Clinical Infectious Diseases, 2001;33:523-530.

-Agnes Balla, MD is a 3rd year anatomic and clinical pathology resident at the University of Vermont Medical Center.

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-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Assistant Professor at the University of Vermont.

 

Automated Body Fluid Cell Counts

Body fluid cell count has been part of the hematology laboratory and remains a time-consuming manual task for technologists. The cell count test provides valuable information to clinicians in the diagnosis and treatment of a various medical conditions. Albeit the diagnostic prowess of cell counts, there has also been an intrapersonnel variation in counts that proves the lack of precision among testing personnel. As laboratory professionals, we are trained that precision is important in the performance of cell counting procedures; therefore the implementation of automated body fluid counts will improve these quality parameters.

Automated methods for body fluid cell counts have been rapidly replacing manual hemacytometer methods. Advances in medical technology, especially in hematology instrumentation, have decreased the turnaround times and improved precision counts for body fluids. Technological advances in hardware and software engineering have developed instruments with expanded analytical capabilities that enable processing multiple specimen types including urine, CSF, peritoneal fluid, pleural fluid, synovial fluid, and lavages on a single analyzer.1 Most body fluid instruments like the Sysmex XE-5000 have analyzed body fluids easily and quickly. In a study published in Lab Medicine, the Sysmex XE5000 technology showed significant improvement in the ability of automated hematology analyzers regarding body fluid analysis.2 This technology provides counting nucleated cells in an acellular fluid(i.e. Cerebrospinal fluid). This technology also offers differential capabilities between mononuclear and polymorphonuclear cells, providing laboratory technologists and clinicians rapid, cellular differential analysis.

Laboratory technologists should not fear that their jobs will be replaced by these instruments. In fact, laboratory professionals should be enthused that it provides ease in their work, improves quality, decreases work load, and increases efficiency in their processes. The limitations that need to be considered in automated cell counts analyzers are the use of purulent specimens where the main concern is clogging the instrument’s flow cell apertures. Crystals in synovial fluids may cause a false increase in counts; in these cases, manual intervention in cell count may be warranted. Extremely clear fluids with low cell counts also limit the application of automated methods and may warrant manual analysis. Of important consideration as well is the microscopic review of cellular distribution when malignancy is of diagnostic consideration.

Modernization of laboratory equipment and analysis provide ease in operation from a management stand point but also efficiency, accuracy and precision in reporting of results. Automation of body fluid counts provides help to technologists and a rapid diagnosis tool for clinicians.

 

Reference

 

  1. Scott, G. (2014, June 9). An automated approach to body fluid analysis. Medical Laboratory Observer.

Williams, J., MD. (2011). Gaining Efficiency in the Laboratory – Automated Body Fluid Cell Counts: Evaluation of the Body Fluid Application on the Sysmex XE-5000 Hematology Analyzer . Lab Medicine, 42(7).

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Carlo Ledesma, MS, SH(ASCP)CM MT(ASCPi) MT(AMT) is the program director for the Medical Laboratory Technology and Phlebotomy at Rose State College in Midwest City, Oklahoma as well as a technical consultant for Royal Laboratory Services. Carlo has worked in several areas of the laboratory including microbiology and hematology before becoming a laboratory manager and program director.

Microbiology Case Study: A 14 Year Old Cystic Fibrosis Patient

Case History

14 year old cystic fibrosis (CF) patient was admitted to the hospital for a CF exacerbation with a known rhinovirus infection. The patient reported congestion and cough with production of greenish sputum. The following was isolated from a sputum culture.

Laboratory Culture

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Image A. MacConkey Agar plate with mucoid Pseudomonas aeruginosa colonies.

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Image B. Kirby-Bauer Method of antimicrobial susceptibility.

Discussion

Cystic fibrosis patients have complex polymicrobial respiratory flora. Routine cultures may reveal different bacterial species that can contribute to the difficulty in treating and preventing infections in these patients. Staphylococcus aureus, Haemophilus influenza and Pseudomonas aeruginosa are main contributors to the infections found in CF patients.

In this case, we isolated a mucoid Pseudomonas aeruginosa (Image A). Pseudomonas aeruginosa is an oxidase-positive, gram negative rod-shaped bacterium that is commonly found in the environment. It is considered a severe and frequent pathogen in patients with cystic fibrosis. In chronic infections, it is thought that P. aeruginosa can undergo a “mucoid switch” where the bacterium can acquire mutations that lead to the mucoid phenotype. The phenotype is so impressive that excess polysaccharide will often drip onto the lid of the plate when stored upside down during incubation.

One of the key features of mucoid strains of P. aeruginosa is their ability to form biofilms. Biofilms consist of a matrix of polysaccharide, protein and DNA. This provides not only a protective barrier from antibiotics and the immune system, but also may contribute to the growth of other bacteria within the microenvironment.

With all the excess polysaccharide, it can be difficult to standardize the inoculum of mucoid isolates of P. aeruginosa which is an essential starting point for the microbroth dilution method of antimicrobial susceptibility testing. For this reason, susceptibility testing of mucoid isolates is often performed by Kirby-Bauer (KB) disk diffusion method. The KB method is a test of antimicrobial susceptibility that is based on the zone of inhibition surrounding disks that contain antimicrobial drugs (Image B). The strain of mucoid P. aeruginosa isolated in this case was found to be susceptible to aztreonam, ceftazidime, piperacillin/tazobactam and resistant to amikacin, cefepime, ciprofloxacin, gentamicin, levofloxacin, meropenem and tobramycin, by the Kirby Bauer method.

Case Follow Up

The patient was ultimately treated with IV piperacillin/tazobactam, as well as with chest physical therapy and hypertonic saline inhalation. They clinically improved and were ultimately discharged home after a 2 week hospital stay.

References

The mucoid switch in Pseudomonas aeruginosa represses quorum sensing systems and leads to complex changes to stationary phase virulence factor regulation. Ben Ryall, Marta Carrara, James EA Zlosnik, Volker Behrends, Xiaoyun Lee, Zhen Wong, Kathryn E. Lougheed, Huw D. Williams. PLOS ONE, May 2014, Vol. 9, Iss. 5, Pages 1-11.

Pseudomonas aeruginosa biofilms in cystic fibrosis. Niels Høiby, Oana Ciofu, and Thomas Bjarnsholt. Future Microbiology, November 2010, Vol. 5, No. 11, Pages 1663-1674.

Insights into Cystic Fibrosis Polymicrobial Consortia: The Role of Species Interactions in Biofilm Development, Phenotype, and Response to In-Use Antibiotics. Magalhaes AP, Lopes SP, Pereira MO. Frontiers in Microbiology, January 13, 2017, Vol. 7, Article 2146.

Koneman’s Color Atlas and Textbook of Diagnostic Microbiology. Gary W. Procop, Deirdre L. Church, Geraldine S. Hall, William M. Janda, Elmer W. Koneman, Paul C. Schreckenberger; Gail L. Woods. Seventh Edition. 2017. Pages 343, 1110.

 

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-Megan B. Wachsmann, MD, MSCS, is a 4th year Anatomic and Clinical Pathology Resident and Chief Resident at UT Southwestern Medical Center.

Erin McElvania TeKippe, PhD, D(ABMM), is the Director of Clinical Microbiology at Children’s Medical Center in Dallas Texas and an Assistant Professor of Pathology and Pediatrics at University of Texas Southwestern Medical Center.

Phlebotomists and PPE: How Do You Decide?

When it comes to making a decision about Personal Protective Equipment (PPE) in the laboratory, OSHA is pretty clear about how to go about making the selection. The use of risk assessments and task assessments is required by OSHA’s Bloodborne Pathogens standard, and these can be essential tools in making decisions regarding safety throughout the laboratory. The decision-making tools and processes can be applied to the patient collection area as well. You might think selecting PPE for phlebotomists would be straightforward, but in some cases, it is not.

Deciding on gloves for phlebotomists is easy. The Bloodborne Pathogens standard states, “Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood … (and) when performing vascular access procedures.” (The one exception here is when collecting blood at a volunteer donor center, although gloves may be worn there as well.) So, if you have phlebotomists on your team, whether they collect blood on the patient units, at client sites, or in the lab, they all need to be wearing gloves, and it is required that they change those gloves after each patient contact. The gloves should be constructed of latex, nitryl, or another material that prevents the passage blood or body fluids (vinyl gloves should not be used).

Some of the decisions about the use of lab coats and phlebotomists are, unfortunately, more complicated. This first part of this conversation is easy. The BBP standard requires lab coats “in occupational exposure situations.” That means that if phlebotomists perform any work in the lab- if they process blood, spin it down, pour it off, etc. – they are in such an exposure situation and need a lab coat (and face protection if they handle open specimens or chemicals).

The second part is a bit more troublesome. Do phlebotomists need to wear lab coats when collecting blood from patients? According to OSHA, the answer is a clear “no.” A 2007 OSHA letter of interpretation states, “ Laboratory coats… are not typically needed as personal protective equipment (PPE) during routine venipuncture.” The letter does also go on to say that employers should perform risk assessments for any potential exposure situation in order to make decisions about lab coat use.

I do not favor the use of lab coats for phlebotomists, and I have my reasons. In my years of collecting specimens, I never obtained a splash of blood above my wrist, and I believe the risk of such a splash is minimal. As a Lab Safety Officer, I also know the use of a lab coat for phlebotomists creates several issues. If a lab coat is worn as PPE, should the same coat be worn from patient to patient? That would never happen with gloves, so if the lab coat is for protection against blood spatter, should that used and potentially contaminated protection be re-used? If a phlebotomist uses a lab coat while processing specimens in the lab, should that same lab coat be used with patients? No, OSHA says PPE used in the lab should never be worn outside the lab. Will phlebotomists change their lab coats? That is not convenient for them, and it opens the door to regulation violations and potential patient harm.

When having conversations about this topic, I have heard the argument that clothes or scrubs are worn from patient to patient if lab coats are not used. What’s the difference between that and wearing the same lab coat? The difference is that clothes and scrubs are not PPE. They are not designed to offer protection against splashes. Once you use an item as PPE, the OSHA regulations that cover the employee and how it should be viewed change.

On the other side of the coin, however, is a survey that was conducted in 2008 by DenLine Uniforms, Inc.[1] 180 phlebotomists across the country responded to questions about exposure and lab coat use. 64% of those surveyed regularly used semi-impermeable lab coats as PPE while collecting blood. 74% of respondents said they had encountered blood splashing beyond the hand area multiple times during the years they had been drawing blood. Given just this data, it seems clear that there is a high risk of blood exposure while performing venipuncture procedures, and that should mean that a lab coat should be used.

So how do you decide what to do with phlebotomists and lab coats in your lab or hospital? First, start with a risk assessment. Determine the risk of exposure above the wrist based on the collection equipment and procedures used at your location. If the risk is low, you should feel comfortable choosing not to provide lab coats for this process. If you find the risk of splash is high, implement the use of lab coats. Use caution, however, and consider the impact to patients of wearing what you consider to be contaminated PPE from patient to patient. As with all decisions about lab safety, think about the regulations, but if they don’t give you the answer you need, fall back to the choice that offers the best safe practice for your staff.

[1] https://www.denlineuniforms.com/assets/images/pdf/Blood_Draw_Exposure_Survey-October_2008.pdf

 

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Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

Diagnosing Displaced Populations

If you are at all aware of current politics, you are aware of the refugee crisis. The United Nations High Commissioner for Refugees Global Trends report estimates that 65.3 million people were displaced from their homes as refugees or internally displaced persons in 2015. Refugees are a population at risk for many diseases and health complications, and also lack access to adequate diagnostic testing. The average length of conflict-induced displacement is 17 years, resulting in significant healthcare ramifications. The health of refugees is important for obvious general humanitarian reasons, because the risk of spread to the host population when refugees find asylum, and for the burden untreated chronic diseases place on the healthcare systems of host countries.

The most common diseases in refugee camps are communicable, and include diarrheal disease, acute respiratory disease, measles, malaria, meningitis, TB, and HIV. Poor sanitary conditions and close accommodations are driving factors for these diseases. Loss of infrastructure in the country of origin increases the likelihood that a refugee will enter camp with a communicable disease. For example, disruption of vector control programs or efforts in a volatile country increase the risk of vector-borne diseases such as malaria. Breakdown of vaccine programs increases risk of vaccine-preventable diseases; the low vaccine rates in areas producing most of the world’s refugees contributes to the mortality of measles in refugee camps.

While there’s no denying that communicable diseases are a huge threat to refugee populations, non-communicable diseases (NCDs) are also a significant burden. In 2008, the WHO estimated 63% of deaths occurring globally were attributable to NCDs. The number is projected to increase to 55 million by 2030, with the most rapid rise expected to occur in developing countries – which are also the main source of displaced persons. Displaced persons are also more vulnerable to NCDs because of risks associated with population movements, including psychosocial disorders, reproductive health problems, higher newborn mortality, drug abuse, nutritional disorders, alcoholism and exposure to violence. Unfortunately, there is not much published on the incidence of NCDs in refugee populations, but at least two studies describe diabetes, hypertension, and seizure disorders are frequent diagnoses in refugee camps. A study of Congolese refugees found 9.5 cases of diabetes/100,000, 5.9 cases of seizure disorders/100,000, and 2.6 cases of diabetes/100,000. A Belgian study found a high number of refugees with chronic diseases and interrupted maintenance treatments in addition to those with diabetes, hypertension, and seizure disorders. Not diagnosing and managing non-communicable diseases in refugee populations increases the risk of morbidity and mortality in these populations, and means that the refugee will present a larger burden to the health system of the country in which the refugee finds asylum. Any loss of function due to an unmanaged NCD – loss of limbs from diabetic neuropathy, for example – will impact the future livelihood of a displaced person.

Increasing rates of antimicrobial resistance, of malaria and TB for example, make it even more important the that correct diagnosis – including pathogen strain where appropriate – is made before treatment is started. However, most health-related efforts in refugee populations focus on disease prevention and control, and less with building diagnostic capacity. The CDC Division of Global Migration and Quarantine (DGMQ) recommends testing refugees for infectious disease, especially those with long latency. Some of the diseases the DGMQ recommends testing for include malaria, TB, and intestinal parasites. There’s less guidance regarding testing for non-communicable diseases. The WHO recommends “ensuring the essential diagnostic equipment, core laboratory tests and medication for routine management of NCDs are available in the primary health care system”, with no further detail.

There’s very little in the peer-reviewed or even lay literature about the availability of laboratory diagnostics, but from what is available and anecdotally, diagnostics are often not at the forefront of medical efforts in refugee camps. The Belgian medical team consisted of 400+ volunteer medical staff, and yet was severely under-supported in terms of diagnostics.

Challenges to bringing laboratory diagnostics include infrastructure needs and cost. Unfortunately, lab diagnostics are not cheap! The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) spent $6.9 million USD to operate comprehensive labs in 124 of it’s 139 health facilities. Infrastructure needs – electricity and clean water –  and the need for trained personnel are common limitations to operating diagnostic laboratories in resource-poor settings such as refugee camps. Political instability also contributes to the challenge. In 2013, the DGMQ reported that the Dadaab refugee camp, home to over 300,000 refugees, had a fully functioning comprehensive laboratory. In May 2016, this camp was closed due to safety risks, eliminating the laboratory resource.

So what do we do? I have to be honest that – even though I thought I knew about this problem – writing this blog post has been eye-opening for me and I’m not sure I can answer the question. I’m definitely going to be thinking about this for some time. In the meantime, I think being aware of the problem of limited access to diagnostic laboratory testing in refugee populations is a good start. We need to get a better understanding of the scope of the problem. We should be ready and able to provide specific recommendations for meeting diagnostic needs in these populations including most appropriate diagnostics given clinical needs, infrastructure, and available treatment options. The road toward a solution will include global collaboration, research, and advocacy.

 

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Sarah Riley, PhD, DABCC, is passionate about bringing the lab out of the basement and into the forefront of global health.