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.

Asymptomatic Giant Intraventricular Cysticercosis: A Case Report.

Neurocysticercosis is a growing health problem in the United States and worldwide. Diagnosis and treatment is challenging especially if the physician is not familiar with this condition. The World Health Organization (WHO) estimates that neurocysticercosis affects 50 million people worldwide, especially in developing countries and causes approximately 50,000 deaths annually.1 Neurocysticercosis is of emerging importance in the United States especially in Hawai'i because of immigration from disease-endemic regions.2 We present a case of a young Chinese immigrant male who presented with impressive imaging studies of a giant intraventricular neurocysticercosis. This case emphasizes the importance of recognizing neurocysticercosis, especially in the immigrant population.

Bordetella trematum sepsis with shock in a diabetic patient with rapidly developing soft tissue infection.

Bordetella is a gram-negative, glucose non-fermenting bacillus, consisting of many host-associated species. B. trematum has previously been identified in wound infections, but rarely known to be a source of bacteremia. Currently, 16S rRNA sequencing represents the reference standard method by which identification is made. Herein, we present a case of fatal B. trematum bacteremia with septic shock. The presumed primary site of the infection was a rapidly developing left leg deep soft tissue infection without necrotizing fasciitis. B. trematum should now be considered as a significant pathogen in sepsis.

Five cases of recurrent meningitis associated with chronic strongyloidiasis.

Although meningitis secondary to chronic strongyloidiasis is a rare complication, it is associated with a high mortality rate. Recurrent meningitis can occur if the underlying parasitic infection is left untreated. We report five cases of recurrent meningitis related to chronic strongyloidiasis that were associated with human T-lymphotropic virus type 1 (HTLV-1) infection. Common causative organisms are Escherichia coli, Streptococcus bovis, and Klebsiella pneumonia. One patient died during the second episode of meningitis. Three patients showed significant gastrointestinal and respiratory symptoms before developing headache and fever. In four cases, patients developed multiple recurrences even with the treatment of thiabendazol. Ivermectin seems to be a better agent compared with thiabendazol to achieve eradication of strongyloidiasis.

Streptococcus suis meningoencephalitis with seizure from raw pork ingestion: a case report.

BACKGROUND: Streptococcus suis meningoencephalitis is a rare but increasingly important condition. Good history taking will give clues to the diagnosis. This is the fourth case report in the United States. CASE: A 52-year-old Filipino man who recently returned from a trip to the Philippines was admitted with classic symptoms of bacterial meningitis. His cerebrospinal fluid culture grew Streptococcus suis. His clinical course was complicated by seizures, hearing loss, and permanent tinnitus. CONCLUSION: Clinicians should be aware of this emerging disease especially in patients with recent travel history to endemic areas. Early recognition and appropriate management could potentially prevent complications.

Mycobacterium avium complex empyema in a patient with interferon gamma autoantibodies.

Interferon gamma (IFN-γ) autoantibodies are a relatively recently discovered clinical entity, which have been shown to be associated with disseminated non-tuberculous mycobacterial (NTM) infections and other opportunistic infections. Interestingly, isolated NTM infections (without disseminated NTM infection) have not been shown to be a good predictor of the presence of IFN-γ autoantibodies. This case describes an isolated NTM empyema in a patient with IFN-γ autoantibodies and makes the argument that the development of an NTM empyema in a patient with no known immunodeficiency should prompt consideration for IFN-γ testing. Additionally, this case underscores the importance for clinicians to recognize that an unusual infection without the typical cause of impairment in immunity should prompt a more thorough investigation of the patient's immune system.

Group B streptococcal (GBS) bacteremia with mycotic thoracic aortic aneurysm and suppurative pericardial effusion.

Mycotic aortic aneurysm associated with suppurative pericardial effusion is a rare and serious clinical phenomenon that is linked with significant morbidity and mortality. We report a case of a 78-year-old man who presented with purulent pericardial effusion with tamponade physiology in association with a progressively enlarging, transverse aortic arch, mycotic aneurysm due to group B streptococci. To our knowledge, this is only the second reported case of this nature. Despite advances in the current era of antibiotics and surgical techniques, early diagnosis and aggressive treatment remain sentinel to successful management of the cardiovascular complications of group B streptococcus bacteremia.

Pancreatic anastomosis leak 15 years after simultaneous pancreas-kidney transplantation from late-onset allograft cytomegalovirus duodenal ulcers presenting with gross hematuria.

Cytomegalovirus (CMV) infection is one of the most important causes of morbidity and mortality in solid organ transplantation. It can present with hematuria, the most common urological complication in the early post-simultaneous pancreas-kidney (SPK) transplant period. In SPK transplantation, CMV infection usually occurs 1 month after transplantation. We report an instance of bladder-drained SPK transplant presenting with recurrent gross hematuria from CMV infected duodenal graft ulcers 15 years after preserved well-functioning grafts. Serum quantitative Polymerase Chain Reaction (qPCR) for CMV was negative. Postmortem duodenal graft staining for CMV was positive, and revealed the cause of the inciting ulcer. To our knowledge, our patient is the first reported case of very late onset invasive CMV disease causing duodenal graft ulcers 15 years after transplantation, as previously reported cases of posttransplant CMV disease occurred only as late as 18 months. In addition, the absence of correlation between CMV viremia and CMV-infected duodenal allograft in SPK transplant has not been reported. Our case demonstrates that CMV viral load is -unreliable to diagnose invasive CMV disease, and tissue biopsy should be obtained to avoid missed diagnosis causing high morbidity and mortality.

Euthermic endocarditis.

BACKGROUND: Most patients with infective endocarditis (IE) manifest fever. Comparison of endocarditis patients with and without fever, and whether the lack of fever in IE is a marker for poorer outcomes, such as demonstrated in other severe infectious diseases, have not been defined. METHODS AND RESULTS: Cases from the Mayo Clinic, Rochester, Minnesota, Division of Infectious Diseases IE registry, a single-center database that contains all cases of IE treated at our center. Diagnosis date between 1970 and 2006, which met the modified Duke criteria for definite endocarditis, without fever was included. There were 240 euthermic endocarditis cases included in this analysis, with 282 febrile controls selected by frequency matching on gender and decade of diagnosis. Euthermic patients had a median age of 63.6 years (± 16.1) as compared to 59.0 years (± 16.4) in the febrile control group (p=0.001). Median (IQR) symptom duration prior to diagnosis was 4.0 (1.0, 12.0) weeks in the euthermic group compared to 3.0 (1.0, 8.0) weeks in the febrile controls (p= 0.006). From unadjusted analyses, survival rates were 87% in euthermic cases versus 83% in febrile controls across 28-day follow-up (p=0.164), and 72% in euthermic group cases versus 69% in febrile controls across 1-year follow-up (p=0.345). Also unadjusted, the 1-year cumulative incidence rate of valve surgery was higher in euthermic cases versus febrile controls (50% vs. 39%, p= 0.004). CONCLUSIONS: Patients with euthermic endocarditis are older, and lack of fever was associated with longer symptom duration and delayed diagnosis prior to IE diagnosis. Despite a higher unadjusted rate of valve surgery in euthermic patients, the result was not significant when adjusting for baseline confounders. Differences in survival rates at both 28-days and 365-days were not statistically significant between the two groups.

Emergence of community-acquired extended-spectrum beta-lactamase Escherichia coli (ESBLEC) in Honolulu: a case series of three individuals with community-acquired ESBLEC bacteriuria.

Community-acquired extended-spectrum beta-lactamase E coli (ESBLEC) have not been previously described in Honolulu. Its emergence as a community-acquired pathogen is concerning. This case series describes three patients who were diagnosed with community-acquired ESBLEC bacteriuria in 2010.

Fungal prosthetic valve endocarditis: Mayo Clinic experience with a clinicopathological analysis.

Fungal prosthetic valve endocarditis is a rare but devastating disease. To better characterise this syndrome, we retrospectively reviewed 21 cases of fungal prosthetic valve endocarditis seen at Mayo Clinic over the past 40 years. The average patient age was 65 years with a 2 : 1 male predominance. Twelve of 21 cases (57%) occurred within 1 year of prosthetic valve placement. The aortic valve was most commonly affected, and the most common aetiological agent was Candida species, followed by Histoplasma capsulatum. Although 20 of 21 patients (95%) were immunocompetent, they had other risk factors for fungal infection. Patients typically presented with systemic signs and symptoms of infection, and cardiac imaging was abnormal in 68% of cases. Pathological evaluation of valve material was of high yield, with organisms identified in 92% of cases who underwent valve replacement surgery or had an autopsy performed. Prosthetic valve fungal endocarditis was associated with a high morbidity and mortality, with 67% of patients experiencing complications and 57% of patients dying of infection-related disease. Hopefully, with the prompt institution of early medical therapy, surgical intervention and lifelong oral antifungal suppressive therapy, cure rates will continue to improve.

Distribution of eosinophilic meningitis cases attributable to Angiostrongylus cantonensis, Hawaii.

During November 2004-January 2005, 5 cases of eosinophilic meningitis (EM) attributable to Angiostrongylus cantonensis infection were reported in Hawaii. To determine if this temporal clustering reflected an increased incidence, we ascertained EM and A. cantonensis cases by systematic review of statewide laboratory and medical records for January 2001-February 2005 and generalized the data to population estimates. We identified 83 EM cases; 24 (29%) were attributed to A. cantonensis infection, which was included in the discharge diagnoses for only 2 cases. Comparison of A. cantonensis infection incidence rates (per 100,000 person-years) for the baseline (January 2001-October 2004) and cluster (November 2004-February 2005) periods showed statistically significant increases for the state as a whole (0.3 vs. 2.1), the Big Island of Hawaii (1.1 vs. 7.4), and Maui County (0.4 vs. 4.3). These findings underscore the need to consider the diagnosis of A. cantonensis infection, especially in the state of Hawaii.

Leptospirosis misdiagnosed as pulmonary-renal syndrome.

A case of leptospirosis complicated by diffuse alveolar hemorrhage, acute renal failure, and apparent hemoglobinuria was initially diagnosed and managed as a pulmonary-renal syndrome. However, renal biopsy findings were normal. Leptospirosis may manifest with severe lung injury characterized by diffuse alveolar hemorrhage, acute respiratory distress syndrome, and acute renal failure and be accompanied by high mortality rates. Leptospirosis should be considered in patients with features of pulmonary-renal syndrome, particularly in regions known to be endemic for leptospirosis. A history of potential exposure to Leptospira is an important diagnostic clue, and empiric antimicrobial therapy should be considered.