Chest wall masses are an uncommon result of Mycobacterium tuberculosis (MTB) infection especially in immune-competent patients. Herein, we report a case of 47-year-old previously healthy man who presented with an anterior chest wall mass, along with a swelling of the left fourth finger. MTB was recovered from the patient's sputum and from the aspirate of the chest wall mass. Four anti-tuberculous drugs for 2 months then 2 drugs for 7 months resulted in complete resolution of both masses with no need for surgical resection. Conclusion: MTB can present in disseminated form in a healthy man and treated with quadruple anti-tuberculous medications without surgical intervention.
Gram positive rods seen on Gram’s stain are often dismissed as skin commensal organisms. Diphtheroids (Non-diphtherial Corynebacterium species), as they are collectively called, are taken as harmless bystanders in a skin and soft tissue infection (SSTI). However, emerging evidence has established virulence factors in some of these species leading to various infections.Here, we describe a case of mastitis in a 43 year old female caused by Corynebacterium amycolatum. The organism was seen as thick Gram positive rods on Gram stain and was isolated as a pure growth on Blood agar. Identification was done on Vitek-2 and confirmed by matrix assisted laser desorption-ionization - Time-offlight (MALDI-TOF). Patient was managed successfully with surgical excision and antibiotics.
Tumor necrosis factor (TNF) inhibitors are widely used in the treatment of inflammatory conditions and are associated with risks of invasive infections. We present a diagnostically challenging patient with unique comorbidities and travel history. A 53-year-old man with a history of polysubstance abuse and psoriasis on adalimumab presented to our hospital directly from the airport with fever, dyspnea, and cough. He had been living in Costa Rica and engaged in many outdoor activities. Within 6 hours and a limited history, he was intubated; vasopressors and antimicrobials were promptly administered. An extensive infectious disease investigation was undertaken, considering potential travel-related exposures and his immunosuppressive state. However, multi-organ failure with worsening disseminated intravascular coagulation ensued, and within four days of admission, the patient passed away. Five days after his death, the urine Histoplasma antigen resulted positive. Disseminated histoplasmosis should be suspected in a patient on anti-TNF therapy, with a severe febrile illness and pneumonia refractory to antibacterial therapy. A high index of suspicion is necessary to make the diagnosis and initiate prompt treatment. Keywords: Histoplasmosis, Traveler, Tropical infections, Tumor necrosis factor
Nocardia is characterised as a Gram positive filamentous rod and is found worldwide in soil, decaying vegetable matter and aquatic environments. Localised pulmonary infection is the most common clinical presentation. However, Nocardia can present in a wide variety of clinical manifestations, especially in the immunocompromised individual. We present the first case of a prostate abscess caused by Nocardia farcinica in a man with a history of severe psoriasis and psoriatic arthritis. He had been on long term immunosuppression for this with prednisolone and etanercept. His Nocardia was likely contracted through direct skin inoculation while gardening with haematological dissemination to the prostate. He responded well to long term sulfamethoxazole and trimethoprim.
Salmonella osteomyelitis is a rare clinical entity more commonly described in grounds of sickle cell disease however some cases has been described in patients without this pathology but an immunocompromised state, which also predisposes to the development of a psoas abscess.We present the case of a 77-year-old man with persistent hip pain and recent diagnosis of prostate cancer who developed lumbar osteomyelitis and a secondary psoas abscess due contiguous spread. Treatment included a third-generation cephalosporine and fluoroquinolone without surgical drainage with a good prognosis overall.
We report a case of a 17-year-old male who presented with pain in his right first toe. His pain and swelling had worsened and x-rays of his foot revealed erosive changes of the great toe distal phalanx suggesting possible osteomyelitis. His co-morbidities were morbid obesity and diabetes insipidus. He was admitted to the hospital, blood cultures were drawn, and he was started on vancomycin for presumed bacterial osteomyelitis. He underwent incision and drainage of the fluctuant abscess of the toe, where a culture of the wound was taken. Preliminary results grew fungi. Being located in an endemic area, he was started on anti-fungal treatment for presumed disseminated coccidioidomycosis; culture was positive for Coccidiodes immitis. He also had serology positive for coccidioidomycosis titers. He had uneventful hospital stay and was discharged on long-term oral antifungal therapy.
DOI : 10.1016/j.idcr.2017.04.011
ISSN: 2214-2509 Cilt: 9 Sayı: C Sayfa: 14 - 16
The ongoing outbreak of COVID-19 has been expanding worldwide. As of 17 April 2020, the death toll stands at a sobering 147,027 and over two million cases, this has been straining the health care systems all over. Respiratory failure has been cited as the major cause of death but here we present a case about a patient who instead succumbed to severe metabolic acidosis with multiple organ failure.
A 26-year old woman presented for evaluation of extensive edema, erythema, sinus tract formation and purulent drainage from the left lower extremity after trauma from a wooden object approximately three months prior. Skin biopsies and blood cultures revealed Phaeoacremonium parasiticum consistent with a diagnosis of phaeohyphomycosis. Despite hospitalization and initial treatment with several antifungals, including voriconazole, her infection progressed. Surgical debridement with split thickness skin grafting was performed. Subsequent clinical improvement allowed a transition from intravenous to oral voriconazole and discharge home. Seven months post presentation she remained on oral voriconazole with significant improvement and no clinical evidence of recurrence. This case illustrates an approach to management where aggressive debridement with split-thickness skin grafting and a prolonged course of intravenous and oral antifungals resulted in a good long-term outcome for the patient.
Talaromyces marneffei is an opportunistic fungal infection seen in immunocompromised patients including those with HIV/AIDS. It is usually seen in patients who live in or are from tropical Asia. In HIV patients, oropharyngeal and laryngeal lesions are usually part of disseminated infection. We describe a case of 63-year-old Vietnamese male with history of HIV/AIDS who presented with localized T. marneffei tonsillar infection without disseminated disease. Imaging studies showed a right tonsillar mass with right cervical lymphadenopathy which was initially thought to be malignancy. The patient underwent biopsy of the mass and histology showed noncaseating granulomas on hematoxylin and eosin stain as well as yeast on Grocott methenamine silver stain. Fungal culture of the biopsy specimen grew suede-like grayish-white colonies with diffuse underlying deep red color pigment which was identified as Talaromyces marneffei. The patient was treated with intravenous liposomal amphotericin B and achieved resolution of symptoms and tonsillar mass. In HIV/AIDS patients who are either from endemic regions or with history of travel to endemic areas particularly Southeast Asia and China, T. marneffei infection should be considered in differential diagnoses of a tonsillar mass.
The spectrum of Neisseria meningitidis-associated clinical entities involves mild forms of disease, without neurological involvement or sepsis, and asymptomatic carrier states. Rarely, N. meningitidis bacteremia can be associated with a prolonged fever with or without arthritis, which we designate as chronic meningococcemia. Chronic meningococcemia is an uncommon entity, usually associated to serogroup B N. meningitidis. Diagnosis is frequently delayed as blood cultures collected outside febrile periods can be negative. We present a case of chronic meningococcemia in a 22-year-old woman with no relevant clinical background, presenting with fever, arthralgia and exanthem. Due to the potential for progression to more severe disease and the risk of N. meningitidis transmission and development of secondary cases, a high degree of clinical suspicion is required to ensure prompt recognition and adequate treatment. Our patient had a favorable outcome probably due to early recognition and adequate treatment, which is critical for the resolution of the disease without complications. Keywords: Chronic meningococcemia, Mild meningococcal disease, Meningococcal rash and arthritis, Arthritis-dermatitis syndrome
Infective endocarditis (IE) caused by Aerococcus urinae is rare. The true incidence rate of this pathogen is likely underestimated as this is easily misidentified as Staphylococci or Streptococci. It is also associated with increased risk of complications such as systemic emboli. Aerococcus usually affects elderly males with underlying urological conditions. Here we present a case of IE with this rare Aerococcus urinae in a young man with a bioprosthetic aortic valve, despite negative urine cultures.
Fungal endocarditis/aortitis is an uncommon yet emerging entity accounting for 2% to 4% of all cases of infective endocarditis and continues to be associated with a poor prognosis. We present the first case of polyethylene-terephthalate (PETE) graft aortitis caused by A. niger, a rare fungal agent. Early diagnosis with frequent transoesophageal echocardiography (TEE) and a prompt surgical intervention coupled with optimal antifungal therapy are still the only option to reduce the exceedingly high mortality and morbidity.
Clostridium subterminale is a low virulence species of Clostridium that is an infrequent cause of human infections. We report a case of C. subterminale bacteremia in an immunocompetent patient who developed botulism-like symptoms.
DOI : 10.1016/j.idcr.2018.01.014
ISSN: 2214-2509 Cilt: 11 Sayı: C Sayfa: 80 - 82
We report two cases of co-infection with Salmonella Typhi and Salmonella Paratyphi A identified by blood culture and confirmed by serotyping from an ongoing fever surveillance cohort in an urban slum in New Delhi. Co-infections such as these have important implications on diagnosis, treatment options including choice of antimicrobial(s), disease outcome and strategy for prevention.
Central nervous system (CNS) vasculopathy associated with Varicella Zoster Virus (VZV) infection, usually manifesting as stroke due to ischemic lesions by involvement of small arteries, is frequently misdiagnosed. Immunocompromised patients have a particularly higher risk of severe disease and also CNS involvement during or following VZV presentations. We report a case of an 84-year-old man, with myelodysplastic syndrome, who presented with herpes zoster ophthalmicus complicated with left periocular cellulitis and an abnormal neurological exam. Intravenous treatment with acyclovir and amoxicillin/clavulanic acid was began. VZV DNA was detected in the cerebrospinal fluid (CSF) and brain magnetic resonance imaging revealed three acute ischemic lesions in the left frontal and both cerebellar lobes. A VZV CNS multifocal vasculopathy was diagnosed and treatment with intravenous acyclovir continued for 21 days.Immunocompromised patients with VZV infection can have a more severe course of disease with disseminated involvement and multifocal vasculopathy. In these patients the CSF detection of anti-VZV IgG as well as VZV DNA can be helpful in the diagnosis of CNS VZV vasculopathy. The antiviral treatment can improve the outcome and should be adjusted taking in consideration the degree of immunosuppression. This clinical case and review of the literature highlights the challenges in the diagnosis and management of VZV CNS vasculopathy in immunocompromised patients. Keywords: Varicella Zoster Virus, Vasculopathy, Stroke, Immunocompromised, Acyclovir
Late diagnosis of HIV is associated with increased morbidity and mortality. Infected individuals need to be identified early and started on antiretroviral therapy to increase their survival and to limit transmission to the community. Historically speaking, late diagnosis has been a common occurrence in the United States, despite the majority of those patients having had a medical encounter in the year prior to their diagnosis. These visits represent missed opportunities for HIV testing and therefore delays in initiation of appropriate antiretroviral therapy. Herpes zoster is a common infection that may indicate a weakened immune system, and as such should prompt consideration for HIV testing, even in patients who lack or deny classic risk factors such as “risky sexual behavior” or drug use. Here, we present a case of severe herpes zoster in a middle aged woman with no other HIV risk factors, who was tested and found to be HIV positive. Her CD4 count at diagnosis was <200 cells/mcL, consistent with AIDS. Keywords: HIV, Herpes zoster, Cutaneous infection, Antiretroviral, Screening, Diagnosis
Guillain-Barre Syndrome, an acute flaccid paralysis known to be caused by recent Gastro-intestinal infections mainly campylobacter, and Respiratory infections mainly mycoplasma pneumoniae and influenza. One reported case of severe invasive pneumococcal disease in a 68 year old female, that presented with Austrian’s triad of meningitis, pneumonia and endocarditis, and progressed to develop Guillain Barre syndrome, an association never been documented before. We present a case of 13 year old male, presented with hypoactivity and inability to bare his own weight, developed septic shock due to pneumococcus with Acute Respiratory Distress Syndrome, and was found to have neurological findings of Guillain-Barre Syndrome. A new association in pediatric age group, never been reported before.
Q fever is a worldwide zoonotic infection caused by the obligate intracellular bacterium Coxiella burnetii that can course with acute or chronic disease. This series describes 7 cases of acute Q fever admitted in a Portuguese University Hospital between 2014 and 2015. All cases presented with hepatitis and had epidemiological history. Diagnosis was done by PCR on majority (5) and by serology and PCR in only 2. Serological tests can be negative in the initial period of the disease. Molecular biology methods by polymerase chain-reaction are extremely important in acute disease, allowing timely diagnosis and treatment.
With the emergence of Human immunodeficiency virus (HIV) and the resulting immunocompromised state, Cryptococcus neoformans infections have gained more importance in clinical practice. Cryptococcal infections in immunocompetent hosts continue to be uncommon. We present a rare case of Cryptococcus neoformans infective endocarditis (IE) in a young immunocompetent male. As per our literature review, this is the first reported case of native valve Cryptococcus neoformans endocarditis in an immunocompetent host. All cases till date have been reported in patients with underlying immunocompromised state or prosthetic valve.
We present a case of massive lower gastrointestinal hemorrhage secondary to Salmonella enterica subtype Typhi (S. Typhi) colitis, in a 29 year-old female treated for S. Typhi bacteremia. One week post-treatment, she unexpectedly developed a large volume of rectal bleeding. Endoscopy showed colonic ulcers and ileitis, but no endoscopic hemostasis was required. Treatment was supportive with transfusions and a prolonged course of antimicrobials, with the bleeding stopping spontaneously. This case illustrates the phenomenon of delayed lower gastrointestinal hemorrhage, as a rare complication of S. Typhi infection.
Visceral leishmaniasis is an infection with an insidious and disabling course caused by parasites of the genus Leishmania. In Europe, it is mostly associated with HIV infection. Systemic lupus erythematosus and its treatment are associated with increased risk of infection, neoplastic and concomitant autoimmune disorders. The association of these diseases may go unnoticed. A 60 year-old Caucasian woman with lupus presented with a one-year history of fever, malaise, weakness and weight loss. The highlights on physical examination were pallor, palpable hepatosplenomegaly and low-grade fever. Blood tests showed pancytopenia, hyperproteinemia with hypoalbuminemia and hypergammaglobulinemia; electrophoresis showed a polyclonal gamma curve. Full-body CT scan revealed massive hepatosplenomegaly. Microbiology investigation was negative for the most common pathogens, including tuberculosis. There were no signs of hematologic malignancy in the bone marrow smear. PCR for Leishmania infantum was positive both in blood and bone marrow. The patient was treated with liposomal amphotericin B, and immunosuppression was adjusted. She showed rapid clinical improvement and 6 months later had no signs of disease. The differential diagnosis in a patient with lupus presenting with fever and multisystemic manifestations includes infectious or neoplastic disorders. The patient lived in an endemic area of Leishmania, and typical clinical and analytical changes were all present, making this case highly educational. The case highlights the importance of a patient's epidemiological background and how it can lead to the diagnosis and timely treatment of a rare disease.
Bezold’s abscess is a suppurative complication of mastoiditis rarely seen in the current era of antimicrobials. It can lead to seriously sequelae if not diagnosed and treated early. We describe a patient with recurrent bilateral otalgia who had received multiple courses of antimicrobials who presented with severe headache, neck pain and right sided hearing loss. Imaging studies showed chronic mastoiditis and formation of a Bezold’s abscess. Drainage was performed but symptoms persisted. Our report highlights the need for further evaluation of patients presenting with complicated mastoiditis and the need for prolonged antimicrobial therapy. Keywords: Bezold’s abscess, Suppurative mastoiditis, Skull base osteomyelitis
We report a case of bronchoesophageal fistula associated with tuberculosis. A 25 year old woman presented to us with 3 month history of cough worsening with deglutition. Radiological examination revealed mediastinal lymphadenopathy and bronchoscopy with esophagoscopy confirmed the presence of fistulous communication with features of endobronchial tuberculosis. Histological examination of bronchial biopsy specimen showed non necrotic granuloma with the PCR positive for Mycobacterium tuberculosis in her bronchial secretions. She was begun on antituberculous treatment and became asymptomatic after 2 months. Bronchoscopy done during follow up after 4 months showed normal bronchial lumen with disappearance of fistulous tract. Imaging showed resolution of lung lesions.
DOI : 10.1016/j.idcr.2017.02.008 Anahtar Kelimeler :
Bronchoesophageal fistula, Tuberculosis
ISSN: 2214-2509 Cilt: 8 Sayı: C Sayfa: 19 - 21
Scrub typhus, an acute rickettsial febrile illness, is an emerging cause of prolonged fever and Pyrexia of Unknown Origin(PUO). Scrub typhus infection can have myriads of clinical manifestations ranging from mild asymptomatic disease to fatal multi-organ failure. Massive splenomegaly in scrub typhus is rarely reported. We present a diagnostic conundrum of a 22 year old male presenting with fever, hepatomegaly, massive splenomegaly and lymphadenopathy. Tests for malarial parasite, visceral leishmaniasis, enteric fever were negative. Bone marrow aspiration showed normal hemopoeisis. IgM Scrub tested positive. High grade of clinical suspicion and awareness is required among treating physicians for early diagnosis of scrub since delay in treatment initiation may lead to a dismal clinical outcome. Keywords: Scrub typhus, Pyrexia of unknown origin, Massive splenomegaly in scrub typhus, Splenomegaly in scrub typhus, Scrub and hepatosplenomegaly
To date Bordetella petrii has infrequently been identified within the clinical setting likely due to the asaccharolytic nature of this organism. We present a case of B. petrii recovered on two separate events in a patient with adult cystic fibrosis experiencing chronic pansinusitis.
Streptococcus canis (Sc) is a zoonotic pathogen that is transferred mainly from companion animals to humans. One of the major virulence factors in Sc is the M-like protein encoded by the scm gene, which is involved in anti-phagocytic activities, as well as the recruitment of plasminogen to the bacterial surface in cooperation with enolase, and the consequent enhancement of bacterial transmigration and survival. This is the first reported human case of uncomplicated bacteremia following a dog bite, caused by Streptococcus canis harboring the scm gene. The similarity of the 16S rRNA from the infecting species to that of the Sc type strain, as well as the amplification of the species-specific cfg gene, encoding a co-hemolysin, was used to confirm the species identity. Furthermore, the isolate was confirmed as sequence type 9. The partial scm gene sequence harbored by the isolate was closely related to those of other two Sc strains. While this isolate did not possess the erm(A), erm(B), or mef(A), macrolide/lincosamide resistance genes, it was not susceptible to azithromycin: its susceptibility was intermediate. Even though human Sc bacteremia is rare, clinicians should be aware of this microorganism, as well as Pasteurella sp., Prevotella sp., and Capnocytophaga sp., when examining and treating patients with fever who maintain close contact with companion animals.
DOI : 10.1016/j.idcr.2017.01.002 Anahtar Kelimeler :
Streptococcus canis, scm gene, Sequence type 9, Human case, Bacteremia
ISSN: 2214-2509 Cilt: 7 Sayı: C Sayfa: 48 - 52
Titanium plane screw fixation of the frontal sinus is an approach used by otolaryngologists to obliterate this space in an attempt to reduce sinus infections. In this case, however, the titanium used became a nidus of infection which cultured the fungus Paecilomyces. The patient also had a hypersensitivity reaction to mold with positive skin tests and IgE, as well as eosinophilic esophagitis. Treatment entailed anti-fungals, anti-IgE, and fungal immunotherapy to multiple fungal antigens prevalent to the geographic region. The patient also had aspirin exacerbated respiratory disease which responded to aspirin desensitization. Her symptoms resolved after 3 months.
DOI : 10.1016/j.idcr.2017.04.002
ISSN: 2214-2509 Cilt: 8 Sayı: C Sayfa: 96 - 100
Chronic Q fever caused by Coxiella burnetii is uncommon in the United States and is most often associated with infective endocarditis. We present a 52-year-old woman with a history of aortic valve replacement and rheumatoid arthritis treated with Etanercept with chronic Q fever manifesting as prosthetic valve infective endocarditis. Explanted valve tissue showed organisms confirmed to be C. burnetii by PCR (polymerase chain reaction) sequencing. She subsequently reported consumption of unpasteurized cow milk which was the likely source of C. burnetii. She continues to do well 6 months after valve replacement on oral doxycycline and hydroxychloroquine.