Chronic Lymphogranuloma Venereum Proctocolitis Masquerading as Inflammatory Bowel Disease.

Rectal infection with the L1, L2, and L3 serovars of Chlamydia trachomatis can cause lymphogranuloma venereum (LGV) proctocolitis, particularly among men who have sex with men (MSM). Symptoms of this sexually transmitted infection include anal pain, rectal bleeding and discharge, tenesmus, constipation, and fever. Clinicians should consider LGV when there is a history of receptive anal intercourse and symptoms of proctocolitis. A positive nucleic acid amplification test (NAAT) on a rectal sample is diagnostic. This report describes a man with HIV and chronic proctocolitis in whom the diagnosis of LGV was delayed because the clinical picture mimicked inflammatory bowel disease.

Comparison of Blood (1->3)-ß-d-Glucan Levels in AIDS-Related Pneumocystis jirovecii Pneumonia and AIDS-Related Progressive Disseminated Histoplasmosis.

In this retrospective study, (1->3)-ß-d-glucan (B-glucan) was an unreliable marker for AIDS-related Pneumocystis jirovecii pneumonia (PCP) because a high percentage of participants with progressive disseminated histoplasmosis and respiratory symptoms had a positive B-glucan result. Where histoplasmosis is common, attributing B-glucan positivity to PCP without further testing risks misdiagnosis.

Sweet Syndrome precipitated by Mycobacterium abscessus in a Laotian Man with Autoantibodies to Interferon Gamma.

Autoantibodies to interferon γ, part of the first line of defense in the human immune response, constitutes a rare form of an acquired immunodeficiency in HIV-uninfected adults that can predispose to disseminated atypical mycobacterial infection. Particularly, this has been described in people of Southeast Asian origin. In this case report, we describe a previously healthy, Laotian man who presented with skin lesions consistent with Sweet syndrome that were later found to be precipitated by disseminated atypical mycobacterial disease. Extensive immunological workup revealed the patient to have autoantibodies to interferon γ, rendering him susceptible to this infection. Our report demonstrates a complex case with a multilayered diagnosis, while inviting perspective from multiple specialties. This enigmatic case emphasizes the importance of a broad differential with special attention to demographics while demonstrating the difficulty in treating certain atypical infections that are inherently multidrug resistant.

Clinical and laboratory update on blastomycosis.

Blastomycosis is endemic in regions of North America that border the Great Lakes and the St. Lawrence River, as well as in the Mississippi River and Ohio River basins. Men are affected more often than women and children because men are more likely to participate in activities that put them at risk for exposure to Blastomyces dermatitidis. Human infection occurs when soil containing microfoci of mycelia is disturbed and airborne conidia are inhaled. If natural defenses in the alveoli fail to contain the infection, lymphohematogenous dissemination ensues. Normal host responses generate a characteristic pyogranulomatous reaction. The most common sites of clinical disease are the lung and skin; osseous, genitourinary, and central nervous system manifestations follow in decreasing order of frequency. Blastomycosis is one of the great mimickers in medicine; verrucous cutaneous blastomycosis resembles malignancy, and mass-like lung opacities due to B. dermatitidis often are confused with cancer. Blastomycosis may be clinically indistinguishable from tuberculosis. Diagnosis is based on culture and direct visualization of round, multinucleated yeast forms that produce daughter cells from a single broad-based bud. Although a long course of amphotericin B is usually curative, itraconazole is also highly effective and is the mainstay of therapy for most patients with blastomycosis.

A clinical review of Lyme disease in Arkansas.

Lyme disease is the most common tick-borne disease in the northern hemisphere. Since it was first described more than 30 years ago, Lyme disease has generated a great deal of controversy. Lyme disease is not endemic in Arkansas, and testing for Borrelia burgdorferi can lead to clinical confusion, unnecessary treatment and excess cost. This article will present a brief review of Lyme disease, with an emphasis on what is known regarding Lyme disease in Arkansas.

Isolated tuberculosis of the pancreas: a case report.

CONTEXT: Pancreatic tuberculosis is a rare entity. Only a few cases have been reported in the medical literature. We hereby describe a case of pancreatic tuberculosis in an immunocompromized individual. CASE REPORT: A fifty-year-old African-American gentleman with history of HIV non-compliant on anti-retroviral therapy presented with epigastric pain for five weeks duration. CT scan of abdomen showed large necrotic node on the posterior aspect of the head of pancreas and multiple cystic masses adjacent to the pancreas. Acid fast bacilli were found on staining of CT guided biopsy of the node. Cultures grew Mycobacterium tuberculosis. Anti-tubercular therapy was initiated and resulted in gradual resolution of symptoms. CONCLUSION: Pancreatic tuberculosis is rare and is frequently confused with pancreatic cancer on clinical presentation as well as on imaging studies. Since it is a curable disease, accurate diagnosis is paramount CT or ultrasound guided biopsy is cornerstone of diagnosis. Endoscopic ultrasound is now increasingly being used for obtaining tissue for diagnosis. Anti-tubercular therapy is curative in majority of the cases.

Central nervous system histoplasmosis.

Involvement of the central nervous system (CNS) is recognized clinically in 5% to 10% of patients with progressive disseminated histoplasmosis. The risk of developing CNS histoplasmosis is increased in individuals with impaired cellular immunity, but not all patients with this condition are immunocompromised. Clinical syndromes include chronic meningitis, focal parenchymal lesions of the brain or spinal cord, stroke due to infected emboli, and diffuse encephalitis. CNS histoplasmosis should be considered in any patient with one of these syndromes who has resided in an area endemic for histoplasmosis. A high index of suspicion is necessary when extraneural signs and symptoms are absent. Culture of the causative fungus, Histoplasma capsulatum, from cerebrospinal fluid, brain tissue, or other sites is the gold standard for diagnosis. In culture-negative cases, detection of H. capsulatum antigen in cerebrospinal fluid, urine, or blood is helpful diagnostically. Aggressive and prolonged antifungal therapy is indicated in all cases of CNS histoplasmosis. There are no data from prospective comparative trials upon which to base specific recommendations for treatment. Expert opinion favors an initial course of liposomal amphotericin B, followed by at least 1 year of itraconazole.

Examining sex-related differences in enteric itraconazole metabolism in healthy adults using grapefruit juice.

OBJECTIVE: To explore whether sex-related differences in intestinal itraconazole metabolism exist in healthy adults using grapefruit juice (GFJ) as a selective enteric cytochrome P450 3A4 (CYP3A4) inhibitor. METHODS: Twenty (ten female) subjects received 240 mL bottled water or single-strength GFJ from a frozen concentrate three times daily for 2 days. On day 3, the subjects received an itraconazole oral solution 200 mg with 240 mL of beverage followed 2 h later by 240 mL of the same beverage. Serial blood sampling for itraconazole and hydroxyitraconazole serum concentrations was performed over a 72-h period. After a 20-day washout, the subjects crossed over and repeated the study. RESULTS: Among the female subjects, GFJ reduced itraconazole weight-adjusted apparent oral clearance (Cl/F) (19%, p = 0.006) and increased AUC(0-infinity) (30%, p = 0.01), but produced no significant change in hydroxyitraconazole pharmacokinetics. In males, GFJ produced no significant change in either itraconazole, or hydroxyitraconazole pharmacokinetics. Grapefruit juice also significantly reduced the metabolite:parent AUC(0-infinity) ratio (12%, p = 0.047), in females, but not males. Itraconazole weight-adjusted oral Cl/F was significantly higher in females than males when itraconazole was administered with water (56%, p = 0.009), and although the extent to which GFJ altered itraconazole weight-adjusted oral CL/F was greater in females, it did not differ significantly between the sexes (p = 0.085). RESULTS: The influence of GFJ on the presystemic metabolism of itraconazole was greater in females than males. Repeated ingestion of GFJ significantly reduced itraconazole weight-adjusted oral CL/F and significantly increased exposure in females, but it produced no significant change among males. Although itraconazole weight-adjusted oral Cl/F was much higher in females than in males, the extent to which GFJ altered itraconazole weight-adjusted oral CL/F did not differ significantly between the sexes.

Candida lusitaniae septic arthritis: case report and review of the literature.

Candida lusitaniae is an infrequently encountered Candida species that has been associated with resistance to amphotericin B. We present a case of septic arthritis with C. lusitaniae and provide a brief review of the organism, especially in regard to current information about its pattern of resistance to antifungal agents.

Mycobacterium fortuitum group periprosthetic joint infection.

The Mycobacterium fortuitum group of rapidly growing mycobacteria is recognized infrequently as a cause of periprosthetic joint infection. This report describes a case of periprosthetic joint infection due to a member of the M. fortuitum group where failure to consider this pathogen caused months of diagnostic delay. Aggressive surgery and 6 months of combination antimicrobial therapy eradicated the infection.

Influence of grapefruit juice on the systemic availability of itraconazole oral solution in healthy adult volunteers.

STUDY OBJECTIVE: To evaluate the effect of repeated ingestion of grapefruit juice on the systemic availability of itraconazole (ITZ) and hydroxyitraconazole (OHITZ) serum concentrations in subjects administered hydroxypropyl-beta-cyclodextrin-ITZ (HP-beta-CD ITZ) oral solution. DESIGN: Randomized, two-period, crossover study. SETTING: College of pharmacy research unit. SUBJECTS: Twenty healthy, adult volunteers (10 men, 10 women). INTERVENTION: Subjects received 240 ml of regular-strength grapefruit juice from frozen concentrate or bottled purified water 3 times/day for 2 days. On the third day they received a single dose of HP-beta-CD ITZ oral solution 200 mg (20 ml) with 240 ml of the beverage. Two hours after dosing they received another 240 ml of the beverage. MEASUREMENTS AND MAIN RESULTS: Repeated blood samples were drawn for 72 hours after dosing. After a 14-day washout period, subjects were crossed over to the beverage they had not received previously and the above procedure was repeated. There was no difference in peak ITZ concentration (Cmax) or time to Cmax (Tmax). Coadministration of grapefruit juice reduced OHITZ Cmax nearly 10%, but this difference was not statistically significant. It produced a statistically significant increase in ITZ area under the concentration-time curves from 0-48 hours (AUC(0-48)) (17%) and from time zero extrapolated to infinity (AUC(0-infinity)) (19.5%). Apparent oral clearance of ITZ was significantly reduced (14%). Significant changes in OHITZ exposure were not observed; however, grapefruit juice coadministration produced statistically significant decreased mean OHITZ:ITZ AUC(0-48) and AUC(0-infinity) ratios. Grapefruit juice also decreased the mean OHITZ:ITZ Cmax ratio, but the difference was not statistically significant. CONCLUSION: Repeated grapefruit juice consumption moderately affects ITZ systemic availability in subjects administered HP-beta-CD ITZ oral solution. Unlike previous findings with ITZ capsules, changes in the disposition of ITZ and OHITZ after repeated grapefruit juice consumption are consistent with grapefruit juice inhibition of intestinal cytochrome P450 3A4.

Cerebral histoplasmosis in the azole era: report of four cases and review.

We report four cases of cerebral histoplasmosis and discuss features of six additional cases reported in the medical literature in the past 10 years, when azoles have been available for therapy. Most patients with this disease are immunocompromised or have a history that suggests heavy exposure to Histoplasma capsulatum. Fever and other clinical findings of systemic toxicity caused by disseminated histoplasmosis may be absent; 5 of 10 patients did not manifest these findings. Although the mainstay of treatment for central nervous system histoplasmosis remains amphotericin B, 9 of the 10 patients received itraconazole or fluconazole either as initial therapy or after a course of treatment with amphotericin B.

Detecting bacterial colonization of implanted orthopaedic devices by ultrasonication.

Glycocalyx-producing bacteria have been observed on orthopaedic devices that were removed for reasons other than infection. It has been suggested that the bacteria adhere to foreign surfaces within a biofilm and elude standard culture techniques. The authors adapted previously used ultrasonication protocols that disrupt the surface biofilm before culturing removed orthopaedic devices from patients without clinical evidence of infection. Patients having revision total joint arthroplasty of the hip or knee who lacked current or prior clinical evidence of infection were studied prospectively. During surgery, the femoral component and a corresponding control femoral implant were placed in separate sterile bags of saline. The implant and saline combination was placed in an ultrasonication bath for 30 minutes at 60 Hz. The saline solution was passed through a 0.45-microm pore filter, and the filter residue was cultured on sheep blood agar. None of the 21 implants yielded positive culture on routine microbiologic testing. However, using the ultrasonication protocol, a coagulase-negative Staphylococcus grew from one of the removed implants. Numerous total joint implant failures that are attributed to aseptic loosening may be a result of subclinical infection from bacteria within a biofilm. The current study supports the concept that biofilm-protected bacterial colonization of implants may occur without overt signs of infection and ultrasonication can be used to enhance identification of these bacteria.