Dr. Ana Velez’s “Art In Infectious Diseases”

April 10th, 2018

 

Dr. Ana Velez is an accomplished artist and University of South Florida Associate Professor and Infectious Diseases physician who has practiced at Moffitt Cancer Center among immunocompromised patients since 2007.  Although she paints in many different styles, among her favorite subjects are the microorganisms she confronts everyday as a health care provider.  With her art, she conveys the complexity and beauty present in even some of the most challenging pathogens.  Her paintings mix bright colors and subtle shades to capture the simple yet elegant nature of fungi, bacteria, and viruses. Below is some of her artwork each with an accompanying legend. Please click each picture to link to a larger version.

 

Aspergillus

Aspergillus is a fungus found throughout the world that can cause infection in primarily immunocompromised hosts and individuals with the underlying pulmonary disease. There most important types of respiratory tract infections caused by aspergillus include: invasive aspergillosis, and allergic bronchopulmonary aspergillosis. Aspergillosis infection can also manifest as sinus disease in immunocompromised hosts and cutaneous disease after traumatic inoculation.

The treatment of choice is Voriconazole. Isavuconazole, Posaconazole and Amphotericin also have activity.

The painting below illustrate aspergillus with its septate acute angle hyphae (white arrow) a vesicle (blue arrow) with phialides (orange arrow) and sporulating conidia (red arrow).

 

 

Dengue Virus

The dengue virus is a single positive-stranded RNA virus of the family Flaviviridae. It is transmitted by the Aedes aegypti female mosquito. The clinical presentations include dengue fever, dengue hemorrhagic fever and dengue shock syndrome.

The painting below illustrates the main parts of the virus including the E protein (white arrow), the M protein (black arrow), the capsid protein (red arrow) and the genomic RNA (blue arrow)

 

 

Fusarium

Fusarium is a hyaline mold that can cause severe invasive infections in neutropenic and transplant patients. The most common type of infections in this population includes invasive nodular pneumonia, sinusitis and necrotizing cutanous infections from traumatic inoculation.

This mold is angioinvasive, but can also cause disseminated disease from metastatic conidias that travel distally from the initial site of inoculation thru the bloodstream.

The treatment is Voriconazole orAmphotericin depending on the subspecies and suceptibilities of fusarium.

The painting below illustrates septated hyphae (green arrow) and banana shape conidia (black arrow).

 

 

Actinomycetes

Actinomycetes are acid-fast gram positive bacilli that are sometimes branching depending of the species.

The Actinomycetes sppinclude Mycobacterium spp, Corynebacterium spp, Nocardia spp, Actinomyces spp, Rhodococcus spp, Tsukumurella spp, Gordona spp, Actinomadura spp, Streptomyces spp, and Tropheryma wippelii.

The painting below illustrates Nocardia, Actinomyces and Rhodococcus.

Nocardia spp(black arrow) are aerobic filamentous branching beaded, gram positive rod, that stain acid-fast positive given its mycolic content of the cell wall.

Actinomyces spp(white arrow) are anaerobic branching gram positive rods that can be differentiated from Nocardia because they are acid-fast negative.

Rhodococcus spp(yellow arrow) are aerobic gram positive rod non branching acid-fast positive.

 

Chikungunya

Chikungunya virus is an RNA alphavirus transmitted by Aedes mosquitoes in the tropical and subtropical areas.

It causes acute febrile illness with polyarthralgia, arthritis and occasionally headache, rash and periarticular edema.

The painting below illustrates the structure of the Chikungunya virus with the E proteins (yellow arrow) Membrane (white arrow) capsid (red arrow) and the genomic structure (black arrow).

 

 

Herpes Simplex Virus

HSV is an enveloped double stranded DNA virus that belongs to alpha herpes virus.

There are 2 types of herpes virus (HSV): herpes virus type 1 (HSV-1) and herpes virus type 2 (HSV-2). Both are closely related.  HSV1 is more commonly associated with orofacial disease whereas HSV2 is more commonly associated with genital disease.

Medications to treat HSV infections include acyclovir, valacyclovir, and famciclovir.

The painting below illustrates the HSV virus. It has the DNA gene (white arrow), nucleocapsid (black arrow) the tegument (blue arrow), the lipid envelop (orange arrow), and the envelope proteins (red arrow).

 

 

Polymicrobial abscess

The painting below illustrates the polymicrobial purulent and bloody fluid from an abscess. The gram positive cocci in chains are Streptococcus spp (orange arrow), the gram positive cocci in clusters are Staphylococcus aureus (blue arrow) and the gram negative rods are Pseudomonas spp (white arrow).

 

 

Scedosporium

Scedosporium is a filamentous mold present in soil, sewage, and polluted water. It has two main species: Scedosporium apiospermum(and its sexual form Pseudallescheria boydii) and Scedosporium prolificans. Scedosporium spp may colonize transitory previously damaged airways, but can also cause severe respiratory infections in near-drowning and immunosuppressed patients. The infection may spread locally by angioinvasion or hematogenously to distant organs (lung and brain are common organs). Scedosporium spp are often resistant to several antifungals. Voriconazole can be used to treat infections by Sedosporium angiospermum. Scedosporium prolificans is often multi-drug resistant.

The painting below illustrates Scedosporium spp with broad hyphae (blue arrow) and Pseudallescheria boydii (red arrow) with fully developed and ruptured cleistothecium, the typical form of the sexual stage of Scedosporium apiospermum.

 

 

Zygomyces

Zygomyces is hyaline fungus that causes severe invasive infections in transplant and neutropenic patients. It can also cause severe infections in poorly controlled diabetic patients.

The most common type of infections includes invasive necrotizing nodular pneumonia, severe sinusitis with peri-orbital cellulitis, and cutaneous infections  from traumatic inoculation.

The treatment of choice is Amphotericin. Isavuconazole and Posaconazole are also effective but are often used as an alternative to Amphotericin.

The painting below illustrates different Zygomyeces spp with the typical large ribbon like non septate 90 degree angle hyphae (green arrow).

 

A Textbook Case: Making the Transition to the Online Universe

January 28th, 2017

With this blog, IDPodcasts inaugurates its new online presence. At its inception in 2007, our original goal was to make our division’s infectious diseases teaching available via a simple web site to a broad online audience. Since then, IDPodcasts has followed the pace of technology, explanding its reach to smartphones, tablets, YouTube, and to social media. In 2017, we celebrated our tenth anniversary. Recently, the development of our new web site led me to reflect again on how far online medical education resources have progressed since the beginning of this decade. For instance, In 2010, one of Oxford University’s “great medical legends” received a long awaited transplant. Long the close confidant and trusted aide to generations of doctors and medical students, it had become impersonal, grossly overweight, and unwieldy. Oxford University Press’s Textbook of Medicine, 5th Edition, first published in 1983, long regarded as perhaps the most comprehensive medical reference in publication and an emissary for evidence-based medicine around the world, was launched as a complete online edition. The project, five years in the making, brought the entirety of its massive twenty-five pound, three-volume, six thousand page print edition to the web, complete with all of the text, figures and illustrations. Though available to hospitals, universities and individuals as a paid subscription, the move to an online edition offered an unexpected benefit: inexpensive and even free access for more than 3,500 institutions in less-developed countries sponsored by the U.K.’s Wellcome Trust. 1

Oxford’s initiative, following a trend established by many medical publishers in the last decade and a half, reflected not just a gesture of altruism to third world countries but also a matter of contemporary professional and economic necessity. Since at least 2600 B.C., when Imhotep is said to have written his first papyrus on ancient Egyptian medicine 2, heralding the age when medical knowledge could be shared and adopted by others, clinicians have attempted to codify the practice of medicine onto the printed page. For more than 4500 years, the tradition of the paperbound medical text thrived, surviving the destruction of the Alexandria library in Egypt, the austere anti-intellectualism of the middle ages, and even the emergence of the new broadcast media of the second half of the 20th century. But as the practice of medicine now approaches the third decade of the new millennium, the bound medical textbook, so symbolic of the scholarly traditions that form the basis of our craft, is facing extinction. The solidification of electronic media, from online peer-reviewed information resources, medical web portals and search engines, to personal smart phones and tablet computers has now supplanted the hardbound textbook for many health providers.

In an original informal January, 2011 survey of internal medicine housestaff I conducted at my institution, only 15% had consulted a hardbound textbook in the last month, preferring instead to reference online resources such as “Up to Date,” “Harrison’s Online, “ and “Emedicine.” Less than half (47%) had reviewed a printed reference of any kind, underscoring the waning popularity of the softbound handbook or pocket guide. Now, seven years later, that number is probably close to nil. The migration that medical publications have made online reflects a societal shift away from the printed page, especially in basic and secondary education. Having a son and daughter, in both college and high school, respectively, I know that it is possible for my tablet and notebook-laden kids to never open a physical text if they wished to do so. For those of us who have been in practice more than twenty years, the transition away from the printed textbook in the last decade has presented some unexpected problems. No longer is a clinical question or controversial medical decision between clinicians resolvable via an obsolescent, forlorn text in the corner of a nurse’s station. Many resourceful clinicians now consider even a newly published hardbound volume to be out of date, questioning the validity of any reference that is not updated continuously. In an era where every question seems to be answerable via an online query, use of the search engine may have even superseded Pubmed or the National Library of Medicine, with sometimes variably reliable results.

In the past, the immutability and permanence of the printed page added certainty to hardbound textbook-based medical decisions. With the increasing reliance on online resources, it has become more difficult to distinguish credible from less credible sources of medical information, especially for patients who are sometimes forced to seek online medical advice in an era of “fake news.”. For less technologically adroit clinicians, clinging to hardbound medical resources they have used for decades, adaptation to electronic media may present formidable obstacles to reaching the information they once felt comfortable obtaining.

Yet, the online transition has had far more positive than negative consequences. Online reference sources are easier to produce and distribute, and for subscribers, often more affordable to obtain. In many medical facilities equipped with an electronic medical record, online medical references have been integrated with desktop, mobile or handheld devices at the point of care, permitting instantaneous access to evidence-based information critical to medical decision making. In fact, the growth of the evidence-based medicine (EBM) movement is likely to have been fueled since the turn of the millennium by the rapid growth of online medical resources. For many providers, the availability of medical blogs, subscription online content, YouTube videos, podcasts like our own, online access to full text medical journals and even social networking sites (e.g., Facebook and Twitter) ensure that no major medical advance, clinical trial, drug recall or outbreak can escape our awareness. In less developed countries, where medical reference resources were once limited to antiquated or donated textbooks, online resources offer resource-challenged providers with access that can level the playing field of medical information with wealthy countries, a development that is likely to be crucial to improving the quality of medical training and care in the third world. In the U.S., health information companies have also increasingly begun to acknowledge the promise of the new online frontier. Both Emedicine and Up-to-Date, among the most popular of the online peer-reviewed sites, began as struggling start-up firms in the 1990s, attracted an sizable user base, and then were ultimately acquired by large multimedia conglomerates. 3,4 For traditional publishers, almost every major hardbound text now coexists with an online edition, many enhanced for portable devices.

Like audiophiles who still extol the tonality, sonic imperfection, and nostalgia of the vinyl LP in an age of digital music streaming, there will always be those who cherish the great joy inherent in un-wrapping a new-edition hardbound text, resting its weighty spine on one’s lap, and thumbing through its unwrinkled and carefully typeset pages. Although classic medical textbooks may never completely disappear, they may be relegated to the novelty of display cases.   The ongoing transformation of medical information to the online universe will continue to affect the discipline of medicine in many ways and may even alter the foundation of what it means to be a physician. For if healthcare providers can now have access to a portal that can instantly provide them with unlimited online knowledge, updated constantly, and personalized to their patient’s individual needs, at what point could the physician, like an out of print textbook, also become obsolete, replaced by an artificially intelligent machine? It seems unlikely that this will happen anytime soon, one might think, because it is not what we know that endears us most to our patients.   “The art of medicine,” the 16th century Renaissance physician Paracelsus once wrote, “cannot be inherited, nor can it be copied from books.” 5

 

 

References:

  1. Moisse K. A medical classic gets a 21st century makeover, going online and low cost. Scientific American http://bit.ly/dpVuEk. Accessed February 2, 2010.
  2. Breasted JH, ed The Edwin Smith Surgical Papyrus: published in facsimile and hieroglyphic transliteration with translation and commentary on two volumes. Chicago: University of Chicago Press; 1991; No. 3-4.
  3. Emedicine.com. http://emedicine.medscape.com.
  4. Uptodate.com. http://www.uptodate.com. Accessed 01/15/2018.
  5. Jacobi J, ed Paracelsus, Selected Writings. New York: Pantheon books; 1951.