Anaplasmosis-induced hemophagocytic lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening inflammatory syndrome of severe immune system activation. It is a diagnostic challenge with high morbidity and mortality. We present a case of HLH due to anaplasmosis infection. A 54-year-old man with chronic obstructive pulmonary disease presented with fever, nausea, vomiting, dyspnea, and arthralgias for 6 days. He had a rapidly progressive clinical decline requiring intubation for acute respiratory failure and dialysis for acute renal failure. He tested positive for anaplasmosis. His workup met criteria for HLH. He was treated with doxycycline and a steroid taper with clinical improvement allowing for extubation and renal recovery. Patients with persistent fevers, hepatosplenomegaly, cytopenias, and hyperferritinemia should be worked up for HLH.

An Outbreak of Severe Group A Streptococcus Infections Associated with Podiatric Application of a Biologic Dermal Substitute.

OBJECTIVE: To describe an outbreak of severe Group A Streptococcus (GAS) infections that appeared to be associated with use of a biologic dermal substitute on foot wounds DESIGN: Retrospective cohort study of cases and similar uninfected patients SETTING/PATIENTS: Patients attending the podiatry clinic at a Veterans Affairs Medical Center between July 2011 and November 2011 INTERVENTIONS: Microbiology laboratory data were reviewed for the calendar year, a case definition was established and use of the biologic dermal substitute was discontinued. Staff were cultured to identify potentially colonized employees. A case-cohort study was designed to investigate risk factors for disease. Emm typing and pulsed field gel electrophoresis (PFGE) were performed to identify strain similarity. RESULTS: In 10 months, 14 cases were identified, and 4 of these patients died. All strains were emm type 28 and were identical according to PFGE. Discontinuation of biologic dermal substitute use halted the outbreak. A prior stroke was more common in the case cohort vs uninfected patient cohorts. The number of patients attending the clinic on 13 probable transmission days was significantly higher than on nontransmission days. We identified 2 patients who were present in the clinic on all but 1 probable transmission day. Surveillance cultures of podiatry clinic staff and cultures of the same lot of retained graft material were negative. CONCLUSIONS: A carrier was not identified, and we believe the outbreak was associated with inter-patient transmission likely due to lapses in infection control techniques. No additional cases have been identified in >3 years following the resumption of dermal substitute use in May 2012.

Non-typeable Haemophilus influenzae infective endocarditis in a renal transplant recipient: compromised host or virulent strain?

Non-typeable Haemophilus influenzae (NTHI) rarely cause endocarditis. Of the limited reports of H influenzae endocarditis, most have been due to encapsulated organisms or have had limited bacterial characterisation. We encountered a transplant recipient with native valve NTHI endocarditis and were intrigued to find no previous descriptions of this entity. Although it was tempting to ascribe this infection to our patient's immunocompromised status, we investigated his pathogen further and found that it displayed features common to invasive NTHI strains including gene expression for two IgA proteases and serum resistance. Multilocus sequence typing grouped our NTHI strain with MLST 159, a group associated with invasive NTHI infections. Our strain shared identical outer membrane protein P2 sequences and protein patterns with MLST 159 strains. Aside from providing the first characterisation of native valve NTHI infection, our investigation reveals features of epidemiologically unrelated, clonal NTHI strains that have a predilection for invasive infections.