Nocardia cyriacigeorgica threatening an immunocompetent host; a rare case of paramediastinal abscess.

We describe a rare case of anterior paramediastnial abscess due to Nocardia cyriacigeorgica in an immunocompetent patient without pre-existing lung disease. High suspicious should be taken in those patients that failed to improve after first course of antibiotic therapy. Similarly, when suspected, isolation is crucial because of the variation in antibiotic susceptibilities among Nocardia spp. in order to provide adequate therapy to reduce associated comorbidities and mortality rate.

New strain multidrug resistant tuberculosis G24767 in Puerto Rico: Old disease a continuous threat.

Multidrug resistant tuberculosis (MDR-TB) is defined as a Mycobacterium tuberculosis strain resistant to two or more first-line anti-tuberculous drugs. Tuberculosis (TB) is a global threat to society despite improvement in therapy as it continues to be an economic burden especially in underdeveloped countries. The downfall of global economics and growing travel destinations in developing countries has escalade the exposure of organism not previously encountered in industrialized nations. Most cases of MDR-TB are reported on immunosuppressed patients with risk factors and from endemic areas. Nevertheless new strains with higher transmission degree are emerging as a threat in patients who have low risk factors for the development of MDR-TB.

Uncommon cause of dysphagia, shortness of breath and hoarseness: Large subclavian artery pseudoaneurysm.

The subclavian artery pseudoaneurysm is a rare entity with only few cases re- ported in the literature. Most injuries were related to iatrogenic manipulation with catheters for canalization of central lines in the hospital setting. In rare cases, this injury has been described secondary to a blunt trauma and motor vehicle accidents with traumatic injury to the subclavian artery caused by seatbelt use. We report an unusual case presentation of subclavian artery pseudoaneurysm.

Pasteurella multocida: a nightmare for a replaced joint and the challenge to save it.

Pasteurella multocida a small gram-negative coccobacilli is primarily found as normal flora of cats and dogs. These organisms can cause a variety of infections in humans, usually the result of scratches, bites and licks by percutaneous inoculation of the organism. Most cases of septic arthritis involve a cat or dog bite distal to the involved joint without direct penetrating injury to the joint. On scenarios were Pasteurella infection is suspected within a prosthetic joint, aggressive surgical debridement and/or removal of the prosthesis with intravenous antibiotics is recommended. Prosthetic joint infections secondary to animal bites are an extremely rare complication and few cases have been reported in the literature. This is a case report of a patient that suffered a cat's bite of his right prosthetic knee and against all odd was able to save it without surgical intervention.

Just a flare---the Pandora's box approach.

Systemic lupus erythematosus is a chronic inflammatory autoimmune disease characterized by autoantibodies specific for highly conserved nuclear antigens, such as double-stranded DNA, histones and ribonuclear proteins. The course of the disease is unpredictable and nine times more common in females. Among the neurological manifestations of collagen vascular diseases is the most commonly recognized and better studied disease. Central nervous system lupus is a serious and potentially treatable illness presenting as difficult diagnostic challenge. This is a case report of a patient that suffered central nervous system manifestations of severe active lupus. Early recognition of this entity is essential to expedite appropriate to treatment and avoid future complications.

An unusual presentation of herpes simplex in an immunocompromised patient.

Herpes simplex virus (HSV) is a host-adapted human pathogen. HSV-I usually infects non-genital sites at a variety of locations. HSV-2 primarily involves genitalia. Both types can cause genital and orofacial infections, which are clinically indistinguishable. Initial HSV infection is usually asymptomatic or mild and self-limited, but instead of disappearing from the body during convalescence, the virus establishes a latent infection that persists for life. Rarely, there is severe visceral dissemination. This is a case report of an unusual presentation of herpes simplex in an immunocompromised adult patient with generalized skin lesions on the entire body. To our knowledge, this is the first case reported in the literature of a disseminated herpes simplex in a patient with history of non-Hodgkin Lymphoma. Generalized HSV infection in immunodeficient adult patients could be fatal in spite of antiviral therapy. Early recognition of this entity is essential to expedite appropriate treatment and avoid future complications.

Right lower quadrant abdominal pain in an immunocompromised patient: importance for an urgent diagnosis and treatment.

This is a case of a 34 years old male Hispanic patient with history of AIDS who presented to the ER with severe right lower quadrant abdominal pain of three days of evolution, associated with fever, chills, nausea, vomiting, watery diarrhea, weakness and general malaise. Acute appendicitis, Clostridium Difficile Colitis and Ischemic Colitis were the most important clinical conditions to consider in the differential diagnosis. Abdominal CT with IV contrast demonstrated thickening of the ascending colonic wall a finding highly suggestive of a transmural inflammatory necrotizing colitis of infectious etiology. Broad-spectrum antibiotic therapy, cancidas and ganciclovir were started with mark clinical improvement. IgG antibodies against CMV were elevated. Typhlitis is a serious illness that affects patients with impairment in immunity. It is important to include it in the differential diagnosis of an HIV/AIDS patient that presents with RLQ pain and fever. Contrast enhanced CT-Scan is mandatory to establish the diagnosis and to differentiate typhlitis from other intra-abdominal pathologies. Therapy needs to be individualized.

Mycotic aneurysm: a rare complication of vertebral osteomyelitis.

We report the case of a 49-year-old man that presented with persistent low back pain after being treated for vertebral osteomyelitis. An abdominopelvic CT scan with intravenous contrast showed a mycotic aneurysm of the abdominal aorta. The patient was taken to the operating room where a bypass reconstruction surgery was successfully performed. The history, pathophysiology, most common organisms, risk factors, and clinical presentation of mycotic aneurysms are discussed. The importance of a high index of suspicion for prompt and proper diagnosis and treatment, is emphasized to create awareness about this dreadful complication of vertebral osteomyelitis.

A comparison of the antimicrobial resistance patterns of gram-negative bacilli isolated from community-private and university-affiliated hospitals from Puerto Rico.

Few studies have been performed in Puerto Rico concerning the antimicrobial resistance pattern of clinically significant Gram-negative bacilli. The antimicrobial resistance patterns of 5,590 Gram-negative bacteria obtained from three Community-Private Hospitals (CPH) and three University-Affiliated Hospitals (UAH) were evaluated utilizing the institutions' antimicrobial susceptibility reports for the year 2000. The objectives of this study were: to retrospectively evaluate the reported in vitro resistance of clinical isolates of E. coli, K. pneumoniae, E. cloacae, S. marcescens, P. aeruginosa and A. baumannii to selected standard antibiotics and to compare the antimicrobial resistance patterns between Community-Private (CPH) and University Affiliated hospitals (UAH). E. coli was the most common Gram-negative enteric bacilli in both CPH and UAH. In UAH, E. coli demonstrated a statistically significant higher resistance to the selected beta lactams and amikacin antibiotics but not to ciprofloxacin or gentamicin. For K. pneumoniae, the antimicrobial resistant pattern showed that UAH isolates were significantly more resistant to the tested antibiotics with the exception of ceftriaxone. In CPH, E. cloacae isolates were significantly more resistant to piperacillin-tazobactam, ciprofloxacin and gentamicin, while in UAH this organism was more resistant to amikacin. In UAH, S. marcescens isolates demonstrated a statistically significant higher resistance to all tested antibiotics with the exception of imipenem, which was similar in both hospitals group. Pseudomonas aeruginosa demonstrated a statistically significant higher resistance in UAH to all selected antibiotics with the exception of ciprofloxacin and gentamicin, which was similar in both hospitals group. Acinetobacter baumannii was the most resistant organisms in both hospitals group. UAH isolates were significantly more resistant than CPH isolates for all tested antibiotics. When compare with other large-scale antimicrobial resistance studies, the present study results suggest an apparent higher resistance in the Puerto Rican isolates. The high numbers of antimicrobial resistant Gram-negative bacilli in our study strongly suggest multiple mechanisms of antimicrobial resistance including the presence of extended spectrum and chromosomally derepressed beta-lactamases.

A comparison of the antimicrobial resistance patterns of gram-positive cocci isolated from community-private and university-affiliated hospitals from Puerto Rico.

The antimicrobial resistance patterns of 2,462 selected Gram-positive cocci obtained from three Community-Private Hospitals (CPH) and three University-Affiliated Hospitals (UAH) were evaluated utilizing the institutions' antimicrobial susceptibility reports for the year 2000. The objectives of this study were: 1) to evaluate the in vitro resistance to selected standard antibiotics of Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium and Streptococcus pneumoniae clinical isolates, and 2) to compare the antimicrobial resistance patterns between community-private (CPH) and university-affiliated hospitals (UAH). Staphylococcus aureus was the most common Gram-positive isolated organism in CPH (63.3%) followed by E. faecalis (31.0%). In UAH, the most prevalent cocci were E. faecalis (51.7%) followed by S. aureus (43.9%). Enterococcus faecium represented 2.3% and 4.4% of CPH and UAH isolates, respectively. Streptococcus pneumoniae represented 3.4% of the total Gram-positive isolates from CPH, no S. pneumoniae was reported in UAH. The antimicrobial susceptibility results showed that for Staphylococcus aureus there was a statistically significant higher resistance to methicillin and thrimethoprim sulfamethoxazole in UAH, while resistance to erythromycin was significantly higher in CPH. There was no difference in the resistance of S. aureus to other antimicrobial agents between hospitals groups. A statistically significant resistant to vancomycin was found between enterococcal isolates from UAH (43%) and CPH (12.7%). High-level aminoglycoside resistance (HLAR) was observed among UAH enterococcal isolates with E. faecium showing a higher resistance than E. faecalis, no data for HLAR in CPH could be obtained. For pneumococci 46% of CPH isolates were resistant to penicillin. In summary, there are important differences in the prevalence and antimicrobial resistance between the Gram-positive bacteria isolated from community and teaching hospitals.

Cytomegalovirus as nosocomial infection

Nosocomial infections with cytomegalovirus are on area of great concern and controversy within the medical community. With the advent of organ transplantation there rave been an increased number of susceptible individuals. In the past most cases were confined to newborn nurseries and the neonatal intensive care unit. It is of great interested that recent evidence suggests that health care providers are at no greater risk of acquiring CMV infection inside the hospital setting when compared to a representative control group within the same community. This paper will review some of the literature that deals with the nosocomial transmission of CMV. We will try to emphasize transmission, diagnosis, prevention, and treatment of CMV infection

Unusual presentation of pseudomonas aeruginosa infections: a review

Pseudomonas aeruginosa es un bacilo gram negativo, oportunista que causa serias infecciones nosocomiales. Sin embargo, este puede causar infecciones con presentaciones poco usuales adquiridas fuera del ambiente hospitalariao. En este trabajo se discutirá la patogénesis, presentaciones clínicas, y el tratamiento de éstas infecciones poco comunes, como por ejemplo: 1) Foliculitis: infección bacteriana superficial o profunda que se asocia a el uso de saunas y piscinas contaminadas. 2) Otitis externa invasiva: infección que puede progresar hasta la base del cerebro y está asociada mayormente con pacientes diabéticos de avanzada edad. Usualmente esta condición es secundaria a irrigación aural con agua contaminada. 3) Osteomielitis: infección que usualmente se asocia con heridas punzantes con clavos en especial si se tienen puesto zapatos deportivos. 4) Infección entre los dedos de los pies: infección mayormente asociada a individuos utilizando agentes antimicrobianos tópicos. 5) "Green nail syndrome": lesión en la paranoquia no dolorosa que aparece mas comunnente en personas cuyas manos estan en constante exposición al agua, jabones, detergentes o a traumas mecánicos. 6) Keratitis-úlcera en al cornea: mayormente asociada a usuarios de lentes de contacto suave, gotas para los ojos, mascara o piscinas contaminadas. Esta condición podría terminar en una panoftalmitis. 7) Endocarditis: condición mayormente asociada a adictos a drogas intravenosas