Delayed Diagnosis of Mycobacteriumbovisbacillus Calmette-Guérin Periprosthetic Joint Infection Following Total Knee Arthroplasty.

Periprosthetic joint infection (PJI) can present challenges in diagnosis and treatment, particularly in the setting of atypical causative organisms such as fungi and mycobacteria. Herein, we present a case and provide a review of the diagnosis and treatment of an unusual PJI caused by bacillus Calmette-Guérin, administered during the treatment of bladder cancer 3 years prior to total knee arthroplasty and subsequent PJI. Although the patient's history of bladder cancer was known, neither his Bacillus Calmette-Guérin treatment nor its potential for distant site spread that could lead to PJI were appreciated, leading to a prolonged diagnostic evaluation and treatment course.

Global Epidemiology and Burden of Elderly-Onset Inflammatory Bowel Disease: A Decade in Review.

Inflammatory bowel disease (IBD), once thought to impact younger individuals, now manifests in approximately 10% of patients over 65, characterized by a heightened vulnerability to complications and greater diagnostic intricacies than conventional cases. However, comprehensive global epidemiological data regarding elderly-onset IBD are currently insufficient. Our study addresses this critical gap by analyzing trends in elderly-onset IBD over a decade, encompassing the estimation of annual frequencies and age-standardized rates of elderly-onset IBD burden for both genders, stratifying the data by geographical and sociodemographic factors. Our research highlights a notable increase in the proportion of elderly-onset IBD, constituting around 13% of all IBD cases. We observed a rising incidence in males, contrasted by a decreasing trend in females. The highest surge in incidence rates was seen in the Western Pacific region in both genders, but the highest burden was observed in America. Countries with high sociodemographic index (SDI) carried the greatest burden of elderly-onset IBD, while countries with low SDI had the least. The mortality and disability-adjusted life years (DALYs) rates trend downward in most regions. This study underscores an increasing incidence and proportion of IBD, particularly in elderly-onset IBD, particularly in males. While mortality and DALYs are decreasing in most regions, the overall burden remains highest in America and high-SDI countries. Effective public health interventions and comprehensive studies are required to tackle this mounting burden.

Incidence Rate and Risk Factors Associated with Travelers' Diarrhea in International Travelers Departing from Utah, USA.

Despite knowledge on the causes and prevention strategies for travelers' diarrhea (TD), it continues to be one of the most common illnesses experienced by U.S. international travelers. However, studies of risk factors associated with TD among U.S. travelers are limited. In this study, we aimed to determine the incidence rate of TD, the proportion of travelers who experience TD, and to identify risk factors associated with TD. In this cross-sectional study, we collected and analyzed data from anonymous posttravel questionnaires submitted by international travelers recruited during their pretravel visit at two travel clinics in Salt Lake City, Utah, from October 2016 to March 2020. Of 571 travelers who completed posttravel surveys, 484 (85%) answered the TD question, of which 111 (23%) reported TD, for an incidence rate of 1.1 episodes per 100 travel-days (95% confidence interval [CI]: 0.9-1.4). In a multivariable model, visiting Southeast Asian (odds ratio [OR]: 2.60; 95% CI: 1.45-4.72) and African (OR: 2.06; 95% CI: 1.09-3.93]) WHO regions, having 10 or more individuals in the group (OR: 3.91; 95% CI: 1.50-11.32]), longer trip duration (OR: 1.01; 95% CI: 1.00-1.02), visiting both urban and rural destinations (OR: 1.94; 95% CI: 1.01-3.90), and taking medications/supplements to prevent TD (OR: 2.74; 95% CI: 1.69-4.47) were statistically significantly associated with increased odds of reporting TD. TD continues to be common in international travelers from the United States. Our findings provide insights regarding travelers' behaviors regarding TD in international travelers from high-income countries and shows the need for additional research into prevention strategies for travelers' diarrhea.

Bacillus cereus meningoencephalitis in an immunocompetent patient.

Central nervous system (CNS) infection from Bacillus cereus (B. cereus) is rare and usually occurs in immunosuppressed patients or in a presence of invasive CNS devices. Our case reported here is a very rare case of an immunocompetent elderly patient without any CNS devices who was diagnosed with B. cereus meningoencephalitis and bacteremia. According to our patient, preceding gastrointestinal (GI) symptoms and trans-sphenoidal hypophysectomy could be the precipitating factors. A positive blood culture should not be concluded as a contamination but prompt repeating another set of blood culture for a better clinical judgment. Given its abrupt clinical course and high mortality rate, high index of suspicion for rapid detection and management is needed for a preferable clinical outcome. Empiric treatment with intravenous vancomycin is reasonable before a susceptibility result becomes available.

Travel-Related Behaviors and Health Outcomes of Adolescents Compared with Adults on Short-Term International Service Missions.

With an increasing number of adolescents participating in international travel, little is known about travel-related behaviors and health risks in this age group. In the years 2015-2016, we conducted an anonymous, posttravel, questionnaire-based survey with the aim to compare self-reported practices and travel-related symptoms between adolescents (< 18 years old, N = 87) and adults (≥ 18 years old, N = 149) who came to our travel clinic before their humanitarian missions. They had the same pretravel health education, and traveled together to perform similar activities. In univariate analysis, compared with adults, we found that adolescents reported less prior international travel (P < 0.001), more often wore long-sleeved clothing for malaria prevention (P < 0.001) but less often for sun protection (P = 0.009), more often used insect repellents (P = 0.011), and less often had diarrhea (P = 0.024). All other practices and health outcomes were similar between the groups. Multivariate analyses using Bayesian network show strong associations between adults and prior travel experience, and not wearing long-sleeve clothing for malaria prevention. We also found strong associations between prior international travel and sustaining an injury, and having jet lag, as well as between taking malaria prophylaxis and not having diarrhea. Overall, most practices and health outcomes were similar between age groups. Adolescent age and lack of prior international travel experience did not have significant impacts on practices and health outcomes. Our findings highlight the need for more effective strategies to improve the behaviors and health outcomes in both adolescents and adults.

The effect of an electronic medical record intervention on hydroxychloroquine prescribing habits and surveyed providers' opinions of the 2016 American Academy of Ophthalmology guidelines in the rheumatology and dermatology practices of an academic institutionle.

BACKGROUND: Retinal toxicity is a rare adverse event related to the use of hydroxychloroquine (HCQ). To address this, in 2016, the American Academy of Ophthalmology (AAO) issued guidelines recommending that HCQ not exceed 5 mg/kg/day. We analyzed HCQ prescribing habits at our institution, compared to these guidelines, and used surveys to determine the opinions on these guidelines. We then introduced, in a prospective and non-controlled study, a clinical decision support (CDS) tool into the electronic medical record (EMR) to study how this intervention might affect adherence with or opinions on these guidelines. METHODS: Data were collected pre-intervention (June 2017-January 2019) and post-intervention (March 2019-April 2020). In January 2019 we released our CDS tool. Results were analyzed using descriptive statistics for demographic data and Fisher's exact tests for comparisons of proportions between groups. RESULTS: Pre-intervention, we reviewed 1128 rheumatology charts and 282 dermatology charts. 31.0 and 39.7% respectively (32.8% combined) were prescribed HCQ > 5 .0 mg/kg/day. Post-intervention, we reviewed 1161 rheumatology charts and 110 dermatology charts. 23.0 and 25.5% respectively (23.2% combined) were prescribed HCQ > 5.0 mg/kg/day. Post-intervention, 9.6% fewer patients were prescribed HCQ > 5 mg/kg/day (P < .001). Pre-intervention, we compiled 18 rheumatology surveys and 12 dermatology surveys. Post-intervention, we compiled 16 rheumatology surveys and 12 dermatology surveys. Post-intervention, fewer rheumatologists incorrectly described the AAO weight-based guidelines. Combined, there was an overall reduction but not of statistical significance (P = .47). The majority of providers surveyed believed that the CDS tool was useful (72.2%). CONCLUSIONS: At our academic institution, there remains unfamiliarity with and hesitation to comply with the 2016 AAO guidelines. Prescribed doses often exceed what is recommended in these guidelines. A CDS tool can improve adherence with these guidelines and might improve providers' familiarity with these guidelines.

Clinical Experience With a Coordinated Multidisciplinary Approach to Treating Prosthetic Joint Infection.

The successful treatment of prosthetic joint infection (PJI) is difficult, requiring coordination across multiple specialties. In 2017, we formed a collaboration between our infectious disease clinicians and our orthopaedic arthroplasty surgeons in an effort to optimize care, accommodate patients, and expedite clinical decision-making in the treatment of PJI. The model consisted of combined infectious disease and arthroplasty clinics, standardized lab results, and planned staged revision procedures. We named this the arthroplasty infection service. Our early experience with a defined multidisciplinary approach to PJI was positive. Although the impact of the arthroplasty infection service on PJI outcomes is yet to be determined, we believe this is a step forward in the management of this complex patient population. With an increasing burden of PJI in the United States, this model could be emulated at many institutions that regularly treat these challenging cases.

Alpha-defensin-novel synovial fluid biomarker for the diagnosis of periprosthetic joint infection.

PURPOSE: Periprosthetic joint infection (PJI) continues to be a significant complication after total joint arthroplasty. Diagnosis of PJI can be challenging and elusive in the absence of a gold standard. This purpose of this article is to review the current evidence on the utility of serum and synovial fluid biomarkers to help aid in the diagnosis of PJI with focusing on synovial fluid alpha-defensin. METHODS: Articles and data for this review were identified by searches of PubMed and Ovid MEDLINE up to June 1, 2016. In addition, we manually reviewed the bibliographies of the retrieved articles for additional citations for references from relevant articles on the diagnosis of PJI. RESULTS: Serum biomarkers can be elevated in various inflammatory conditions. Synovial fluid biomarkers are more accurate for the diagnosis of PJI compared to serum biomarkers. Based on current available data, alpha-defensin is the most promising synovial fluid biomarker for the diagnosis of PJI and is commercially available. CONCLUSIONS: Synovial fluid alpha-defensin could enhance our ability to identify PJI and incorporate into the diagnostic algorithm in the future. Large-scale studies are needed to provide more data for its significance for the diagnosis of PJI.

The utility of image-guided percutaneous needle aspiration biopsy for the diagnosis of spontaneous vertebral osteomyelitis: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Spontaneous vertebral osteomyelitis (SVOM) is mostly acquired via hematogenous seeding. Diagnosis of SVOM is often delayed because of the insidious nature and rarity of this disease. The microbiological yield of image-guided needle biopsy varies between 36% and 91%. The utility and accuracy of this procedure have not been systematically reviewed. PURPOSE: To systematically review and assess the diagnostic accuracy of image-guided spinal biopsy for SVOM in adults when compared with combined reference standards. STUDY DESIGN: A systematic review and meta-analysis. SAMPLE: Seven retrospective studies involving 482 patients with clinical and/or radiologic suspicion of SVOM who underwent image-guided spinal biopsy were included. OUTCOME MEASURES: The primary outcome measure was diagnostic odds ratio (DOR). Other outcomes included likelihood ratio of a positive test (LRP), likelihood ratio of a negative test (LRN), sensitivity, and specificity. METHODS: We searched in six medical databases through September 1, 2013 for studies evaluating the performance of image-guided spinal biopsy for SVOM with no limits on language or publication date. Combined reference standards, which included histopathologic findings consistent with vertebral osteomyelitis, identifications of pathogens from open surgery and/or blood cultures, and/or evidence of clinical and radiologic improvement after empiric antimicrobial therapy, were used for comparison. The random-effect model was used for meta-analysis. Two reviewers independently selected the studies. RESULTS: Three hundred fifty-eight potentially relevant studies were identified. Seven studies were included in our analysis. Two studies that used only single reference standard were excluded in the sensitivity analysis, and five studies involving 352 patients were pooled. Image-guided spinal biopsy had a DOR of 45.50 (95% confidence interval [CI], 13.66-151.56), an LRP of 16.76 (95% CI, 5.51-50.95), an LRN of 0.39 (95% CI, 0.24-0.64), a sensitivity of 52.2% (95% CI, 45.8-58.5), and a specificity of 99.9% (95% CI, 94.5-100). This is based on the assumption that combined reference standards are a valid standard for comparison. CONCLUSIONS: Image-guided spinal biopsy is highly specific and performs well in predicting SVOM, but has a moderate accuracy for ruling out this diagnosis. This procedure should be considered in the diagnostic work-up of adults suspected with SVOM.

Acute renal failure associated with albendazole therapy in a patient with trichinosis.

A 72-year-old Caucasian woman presented with a 3-week history of confusion, cramping abdominal pain, nausea, vomiting, diarrhoea, fatigue and dehydration. By history, she reported consumption of raw pork and bacon that was salted and cured in brine, but not boiled or cooked. Laboratory testing was significant for an absolute eosinophil count of 3.09×10(9)/L. She was found to have a positive Trichinella serology by ELISA testing. Based on history of raw pork consumption, symptoms, peripheral eosinophilia and positive serology, a diagnosis of trichinosis was made. Treatment was started with oral albendazole. Following initiation of therapy, the patient developed acute kidney injury presumably secondary to albendazole. Therapy was discontinued. Her serum creatinine returned to baseline over the following days. The decision was made to proceed with observation alone, as she did not tolerate treatment. At the 3-week follow-up, her gastrointestinal symptoms had improved and her eosinophilia had resolved.

Other HIV-associated pneumonias.

The incidence, mortality, and epidemiology of human immunodeficiency virus (HIV)-associated pulmonary infections have changed as a result of effective antiretroviral and prophylaxis antimicrobial therapy. The clinical presentation, radiographic abnormalities, and treatment of pneumonia from various uncommon pathogens in patients with AIDS can be different from those in immunocompetent patients. Advances in invasive and noninvasive testing and molecular biological techniques have improved the diagnosis and prognosis of pulmonary infections in patients infected with HIV. This review focuses on pulmonary infections from nontuberculosis mycobacteria, cytomegalovirus, fungi (aspergillosis, cryptococcosis, endemic fungi), and parasites (toxoplasmosis), and uncommon bacterial pneumonia (nocardiosis, rhodococcosis) in these patients.

Characterization of the Pneumocystis carinii histone acetyltransferase chaperone proteins PcAsf1 and PcVps75.

Rtt109 is a lysine acetyltransferase that acetylates histone H3 at lysine 56 (H3K56) in fungi. This acetylation event is important for proper DNA replication and repair to occur. Efficient Rtt109 acetyltransferase activity also requires a histone chaperone, vacuolar protein sorting 75 (Vps75), as well as the major chaperone of the H3-H4 dimer, anti-silencing factor 1 (Asf1). Little is known about the role of these proteins in the opportunistic fungal pathogen Pneumocystis carinii. To investigate the functions of Asf1 and Vps75 in Pneumocystis carinii, we cloned and characterized both of these genes. Here, we demonstrate that both genes, P. carinii asf1 (Pcasf1) and Pcvps75, function in a fashion analogous to their Saccharomyces cerevisiae counterparts. We demonstrate that both P. carinii Asf1 (PcAsf1) and PcVps75 can bind histones. Furthermore, when Pcasf1 is expressed heterologously in S. cerevisiae asf1Δ cells, PcAsf1 can restore full H3 lysine acetylation. We further demonstrated that the Pcasf1 cDNA expressed in asf1Δ S. cerevisiae cells can restore growth to wild-type levels in the presence of genotoxic agents that block DNA replication. Lastly, we observed that purified PcAsf1 and PcVps75 proteins enhance the ability of PcRtt109 to acetylate histone H3-H4 tetramers. Together, our results indicate that the functions of the Rtt109-Asf1-Vps75 complex in the acetylation of histone H3 lysine 56 and in DNA damage response are present in P. carinii DNA and cell cycle progression.

Multiple Pyogenic Liver Abscesses Caused by Eggerthella lenta Treated with Ertapenem: A Case Report.

Anaerobic gram-positive bacilli can occasionally be implicated in infections but are difficult to identify in culture by conventional biochemical methods. We report a case of liver abscesses caused by Eggerthella lenta, identified via 16S rRNA sequencing in a previously healthy patient, successfully treated with percutaneous drainage and ertapenem.