Detection of Leishmania RNA Virus 1 in Leishmania (Viannia) panamensis Isolates, Panama.

We detected Leishmania RNA virus 1 (LRV1) in 11 isolates of Leishmania (Viannia) panamensis collected during 2014-2019 from patients from different geographic areas in Panama. The distribution suggested a spread of LRV1 in L. (V.) panamensis parasites. We found no association between LRV1 and an increase in clinical pathology.

Hot Tub Lung: Case Report and Review of the Literature.

INTRODUCTION: Nontuberculous mycobacteria-related hypersensitivity pneumonitits (NTM-HP), otherwise known as hot tub lung, is an uncommon disease produced by exposure to aerosolized hot tub water containing nontuberculous mycobacteria. Patients usually present with nonspecific, prolonged respiratory symptoms and require a thorough respiratory workup, including radiography and even pulmonary biopsies. CASE PRESENTATION: We present the case of a 58-year-old patient with chronic respiratory symptoms and history of exposure to a hot tub. DISCUSSION: There is little data on why certain patients develop NTM-HP; however, it seems to be an immunologic response to the nontuberculous mycobacteria, not a primary infection. The treatment, as in this case, is typically just hot tub avoidance. CONCLUSION: To our knowledge, this is the first case of NTM-HP reported from Wisconsin. NTM-HP can mimic nontuberculous mycobacterial disease and should be on the differential diagnosis for patients with unclear chronic respiratory problems.

Understanding the relationship between patient characteristics and complication in veterans discharged on parenteral antibiotic therapy.

BACKGROUND: Many facilities utilize outpatient parenteral intravenous (IV) antimicrobial therapy (OPAT) to reduce cost, length of stay, and risk of nosocomial infections. OBJECTIVE: The objective of this study was to analyze patient demographics, substance use, mental and physical health diagnoses, and social determinants of health to seek relationships with complications for veterans discharged from the Zablocki Veterans Affairs Medical Center (ZVAMC) on OPAT. METHODS: This study was a retrospective chart review of veterans who completed OPAT between the years of 2013 and 2017 at the ZVAMC in Milwaukee, Wisconsin. Prior to discharge, patients were screened by the OPAT team for eligibility; patients were followed after discharge by pharmacy, home care, and providers. OPAT complication was defined as antibiotic change/dose adjustment, IV catheter complication, or an additional hospital visit secondary to current infection or therapy. RESULTS: 294 veterans' charts were reviewed. Of these patients, 106 (36.05%) had a complication. Tobacco use was the only factor significantly associated with OPAT complication. CONCLUSIONS: Cohabitation, employment status, mental health diagnosis and alcohol use were not associated with OPAT failure; however, tobacco use merits further review for use in OPAT screening protocols.

Implementation of Veterans Affairs Primary Care Antimicrobial Stewardship Interventions For Asymptomatic Bacteriuria And Acute Respiratory Infections.

BACKGROUND: Outpatient antimicrobial prescribing is an important target for antimicrobial stewardship (AMS) interventions to decrease antimicrobial resistance. The objective of this study was to design, implement, and evaluate the impact of AMS interventions focused on asymptomatic bacteriuria (ASB) and acute respiratory infections (ARIs) in the primary care setting. METHODS: This stepped-wedge trial evaluated the impact of multifaceted educational interventions to providers on adult patients presenting to primary care clinics for ARIs and ASB. The primary outcome was percentage of overall antibiotic prescriptions as a composite of prescriptions for ASB, acute bronchitis, upper respiratory infection not otherwise specified, uncomplicated sinusitis, and uncomplicated pharyngitis. Secondary outcomes were the individual components of the primary outcome; a composite safety endpoint of related hospital, emergency department, or primary care visits within 4 weeks; antibiotic selection appropriateness; and patient satisfaction surveys. RESULTS: A total of 887 patients were included (405 preintervention and 482 postintervention). After controlling for type I error using Bonferroni correction, the primary outcome was not significantly different between groups (56% vs 49%). There was a statistically significant decrease in prescriptions for acute bronchitis (20.99% vs 12.66%; P = .0003). Appropriateness of antibiotic prescriptions for uncomplicated sinusitis (odds ratio [OR], 4.96 [95% confidence interval {CI}, 1.79-13.75]; P = .0021) and pharyngitis (OR, 5.36 [95% CI, 1.93-14.90]; P = .0013) was improved in the postintervention vs the preintervention group. The composite safety outcome and patient satisfaction surveys did not differ between groups. CONCLUSIONS: Multifaceted educational interventions targeting providers can improve antibiotic prescribing for indications rarely requiring antimicrobials without increasing re-visits or patient satisfaction surveys.

Intervenciones en infecciones del tracto urinario, neumonías, COVID-19 y bacteriemias por programas de uso optimizado de antimicrobianos (PROA): enfoque síndrome específico

Introducción: El uso de los antibióticos ha logrado curar infecciones anteriormente letales. Como profilaxis ha mejorado el pronóstico de pacientes en múltiples escenarios; sin embargo, estos fármacos tienen efectos adversos los cuales pueden ocurrir en 1 de cada 5 pacientes hospitalizados que los reciben, algunos de estos eventos son potencialmente mortales. Los programas de Antimicrobial Stewardship (ASP), conocidos en español como Programas de Uso Optimizado de Antibióticos (PROA), son intervenciones coordinadas, diseñadas para mejorar y medir el uso apropiado de antibióticos, promoviendo la selección del régimen óptimo, incluyendo dosis, duración de la terapia y su ruta de administración. Objetivo: describir el beneficio de las intervenciones síndrome específico en infecciones del tracto urinario, neumonías, bacteriemias y COVID-19, realizadas por programas de uso optimizado de antimicrobianos (PROA). Metodología: se realizó una búsqueda en PubMed y se seleccionó aquellos artículos donde se realizaron intervenciones que mostraron beneficios clínicos en infecciones del tracto urinario, neumonías, bacteriemias y COVID-19 por parte de programas de uso optimizado de antimicrobianos. Síntesis de los datos: se seleccionaron 18 estudios, de los cuales 3 mostraron intervenciones con beneficios en el tratamiento de Infecciones del tracto urinario, 9 en neumonías, 1 en COVID-19 y 5 en bacteriemias. Conclusión: Las intervenciones síndrome específicas, en Infecciones del tracto urinario (ITU), neumonías COVID-19 y bacteriemias, de los programas de uso optimizado de antibióticos (PROA) se han asociado con disminución de los costos de atención y mejores resultados clínicos. (provisto por Infomedic International)

Is ibrutinib associated with disseminated cryptococcosis with CNS involvement?

Chronic lymphocytic leukemia (CLL) is a disorder of B cells that affects humoral as well as cell-mediated immunity. Protection against cryptococcal infections is mounted by an intricate and synchronized interplay of both integral arms of immunity. Whether CLL or small molecule tyrosine kinase inhibitors are independently predisposing hosts to cryptococcal infections remain to be explored. Herein, we present a report of a patient who developed disseminated cryptococcosis while receiving ibrutinib therapy for CLL in the salvage setting. We further present relevant literature available thus far on the topic and discuss immunologic mechanisms that may be involved in the fungal pathogenesis in such patients.

First Case of Diffuse Leishmaniasis Associated With Leishmania panamensis.

Leishmania panamensis is the most common species of Leishmania in Panama, and it is known to cause cutaneous leishmaniasis, disseminated cutaneous leishmaniasis, and mucocutaneous leishmaniasis; however, it not associated with diffuse cutaneous disease. In this study, we report the first case of diffuse cutaneous leishmaniasis caused by L panamensis.

Zika Virus-Associated Cerebellitis with Complete Clinical Recovery.

Zika virus (ZIKV) was first detected in the Americas in Brazil in 2015, with a rapid spread to surrounding countries. In Panama, the outbreak began in November 2015 in an indigenous community located on the Caribbean side of the country. Zika virus is typically associated with a diffuse rash, fever, and conjunctivitis. It can rarely cause neurologic manifestations, most commonly microcephaly and Guillain-Barré syndrome. Encephalitis and acute encephalomyelitis are known complications, but ZIKV-associated cerebellitis has yet to be reported in the literature. Herein, we report a case of cerebellitis in a patient infected with ZIKV. This patient developed severe frontal headache and vertigo on the third day of illness, and dysarthria and ataxia on the fifth day. After 1 week of hospitalization, the patient completely recovered. The laboratory serological diagnosis was complicated because of the detection of antibodies against dengue, suggesting a secondary flavivirus infection.

Descriptive epidemiology of snakebites in the Veraguas province of Panama, 2007-2008.

Background: Panama has the highest incidence of snakebites in Central America, however, few studies have looked at the epidemiology of human snakebites in Panama. Methods: This retrospective, single-center study reviewed individuals who sustained a snakebite from 2007-2008. Demographic data, disease severity, species of snake, treatment, infectious complications and antibiotic usage were collected from the hospital records. Results: Data were collected over a 2-y period, with a total of 390 records of snakebites. Bothrops asper was responsible for 43.8% of cases and the majority of the cases occurred during the rainy season. The majority of bites (74.7%) occurred on the hands, feet or toes. Antivenom was used in 55% of patients and 67% of patients received tetanus toxoid. Only 8.7% of individuals presented to the hospital within 1 h of envenomation and more than 25% presented >6 h after envenomation. Conclusions: B. asper is responsible for the majority of snakebites in the Veraguas province of Panama. Snakebites tend to occur during the rainy season, with the majority of bites occurring on the feet. Several management factors need to improve in Panama: time to presentation, which is prolonged in the majority of cases, and antivenom, antibiotic and tetanus toxoid delivery should be standardized to optimize care.

The reintroduction of DENV-2 in 2011 in Panama and subsequent outbreak characteristic.

The circulation of the South-east Asian/American (AS/AM) dengue 2 virus (DENV-2) genotype in the Americas has been associated with a high rate of severe disease. From 1993, the year DENV was reintroduced in Panama, until 2011 there were 29 dengue-associated deaths, 17 of which occurred in 2011, the most severe outbreak with a case fatality rate (CFR) of 44% (17 deaths out of 38 severe dengue cases). During this outbreak DENV-2 was reintroduced into the country, whereas over the prior five years DENV-1 and -3 were predominant. Herein, we describe the 2011 Panama outbreak and genetically characterize the Panamanian DENV-2 strains, which were associated with severe dengue disease in Panama. Our results suggest that the DENV-2 isolates from this outbreak belonged to the AS/AM genotype sub-clade 2BI and were genetically close to viruses described in the outbreaks in Nicaragua, Honduras, Guatemala and Mexico from 2006-2011. Sub-clade 2BI has previously been associated with severe disease in Nicaragua during outbreaks from 2005-2007.

Clinical Manifestations of Punta Toro Virus Species Complex Infections, Panama, 2009.

An investigation in Panama found that Punta Toro virus species complex (PTVs) may contribute to febrile illnesses with symptoms mirroring those of dengue fever. However, further studies are needed to determine if PTV infection causes only a mild disease or if it can have more serious manifestations in some patients.

Infections associated with adventure travel: A systematic review.

AIM: To review infections associated with adventure travel. METHODS: The PubMed, Embase and Scopus databases were searched combining the words infection with the following keywords: rafting, whitewater, surfing, (surfer* or windsurf*), (caves or caving or spelunking), (triathlon or trekking) or (hiking or adventure race), bicycling, backpacking, (mountain climb* or bouldering), horseback riding, orienteering, trekking, and skiing. RESULTS: Adventure travel is becoming much more common among travelers and it is associated with a subset of infectious diseases including: leptospirosis, schistosomiasis, viral hemorrhagic fevers, rickettsial diseases and endemic mycosis. Caving and whitewater rafting places individuals at particular risk of leptospirosis, schistosomiasis and endemic mycosis, while adventure races also place individuals at high risk of a variety of infections including campylobacter, norovirus and leptospirosis. CONCLUSION: Travel practitioners need to be aware of the risks associated with adventure travel and should educate individuals about the risks associated with various activities. Doxycycline prophylaxis should be considered for travelers who are susceptible to leptospirosis due to participation in high-risk sports such as whitewater rafting, caving or adventure races.

Acute Cryptococcal Immune Reconstitution Inflammatory Syndrome in a Patient on Natalizumab.

Presented is the first case of acute immune reconstitution inflammatory syndrome (IRIS)-associated cryptococcal meningoencephalitis in a patient on natalizumab for multiple sclerosis. The patient developed acute cerebral edema after initiation of amphotericin B. We propose several mechanisms that explain the acuity of IRIS in this specific patient population and suggest possible therapies.

Acute disseminated encephalomyelitis presenting as a brainstem encephalitis.

Acute disseminated encephalomyelitis (ADEM) is a disease characterized by inflammation and destruction of myelin. Acute hemorrhagic leukoencephalitis (AHLE) is a severe form of ADEM known for its particularly poor outcome. We present a case of a young Caucasian female who presented with drowsiness and slurred speech followed by rapid brainstem involvement resembling rhomboencephalitis. Despite multiple diagnostic tests and empiric therapy with immunosuppressants, immunoglobulins, and antimicrobials, she lost most brainstem reflexes within a few weeks and ultimately passed away. Magnetic resonance imaging (MRI) showed progression of lesions from the brainstem to eventually involve bilateral cerebral hemispheres. Autopsy and microscopic examination of the brain revealed several hemorrhagic lesions throughout the brain and rendered a diagnosis of AHLE. AHLE was initially described in 1941 and is thought to be autoimmune related, possibly related to cross reactivity between the immune system and CNS tissues like myelin. While a definitive inciting pathogen was not discovered, this case emphasizes the importance of considering AHLE in the differential diagnosis of patients with rapid loss of neurologic function and highlights an atypical presentation of ADEM/AHLE.