Giant kidney worms in a patient with renal cell carcinoma.

Dioctophyma renale (D. renale), or giant kidney worms, are the largest nematodes that infect mammals. Approximately 20 cases of human infection have been reported. We present a case of a 71-year-old man with a recent history of unintentional weight loss and painless haematuria, passing elongated erythematous tissue via his urethra. CT revealed a left renal mass with pulmonary nodules and hepatic lesions. On microscopy, the erythematous tissue passed was identified as D. renale. On subsequent renal biopsy, pathology was consistent with renal cell carcinoma. This is the first reported case of concomitant D. renale infection and renal cell carcinoma, and the second reported case of D. renale infection of the left kidney alone.

Enteric pathogens in stool samples of Chicago-area water recreators with new-onset gastrointestinal symptoms.

BACKGROUND: Characterizing pathogens responsible for recreational waterborne gastrointestinal illness is important in estimating risk and developing management strategies to prevent infection. Although water recreation is associated with sporadic cases of gastrointestinal illness, pathogens responsible for such illness are not well characterized. METHODS: A prospective cohort study was conducted enrolling non-water recreators (such as cyclists and joggers) and two groups of limited-contact waters recreators (such as boaters and kayakers): those on an effluent-dominated urban waterway and those on general use waters. Stool samples were collected from participants who developed gastrointestinal symptoms during a three-week follow-up period. Samples were analyzed for bacterial, viral, and protozoan pathogens. Logistic regression models were used to identify associations between water recreation and the presence of pathogens in stool samples. RESULTS: Among 10,998 participants without gastrointestinal symptoms at baseline, 2,429 (22.1%) developed at least one symptom during 21 days of follow-up. Of those, 740 (30.5%) provided at least one stool sample, of which 76 (10.3%) were positive for a pathogen. Rotavirus, found primarily among adults, accounted for 53 of the 76 (70%) infections. Among participants with symptoms, pathogen presence was not associated with water recreation or the extent of water exposure. The range of pathogens that could be identified and sample size limitations may have contributed to this lack of association. CONCLUSIONS: We did not find specific pathogens or groups of pathogens associated with recreational waterborne gastrointestinal illness. Although pathogens responsible for outbreaks of waterborne gastrointestinal illness have been described, microbes that cause sporadic cases remain poorly defined.

Risk factors and outcomes associated with vancomycin-resistant Enterococcus infections with reduced susceptibilities to linezolid.

A retrospective matched case-control study of hospitalized patients with vancomycin-resistant Enterococcus (VRE) infection with reduced susceptibility to linezolid was performed in order to identify risk factors for this infection and describe patient outcomes. Forty-eight linezolid nonsusceptible VRE cases were identified between January 1, 2000, and September 30, 2008, and compared to 96 controls with linezolid-susceptible VRE, matched based on culture date and anatomic site of infection. Demographic, clinical and microbiological data were collected. On univariable analysis, risk factors for reduced linezolid susceptibility included allogeneic hematopoietic stem cell transplant and/or solid organ transplant (odds ratio [OR]: 2.63; 95% confidence interval [CI]: 1.13-6.15; P = 0.025), receipt of immunosuppressive medications (OR: 2.39; 95% CI: 1.08-5.29; P = 0.032) including corticosteroids (OR: 2.40; 95% CI: 1.03-5.58; P = 0.042) and noncorticosteroid immunosuppressives (OR: 2.31; 95% CI: 1.00-5.30; P = 0.049), and receipt of linezolid within 1 year prior to infection (OR: 34.50, 95% CI: 4.60-259.02; P < 0.001). On multivariable analysis, only receipt of linezolid within 1 year remained an independent risk factor for reduced linezolid susceptibility (OR: 31.84; 95% CI: 4.20-241.39; P < 0.001), although most patients with VRE with reduced linezolid susceptibility had not received linezolid in the year prior. Reduced linezolid susceptibility did not impact patient outcomes including clinical or microbiological cure, hospital length of stay, or all-cause mortality.

Timing of susceptibility-based antifungal drug administration in patients with Candida bloodstream infection: correlation with outcomes.

OBJECTIVES: We sought to determine the impact of timing of appropriate antifungal therapy, as assessed by susceptibility results, on patient survival. METHODS: Patients ≥16 years of age with first episodes of candidaemia during 2001-09 were included. Clinical data were collected retrospectively, including time to appropriate antifungal therapy and patient survival. RESULTS: The study population included 446 patients [243 (54%) female, mean age 53 years] with candidaemia, 380 (85%) of whom had antifungal susceptibility data. Candida albicans was the most common pathogen (221, 50%) followed by Candida glabrata (99, 22%), Candida parapsilosis (59, 13%), Candida tropicalis (48, 11%) and Candida krusei (6, 1%). Appropriate antifungal therapy consisted of fluconazole (177, 40%), an echinocandin (125, 28%), amphotericin B (41, 9%) and voriconazole (6, 1%); 97 (22%) failed to receive appropriate antifungal therapy. The 30 day mortality was 34% (151/446) and there was no clear relationship between time from positive culture to receipt of appropriate antifungal therapy and 30 day survival. On multivariable Cox regression, increased APACHE II score [hazard ratio (HR) 1.11, 95% CI 1.09-1.13, P<0.001], cirrhosis (HR 2.15, 95% CI 1.48-3.13, P<0.001) and HIV infection (HR 2.03, 95% CI 1.11-3.72, P=0.02) were independent predictors of mortality. A secondary analysis requiring patients in the early treatment group to have received ≥24 h of effective antifungal therapy did show a significant mortality benefit to receiving antifungal treatment within 72 h of a positive blood culture being drawn (30 day mortality for early treatment: 27% versus 40%, P=0.004; HR for mortality with delayed treatment on multivariable analysis: 1.41, 95% CI 1.01-1.98, P=0.045). CONCLUSIONS: Candida bloodstream infection is associated with high mortality, despite timely receipt of appropriate antifungal therapy.

Active surveillance for methicillin-resistant Staphylococcus aureus in the neonatal intensive care unit.

BACKGROUND: We describe our experience using a real-time polymerase chain reaction (PCR) assay for methicillin-resistant Staphylococcus aureus (MRSA) during a period of active surveillance in the neonatal intensive care unit (NICU) from March 2007 until November 2007. OBJECTIVE: To compare PCR with bacterial culture methods and find the screening algorithm that most successfully ensures appropriate isolation of colonized patients. METHODS: Patients in the NICU were screened for MRSA on admission and weekly thereafter until discharge. Healthcare workers (HCWs) were also screened as part of an outbreak investigation. A total of 599 individuals were screened for MRSA with both a PCR assay and selective bacterial culture. Strain typing was performed on all MRSA isolates to determine clonal relatedness. RESULTS: Twenty-one of 435 infants (4.8%) screened positive for MRSA with the PCR assay. Only 11 patients (52.4%) had concomitant bacterial cultures positive for MRSA. Compared to bacterial culture, the PCR assay had a sensitivity of 100% and a specificity of 97.6%, with a positive predictive value (PPV) of 52.4%. Infants that tested positive for MRSA by both culture and PCR were more likely to have a positive PCR assay result when retested than were those who tested positive by PCR alone (80% vs 20%; P = .02). Strain typing of MRSA isolates identified a common clone in only 2 colonized infants. CONCLUSION: Our data show that, in our neonatal population, the reproducibility of PCR assay results for culture-negative patients was low compared with the reproducibility of results for culture-positive patients. Furthermore, the low PPV suggests that for nearly half of individuals who were PCR-positive, the result was falsely positive, which argues against the use of PCR assays alone for MRSA screening in the NICU.

Rapid development of Acinetobacter baumannii resistance to tigecycline.

A 53-year-old woman experienced a multidrug-resistant (MDR) Acinetobacter baumannii urinary tract infection 5 months after undergoing kidney and liver transplantation. The tigecycline minimum inhibitory concentration (MIC) for her A. baumannii isolate was 1.5 microg/ml; the patient received 2 weeks of therapy with intravenous tigecycline as a 100-mg loading dose followed by 50 mg every 12 hours, with no lapses in treatment and with resolution of the infection. Three weeks later, MDR A. baumannii was isolated from her sputum in the setting of clinical evidence of pneumonia, and tigecycline was restarted; the tigecycline MIC for the A. baumannii isolate was 2 microg/ml. At approximately the same time, the patient was found to have a paraspinal abscess and spinal osteomyelitis. Cultures of the abscess fluid grew A. baumannii with a tigecycline MIC of 24 microg/ml. A follow-up sputum culture again yielded A. baumannii, but with a tigecycline MIC of 24 microg/ml. Urine culture at that time also grew A. baumannii with a tigecycline MIC of 24 microg/ml. Clinicians should be aware that tigecycline MICs for A. baumannii isolates may increase during therapy with tigecycline after only brief exposure to the drug. Patients receiving tigecycline for Acinetobacter should be monitored for the development of clinical resistance, and isolates should be monitored for evidence of microbiologic resistance.

Atypical favic invasion of the scalp by Microsporum canis: report of a case and review of reported cases caused by Microsporum species.

Favus is an uncommon pattern of dermatophytic infection of the scalp, glabrous skin and nails. We report the first documented case of favus of the scalp caused by Microsporum canis in an immunocompetent 8-year-old girl. The classic and various atypical clinical presentations of favus are discussed, as well as a brief review of the literature given.

Gemella haemolysans infectious crystalline keratopathy.

PURPOSE: To report a case of infectious crystalline keratopathy caused by Gemella haemolysans. METHODS: Observational case report. A 65-year-old woman underwent penetrating keratoplasty for contact lens-related Acanthamoeba keratitis and developed a nonhealing epithelial defect. Despite continued prophylaxis with topical gatifloxacin, small superficial stromal opacities were noted and cultured 6 months after penetrating keratoplasty. The opacities coalesced into a fine, crystalline keratopathy in the superficial stroma with persistent overlying epithelial defect. RESULTS: Culture results from corneal scraping showed more than 100 colonies of G. haemolysans. Topical vancomycin was instituted, with complete resolution of the crystalline keratopathy and epithelial defect over the next 2 months. CONCLUSIONS: G. haemolysans can be a causative organism of infectious crystalline keratopathy. This infection can arise in a postkeratoplasty patient despite prophylaxis with a fourth-generation fluoroquinolone.

Women find it easy and prefer to collect their own vaginal swabs to diagnose Chlamydia trachomatis or Neisseria gonorrhoeae infections.

BACKGROUND: Self-collected specimens can be used to screen asymptomatic women for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC). We surveyed women's opinions on ease and preferences as to sampling after collecting their own vaginal swab and urine and a physician collection of vaginal swab and cervical swab. METHODS: In 7 North American cities, a questionnaire was used for women after they participated in a clinical trial of nucleic acid amplification testing of various specimens. A total of 1,090 women consenting to gynecologic sampling for CT and GC (82% of those sampled) volunteered to complete the survey. We analyzed the data for ease of self-collection and preferences for a vaginal swab, urine, or cervical swab. RESULTS: The average age was 26.6 years; 59.6% were black, 25.5% white, 11% Hispanic, 1.9% Asian, and 2% unknown. Thirty-five percent had more than one sex partner in the past 6 months, 84.9% had been previously tested for a sexually transmitted infection (STI), and 49.2% had experienced an STI. A total of 90.4% found it very easy to self-collect a vaginal swab. This was not influenced by age, education, or study site. Seventy-six percent preferred a vaginal swab over a pelvic examination, 60% over a urine collection, and 94% indicated that they would be tested more often if a vaginal swab was available. CONCLUSION: Self-collected vaginal swabs were easy to collect and patients preferred them over urine and cervical swabs.

Secondary intracerebral blastomycosis with giant yeast forms.

Secondary central nervous system (CNS) blastomycosis is an unusual manifestation of blastomycosis. We report a case of recurrent intracerebral blastomycosis that presented histopathologically with giant yeast-like cells and multinucleation that mimicked Coccidioides immitis. The yeast forms of Blastomyces dermatitidis usually range in size from 8 to 20 microm in diameter. Large or giant yeast forms (20-40 microm) are rare. The four cases previously reported in the literature involving giant yeast cell forms of B. dermatitidis are reviewed here. Intracerebral blastomycosis should be suspected in patients with signs and symptoms of CNS lesions and histories of primary blastomycosis, or treatment with corticosteroids, or comprised immune systems. The diagnosis should be confirmed by culture which presents typical biphasic microbiologic features.

Arcanobacterium haemolyticum sinusitis and orbital cellulitis.

We present a case of sinusitis and orbital cellulitis in a 9-year-old girl caused by the Gram-positive bacillus Arcanobacterium haemolyticum. In addition to antimicrobial chemotherapy, two surgical procedures were required to drain the ethmoid and maxillary sinus cavities and a subperiosteal abscess.

Chronic vulvovaginitis caused by antibiotic-resistant Shigella flexneri in a prepubertal child.

A 7-year 8-month-old girl was diagnosed with a prolonged course of vulvovaginitis caused by Shigella flexneri. The child was symptomatic with intermittent vaginal bleeding, dysuria and foul smelling vaginal discharge for a 3-year period. Initial attempts to resolve the infection with successive courses of antibiotic therapy using ampicillin, trimethoprim-sulfamethoxazole, cefixime and amoxicillin/clavulanic acid failed. The child's infection was finally resolved by a 14-day course of ciprofloxacin.