Disseminated nocardia cyriacigeorgica presenting as right lung abscess and skin nodule.

Nocardia species are ubiquitous in the environment and can be found worldwide. Direct inhalation remains the most commonly attributed route of infection with Nocardia asteroides complex, causing 50% of invasive infections. Improved molecular methods have identified a significant proportion of N. asteroides complex isolates to be Nocardia cyriacigeorgica. We report a case of a 58-year-old male working as a contractor in Bagram Air Force Base, Afghanistan, with disseminated N. cyriacigeorgica involving the lung, brain, and dermis. Diagnosis was facilitated by early identification of branched, filamentous bacteria using Fite and gram staining along secA DNA sequencing of clinical isolates. Our patient is the first confirmed case of N. cyriacigeorgica infection in Afghanistan.

Infectious disease teleconsultative support of deployed healthcare providers.

Specialty teleconsultation is being provided to deployed healthcare providers in the current wars in Iraq and Afghanistan through the use of the Army Knowledge Online (AKO) e-mail service. We reviewed 374 teleconsults received by the infectious disease (ID) service between January 2005 and June 2008. The patients were 65% male, 12% female, 33% the gender was not stated or the consult did not involve an individual, and 41% were U.S. Army. The average response time was under 5 hours. Ninety-one percent of consults originated from the U.S. Central Command area of responsibility. Consults included questions pertaining to therapy (42%), diagnosis (21%), prevention (13%), or mixed categories (24%). Bacterial infections were the most common (32%), followed by parasitic infections (16%). Tuberculosis and methicillin-resistant Staphylococcus aureus accounted for 13% and 8% of consults, respectively. Data from this program should be useful in focusing predeployment provider training. It also provides the military ID community situational awareness of problems encountered in theater.

Pulmonary blastomycosis diagnosed in Hawai'i.

Blastomycosis, a fungal infection caused by Blastomyces dermatitidis, was once thought to be endemic only to the Central and Great Lakes regions of the United States of America. We present the first reported case series of patients documenting the diagnosis of blastomycosis in the Pacific region. In both cases, exposure to endemic areas was retrospectively identified.

Increasing age at HIV seroconversion from 18 to 40 years is associated with favorable virologic and immunologic responses to HAART.

BACKGROUND: Studies evaluating the effect of age on response to highly active antiretroviral therapy (HAART) have been limited by their inability to control for duration of human immunodeficiency virus (HIV) infection. We examined the effect of age at HIV seroconversion on response to HAART. METHODS: A retrospective analysis of a longitudinal US military cohort of HIV-infected subjects. Time to and maintenance of viral suppression, rate of CD4 cell increase, and rate of progression to acquired immunodeficiency syndrome or death were compared across age groups using time-to-event methods. RESULTS: Five hundred sixty-three HIV-infected adults who seroconverted after January 1, 1996, and started HAART were included. Increasing age at seroconversion was significantly associated with faster time to viral suppression (P = 0.002). Increasing age also correlated with duration of suppression, with a 35% reduction in risk of viral rebound for every 5-year increase in age above 18 years (hazard ratio: 0.65, 95% confidence interval 0.55 to 0.75). The rate of CD4 cell increase from 6 to 84 months post-HAART was significantly greater in those who seroconverted at older ages (P = 0.0002). Rates of progression to acquired immunodeficiency syndrome or death did not differ between groups. CONCLUSIONS: Increasing age at seroconversion was associated with shorter time to and longer maintenance of viral suppression and a faster increase in CD4 cell count.

Antimicrobial susceptibilities of geographically diverse clinical human isolates of Leptospira.

Although antimicrobial therapy of leptospirosis has been studied in a few randomized controlled clinical studies, those studies were limited to specific regions of the world and few have characterized infecting strains. A broth microdilution technique for the assessment of antibiotic susceptibility has been developed at Brooke Army Medical Center. In the present study, we assessed the susceptibilities of 13 Leptospira isolates (including recent clinical isolates) from Egypt, Thailand, Nicaragua, and Hawaii to 13 antimicrobial agents. Ampicillin, cefepime, azithromycin, and clarithromycin were found to have MICs below the lower limit of detection (0.016 microg/ml). Cefotaxime, ceftriaxone, imipenem-cilastatin, penicillin G, moxifloxacin, ciprofloxacin, and levofloxacin had MIC(90)s between 0.030 and 0.125 microg/ml. Doxycycline and tetracycline had the highest MIC(90)s: 2 and 4 microg/ml, respectively. Doxycycline and tetracycline were noted to have slightly higher MICs against isolates from Egypt than against strains from Thailand or Hawaii; otherwise, the susceptibility patterns were similar. There appears to be possible variability in susceptibility to some antimicrobial agents among strains, suggesting that more extensive testing to look for geographic variability should be pursued.

A case of Enterococcus faecalis prosthetic joint infection: a rare and difficult infection to treat.

Enterococcus faecalis septic arthritis in native and prosthetic joints is a very rare infection. A case of an African American man with Enterococcus faecalis prosthetic joint infection is presented as well as a brief review of the literature.

Fatal pulmonary Mycobacterium abscessus infection in a patient using etanercept.

A case of fatal pulmonary Mycobacterium abscessus infection in a 56-year-old man is reported. The patient had a longstanding history of seropositive, nodular rheumatoid arthritis with severe joint manifestations that had been treated with a regimen of prednisone, leflunomide, and etanercept. He presented to our facility with complaint of productive cough, persistent fevers, pleuritic chest discomfort, and dyspnea at rest. The patient was admitted to hospital, placed in isolation, a left-sided chest tube was inserted (left pneumothorax identified), and sputum acid-fast bacteria stains and cultures were obtained. Fluorochrome stains demonstrated numerous acid-fast bacteria, and M. abscessus was recovered from the culture media. He was treated with a regimen of amikacin, cefoxitin, and clarithromycin. He initially responded well, and was discharged home with this regimen. He remained afebrile with decreased cough and sputum production until 15 days after discharge when he was again admitted to hospital, with acute onset dyspnea and right-sided chest discomfort (right pneumothorax identified). He ultimately expired, due to overwhelming pulmonary infection, 20 days after readmission to hospital. Autopsy revealed acid fast bacilli in the setting of numerous, bilateral, necrotic, granulomatous, cavitary pulmonary lesions. Based on its mechanism of action, we propose an association between the use of etanercept, a tumor necrosis factor alpha (TNF-alpha) inhibitor, and this case of fatal pulmonary mycobacterial infection. We recommend that physicians exercise cautious clinical judgment when initiating etanercept therapy in persons with underlying lung disease, especially in communities in which mycobacterial organisms are highly prevalent. We also advise physicians to maintain a high level of vigilance for late onset granulomatous infection in persons using etanercept.

Two cases of Klebsiella pneumoniae primary liver abscesses; an emerging clinical entity among diabetics.

Klebsiella pneumoniae liver abscesses with limited antibiotic resistance have been increasing among diabetics in various geographic regions, most notably in Taiwan. Two cases of Hawaiian diabetic men with Klebsiella pneumoniae primary liver abscesses are presented as well as a brief review of the literature.

Hemophagocytic lymphohistiocytosis: a rare cause of pancytopenia.

A 36-year-old man with fever and pancytopenia due to Hemophagocytic Lymphohistiocytosis is reported. The patient was started on the HLH-94 based treatment. Two weeks after the initiation of therapy the patient's pancytopenia had resolved and he was discharged to complete treatment as an outpatient. The initial clinical presentation, diagnostic criteria, pathophysiology and treatment will be discussed.

Low serum vitamin B12 levels in an outpatient HIV-infected population.

A retrospective review was conducted on serum vitamin B12 levels in an HIV-infected outpatient cohort, many of whom received antiretroviral therapy. B12 levels were obtained at most staging visits (every six months) and when clinically indicated. For each serum B12 level, laboratory values and clinical symptoms were recorded. Thirty-two patients (32/251 or 13%) had at least one low B12 level (<211pg/mL) during the course of their HIV infection. Within two years of their initial HIV presentation, 6/57 patients had a low serum B12. Using multiple linear regression analysis, a higher serum B12 level was significantly associated with higher folate levels, African-American race, and lower mean corpuscular volume. B12 levels increased significantly after initiating antiretroviral therapy (416 vs 535 pg/mL, P=0.04). In conclusion, low serum B12 levels occur commonly among HIV-infected patients, even at early stages without overt symptoms of B12 deficiency. Antiretroviral therapy may increase serum B12 levels.

Diverse HIV-1 subtypes and clinical, laboratory and behavioral factors in a recently infected US military cohort.

OBJECTIVE: To describe the demographics, risk behaviors, and HIV-1 subtypes in a large cohort of recently HIV-infected military personnel. DESIGN: Descriptive, cross-sectional study. METHODS: US military personnel with recent HIV seroconversion from six medical referral centers were enrolled with a self-administered questionnaire, CD4 cell counts, syphilis and hepatitis B serologies, plasma viral RNA levels, and HIV-1 subtype nucleic acid sequencing. RESULTS: Between February 1997 and May 2000, 520 patients were enrolled. Most [488 (94.3%)] were infected with HIV-1 subtype B. The most prevalent non-B subtype was a circulating recombinant form (CRF01_AE) [17 (61%)]; however, two pure subtypes (C and D), as well as CRF02_AG, CRF09_cpx and a BE recombinant were identified. The likely area of HIV-1 acquisition was the United States for 70% of the volunteers. At least three non-B subtype infections (two subtype C, one subtype CRF01_AE) were apparently acquired domestically. Risk behaviors and comorbid sexually transmitted diseases were reported during the seroconversion period. Volunteers with non-B subtype HIV infection were more likely to report heterosexual contacts [92% vs. 39%; odds ratio (OR), 10.0], including contacts with commercial sex workers (41% vs. 13%; OR, 4.9). The Roche Amplicor version 1.0 assay was less sensitive for non-B subtype infections than the Roche Amplicor version 1.5 assay. CONCLUSION: There is a high prevalence and diversity of non-B HIV subtypes in this large cohort. Efficient diagnosis of acute primary HIV-1 infection was identified as a goal for prevention programs. Modifiable risk behaviors and target populations for intervention were identified.

Septic arthritis caused by Granulicatella adiacens: diagnosis by inoculation of synovial fluid into blood culture bottles.

Granulicatella species, formerly known as nutritionally variant streptococci, cause a variety of infections, primarily endocarditis. We report the first culture-proven case of a Granulicatella species causing septic arthritis. A 68-year-old female presented with knee pain and swelling. She was initially evaluated with arthrocentesis and arthroscopy, but no organism was identified. Her pain improved after a brief course of antibiotics but recurred 3 months later. She underwent repeat arthrocentesis, with direct inoculation of synovial fluid into blood culture bottles. Granulicatella adiacens was recovered from both bottles. She was treated with cefazolin for 4 weeks combined with gentamicin for the first 2 weeks. Her knee pain and swelling resolved without evidence of recurrence. Granulicatella should be considered in cases of septic arthritis with initially negative synovial fluid cultures. Inoculation of blood cultures bottles with synovial fluid may increase the diagnostic yield for these species.