Acute Herpes Simplex Virus Laryngitis Presenting as Airway Obstruction Post Influenza: A Viral Pneumonia.

Herpes simplex virus (HSV) typically presents with mucocutaneous or genital ulcerations but can also manifest with central nervous system involvement and occasionally other visceral or mucosal sites. However, laryngeal involvement almost exclusively presents in infants and children. Very few confirmed adult cases have been reported. Adults present with a broad spectrum of symptoms, usually in the context of significant immunocompromise. Diagnosis is difficult given a wide spectrum of nonspecific presenting symptoms and usually requires tissue biopsy. Frequently, patients have severe laryngeal edema that threatens to compromise the airway and requires tracheostomy. We present a case of HSV laryngitis in a 71-year-old female who presented with septic shock, acute renal failure, and acute hypoxic respiratory failure secondary to Influenza A and bacterial pneumonia for which she required intubation. The hospitalization course included extubation failures due to stridor, a positive cuff leak test resulting in an open tracheostomy, and a laryngeal biopsy confirming HSV infection, which was successfully treated with acyclovir.

Acute left knee prosthetic joint infection by Francisella tularensis with literature review.

Tularemia is a severe zoonotic disease caused by gram-negative bacillus Francisella tularensis. F. tularensis species account for most cases in the United States of America (USA). Apart from the six classical clinical presentations that include glandular, ulceroglandular, oculoglandular, pharyngeal, typhoidal, and pneumonic, skeletal disease is uncommon. Rare clinical manifestations include primary and secondary skin rashes, erythema nodosum, and erythema multiforme. Infrequent skeletal manifestations have presented as osteomyelitis and prosthetic joint infections. Prosthetic joint infection by F. tularensis is a rarity. PubMed literature review revealed a total of five prosthetic joint infection cases. Here we report the sixth and the third case in the USA in a 73-year-old white male with an acute left knee prosthetic joint infection (occurring after a recent episode of left lower extremity cellulitis with septic shock) successfully treated with 14 days of doxycycline.

Acute disseminated actinomycosis presenting as pneumonia with bilateral pulmonary nodules and pelvic osteomyelitis in an immunocompetent patient.

Actinomycosis is an indolent human infectious disease caused by gram-positive anaerobic filamentous bacteria Actinomyces. Despite its sluggish growth, clinical manifestations can be acute or chronic. Over the last five decades, a significant incidence decline in the western world is due to the discovery of effective antimicrobials and improved oral hygiene. Actinomycosis is now rarely encountered and often misdiagnosed as its manifestations mimic malignancy and other infectious diseases. Due to prior use of antimicrobials, laboratory diagnostic processes often fail to isolate the organism making it arduous to establish the diagnosis. Clinical classification is based on the geographical distribution of the disease as oro-cervicofacial, thoracic, abdominopelvic, neurologic, musculoskeletal, and disseminated. Disseminated and pulmonary actinomycosis in an immunocompetent individual is extremely rare. Here we present a 53-year-old healthy male presenting with acute disseminated actinomycosis with bilateral pulmonary nodules, right upper lobe pneumonia, and pelvic osteomyelitis from Actinomyces odontolyticus infection.

Aeromonas hydrophila Community-Acquired Bacterial Pneumonia With Septic Shock in a Chronic Lymphocytic Leukemia Patient Due to Absolute Neutropenia and Lymphopenia.

Aeromonas hydrophila is a gram-negative (GN) bacillus with an opportunistic potential in immunocompromised patients. They are ubiquitary in fresh and brackish water capable of infecting healthy and immunosuppressed patients. Clinical manifestations vary in healthy hosts compared to immunocompromised patients. Community-acquired bacterial pneumonia (CABP) is an infrequent clinical presentation of A. hydrophila infection, even in immunosuppressed patients. It is also an uncommon cause of nosocomial and drowning-related pneumonia. Although a rare cause of CABP, the clinical course is fulminant with higher mortality due to lower clinical suspicion. Here, we present an immunocompromised 63-year-old Caucasian male with chronic lymphocytic leukemia (CLL) presenting with acute A. hydrophila CABP with septic shock due to absolute neutropenia and lymphopenia.

Acute Pneumocystis jirovecii Pneumonia Due to Absolute Lymphopenia.

Pneumocystis pneumonia (PCP) is an opportunistic fungal infection associated with human immunodeficiency virus (HIV) infection as an acquired immunodeficiency syndrome (AIDS)-defining illness. The PCP incidence in patients with HIV has declined over the last few decades due to effective antiretroviral therapy and prophylaxis. The PCP incidence in HIV-negative patients has increased due to the increasing use of a wide array of immunosuppressants in cancer and autoimmune disease. PCP clinical course varies from patients with HIV in their clinical features, the severity of clinical presentation, and mortality. PCP in autoimmune diseases is rare, especially in rheumatoid arthritis (RA) in the United States of America (USA). Here, we describe an elderly Caucasian female with rheumatoid arthritis and left lung mucinous adenocarcinoma status post recent resection with no chemotherapy on a low dose of methotrexate (MTX) and prednisone presenting with acute hypoxic respiratory failure due to PCP from absolute lymphopenia.

Streptococcus constellatus Left Ventricular Apical Mural Infective Endocarditis With Acute Stroke, Septic and Cardiogenic Shock.

Infective endocarditis (IE) is a severe infection of the endocardium and cardiac valves by multiple etiologic agents. Clinical presentation can be acute or subacute based on the host immunity and the causative agent's virulence. Although Streptococci are responsible for most community-acquired native valve bacterial IE, Streptococcus constellatus is an infrequent cause. S. constellatus can rarely infect prosthetic cardiac valves. A middle-aged white male with poorly controlled type 2 diabetes mellitus was transferred to our facility for suspected stroke with an initial presentation of acute encephalopathy of uncertain duration. Transthoracic echocardiogram revealed a left ventricular apical mural vegetation, and brain imaging displayed multiple white matter hypodensities indicative of numerous small strokes. Blood cultures were positive for S. constellatus. Clinical presentation was unusual with an acute encephalopathy due to multiple septic emboli and primary mural IE with high-grade bacteremia due to S. constellatus. PubMed medical literature review reveals this to be a rare clinical presentation by an uncommon etiological agent with an infrequent echocardiogram finding.

Prepatellar Bursitis with Abscess due to Corynebacterium ulcerans.

Corynebacteria are ubiquitous and reside as skin and mucosa commensals in animals. They are considered contaminants in clinical specimens, but significant clinical data points to their virulence and pathogenic potential over the last two decades. Corynebacteria can cause both community-acquired and nosocomial infections. Corynebacterium diphtheriae (C. diphtheriae) responsible for diphtheria has declined over the previous two decades with an increase in a similar clinical syndrome by Corynebacterium ulcerans (C. ulcerans) in Europe. As per recent studies, C. ulcerans shares similar virulence factors with C. diphtheriae. C. ulcerans has been implicated in airway infections, skin and soft tissue infections, lymphadenitis, wound infections, and rarely necrotizing fasciitis. Pet or farm animals have been the source of these infections to humans, as per recent reports. Strains can be either toxigenic or nontoxigenic. Due to recent advances, methods to characterize strains have become easier with mass spectrometry. Antimicrobial susceptibility testing is a must for definite treatment as C. ulcerans can be resistant to first-line antibiotic therapy. If resources are available, it is prudent to find if there is any toxin production. Here, we describe a rural farmer in central Missouri presenting with acute-onset right knee pain diagnosed with right prepatellar bursitis with abscess due to C. ulcerans infection. He recovered with surgical debridement and antimicrobial therapy. This is the first case of C. ulcerans causing prepatellar bursitis with an abscess as per medical literature review.

Electronic Vaping-Induced Methicillin-Sensitive Staphylococcus Aureus Pneumonia and Empyema.

Pneumonia is a severe acute inflammation of the lower respiratory tract due to infectious pathogens. Pathogens responsible include bacteria, viruses, fungi, and parasites. Pneumonia categorizations include community-acquired pneumonia (CAP), hospital-acquired pneumonia, and ventilator-associated pneumonia. It is the single most common cause of infection-related mortality in the United States. Among the typical bacterial CAP causes, Staphylococcus aureus (S. aureus) is responsible for less than 5% of all cases. Among the S. aureus, methicillin-susceptible S. aureus (MSSA) is slightly more common than the methicillin-resistant S. aureus (MRSA). CAP caused by S. aureus is associated with worse clinical outcomes compared to streptococcal pneumoniae. Although S. aureus CAP occurs throughout the year, it is less common except during the influenza season when there is a spike. Multiple studies have stratified risk factors for MRSA infection. MSSA pneumonia in immunocompetent young patients is uncommon due to healthy host defense mechanisms. However, certain individual risk factors promote infection, such as intravenous drug abuse. Recent multiple research studies implicate increased virulence of S. aureus in colonized patients after exposure to electronic cigarette vapor exposure (ECVE), resulting in pneumonia. A PubMed search revealed no MSSA community-acquired bacterial pneumonia due to ECVE. We report a 38-year-old female who developed acute MSSA pneumonia, which was complicated by left empyema due to ECVE from JUUL device with third-party compatible cannabidiol pods. The patient completed treatment successfully with a chest tube placement followed by fibrinolysis and intravenous antibiotics.

Levofloxacin-Induced Acute Hyperpigmentation Changes in a Chronic Kidney Disease Patient.

Medication-induced cutaneous hyperpigmentation has variable clinical presentations and is dependent on the specific drug involved. Most commonly, an attentive patient observes such changes early in the course; when missed by the patient, such changes are usually noted by an observant clinician. Clinical diagnosis can be challenging if the patient is on multiple medications because other causes must be excluded. This condition occurs via multiple mechanisms. Frequently, the pigmentary change is reversible with discontinuation of the drug. Causative medications include nonsteroidal; anti-inflammatory agents, antimalarials, antibiotics, psychotropics, amiodarone, and chemotherapeutic agents. The; antimicrobials responsible for hyperpigmentation are antimalarials, tetracyclines, tigecycline, dapsone, rifampicin, and antiretrovirals such as zidovudine. Sunlight exposure can worsen the pigmentation seen with some of the above antimicrobials (e.g., dapsone). Here, we describe an older adult white woman presenting with acute cutaneous; hyperpigmentation of the bilateral lower extremities while on levofloxacin therapy. Hyperpigmentation resolved after cessation of the agent. Our case highlights this unique acute presentation after only a few days of oral levofloxacin.

Postpartum-Isolated Native Pulmonic Valve Methicillin-Resistant Staphylococcus aureus Infective Endocarditis Complicated by Pelvic Abscess, Clavicle Osteomyelitis, and Polyarticular Septic Arthritis.

Isolated native pulmonic valve infective endocarditis (IE) is a rare occurrence. The most commonly involved valves in injection drug users are the tricuspid valve followed by mitral and then aortic valves. Most reported cases of methicillin-resistant Staphylococcus aureus (MRSA) IE involve multiple valves. Isolated involvement of the pulmonic valve in IE is infrequent, especially in intravenous drug users or patients with indwelling catheters, prosthetic valves, or implantable cardiac devices. Here, we report a young postpartum female patient with isolated native pulmonic valve MRSA IE with MRSA bacteremia and history of active injection drug use. A PubMed literature review revealed a single described prior case report in a postpartum female. The patient's clinical course was complicated by a large native pulmonic valve vegetation, septic pulmonary emboli, pelvic abscess, polyarticular septic arthritis, and clavicular osteomyelitis. The patient underwent bioprosthetic pulmonic valve replacement and finished six weeks of intravenous vancomycin for complete recovery.

Cytomegalovirus pneumonitis-induced secondary hemophagocytic lymphohistiocytosis and SIADH in an immunocompetent elderly male literature review.

Hemophagocytic lymphohistiocytosis (HLH) is also known as hemophagocytic syndrome. It is a lethal hematologic condition due to a dysregulated immune response which results in inappropriately activated macrophages damaging host tissues. Based on the etiology, HLH can be primary (genetic) or secondary (acquired). The most common cause of a secondary HLH is an infection. Viral infections are the most common cause of secondary HLH. Among the viral causes of secondary HLH, Epstein-Barr virus is the most common etiologic agent. Cytomegalovirus (CMV) is a common causative pathogen in the immunocompromised host but is rare in an immunocompetent adult. In infection- associated secondary HLH, treatment includes antimicrobial therapy. HLH carries a high mortality and morbidity rate as it is an underdiagnosed clinical condition. Successful early diagnosis allows for adequate time for curative therapy. Treatment for HLH includes chemotherapy, immunomodulators, and a hematopoietic stem-cell transplant. The 2004 diagnostic criteria set by the Histiocyte Society serves as a guide to make an earlier clinical diagnosis. A review of PubMed literature revealed only five reported cases of CMV-induced HLH. We describe the sixth case of CMV pneumonitis-induced HLH and syndrome of inappropriate antidiuretic hormone secretion in a 72-year-old White male. He was treated successfully with oral valganciclovir and corticosteroids.

Primary cutaneous cryptococcal infection due to fingolimod - Induced lymphopenia with literature review.

Cryptococcus. Neoformans (C. neoformans) is an encapsulated heterobasidiomycetous fungus responsible for opportunistic infections worldwide in immunocompromised patients. Clinical presentation ranges from asymptomatic respiratory tract colonization to disseminated infection in any human body part. The central nervous system (CNS) and pulmonary diseases garner most of the clinical attention. Secondary cutaneous cryptococcosis is an uncommon manifestation seen as a sentinel sign commonly in disseminated cryptococcal infection. Primary cutaneous cryptococcosis (PCC) is a rare manifestation seen in both immunocompromised and immunocompetent patients. It is a discrete infection with different epidemiological trends. Immunosuppressive therapy (corticosteroids, tacrolimus) predisposes a patient to acquire this clinical entity. We present a case of an elderly Caucasian male on fingolimod for relapsing-remitting multiple sclerosis with nonhealing scalp lesions for four years. He was a referral to our healthcare center for the presence of fungal elements seen on a scalp biopsy fungal stains. Final cultures returned positive for C. neoformans susceptible to fluconazole (MIC = 8 µg/mL). The CD4 count was 13 cells/uL, and workup for CNS and disseminated cryptococcal infection were negative. Fingolimod is an immunomodulator that acts on sphingosine 1-phosphate receptors, affecting the lymphocytes. Pubmed literature review revealed few case reports (< 5) with PCC in patients on fingolimod. To our knowledge, ours is the first case with scalp cryptococcosis, with the lowest CD4 count while being on fingolimod. No randomized controlled trial data exist for the treatment of PCC. Therapy initiated with oral luconazole for six months with significant improvement at three months.

Native Valve Infective Endocarditis with Osteomyelitis and Brain Abscess Caused by Granulicatella adiacens with Literature Review.

Granulicatella adiacens is a type of NVS (nutritionally variant streptococci) rarely causing infective endocarditis (IE). NVS are fastidious and unable to sustain growth on routine culture media due to lack of specific nutrients. Endocarditis caused by NVS due to their virulence is associated with higher treatment failures and mortality rates. New antimicrobial susceptibility patterns are indicative of a significant rise in penicillin resistance and susceptibility differences between NVS subspecies. Initial empirical therapy is essential as a delay in using the appropriate agent leads to poor results. We present a case of an immunocompetent young female with recent intravenous drug abuse resulting in native mitral valve endocarditis with ruptured chordae tendineae and septic embolization, causing brain abscess and lumbar spine osteomyelitis. She was transferred to a tertiary center where she underwent mitral valve replacement successfully and treated with six weeks of intravenous vancomycin and ertapenem. To our knowledge, ours is the first case report of G. adiacens endocarditis in an adult with brain abscess and osteomyelitis with an excellent response to antibiotic therapy. Based on our case report, literature review, and new antimicrobial susceptibility patterns, updates to treatment guidelines are suggested to improve the therapeutic outcomes.