A Rare Case of Melioidosis in the Bronx.

Melioidosis is caused by a gram-negative bacillus Burkholderia pseudomallei (B. pseudomallei), which is found in water and soil in endemic areas. There are indicators that B. pseudomallei is increasing in endemic regions and expanding into new locations. It is unclear whether this is because of expanded boundaries or improved detection capabilities. It is even theorized to be endemic in certain parts of the USA. The most common medical risk factor is diabetes mellitus, and it frequently presents as acute pneumonia, and often progresses to bacteremia. It is designated as a tier 1 select biological agent and toxin by the CDC. In this case report, we present a 67-year-old male with multiple comorbidities, who contracted melioidosis while visiting Honduras, as well as the laboratory's response to the occupational exposure.

Acute Immune Reconstitution Inflammatory Syndrome-HBV Flare in an HIV/HBV Coinfected Patient After Antiretroviral Therapy Initiation: Case Report and Literature Review.

BACKGROUND Immune reconstitution inflammatory syndrome (IRIS) is a well-recognized complication after antiretroviral therapy (ART) initiation among patients with HIV. Acute HBV flares after starting antiretroviral therapy have been reported in 20% to 25% of coinfected patients, among whom only 1% to 5% develop clinical hepatitis. Liver biopsy and serological evaluation help in diagnosis. CASE REPORT A 24-year-old man with history of HIV diagnosed in 2018 developed severe IRIS-related HBV flare after initiation of ART. He was taking ART since 2018 until his immigration to the United States in 2021. He came to establish care and was started on bictegravir/emtricitabine/tenofovir alafenamide (BIC/F/TAF). Three weeks later, he presented to the Emergency Department with polyarthralgia and loose stools; transaminases showed an increasing trend on follow-up. He was admitted for closer monitoring. Workup was remarkable for reactive HBsAg, HBeAg, and HBcIgM antibodies, with HBV viral load of 295 304 copies/mL. Abdominal imaging was unremarkable. ART was switched to rilpivirine/emtricitabine/tenofovir alafenamide (RPV/FTC/TAF), considering the hypothetical risk of hepatotoxicity from BIC/F/TAF. Despite therapy, transaminases were up-trending. He underwent computerized tomography-guided liver biopsy, showing moderate to severe acute hepatitis, compatible with IRIS. He received steroids, and ART was continued. Transaminases resolved, HBV load reduced significantly, HIV load became undetectable at 9 weeks, and he developed HBeAb (seroconversion) at 4 months after initiating ART. CONCLUSIONS Our case highlights the importance of early recognition and management of IRIS-HBV flares after initiation of ART among coinfected patients. Liver biopsy is indicated for definitive diagnosis. ART directed against both viruses should be continued.

New-Onset Cervical Lymphadenopathy in a Patient Undergoing Treatment of Pulmonary Mycobacterium avium Complex Infection: Toxoplasmosis Lymphadenitis.

Immunocompetent hosts with toxoplasmosis are usually asymptomatic. However, T. gondii can present as an acute systemic infection. Symptomatic patients usually have a benign, self-limited course that typically lasts from a few weeks to months. Herein, we present a 66-year-old immunocompetent female who developed dysphagia and new-onset cervical lymphadenopathy during pulmonary Mycobacterium avium complex treatment.

Effective Dosage of Oral Vancomycin in Treatment for Initial Episode of Clostridioides difficile Infection: A Systematic Review and Meta-Analysis.

Background: Oral vancomycin is a first line treatment for an initial episode of Clostridioides difficile infection. However, the comparative efficacy of different dosing regimens is lacking evidence in the current literature. Methods: We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov. from inception to May 2019. Only articles published in English are reviewed. This meta-analysis compares the effects of low dose oral vancomycin (<2 g per day) versus high dose vancomycin (2 g per day) for treatment of initial Clostridioides difficile infection. Results: One randomized controlled trial and two retrospective cohort studies are included. A total of 137 patients are identified, 53 of which were treated with low dose oral vancomycin (39%) and 84 with high dose oral vancomycin (61%). There is no significant reduction in recurrence rates with high dose vancomycin compared to low dose vancomycin for treating initial episodes of non-fulminant Clostridioides difficile infection ((odds ratio (OR) 2.058, 95%, confidence interval (CI): 0.653 to 6.489). Conclusions: Based on limited data in the literature, low dose vancomycin is no different than high dose vancomycin for treatment of an initial episode of Clostridioides difficile infection in terms of recurrence rate. Additional large clinical trials comparing the different dosages of vancomycin in initial Clostridioides difficile infection are warranted.

A nasal hypertrophic lesion as a presentation of herpes simplex virus.

Herpes simplex virus type 1 and type 2 (HSV-1 & HSV-2) are one of the leading causes of ulcer and blister lesions worldwide. These infections are latent with recurrences but many people may have a seropositive antibody yet remain asymptomatic. Although HSV presenting with hypertrophic lesions have been reported in the literature at urogenital, lung, and conjunctival sites, we describe a case of a mass lesion in the nasal cavity of a 46 year-old female with a history of human immunodeficiency virus (HIV). The patient presented initially with nasal congestion and subsequently developed facial edema. The mass lesion regressed after one month of treatment with valacyclovir.

A case report of purulent pericarditis caused by Candida albicans: Delayed complication forty-years after esophageal surgery.

RATIONALE: Candida pericarditis is a rare condition with high mortality. Risk factors include thoracic surgery and immunosuppression. We report a case of candida pericarditis which developed forty-years after esophageal reconstruction surgery. PATIENT CONCERNS: A 42-year-old female presented with nausea, abdominal discomfort, and chest pain, and was found to have a cardiac tamponade secondary to candida pericarditis. Her notable risk factor was colonic interposition done during her infancy for esophageal atresia. DIAGNOSES: The patient underwent emergent pericardial window where 500cc of purulent fluid was drained. The pericardial fluid culture grew Candida albicans. INTERVENTIONS: Esophagram did not show any visible leak and the patient improved with surgical drainage and antifungal treatment with Caspofungin. Caspofungin was continued intravenously for a total of four weeks and was switched to fluconazole. OUTCOMES: An Echocardiogram performed one month after pericardial window revealed trivial pericardial effusion. Serum beta-D-glucan at the time was negative. LESSONS: This report highlights that candida pericarditis infection could occur as a late complication of colonic interposition. We also demonstrate the utility of using an echinocandin in treating this entity.

Cigarette Smoking Behaviors and Beliefs in Persons Living With Hepatitis C.

BACKGROUND AND RATIONALE: Tobacco use is common among persons living with hepatitis C (PLHC), yet little is known about their smoking behaviors and beliefs. Modern hepatitis C treatment offers a unique opportunity to intensively engage this population about other health risks, including smoking. MAIN RESULTS: Seventy-seven tobacco users (40 hepatitis C virus [HCV] seropositive and 37 HCV seronegative) enrolled in an interview study in a New York City clinic. The mean age was 51.6, 57.1% were male, 40.3% Latino, and 49.4% black. 67.5% were single and 18.2% were employed. HCV+ smokers differed from HCV- smokers in having a higher prevalence of illicit substance use, depression, and hypertension. PLHC smokers were highly motivated to quit, with 52.5% stating an intention to quit within 30 days. Most of the PLHC smokers had used cessation-directed pharmacotherapy, but almost none had tried a quitline or a quit smoking website. PLHC smokers scored higher on the intrapersonal locus of control subscale. Almost a quarter (22.5%) believed that smoking "helped fight the HCV." CONCLUSIONS: PLHC smokers have a high burden of psychiatric and substance use comorbidity. They exhibit characteristics that distinguish them from uninfected smokers, and many harbor false beliefs about imagined benefits of smoking. They are highly motivated to quit but underutilize cessation aids. Without aggressive intervention, smoking-related morbidity will likely mute the health benefits and longevity gains associated with hepatitis C treatment. Research such as this may prove useful in guiding the development of future tobacco treatment strategies. IMPLICATIONS: This is the first paper to examine, in detail, sociobehavioral correlates of tobacco use in PLHC. PLHC are recognized by the Department of Health and Human Services as a high-priority health disparities population. We are not aware of any tobacco treatment services designed specifically for PLHC. The first step in designing an intervention is defining the characteristics of the target group. Our findings will begin to address this need, and may prove useful in optimizing tobacco treatment strategies for smokers living with hepatitis C.

Metabolic Syndrome After HIV Acquisition in South African Women.

BACKGROUND: Noncommunicable diseases are common among chronically infected patients with HIV in the developed world, but little is known about these conditions in African cohorts. We assessed the epidemiology of metabolic syndrome among young South African women during the first 3 years after HIV acquisition. METHODS: A total of 160 women were followed prospectively in the CAPRISA 002 Acute Infection study. Metabolic syndrome was defined as a constellation of hyperlipidemia, hypertension, hyperglycemia/diabetes, and abdominal obesity. Time trends were assessed using generalized estimation equation models. RESULTS: Median age was 24 years and body mass index 27 kg/m. Prevalence of metabolic syndrome at infection was 8.7% increasing to 19.2% over 36 months (P = 0.001). The proportion of women with body mass index >30 kg/m increased from 34.4% to 47.7% (P = 0.004), those with abnormal waist circumference and elevated blood pressure increased from 33.5% to 44.3% (P = 0.060) and 23.8% to 43.9% (P < 0.001), respectively. Incidence of metabolic syndrome was 9.13/100 person-years (95% CI: 6.02 to 13.28). Predictors of metabolic syndrome were age (per year increase odds ratio (OR) = 1.12; 95% CI: 1.07 to 1.16), time postinfection (per year OR = 1.47; 95% CI: 1.12 to 1.92), family history of diabetes (OR = 3.13; 95% CI: 1.71 to 5.72), and the human leukocyte antigen (HLA)-B*81:01 allele (OR = 2.95; 95% CI: 1.21 to 7.17), whereas any HLA-B*57 or B*58:01 alleles were protective (OR = 0.34; 95% CI: 0.15 to 0.77). HIV-1 RNA (OR = 0.89; 95% CI: 0.62 to 1.27) and CD4 count (OR = 1.03; 95% CI: 0.95 to 1.11) did not predict metabolic syndrome. CONCLUSIONS: The high burden of metabolic conditions in young South African HIV-infected women highlights the need to integrate noncommunicable disease and HIV care programs. Interventions to prevent cardiovascular disease must start at HIV diagnosis, rather than later during the disease course.

Challenges of diagnosing acute HIV-1 subtype C infection in African women: performance of a clinical algorithm and the need for point-of-care nucleic-acid based testing.

BACKGROUND: Prompt diagnosis of acute HIV infection (AHI) benefits the individual and provides opportunities for public health intervention. The aim of this study was to describe most common signs and symptoms of AHI, correlate these with early disease progression and develop a clinical algorithm to identify acute HIV cases in resource limited setting. METHODS: 245 South African women at high-risk of HIV-1 were assessed for AHI and received monthly HIV-1 antibody and RNA testing. Signs and symptoms at first HIV-positive visit were compared to HIV-negative visits. Logistic regression identified clinical predictors of AHI. A model-based score was assigned to each predictor to create a risk score for every woman. RESULTS: Twenty-eight women seroconverted after a total of 390 person-years of follow-up with an HIV incidence of 7.2/100 person-years (95%CI 4.5-9.8). Fifty-seven percent reported ≥1 sign or symptom at the AHI visit. Factors predictive of AHI included age <25 years (OR = 3.2; 1.4-7.1), rash (OR = 6.1; 2.4-15.4), sore throat (OR = 2.7; 1.0-7.6), weight loss (OR = 4.4; 1.5-13.4), genital ulcers (OR = 8.0; 1.6-39.5) and vaginal discharge (OR = 5.4; 1.6-18.4). A risk score of 2 correctly predicted AHI in 50.0% of cases. The number of signs and symptoms correlated with higher HIV-1 RNA at diagnosis (r = 0.63; p<0.001). CONCLUSIONS: Accurate recognition of signs and symptoms of AHI is critical for early diagnosis of HIV infection. Our algorithm may assist in risk-stratifying individuals for AHI, especially in resource-limited settings where there is no routine testing for AHI. Independent validation of the algorithm on another cohort is needed to assess its utility further. Point-of-care antigen or viral load technology is required, however, to detect asymptomatic, antibody negative cases enabling early interventions and prevention of transmission.