Non-tuberculous Mycobacterium Rhinosinusitis in an Immunocompetent Patient.

Non-tuberculous mycobacteria (NTM) are slow-growing opportunistic pathogens that cause a variety of cutaneous, soft tissue, and pulmonary infections. On rare occasions, NTM causes chronic rhinosinusitis, with the majority of cases presenting in immunocompromised individuals. Other potential risk factors include the presence of foreign bodies, previous sinus surgery or chemoradiation, and use of contaminated water in sinus rinses. We report here a rare case of NTM rhinosinusitis in an otherwise immunocompetent 66-year-old female. The patient underwent functional endoscopic sinus surgery where intraoperative acid-fast bacteria cultures grew Mycobacterium abscessus. She received five weeks of broad-spectrum IV antibiotic therapy followed by three months of oral azithromycin, tigecycline, and linezolid. A one-year post-operative visit showed appropriate healing without crusting or visible infection. This case contributes to the small handful of documented presentations of NTM rhinosinusitis in immunocompetent patients. NTM should be considered when patients present with refractory rhinosinusitis as they may require extended courses of antibiotic treatment. Familiarity with risk factors can further expedite making a diagnosis, ensuring prompt initiation of treatment and relief of symptoms for patients.

An Unexpected Turn of Events in a Patient With Mitral Valve Endocarditis.

A variety of gram-positive infections can be treated with daptomycin. Daptomycin-induced acute eosinophilic pneumonia (DEP) is a rare adverse drug reaction with nonspecific clinical findings of dyspnea, dry cough, and fever. Although diagnostic criteria exist, prompt recognition is important to prevent rapid progression and respiratory failure. In this case, a 69-year-old female was initially admitted due to a prosthetic joint infection; however, her case was complicated by DEP.

Prevalence of antimicrobial resistance in urine, blood, and wound pathogens among rural patients in Karnataka, India.

Background and objective: Antimicrobial resistance (AMR) is increasing in tertiary-care hospitals across India, which consumes more antibiotics than any other country. Microorganisms with novel resistance mechanisms, initially isolated in India, are now recognized worldwide. Until now, most efforts to stem AMR in India have focused on the inpatient setting. Ministry of Health data now suggest that rural areas are playing a more significant role in the pathogenesis of AMR than was previously appreciated. Thus, we conducted this pilot study to ascertain whether AMR is common in pathogens causing infections acquired in the wider rural community. Methods: We performed a retrospective prevalence survey of 100 urine, 102 wound, and 102 blood cultures obtained from patients who were admitted to a tertiary-care facility in Karnataka, India, with infections acquired in the community. The study population included patients >18 years of age who (1) were referred to the hospital by primary care doctors, (2) had a positive blood, urine, or wound culture, and (3) were not previously hospitalized. Bacterial identification and antimicrobial susceptibility testing (AST) were carried out on all isolates. Results: Enterobacteriaceae were the most common pathogens isolated from urine and blood cultures. Significant resistance to quinolones, aminoglycosides, carbapenems, and cephalosporins was noted among pathogens isolated from all cultures. Specifically, high resistance rates (>45%) to quinolones, penicillin, and cephalosporins were evident among all 3 types of culture. Among blood and urinary pathogens, there were high resistance rates (>25%) to both aminoglycosides and carbapenems. Conclusion: Efforts to stem AMR rates in India need to focus on rural populations. Such efforts will need to characterize antimicrobial overprescribing practices, healthcare-seeking behaviors, and antimicrobial use in agriculture in rural settings.

Deep Brain Stimulator Infection by Oligella: A Case Report and Review of the Literature.

Oligella is a commensal bacteria genus of the human urinary tract that rarely precipitates clinical infections. We report the case of an asymptomatic 24-year-old male with a medical history of Tourette syndrome and the recent placement of deep brain stimulator leads, which were found to be co-infected with Oligella species during hardware implantation. This is the first reported case of a deep brain stimulator infection by Oligella, a potentially under-recognized and emerging opportunistic bacteria. We review the previously published cases of extra-genitourinary Oligella infections and detail the clinical management of this uncommon pathogen.

Polymicrobial Prosthetic Valve Endocarditis Due to Neisseria gonorrhoeae and Pseudomonas fluorescens in a Patient With Tetralogy of Fallot: A Case Report.

Disseminated gonococcal infections are rare clinical entities and a few progress to endocarditis. Endocarditis caused by Pseudomonasis even more infrequent, with the few reported cases associated with either intravenous drug use, prosthetic heart valves, or pacemakers. We report a case of a 25-year-old male patient with Tetralogy of Fallot presenting with anasarca and diagnosed with endocarditis due to Neisseria gonorrhoeae and Pseudomonas fluorescens. To our knowledge, this is the first case of tissue-proven infective endocarditis due to P. fluorescens with concomitant N. gonorrhoeae bacteremia. Clinical management of polymicrobial endocarditis in young adults includes obtaining a detailed sexual history, using multiple diagnostic methods to confirm endocarditis, and promptly initiating broad-spectrum antibiotic therapy.

Pasteurella Cerebral Mycotic Aneurysm: A Case Report and Review of the Literature.

Pasteurella species (spp.) are pleomorphic, Gram-negative, facultatively anaerobic bacilli commonly found in the upper respiratory tract and oral cavities of wild and domesticated animals such as dogs and cats. Pasteurella spp. infections in humans are typically caused by animal bites or scratches, or other inadvertent exposure of an open skin lesion to oral secretions of the animal. While skin and soft tissue infections are relatively common, respiratory infections, endocarditis, osteomyelitis, meningitis, and mycotic aneurysms have also been documented. To date, nine cases of mycotic aneurysms caused by Pasteurella spp. have been reported. However, only one of those cases has involved a cerebral mycotic aneurysm, and it had a fatal outcome. This report describes a successfully managed Pasteurella cerebral mycotic aneurysm that had occurred as a complication of underlying mitral valve endocarditis.

Rapid, Noninvasive Diagnosis of Balamuthia mandrillaris Encephalitis by a Plasma-Based Next-Generation Sequencing Test.

Granulomatous amoebic encephalitis (GAE) caused by Balamuthia mandrillaris is a rare subacute infection with exceptionally high mortality. Diagnosis is typically made by brain biopsy or at autopsy. Detection of Balamuthia mandrillaris cell-free DNA by next-generation sequencing of plasma enabled rapid, noninvasive diagnosis in a case of amoebic encephalitis.

Disseminated Nocardia beijingensis Masquerading as Pulmonary Tuberculosis in a Patient With Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome.

Case of disseminated Nocardia beijingensis, initially diagnosed and treated by health department as tuberculosis, presented with worsening symptoms and new lesions. Adjustment to antinocardial treatment resulted in significant clinical and radiographic improvement. Maintain a high index of suspicion for Nocardia in patients diagnosed with tuberculosis with worsening lesions despite therapy.

Severe Case of Plasmodium falciparum Malaria in a Pregnant Woman from Nigeria.

Human malaria has arguably affected more of human history than any other pathogen. Pregnant women have a higher risk of developing severe malaria as well as the risk of severe complications. We present a case of severe malaria in a pregnant patient from sub-Saharan Africa who was treated successfully with artesunate. A 28-year-old Nigerian woman with a 20-week intrauterine pregnancy presented with a five-day history of fever and diffuse joint pains. Evaluation of peripheral thin blood smear demonstrated a parasitemia of 9.8%. The patient was admitted to the intensive care unit, and oral clindamycin/quinine was initiated until intravenous artesunate was obtained. The patient completed four doses of IV artesunate, and after the 4th dose of artesunate, no blood parasites were seen on peripheral smear. The patient was discharged home and, upon clinic follow-up, did not have any further complications associated with either her disease or therapy. A review on the treatment of severe malaria in all trimesters of pregnancy supports the WHO recommendation for intravenous artesunate as the drug of choice. This case illustrates the importance of recognizing malaria in pregnant women from endemic countries and shows that artesunate compounds can be used safely in pregnancy, particularly with high parasitemia.

Outbreak of Acinetobacter baumannii associated with extrinsic contamination of ultrasound gel in a tertiary centre burn unit.

BACKGROUND: During 2011 and 2012, an increase in occurrence of multidrug-resistant Acinetobacter baumannii infections was recorded in the Shands Hospital Burn Intensive Care Unit (BICU). An epidemic curve together with strain typing was consistent with an intermittent common source outbreak. An investigation was therefore initiated. AIM: To identify risk factors for A. baumannii infection, characterize the source of the pathogen, implement control measures to terminate the outbreak, and institute preventive measures. METHODS: We conducted a retrospective case-control study; reviewed BICU infection control policies, practices and procedures, and patient exposure to healthcare workers (HCWs), and obtained epidemiologically-directed environmental cultures. FINDINGS: Eleven patients met the case definition. On multivariate analysis, case-patients were more likely to have undergone an ultrasound procedure in the BICU (adjusted odds ratio [AOR]: 19.5; confidence interval [CI]: 2.4-435) or have a FlexiSeal™ device (AOR: 11.9, CI:1.3-276). Epidemiologically-directed cultures of the environment, ultrasound equipment, and ultrasound gel from opened containers on the ultrasound trolley and in the Ultrasound Department were negative for the outbreak pathogen. Culture of an open ultrasound gel dispenser stored in the Ultrasound Department yielded an A. baumannii strain with DNA banding patterns identical to the outbreak strain. CONCLUSIONS: Based on data from our epidemiologic, microbiologic, and observational studies, we believe that inadvertent extrinsic contamination of the gel dispenser occurred in the Ultrasound Department. Contaminated gel was then dispensed into multiuse vials of gel stored on the mobile carts. The outbreak was stemmed by instituting changes in practices in the Ultrasound Department, including introduction of single-use ultrasound vials and storage of ultrasound gel.

Refractory acute respiratory failure due to Pneumocystis jiroveci (PCP) and Cytomegalovirus (CMV) pneumonitis: A case report and review of literature.

BACKGROUND: Opportunistic infections with Pneumocystis jiroveci pneumonia (PCP) are common in patients with HIV (human immunodeficiency virus) and are encountered once the CD4 count decreases below 200 cells/mm3. Cytomegalovirus (CMV) tends to cause disease once the CD4 count drops below 50 cells/mm3. CMV pneumonitis is not common in this population. However, detecting its presence in broncho-alveolar lavage (BAL) fluid has been associated with increased morbidity and mortality. The role of antiviral therapy against CMV remains unclear. CASE PRESENTATION: We report a newly diagnosed HIV patient with a CD4 count of 44 cells/mm3 presenting with acute respiratory failure secondary to PCP that failed to respond to 3 weeks of standard therapy with trimethoprim-sulfamethoxazole and corticosteroids. He was later diagnosed to have a CMV co-infection causing pneumonitis with BAL cytology findings showing CMV cytopathic effects and PCP. Plasma CMV DNA PCR was 17,424 copies/mL. He responded well after introduction of intravenous ganciclovir. CONCLUSION: The presence of histopathologic changes demonstrating viral cytopathic effects on BAL cytology along with a high plasma CMV DNA PCR should raise the specificity for diagnosing CMV pneumonitis. True PCP and CMV pneumonitis can occur, and the addition of antiviral therapy with ganciclovir may benefit such patients in the right clinical scenario.

Compliance with the Adult Treatment Panel III guidelines for hyperlipidemia in a resident-run ambulatory clinic: a retrospective data analysis.

BACKGROUND: One in every six adults (16.3% of the U.S. adult population) has high total cholesterol levels, and they are at double the risk of heart disease compared with people with optimal levels. OBJECTIVE: To evaluate compliance of internal medicine residents with the latest National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines in treating patients with hyperlipidemia. DESIGN: Retrospective observational study. SETTING: Ambulatory Clinic, Saint Vincent Hospital, Worcester, Massachusetts. PATIENTS: Patients with a diagnosis of hyperlipidemia who attended the clinic during a 1-ear period, from December 2009 to November 2010. MEASUREMENTS: A review of medical records was conducted to evaluate residents' compliance with the NCEP-ATP III guidelines for LDL cholesterol and non-HDL cholesterol management. RESULTS: Seven hundred seventy charts were reviewed. Only 212 (27.5%) met the inclusion criteria. Analysis of data revealed better compliance with drug therapy (44%-77%) and therapeutic lifestyle changes (44%-83%) when compared with follow-up recommendations (22%-31%). An increase in compliance also was noted in all areas of intervention when patients had an abnormal lipid profile. LIMITATIONS: Compliance was assessed on the basis of electronic medical record documentation alone and hence we may be underestimating compliance with therapeutic lifestyle changes and follow-up recommendations. CONCLUSION: Compliance among internal medicine residents in the diagnosis, treatment and follow-up of patients with hyperlipidemia according to NCEP-ATP III guidelines was suboptimal and needs improvement.