Surprising pathological and clinical manifestations of miliary tuberculosis.

We report a surprising pathological finding of miliary tuberculosis (TB) in a 49-year-old Chuukese, immunocompetent woman who was initially admitted to the hospital for a 1-month duration of chronic abdominal pain and intermittent fevers. Her clinical symptoms did not improve despite treatment with vancomycin and piperacillin-tazobactam. Based on the primary abdominal CT findings suggesting advanced ovarian cancer with omental metastatic disease, further workup with omental core biopsy was performed and demonstrated acute neutrophilic necrosis without malignant cells or granulomata. Within the omental tissue, however, many organisms stained positive for acid-fast bacilli despite lack of typical granulomata. The diagnosis of genitourinary TB was confirmed by urine Mycobacterium tuberculosis/rifampin automated molecular rapid nucleic acid amplification test. The chest CT showed a millet seed pattern of infiltration which is a hallmark for miliary TB. After initiation of multidrug TB therapy, her fever and abdominal pain drastically improved.

A 23-year-old Man with Leptospirosis and Acute Abdominal Pain.

Leptospirosis is a zoonosis caused by the spirochete Leptospira interrogans. Most cases of leptospirosis are mild to moderate, and self-limited. The course of disease, however, may be complicated by multiorgan dysfunction such as in Weil's disease. We present a case of Weil's disease with pancreatitis in a young Caucasian man residing in Hawai'i. Although leptospirosis is common in Hawai'i, few patients present with pancreatitis. This report of leptospirosis-induced pancreatitis should help raise awareness of clinicians to assess for pancreatitis when evaluating a patient with leptospirosis and acute abdominal pain.

Native bivalvular endocarditis by Gemella haemolysans requiring venovenous extracorporeal membrane oxygenation.

A 24-year-old otherwise healthy man presented with a 3-week history of malaise, headache, fever and rigors after he was treated with oral clindamycin for left parotitis and Gemella haemolysans bacteraemia. He developed G. haemolysans infective endocarditis, septic emboli and heart failure due to progressive bivalvular disease. He underwent urgent mechanical aortic valve replacement and mitral valve repair, which required venovenous extracorporeal membrane oxygenation, to support severe respiratory failure. This is the first documented case of G. haemolysans infective endocarditis affecting native aortic and mitral valves in a healthy adult.

Thrombotic thrombocytopenic purpura as an initial presentation of systemic lupus erythematosus with acquired ADAMTS 13 antibody.

We report a female patient presenting with headache, fatigue, ecchymoses and recent, excessive vaginal bleeding. Prompt review of the peripheral blood smear showed evidence of microangiopathic haemolytic anaemia (MAHA) and thrombocytopenia. Thrombotic thrombocytopenic purpura (TTP) was suspected. Plasma exchange and corticosteroids were started urgently. The patient responded favourably to the treatment. Subsequently, positive serological markers returned and were compatible with systemic lupus erythematosus (SLE). A disintegrin and metalloproteinase with thrombospondin type 1 motifs, member 13 (ADAMTS 13) activity was remarkably low with a positive inhibitory ADAMTS 13 antibody. Mycophenolate and hydroxychloroquine were started along with a prolonged course and taper of corticosteroids. These medications have been maintained with an excellent response in 14 months of follow-up.

Septic cavernous sinus thrombosis due to Campylobacter rectus infection.

We report a case of cavernous sinus thrombosis in a 55-year-old Chinese man who presented with headache, ophthalmoplegia and ptosis. Campylobacter rectus was eventually isolated from the blood cultures. He was treated with broad-spectrum antibiotics, anticoagulation and steroids with improvement in his condition. To our knowledge, this is the first documented case of septic cavernous sinus thrombosis caused by C. rectus.

Hypercalcaemia: atypical presentation of miliary tuberculosis.

We report an unusual case of miliary tuberculosis in a 77-year-old Filipino man with hypertension, diabetes mellitus, nephrolithiasis status-post left nephrectomy, presenting with 1 month of fever, generalised weakness and weight loss. Laboratory data were significant for anaemia, hypercalcaemia and acute kidney injury. Chest radiograph showed ground glass opacities and interstitial infiltrates. Extensive workup was performed to evaluate fever and hypercalcaemia. Malignancy, hormonal and septic workup were all unremarkable. Tuberculin skin test was negative. Sputum, pleural fluid, bronchoalveolar lavage and cerebrospinal fluid were acid-fast bacilli (AFB) smear negative. Remarkably, urine AFB smear was positive. Caseating granulomas were seen on transbronchial biopsy. Antituberculosis therapy was initiated which lead to defervescence and initial clinical improvement. However, hospital course became complicated by small bowel obstruction and respiratory failure. He subsequently developed pulseless electrical activity and expired. An autopsy confirmed the presence of tuberculosis in multiple organs including his remaining kidney.