A Case of Cryptococcal Meningitis and Fungemia With Relapse in an HIV-Negative, Non-transplant Patient on Azathioprine Therapy for Mixed Connective Tissue Disorder.

Cryptococcal meningitis typically occurs in immunocompromised patients. Approximately 80% of cryptococcal infections occur in HIV patients. Non-HIV, non-transplant recipient patients are the least numerous population groups affected by cryptococcal infections. While this group includes patients on biologics and corticosteroids, very few cases have been reported in patients on azathioprine. Cryptococcal meningitis requires antifungal therapy, the duration of which varies among different population groups. Inadequate duration of antibiotics among these groups is one of the most common reasons for relapse; therefore, it is crucial to consider patient demographic when determining antifungal duration. Here, we report a 68-year-old male with a history of mixed connective tissue disease on azathioprine for six years, who was admitted to the hospital with worsening lethargy. Several days into admission, the patient developed low-grade fevers. Subsequent blood cultures grew Cryptococcus neoformans. He was started on liposomal amphotericin B. Lumbar puncture (LP) was done, which demonstrated positive cryptococcal antigen, and flucytosine was added to the treatment regimen. Repeat CSF culture demonstrated no fungal organisms. Amphotericin B was discontinued after 20 days of therapy. Following clinical improvement, he was subsequently discharged on oral fluconazole. One week following discharge, the patient was readmitted with worsening fevers and altered mental status. CSF studies demonstrated the growth of Cryptococcus on culture. Liposomal amphotericin B was reinitiated, and fluconazole was continued. Imaging showed hydrocephalus, which worsened despite ventriculoperitoneal shunt. The patient expired following transition to comfort care. In conclusion, cryptococcal meningitis should be considered as a differential in non-HIV, non-transplant patients on azathioprine presenting with fever and worsening lethargy, and 4-6 weeks of induction therapy is required in this patient group to prevent relapse.

Mycobacterium arupense finger osteomyelitis: Case report.

We describe a case of persistent tenosynovitis in the right fourth finger of a 50-year-old man that after almost a year of workup was found to be related to osteomyelitis caused by Mycobacterium arupense. The few cases found in the literature were associated with traumatic injuries, environmental contamination, and months of misdiagnosis. Treatment is challenging as there are limited data available on antimicrobial susceptibility and potential side effects of current therapy options.

A case of recurrent Corynebacterium jeikeium endocarditis: Unanswered questions for the treatment of chronic endovascular infections.

A 53-year-old woman with end-stage renal impairment on hemodialysis was evaluated for recurrent episodes of Corynebacterium jeikeium bacteremia and endocarditis. Her recurrences occurred despite surgical debridement and extended courses of culture-directed antimicrobial therapy. The clinical course was complicated by the requirement of various endovascular prostheses for vascular access. To our knowledge this degree of relapse with guideline medical and surgical therapy is rare and challenges current practice and understanding of this group of infection.

Strongyloides Stercoralis Infection Among Human Immunodeficiency Virus (HIV)-Infected Patients in the United States of America: A Case Report and Review of Literature.

BACKGROUND Strongyloides stercoralis infection is endemic in subtropical and tropical regions but is reported rather sporadically in temperate countries. In the USA, the highest rates of infection are from the southeastern states, predominantly among immigrants. There is paucity of case reports on S. stercoralis infection among HIV-infected patients who were born and raised in the USA. CASE REPORT A 61-year-old male with known HIV infection (CD4 count: 235 cells/uL, undetectable HIV RNA, on antiretroviral therapy) presented with a 3-month history of diarrhea. He was initially diagnosed to have diarrhea secondary to norovirus and later with Escherichia coli. He was treated with levofloxacin but the diarrhea persisted. Stool PCR, Clostridium difficile enzyme-linked immunoassay, cryptosporidium and giardia antigen, cyclospora and isospora smear, and fecal microscopy were all negative. Peripheral blood eosinophil count was 1,000 eosinophils/mcL. Colonic biopsies revealed fragments of S. stercoralis larvae within the crypts. The patient was treated with ivermectin with improvement of symptoms. Social history revealed that he was born and raised in the northeastern USA. He was a daily methamphetamine user and engaged in anal sex with men. He denied travel to endemic areas, except for a visit to Japan more than 30 years ago. CONCLUSIONS Our case highlights that S. stercoralis may be an underdiagnosed/under-reported cause of chronic diarrhea among HIV-infected patients. What makes this case peculiar is that the patient was born and raised in the continental USA, absence of recent travel to endemic areas, and relatively high CD4 counts. Parasitic infections, such as S. stercoralis, should be considered among HIV-infected patients with persistent diarrhea and eosinophilia regardless of ethnicity or recent travel history.

Persistent Bacteremia from Pseudomonas aeruginosa with In Vitro Resistance to the Novel Antibiotics Ceftolozane-Tazobactam and Ceftazidime-Avibactam.

Ceftazidime-avibactam and ceftolozane-tazobactam are new antimicrobials with activity against multidrug-resistant Pseudomonas aeruginosa. We present the first case of persistent P. aeruginosa bacteremia with in vitro resistance to these novel antimicrobials. A 68-year-old man with newly diagnosed follicular lymphoma was admitted to the medical intensive care unit for sepsis and right lower extremity cellulitis. The patient was placed empirically on vancomycin and piperacillin-tazobactam. Blood cultures from Day 1 of hospitalization grew P. aeruginosa susceptible to piperacillin-tazobactam and cefepime identified using VITEK 2 (Biomerieux, Lenexa, KS). Repeat blood cultures from Day 5 grew P. aeruginosa resistant to all cephalosporins, as well as to meropenem by Day 10. Susceptibility testing performed by measuring minimum inhibitory concentration by E-test (Biomerieux, Lenexa, KS) revealed that blood cultures from Day 10 were resistant to ceftazidime-avibactam and ceftolozane-tazobactam. The Verigene Blood Culture-Gram-Negative (BC-GN) microarray-based assay (Nanosphere, Inc., Northbrook, IL) was used to investigate underlying resistance mechanism in the P. aeruginosa isolate but CTX-M, KPC, NDM, VIM, IMP, and OXA gene were not detected. This case report highlights the well-documented phenomenon of antimicrobial resistance development in P. aeruginosa even during the course of appropriate antibiotic therapy. In the era of increasing multidrug-resistant organisms, routine susceptibility testing of P. aeruginosa to ceftazidime-avibactam and ceftolozane-tazobactam is warranted. Emerging resistance mechanisms to these novel antibiotics need to be further investigated.

Pulmonary Nocardiosis in a Multiple Myeloma Patient Treated with Proteasome Inhibitors.

BACKGROUND: The use of proteasome inhibitors like Bortezomib to treat multiple myeloma has been associated with increased rates of opportunistic infections, including Nocardia, especially when lymphopenia is present. The prevalence or association of such infections with newer agents like Carfilzomib is not known. CASE REPORT: A 71-year-old man with multiple myeloma presented with a 6-week history of respiratory symptoms and cyclic fevers. He was undergoing chemotherapy with Carfilzomib. Work-up revealed severe lymphopenia and a CT chest showed multiple lung nodules and a mass-like consolidation. He underwent a bronchoscopy, and respiratory cultures grew Nocardia species. He responded well to intravenous antibiotics with resolution of symptoms and CT findings. CONCLUSIONS: With the introduction of newer agents like Carfilzomib for the treatment of multiple myeloma, clinicians must maintain a high degree of suspicion for opportunistic infections to achieve early diagnosis and treatment.

A case of bovine valve endocarditis caused by Engyodontium album.

We report the first case of Engyodontium album bioprosthetic valve endocarditis in a 44-year-old male with a history of juvenile rheumatoid arthritis. There is only one other report of Engyodontium album as a human pathogen. The present case supports the increased incidence of fungal endocarditis especially in patients receiving immunotherapy.