Atypical Infection Research Articles

Интерферонопатии при атипичных хронических активных герпесвирусных инфекциях: тактика проведения коррекции дефицита интерферонов

A cytokine imbalance and interferonopathies associated with deficits of type I and type II interferons (IFN) are often observed in atypical chronic active herpesvirus infections (ACA-HVI). Objective. To study the features of IFN system functioning and cytokine profile in patients with ACA-HVI before and after the immune system correction integrative program (ISCIP) including local and systemic interferon therapy. Patients and methods. A total of 39 male and female patients aged 23–70 years with ACA-HVI characterized by isolated disorders in the IFN system were examined. The study included the following methods for herpesvirus detection: serodiagnostics and a real-time polymerase chain reaction (RT-PCR). The cytokine profile (interleukins IL-1β, IL1Ra, IL-6, IL-17) and the IFN system were analyzed by an enzyme-linked immunosorbent assay (ELISA). The study was approved by the Ethics Committee, and an informed consent was obtained from all patients. Results. Patients with ACA-HVI had antiviral immune response disorders. Against the background of serum IFN deficiency, induced and spontaneous production of IFNα and IFNγ, a functional impairment of cytokine profile with predominant hyperproduction of proinflammatory cytokines IL-1β, IL-6, tumor necrosis factor-α were revealed. Positive clinical and immunological effects of ISCIP were demonstrated. It was shown that IL1Ra can be used as a diagnostic biomarker to monitor the course and outcome of ACA-HVI. Conclusions. The developed ISCIP with the inclusion of targeted local and systemic interferon therapy for patients with ACAHVI demonstrated high clinical and immunological efficacy against the background of the confirmed absence of anti-IFNα autoantibodies. Key words: herpesvirus infections, interferonopathies, neutrophil granulocytes, interferon system

Rapid evaluation of the early pathogen of severe Chlamydophila psittaci pneumonia by diagnostic bronchoscopy

To explore the rapid evaluation of the early pathogen of severe Chlamydophila psittaci pneumonia by bedside diagnostic bronchoscopy, so as to start effective anti-infection treatment before the results of macrogenome next generation sequencing (mNGS) test. The clinical data of three patients with severe Chlamydophila psittaci pneumonia who were successfully treated in the First Affiliated Hospital of Xinjiang Medical University, the First People's Hospital of Aksu District, and the First Division Hospital of Xinjiang Production and Construction Corps from October 2020 to June 2021 were retrospectively analyzed, including the rapid assessment of early pathogens by bedside diagnostic bronchoscopy and the use of antibiotics to start anti-infection treatment. These patients were successfully treated. The three patients were male, aged 63, 45 and 58 years old, respectively. Before the onset of the penumonia, they had a clear medical history of bird exposure. The clinical manifestations mainly included fever, dry cough, shortness of breath and dyspnea. One case had abdominal pain and lethargy. The results of laboratory examination indicated that the peripheral blood white blood cell count (WBC) of two patients were high [(10.2-11.9)×109/L], the percentage of neutrophils increased (85.2%-94.6%) and the percentage of lymphocytes decreased (3.2%-7.7%) in all 3 patients after admission to hospital and entering into intensive care unit (ICU). The procalcitonin (PCT) of 3 patients increased after admission, and still increased when entering ICU (0.3-4.8 ng/L), so did C-reactive protein (CRP, 58.0-162.0 mg/L) and erythrocyte sedimentation rate (ESR, 36.0-90.0 mm/1 h). After admission, serum alanine transaminase (ALT) increased in 2 cases (136.7 U/L, 220.5 U/L), so did aspartate transaminase (AST) in 2 cases (249.6 U/L, 164.2 U/L). ALT (162.2-267.9 U/L) and AST (189.8-223.2 U/L) increased in 3 patients when they entered ICU. The level of serum creatinine (SCr) of 3 patients were normal after admission and entering ICU. The chest computed tomography (CT) findings of 3 patients were acute interstitial pneumonia, bronchopneumonia and lung consolidation, of which 2 cases were accompanied by a small amount of pleural effusion, and 1 case was accompanied by more regular small air sacs. Multiple lung lobes were involved, but mainly one lung lobe. The oxygenation index (PaO2/FiO2) of the 3 patients admitting to ICU were 100.0, 57.5 and 105.4 mmHg (1 mmHg ≈ 0.133 kPa), respectively, which met with the diagnostic criteria of moderate and severe acute respiratory distress syndrome (ARDS). All three patients received endotracheal intubation and mechanical ventilation. Under the bedside bronchoscope, the bronchial mucosa of 3 patients were obviously congested and edematous, without purulent secretion, and there was 1 case with mucosal hemorrhage. Three patients underwent bedside diagnostic bronchoscopy, and the evaluation result of the pathogen was that it might be atypical pathogen infection, so they were given moxifloxacin, cisromet and doxycycline intravenously, respectively, and combined with carbapenem antibiotics intravenously. After 3 days, the detection results of mNGS in bronchoalveolar lavage fluid (BALF) showed that only Chlamydia psittaci was infected. At this time, the condition was significantly improved, and PaO2/FiO2 was significantly increased. Therefore, the antibiotic treatment scheme remained unchanged, and mNGS only served to verify the initial diagnosis. Two patients were extubated on the 7th and 12th day of admission to the ICU, respectively, while one patient was extubated on the 16th day of admission to the ICU due to nosocomial infection. All 3 patients were transferred to the respiratory ward after the condition was stable. The bedside diagnostic bronchoscopy based on clinical characteristics is conducive to not only the rapid assessment of the early pathogens of severe Chlamydia psittaci pneumonia, but also effective anti-infection treatment before the returning of mNGS test results, which can make up for the lag and uncertainty of the mNGS test results.

Pneumocystis jirovecii pneumonia and deep vein thrombosis in a patient with glioblastoma multiforme.

We present a case of disseminated Pneumocystis jirovecii pneumonia in a patient with a medical history of glioblastoma multiforme associated with acute deep-vein thrombosis. The patient presented to the emergency department with clinical features of pulmonary infection, and the chest images showed pneumonia. Antibiotics were initiated (azithromycin, cefepime, and vancomycin) and the patient was transferred to the ward for further management, where the condition of the patient continued to worsen over the second day. The patient developed bilateral lower extremity swelling and the doppler ultrasound revealed bilateral lower extremity acute deep vein thrombosis. Laboratory results showed pancytopenia and transaminitis. However, a repeated chest X-ray showed ground-glass changes and interstitial infiltrates, suggestive of atypical infection. We indeed identified D-glucan which hints to a disseminated form of Pneumocystis jirovecii pneumonia infection in this patient. We further confirmed the Pneumocystis jirovecii pneumonia by polymerase chain reaction test from the fluid obtained via bronchoalveolar lavage. We, therefore, initiated intravenous trimethoprim/ sulfamethoxazole treatment with an anticoagulant, and the patient's condition improved. Our findings strongly suggest a possible link between Pneumocystis jirovecii pneumonia infection and thrombogenesis, with impact in medical practice.

380: RARE PRESENTATION OF COXSACKIE VIRUS B MYOPERICARDITIS AS ATYPICAL PNEUMONIA AND SEPSIS

Introduction: While myopericarditis due to Coxsackie virus-B has been widely reported, multi-organ involvement is rare. We report a unique case of Coxsackie B myopericarditis, which presented with rash, atypical pneumonia, hepatitis, and sepsis. Description: A previously healthy 32-year-old man presented to the emergency department in January 2022 endorsing shortness of breath, high-grade fever (39.2˚C), non-pruritic rash on extremities, vomiting, and diarrhea. He had tachypnea (24/min), hypoxia (SpO2 93% on air), and mild lymphadenopathy in the neck. Initial evaluation was pertinent for leukocytosis (17.8 thousand/µL) with neutrophil predominance (89.4%), elevated inflammatory markers (D-dimer [4390 ng/mL], procalcitonin [1.79 ng/mL], CRP [180.7 mg/L], lactate [3.19 mmol/L]), and transamnitis (AST: 160 U/L, ALT: 116 U/L); SARS-CoV-2 and blood cultures were negative. Chest imaging showed bibasilar consolidation, perihilar ground-glass nodules, and pericardial effusion; ultrasound showed acute hepatitis. He was empirically started on ceftriaxone and azithromycin. However, absence of clinical improvement, persistence of high-grade fever, and leukocytosis with low absolute CD3, CD4, and CD8 counts (286 cells/UL, 199 cells/UL and 71 cells/UL, respectively) suggested atypical infection; vancomycin and doxycycline were added. Further infection and autoimmune workup was negative. He developed atrial fibrillation and an echocardiogram was remarkable for ejection fraction of 50-55%, moderate pericardial effusion circumferential to the heart, and minimal collapse of the right atrium. On subsequent testing, Coxsackie virus B type 3 IgM was positive (1:320, reference 1:10). All antibiotics were discontinued, and the patient was managed with diltiazem, colchicine, ibuprofen, and supportive care; anticoagulation was not initiated. After a remarkable improvement in symptoms and rash, he was discharged home. Follow-up imaging showed resolution of bibasilar consolidations and pericardial effusion. Discussion: The likely mechanism of Coxsackie virus B–induced damage to myocytes (and possibly multi-organ involvement) is immune-mediated and direct viral cytotoxicity. Our patient’s atypical pneumonia responded well to colchicine and ibuprofen. A high index of suspicion is warranted.

Macrophage Activation Syndrome in Adult Onset Still’s Disease: A Life Threatening Complication

Adult onset Still’s disease (AOSD), a multi-systemic inflammatory disorder, is a rare disorder but an important differential to be considered in patients of Pyrexia of Unknown Origin, especially if patient presents with polyarthritis. Macrophage activation syndrome (MAS), a subset of Secondary Hemophagocytic Lymphohistiocytosis (HLH), considered as the most life threatening complication of AOSD, mostly develops around the onset of disease. Hence, in a previously undiagnosed case of AOSD, recognizing MAS as a presenting feature complicating underlying AOSD is essential for increased patient survival, as in our case.
 
 
 A 39 year old diabetic female presented with high grade fever with chills and multiple joint pains symmetrically involving proximal shoulder, knees and distal joints (involving MCP, PIP and DIP joints of hand) associated with swelling and early morning stiffness, relieved on activity, since past 6 months. No history of oral ulcers, rash, jaundice, weight loss, loss of appetite, foreign travel or close animal contact.
 
 On examination, Pallor was present, Blood Pressure was 120/70 mm Hg, pulse rate was 102/min and temperature was 100 F. On per abdomen, mild hepatomegaly was present and other system examination was unremarkable.
 
 Routine laboratory findings on day of presentation have been summarised (Table 1.1). Ultrasound Abdomen revealed hepatomegaly and Chest X-ray showed signs of old infective foci. Peripheral smear for Malarial parasite, Ns1Ag and dengue serology, Widal test and Montoux test were negative. Blood cultures and urine cultures were sterile. X-Ray of joints were normal. USG of B/L Knee joints showed mild joint effusion bilaterally with no internal echoes (non tappable). Trans-thoracic echo and Trans-esophageal echo were normal. CT chest, neck and abdomen showed old tubercular changes in lung. Tests for atypical bacterial infections which was normal (RK 39, Chickungunya, Brucella, Leptospirosis and Scrub typhus). Fever did not respond to Broad Spectrum Antibiotics, Antimalarials or Antitubercular therapy and patient continued to have persistent fever spikes.
 
 Autoimmune profile showed ANA and RA Factor negative but markers of inflammation were raised: CRP- 521, ESR -148, IL-6 – 84.0, Procalcitonin-6.9 and S.Ferritin >2000. During the work up for Anemia, Microcytic hypochromic anemia was found with Elevated NAP SCORE-165. Incidentally, her triglycerides were found to be elevated (356) and a reduced fibrinogen. With these results, we planned for a bone marrow aspirate and biopsy which showed increased myeloid preponderance (32:1), increased histiocytes and evidence of hemophagocytosis.
 
 The 2004 diagnostic criteria of HLH was fulfilled. After ruling out almost all infectious and malignant causes of secondary HLH, we searched for a rheumatologic cause. Thus diagnosis of AOSD (after fulfilling Yamaguchi’s criteria) with MAS (a subset of 2’ HLH) was made. Patient had dramatic improvement after receiving steroids with her fever episodes and joint pains settling completely thereafter.
 
 
 Prompt recognition of life threatening complications like MAS which pose diagnostic difficulty due to overlapping features in a patient of AOSD, should be done at the earliest to improve patient prognosis and survival. Serum Ferritin levels can be considered a useful marker to assess the disease activity and to predict MAS occurrence in such patients.

Diagnostic Testing Procedures and Challenges for Primary Immunodeficiencies

Primary immunodeficiencies are rare but are often on the differential diagnosis list when patients present with recurrent or atypical infections. Patients with primary immunodeficiencies can present with a variety of symptoms and can present providers with diagnostic challenges given this variability, and the severe implications of immunodeficiencies can sometimes lead providers to pursue broad workups that may not be necessary. However, there are certain symptom patterns providers can look out for and diagnostic steps that can be taken to triage these presentations. We have used the practice modeled in the "Five Fingers of the Immune Workup" to outline common laboratory tests for clinicians to order when they are concerned for immunodeficiencies while remembering that these diagnoses are often rare, and true concern for this pathology would warrant referral to a specialist. [Pediatr Ann. 2022;51(12):e480-e484.].

Clinical analysis of hospital acquired mycoplasma pneumoniae infection after cardiac surgery: a case series.

Mycoplasma pneumoniae (MP) is a common pathogen of community-acquired respiratory infections. The clinical characteristics hospital-acquired MP infections are rarely reported in the literature. Our ward is mainly responsible for the management of patients during the perioperative period of cardiac surgery. Several patients had fever during the improvement of their condition after cardiac surgery, and the effect of upgrading antibiotics and increasing the antibacterial spectrum was not good. Using inpatient data of Guangdong Provincial People's Hospital, we conducted a retrospective case series study of hospital-acquired MP infection after cardiac surgery from January 2015 to December 2020 to investigate the clinical characteristics. Clinical data was extracted from patients with a confirmed diagnosis of MP infection after >48 hours of hospitalization. All analyses for this study were descriptive. Data were expressed as mean ± standard deviation (SD), median with range or number with percentage as appropriate. We totally included 22 patients. The time of onset of hospital-acquired MP infection after surgery was 23.32±12.57 days, and the duration of antibiotic use before the onset of infection was 4-40 days. Both fever and sore throat were the main symptoms of nosocomial MP infection, and the rash was the most common physical sign. Laboratory tests were normal for peripheral blood leukocyte count and procalcitonin in most patients (17 cases), while the lymphocyte count was decreased in 10 cases. A single serum anti-MP antibody titer ≥1:160 combined with clinical manifestations and imaging helped confirm nosocomial MP infection, although a double serum anti-MP antibody (four-fold change in titer) wasn't seen. With quinolone therapy, such as levofloxacin, all the patients' temperature gradually returned to normal and were discharged uneventfully. Patients after cardiac surgery should be aware of the presence of hospital-acquired MP infection when they develop new fever accompanied by atypical bacterial infection signs such as sore throat and rash during treatment. In such cases, changes in MP antibody titers need to be monitored and anti-MP therapy is required.

Evaluation of the effects in the <i>in vitro</i> system of synthetic thymic hexapeptide on the expression levels of NF-κB, IFNα/βR and CD119 neutrophilic granulocytes in patients with chronic herpes viral co-infections

Background. Strategies used by herpes viruses with human cells are complex and multifaceted. On one hand, inborn defects in antiviral immune defense have been unveiled, which also affect interferon (IFN) system underlying development of chronic recalcitrant relapsing viral infections such as remittent respiratory viral infections, herpesvirus infections, and papillomavirus infections. On the other hand, numerous viruses are able to damage both immune system and IFN network. During inborn and acquired defects in IFN network, inborn or induced mutation in gene products involved in signaling cascades aimed at upregulating gene expression responsible for IFN production are observed. One of the strategies used by diverse viruses is altering some signaling pathways resulting in activated transcription factors including nuclear factor NF-kB. However, antiviral mechanisms executed by neutrophilic granulocytes (NGs), particularly affecting NF-kB expression have not been elucidated. Aim of the study: to study in vitro features of NF-kB expression and number of neutrophilic granulocytes (NG) expressing membrane IFN/R and IFNR in patients with atypical chronic active herpes virus infections (AChA-HVI), followed by assessing an effect of arginyl-alpha-aspartyl-lysyl-valyl-tyrosyl-arginine hexapeptide (HP), a synthetic analogue of the active center of the thymopoietin (active substance of drug Imunofan, Russia), on the expression of NG NF-kB and IFN/R and IFNR. Materials and methods. We observed 25 patients of both sexes aged 23 to 64 years with AChA-HVI, manifested by chronic fatigue syndrome and cognitive disorders. Study design: stage 1 clinical, ELISA, PCR methods, FC was used. Stage 2 the in vitro experiment: 32 blood samples from 8 healthy adults and 375 blood samples from 25 patients with AChA-HVI were analyzed: % NG expressing NF-kB, IFN/R, IFNR and the relevant MFI levels by using FC before and after incubation with HP. Results. Our study demonstrated low level (MFI) of NF-kB expression in 100% NG associated with decreased % of NG expressing IFN/R and IFNR in all patients with AChA-HVI and low serum level for IFN and IFN in comparison with healthy individuals. In the in vitro experiment there was shown that 100% of NG expressed NF-kB after exposure to HP. However, only 48% patients (SG 2) restored NF-kB expression level (MFI) to normal range and 52% of cases (SG 1) had no response. HP increased % of NG expressing IFN/R in SG 2 and increased % of NG expressing IFNR in SG 1. Conclusions. It was shown, that influence of HP in vitro has ambiguous effects on the expression of NF-kB, % of NG expressing IFN/R and IFNR in patients with AChA-HVI. We assume that different NF-kB response to HP is associated with inborn or secondary NF-kB deficiency.

Hemophagocytic Lymphohystiocytosis in a Patient with Post-Acute COVID-19 Infection

Introduction: Hemophagocytic lymphohistiocytosis [HLH] is characterized by immune dysregulation with extensive inflammation and tissue destruction due to abnormal immune activation. Although primary HLH is commoner in the pediatric population, secondary HLH [sHLH] is more typical in adults, with underlying associations such as hematologic malignancy, infections or rheumatologic conditions. COVID-19 infection has been associated with immune dysregulation syndromes such as cytokine storm as well as HLH. However, post COVID-19 patients who have recovered with negative serologic tests may also present with sHLH, an unusual finding which our case demonstrates. Case report: A 73-year-old male with a notable past medical history of fall COVID-19 infection approximately 11 months prior presented initially to emergency services with a chief complaint of high fevers, lethargy and progressive changes in mentation gradually progressive over the last 5 months duration. Initial work-up for sources of infection including testing for atypical infections and imaging investigations were unrevealing. Laboratory investigations were remarkable initially for transaminitis, elevated LDH, anemia and thrombocytopenia. Coagulation panel revealed prolonged APTT and PT with low fibrinogen. Ferritin level was markedly elevated. This presentation was concerning for hemophagocytic lymphohistiocytosis. The patient did have a bone marrow biopsy two months prior to presentation which was unremarkable for hematologic malignancy or features suggestive of HLH such as hemophagocytosis. In view of the patient's high H score and clinical suspicion for HLH, he was initiated on dexamethasone 20 mg daily. Cryoprecipitate and platelet transfusions were administered for correction of coagulopathy. Over the course of the hospitalization, WBC count continued to drop with critically low absolute neutrophil counts prompting initiation of Filgrastim. No noticeable clinical improvement was noted over the subsequent days of hospitalization, and the patient was subsequently trialed on an intravenous immunoglobulin protocol for 3 days. Despite all treatment offered, the patient continued to deteriorate and after consultation with family members and the palliative care team, patient was transitioned to comfort measures only and code status was changed to DNR/DNI. The patient subsequently passed away a few days later. Conclusion: sHLH following COVID-19 infection, although previously described, remains a poorly understood phenomenon. Even more puzzling is why certain patients develop a delayed sHLH following postacute COVID-19 illness. Notably, the severity of the COVID-19 infection does not appear to be related to one's predisposition to develop sHLH. Regardless of etiology, the mortality of HLH remains high even with appropriate therapy, especially with neurologic involvement and markedly elevated ferritin levels.

Concordance of diagnostic modalities in atypical skin and soft tissue infections in hospitalized patients.

Skin and soft tissue infections (SSTIs) have high rates of morbidity and mortality worldwide but lack reliable standards for diagnostic workup. As a result, atypical infections, more prevalent among immunocompromised patients, can be missed due to deviance from classic features only to be revealed later through inconsistently performed ancillary studies. Our objectives included to evaluate the sensitivities of clinical impression, histopathology, tissue culture, and molecular and non-molecular ancillary tests in diagnosing inpatient SSTIs, as well as to qualitatively discuss the unusual features making a subset of infections "atypical." To do so, we retrospectively reviewed the histopathologic reports and charts of inpatient dermatologic consults at a single tertiary care institution over a 3-year period. We identified a total of 111 cases of SSTIs evaluated by the inpatient dermatology consultation service with concurrent skin or soft tissue biopsy, with 32.4% representing atypical infections. Among these, clinical impression suggested infection in 9(25.0%), routine histopathology in 21(58.3%), specialized stains for microorganisms in 22(68.8%), and tissue culture in 15(68.2%). Due to incomplete picture that each modality by itself creates, we conclude that clinicians and pathologists should carry a low threshold for including SSTIs in their differential diagnoses and should evaluate with skin biopsy, special stains for microorganisms, and ancillary studies, particularly in critically ill individuals who necessitate timely diagnoses.

Cryptococcus Infection Mimicking Lipoid Pneumonia in a Lung Biopsy

Abstract Introduction/Objective Lipoid pneumonia is a non-infectious, rare entity which results from accumulation of exogenous or endogenous lipids in the lungs. It appears as intraalveolar macrophages filled with lipids in the form of fine spherical vacuoles. Cryptococcosis can also appear as vacuolated macrophages filled with yeasts. At low magnification, the distinction is very difficult. The co-existence of the two entities is noted in literature but is exceedingly rare. Methods/Case Report A 33-year-old male, status post renal and pancreatic transplant, on chronic immunosuppression therapy presented with dysphagia. Imaging studies showed cavitary and non-cavitary nodules, patchy, confluent consolidations in the bilateral lungs, and a patulous, debris filled esophagus. This raised the possibility of atypical infections as well as aspiration. Biopsy of a right lower lobe lung lesion was performed. Histology demonstrated fibrotic lung parenchyma with vacuolated histiocytes containing small spherical substances. The differential diagnosis included Cryptococcus infection versus exogenous lipoid pneumonia, both of which were consistent with clinical and radiologic findings. Few, scattered foreign body giant cells were found. Additionally, GMS and mucicarmine stains were positive in the small spheres within the macrophages. The final diagnosis of lung parenchyma with numerous yeast forms, morphologically consistent with cryptococcus species was rendered. The patient was additionally found to have esophageal candidiasis. Concurrent lipoid pneumonia was considered unlikely based on the patient's history of immunosuppression (which made infection a much more likely etiology) and paucity of foreign body giant cell reaction. Results (if a Case Study enter NA) NA Conclusion This case highlights the importance of knowledge of rare entities and correlation with clinical and radiologic findings in arriving at an accurate diagnosis.

Abstract 15242: Donor-Derived Chagas Disease Masquerading as Acute Heart Transplant Rejection

Introduction: Although Chagas disease affects over 300,000 residents in the US, donor-derived Trypanosoma cruzi transmission is an uncommon complication after heart transplantation. We present a case of post-transplant Chagas cardiomyopathy. Results: A 68 year old male with history of heart failure with reduced ejection fraction secondary to ischemic cardiomyopathy, status post HeartMate III and subsequent orthotopic heart transplantation from a Hispanic donor, initially presented four months after transplant for routine right heart catheterization. Endomyocardial biopsy showed grade 2R acute cellular rejection. Patient was treated with IV steroids and discharged. One month later, he presented with one week of fevers, malaise, non-tender erythematous patches on his upper body and hemorrhagic bullae on his buccal mucosa. Initial workup was notable for pancytopenia with WBC 1.3 x10e9/L, hemoglobin 10.3g/dL, and platelets 77 x10e9/L, troponin 3.47 ng/mL, NT-proBNP 11,331 pg/mL, and new right bundle branch block on electrocardiogram. Cardiac MRI showed extensive multifocal late gadolinium enhancement and pericardial exudates, suggestive of atypical infection. Despite treatment with Filgrastim and IVIG, the patient progressed to cardiogenic shock complicated by complete heart block requiring transvenous pacing, and ventricular tachycardia. On hospital day 5, a peripheral smear confirmed Trypanosoma cruzi with high parasite burden and amastigotes were visualized on a shave biopsy of his rash. Patient was initiated on Benznidazole. He was treated in the intensive care unit, where his course was further complicated by recurrent VT, for which he received an implantable cardiac defibrillator, and renal failure requiring hemodialysis. Conclusions: We present a case of suspected donor-derived Chagas Disease. In retrospect, this patient’s initial episode of acute rejection was most likely due to Chagas Disease. Due to increasing globalization of endemic diseases and life-threatening complications associated with this disease, a high index of suspicion is required to diagnose and treat T. cruzi after heart transplantation in the setting of non-specific symptoms.

A Combined Scoring Method Based on 18F-FDG PET/CT for Distinguishing Spinal Infection From Malignancy.

Retrospective study. This study aimed to explore the additional value of fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) for the detection of early-stage and atypical spinal infections and to find the best combination of indicators from laboratory and imaging systems for higher diagnostic efficiency. Diagnosis of early-stage and atypical spinal infections may be challenging for clinicians. It is particularly important to distinguish spinal infection from malignancy to develop a timely treatment strategy and avoid unnecessary biopsy or surgery. All patients with a discharge diagnosis of spinal infection or malignancy who underwent 18F-FDG PET/CT scans before spinal biopsy between January 1, 2014, and July 30, 2021, were included. Laboratory and imaging data were assessed. A receiver operating characteristic (ROC) curve was created, and the best cut-off point and cumulated area under the curve (AUC) were obtained to distinguish between spinal infection and malignancy. Kappa values were used to assess the agreement between the 18F-FDG PET/CT and MRI findings. Binary logistic regression was used to screen for statistically significant indicators and imaging findings. A total of 71 patients with confirmed spinal infections (n=30) or malignancies (n=41) were included in this study. Elevated ESR and significantly elevated tumor biomarkers or positive FLCs assay were significantly different between the two groups. In addition to the total lesion glycolysis of the involved vertebral bodies derived from 18F-FDG PET/CT, four imaging findings (consecutive multilevel vertebral lesions, intervertebral disc, vertebral arch, and extraspinal involvement) also showed significant differences between the two groups (P≤0.010). A combined scoring method based on the above seven indicators was designed with an overall classification accuracy of 95.2%, and it identified all patients with spinal infections (100%, 28/28). In addition, moderate-to-excellent agreement could be reached for the involvement of intervertebral discs, paravertebral soft tissues, and vertebral arches derived from MRI and18F-FDG PET/CT. The combined scoring method based on 18F-FDG PET/CT provided excellent overall accuracy in distinguishing spinal infections from malignancies. This approach may prove useful for patients with MRI contraindications or with equivocal results following laboratory tests or traditional imaging when there is high suspicion for spinal infections or malignancy.

Pyoderma Gangrenosum Affecting the Dorsal Hand: A Case Report.

Pyoderma gangrenosum is an uncommon neutrophilic dermatosis characterized by an ulcerative lesion with a violaceous border. Most frequently, these lesions present in the lower extremity and are associated with underlying immune-mediated comorbidities. Infrequently, these lesions may present in the upper extremity, which presents difficult challenges for upper extremity surgeons as the lesions are frequently misdiagnosed as an infectious process. This often leads to inappropriate surgical debridement and antibiotic administration. Local trauma to the lesion can lead to a process of pathergy and worsening of the lesion. Here, we report on a case of cutaneous pyoderma gangrenosum affecting the dorsal hand, originally misidentified as an atypical infection with subsequent unsuccessful surgical debridement. After involvement of a multidisciplinary team, appropriate diagnosis was made, and treatment with local immunosuppressive agents achieved resolution of the lesion.

Nocardia farcinica pituitary abscess in an immunocompetent patient: illustrative case.

Pituitary abscess is a rare clinical entity, typically precipitated by Staphylococcus, Pseudomonas, or Aspergillus infection. Although Nocardia species-associated central nervous system abscesses have been documented in immunocompromised patients, no case of Nocardia pituitary abscesses has been previously reported. A 44-year-old man presented with hemoptysis and was found to have a cavitary right lung nodule, which was presumed histoplasmosis, prompting antifungal treatment. Several months later, he developed panhypopituitarism. Magnetic resonance imaging identified a pituitary mass, which subsequently underwent transsphenoidal endoscopic biopsy. Infectious workup was negative, and the patient was discharged on intravenous ertapenem therapy. Over several months, he developed progressive headaches, and updated imaging confirmed interval enlargement of the mass with new cavernous sinus invasion. He underwent repeat endoscopic biopsy, which yielded positive cultures for Nocardia farcinica and prompted successful treatment with trimethoprim-sulfamethoxazole and linezolid. The current study highlights a previously unreported clinical entity, the first pituitary abscess attributable to Nocardia sp. or N. farcinica, which arose in a young, immunocompetent individual. Although rare, atypical infections represent an important component in the differential diagnosis for sellar mass lesions.

Recommendations for laboratory testing of UK patients with acute myeloid leukaemia.

Recommendations for laboratory testing of UK patients with acute myeloid leukaemia.

Case report: Unexpected parvovirus B19 infection in a myeloma patient treated with daratumumab

Multiple myeloma patients have an increased risk of infections due to both the inherent nature of the disease and ongoing treatment. We describe the case of a patient who was treated with daratumumab-lenalidomide-dexamethasone regimen for two years and developed a parvovirus B19 infection. The clinical picture, characterized by trilinear cytopenia, was initially attributed to anti-neoplastic treatment. Later on, when the patient’s condition worsened, an extensive diagnostic workup was applied and parvovirus B19 infection was detected by PCR. Due to the lack of effective antiviral drugs, the patient received IV immunoglobulins and it took 10 days to achieve a decrease in viral copies. Physicians should be aware that recent changes in the therapeutic scenario of multiple myeloma would make patients more susceptible to atypical infections in this patient setting.

Atypical Viral Infections in Gastroenterology.

Enteric viruses are commonly found obligate parasites in the gastrointestinal (GI) tract. These viruses usually follow a fecal-oral route of transmission and are characterized by their extraordinary stability as well as resistance in high-stress environments. Most of them cause similar symptoms including vomiting, diarrhea, and abdominal pain. In order to come in contract with mucosal surfaces, these viruses need to pass the three main lines of defense: mucus layer, innate immune defenses, and adaptive immune defenses. The following atypical gastrointestinal infections are discussed: SARS-CoV2, hantavirus, herpes simplex virus I, cytomegalovirus, and calicivirus. Dysbiosis represents any modification to the makeup of resident commensal communities from those found in healthy individuals and can cause a patient to become more susceptible to bacterial and viral infections. The interaction between bacteria, viruses, and host physiology is still not completely understood. However, with growing research on viral infections, dysbiosis, and new methods of detection, we are getting closer to understanding the nature of these viruses, their typical and atypical characteristics, long-term effects, and mechanisms of action in different organ systems.

S3177 The (Icteric) Eye of the Storm: A Case of Weil’s Syndrome

Introduction: Leptospirosis is one of the most prevalent zoonotic diseases affecting humans residing in tropical areas. We herein describe a case of a patient with leptospirosis acquired in the Bronx, NY. Case Description/Methods: A 63 year-old man with no significant medical history was evaluated for muscle pain, fatigue, and diarrhea of 3 days duration. He was feverish to 102 F and icteric. Laboratory evaluation revealed hemoglobin of 7.5 g/dL, total white count of 18 k/uL, platelet count of 40 k/uL, INR 1.5, creatinine of 5 mg/dL, urea nitrogen 85 mg/dL, creatine kinase 4000 U/L, alkaline phosphatase 192 U/L, total bilirubin 39 mg/dL, direct bilirubin > 23 mg/dL, AST 96 U/L, ALT 113 U/L and albumin 2.5 g/dL. Initial laboratory evaluation was negative for common and atypical infections. Radiologic evaluation revealed unremarkable non-contrast MRCP and US abdomen. Upon further detailed history, the patient reported that his basement was recently flooded by a devastating hurricane. Despite negative parasite blood smear and IgM antibodies for leptospira, empiric treatment for leptospirosis with Ceftriaxone resulted in resolution of all symptoms and lab abnormalities. Repeated blood work on follow-up visits at 4 weeks was noted with positive IgM antibodies for leptospira (Figure). Discussion: Leptospirosis is caused by a poorly staining gram-negative spirochetal bacteria. Transmission to humans occurs through mucous membranes, open skin wounds or after drinking, eating, swimming, or wading in water contaminated by stool or urine of infected rodents. Outbreaks have been documented in non tropical, urban areas affected by hurricanes, heavy rains or floods. In approximately 90% of cases, the disease is anicteric. Phase 1 includes viral-like illness, conjunctival suppuration followed by transient improvement. Phase 2 includes myalgia, nausea, vomiting, abdominal pain, hepatomegaly, increased serum bilirubin and serum aminotransferases. 10% of cases manifest as Weil’s syndrome, characterized by jaundice in the first phase, followed by second phase manifesting with high fever, profound jaundice with severely elevated serum bilirubin levels (up to 30mg/dL, mostly direct) and elevated serum transaminases. Renal and liver involvement are predominant and can lead to severe morbidity and death. Blood cultures, urine cultures and specific anti Leptospira IgM serology can assist with diagnosis. Antibiotic treatments, primarily Penicillin, 3rd generation Cephalosporins and Doxycycline, can benefit if administered at an early stage.Figure 1.: Laboratory evaluation during hospital stay and 4 weeks after discharge. Abbreviation: ALP, alkaline phosphatase; TB, total bilirubin; DB, direct bilirubin; AST, Aspartate transaminase; ALT, Alanine transaminase.

Republication de : A silent, trapped guest in the maxillary sinus: Oestrus ovis myiasis with unusual presentation (with CARE guideline)

A sheep bot fly, Oestrus ovis, is an obligate parasite that is found worldwide, especially widespread in the Mediterranean areas and Middle Eastern. Interestingly, in this report, a case with an L3 larva trapped in the human maxillary sinus with other stage larvae is presented. A 32-year-old female patient has no symptoms until the larva is expelled by sneezing. Endoscopic examination was normal on admission. Paranasal sinus computed tomography (CT) revealed left maxillary sinus soft tissue density. Uncinectomy and middle meatal antrostomy was performed to remove the infection and larvae. Human ophthalmic and nasopharyngeal myiasis have been documented but asymptomatic maxillary sinus myiasis is unusual and not reported. Due to changes in environmental factors, this atypical infection may occur with an unexpected presentation.