Multiple Listeria Abscesses in an Immunocompetent Patient.

Listeria monocytogenes is a ubiquitous organism that can potentially cause gastroenteritis and, less commonly, central nervous system infections. Brain abscess is rare and often associated with immunocompromised status. We report a case of multiple abscesses caused by Listeria in a previously immunocompetent elderly patient who developed a headache and left-sided hemiparesis over the course of days. Neuroimaging studies revealed multiple ring-enhancing lesions in the brain and midbrain territories. Blood culture, brain tissue aspirate, and cerebrospinal fluid nucleic acid amplification test were positive for Listeria. Extensive immunologic workup revealed no primary or secondary immunodeficiency disorders. After the initiation of antibiotics, the patient showed gradual clinical improvement and went to a skilled nursing facility after two weeks.

The Impact of Absolute CD4 Count and Percentage Discordance on Pneumocystis Jirovecii Pneumonia Prophylaxis in HIV-Infected Patients.

Current guidelines suggest that HIV-infected patients should receive chemoprophylaxis against Pneumocystis jirovecii pneumonia (PJP) if they have a cluster determinant 4 (CD4) count <200 cells/mm3 or oropharyngeal candidiasis. Persons with CD4 percentage (CD4%) below 14% should also be considered for prophylaxis. Discordance between CD4 count and CD4% occurs in 16% to 25% of HIV-infected patients. Provider compliance with current PJP prophylaxis guidelines when such discordance is present was assessed. Electronic medical records of 429 HIV-infected individuals who had CD4 count and CD4% measured at our clinic were reviewed. CD4 count and percentage discordance was seen in 57 (13%) of 429. Patients with CD4 count >200 but CD4% <14 were significantly less likely to be prescribed PJP prophylaxis compared with those who had CD4 count <200 and CD4% >14 (29% versus 86%; odds ratio = 0.064, 95% confidence interval: 0.0168-0.2436; P < .0001). We emphasize monitoring both the absolute CD4 count and percentage to appropriately guide PJP primary and secondary prophylaxis.

PJP granuloma in an Immune competent host: Case report and literature review.

PJP (Pneumocystis jirovecii) is a fungal agent by taxonomy. Ones considered a protozoan, it is now recognized as fungi based on ribosomal RNA and other gene sequence homologies, the composition of their cell walls, and structure of key enzymes. This organism generally affects immunocompromised hosts with a CD4 count <200 or <15%.Review of literature does support a rare occurrence of PJP infections in immunocompetent hosts.PJP can occur at normal CD 4 levels.

Vancomycin-Induced Leukocytoclastic Vasculitis and Acute Renal Failure Due to Tubulointerstitial Nephritis.

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and sepsis are commonly treated with intravenous vancomycin. However, vancomycin treatment is associated adverse reactions, including skin rashes and nephrotoxicity. We present a case of acute renal failure due to acute tubulointerstitial nephritis associated with a diffuse leukocytoclastic vasculitic skin eruption following intravenous vancomycin treatment. CASE REPORT A 79-year-old Caucasian male patient was treated with intravenous vancomycin for MRSA bacteremia. Prior to treatment, his creatinine was normal at 0.6 mg/dl. He presented one week later with shortness of breath, lower limb edema, and acute renal failure. He had a diffuse maculopapular rash involving the trunk and both upper and lower extremities. A renal biopsy and left arm skin biopsy were examined histologically. The skin biopsy showed leukocytoclastic vasculitis. Renal biopsy showed some sclerosed glomeruli, some with mesangial proliferation, and tubulointerstitial inflammation with eosinophils and plasma cells and mild interstitial fibrosis. Although there was some renal arteriolosclerosis, no vasculitic changes were seen, and no vascular thrombosis was present. A diagnosis of leukocytoclastic vasculitis and acute tubulointerstitial nephritis secondary to intravenous vancomycin therapy was made. CONCLUSIONS Although skin reactions associated with drug therapy are common, vancomycin-associated dermal vasculitis is rare. Tubulointerstitial nephritis is also a rare association with vancomycin treatment. This case report has highlighted that patients being treated with intravenous vancomycin should be carefully observed for acute skin rashes and deterioration in renal function, which can be managed by ceasing treatment with vancomycin, steroid challenge, and preventing future exposure to similar antimicrobial agents.