Course Of Ciprofloxacin Research Articles

1538 An Unusual Presentation of Ischemic Colitis

INTRODUCTION: We present an unusual physical exam finding in ischemic colitis. CASE DESCRIPTION/METHODS: A 44 year old male with no known medical history presented to emergency department with complaint of abdominal pain and flu-like symptoms for 10 days. He had associated bloating and constipation which was minimally relieved with over the counter laxatives. There was no report of hematochezia or melena. Computed tomography of the abdomen and pelvis was notable for severe contiguous wall thickening and pericolonic fat stranding in the descending colon, sigmoid colon, and rectum. These findings were suspicious for either infectious or inflammatory colitis. There were no abnormalities in the mesenteric vasculature. The patient was discharged on an empiric course of ciprofloxacin and metronidazole, and was seen in the office two days later for follow up. On physical examination, there was an unusual finding of a tender, non-pulsating palpable mass over the left hemi-abdomen without rebound, guarding or rigidity. The patient's antibiotics were discontinued due to low suspicion for an infection. Given the finding of abdominal mass on exam, he was referred for urgent colonoscopy out of concern for colon cancer or lymphoma. On colonoscopic examination, findings were notable for altered vascularity, edema, erythema and linear erosions throughout the rectum, sigmoid colon and descending colon which were consistent with colitis. Biopsies from these sites showed edema and superficial prominence of capillary-sized vessels. The patient was given a diagnosis of colonic ischemia and he was provided with appropriate treatment. One week later on telephonic follow up, the patient reported resolution of his symptoms with plan for repeat computed tomography of the abdomen. DISCUSSION: This patient presented with an unusual finding of a palpable mass to his left hemi-abdomen in the setting of colonic ischemia. Abdominal masses on exam are most frequently due to hernias, neoplasms, infectious collections and hematomas. However, the diagnosis of colonic ischemia generally relies on history, imaging and colonoscopy. The available literature on physical exam is generally non-specific and limited to abdominal tenderness. This patient had the characteristic findings of colonic ischemia including edema, linear erosions and segmental erythema to support a diagnosis of colonic ischemia. It is suspected that his abdominal mass represented the affected colonic segments which makes this a rather unique finding for this disease.

1547 Pseudomonas Aeruginosa: A Rare Cause of Community-Acquired Antibiotic-Associated Diarrhea in an Immunocompetent Adult

INTRODUCTION: Pseudomonas aeruginosa (P. aeruginosa) is an opportunistic gram negative pathogen known to cause enterocolitis in children and nosocomial infections, including hospital acquired pneumonia (HAP) and catheter associated urinary tract infections (UTIs). Rarely, P. aeruginosa causes antibiotic-associated diarrhea in immunocompromised hosts, but this has not been reported in immunocompetent ambulatory hosts. CASE DESCRIPTION/METHODS: An 81 year old previously healthy woman presented to the emergency department (ED) with diarrhea for 2 days. A week prior to symptom onset, she completed a 17 day course of ciprofloxacin for a UTI, with resolution of dysuria. She described frequent, watery, nonbloody bowel movements with nausea and emesis. She was treated with intravenous saline and ondansetron, and discharged. The next day, she developed bloody bowel movements associated with weakness and mild lower abdominal pain. With ongoing diarrhea, she returned to the ED. Physical exam showed very mild left lower quadrant abdominal tenderness, without rebound or guarding. Laboratory studies showed white blood cell count 11,800 cells/mcL, potassium 3.3 meq/dL, and lipase 67 units/L. Electrolytes and liver enzymes were otherwise normal. Clostridium difficile (C difficile) stool toxin PCR was negative. CT abdomen and pelvis without contrast showed diverticulosis and mild inflammation surrounding the sigmoid colon (Figures 1 and 2). She was started empirically on ciprofloxacin and metronidazole, and admitted to the medical floor. Over the next 3 days, she gradually improved. Stool culture grew P. aeruginosa, with absence of normal fecal flora. Sensitivities showed resistance to ciprofloxacin and levofloxacin. Given her clinical improvement, antibiotics were discontinued after 7 days. DISCUSSION: We report a case of P. aeruginosa as a cause of bacterial colitis. Our patient's prior antibiotic therapy may have increased her susceptibility to this infection via loss of normal fecal microbiota, leading to a loss of competitive exclusion and diminished colonic barrier protection. To our knowledge, this is the first reported case of post-antibiotic diarrhea caused by P. aeruginosa in an immunocompetent ambulatory host. This may be an important diagnostic consideration in patients presenting with persistent diarrhea following antibiotics, with negative C. difficile stool testing. The role for antibiotic therapy in Pseudomonas associated diarrhea warrants further research.

2375 Unusual Presentation of Spontaneous Bacterial Empyema in Cirrhosis

INTRODUCTION: Spontaneous bacterial empyema (SBEM) is defined as spontaneous infection of the pleural fluid in the absence of underlying pneumonia. Diagnostic criteria include i) serum/pleural fluid albumin gradient (SPAG) >1.1 g/dL, ii) polymorphonuclear (PMN) cells >500/mm3 or positive fluid culture with PMN cell count >250 cells/mm3 and iii) absence of pneumonia or malignancy. SBEM is an under-diagnosed entity, prevalence being 5-12% overall in cirrhotics and 16% in hepatic hydrothorax (HH). HH is usually right-sided (65-85%), however it may be left sided or bilateral. Most patients with SBEM present with dyspnea or pleuritic chest pain. We present a case of SBEM with an unusual presenting complaint. CASE DESCRIPTION/METHODS: 59-year-old male with decompensated alcoholic cirrhosis presented with abdominal pain. Physical exam significant for tachycardia, fever (102.3 F), jaundice, diminished breath sounds over the right lung base and diffuse abdominal tenderness. Lab data notable for mild leukocytosis and deranged liver functions (Total bilirubin 5.8 mg/dl, Albumin 1.8 g/dl, INR 2.3). A chest radiograph showed moderate right sided pleural effusion without pneumonia or lung mass, confirmed on CT. Abdominal CT showed absence of ascites. Thoracentesis yielded 1.5 L of clear yellow fluid, with 7000 WBC (90% PMNs) and albumin was 0.6 g/dl. SPAG was greater than 1.1 g/dl. Cytology and cultures were negative. This confirmed the diagnosis of SBEM. Thoracentesis lead to resolution of abdominal pain and patient was discharged to complete a 7 day course of Ciprofloxacin. DISCUSSION: Pathogenesis of SBEM is unclear, proposed mechanisms being direct bacterial spread from the peritoneal cavity or transient bacteremia in the absence of ascites. Risk factors include low pleural fluid protein, low serum albumin levels, presence of SBP and high Child-Pugh scores. Factors which portend poor prognosis are high MELD-Na, early ICU admission and antibiotic failure. Treatment includes thoracentesis and third generation cephalosporins. Chest tube insertion is not recommended. Role of long term antibiotic prophylaxis is unclear. In conclusion, SBEM is associated with high mortality and often under diagnosed due to lack of routine chest imaging in patients with ascites or suspicion for SBP. Majority of SBEM cases are associated with ascites (88%) and SBP (47%). Our case is unique because patient presented with abdominal pain in absence of ascites and symptom resolution post thoracentesis.

1638 Post-Colonoscopy Diverticulitis: A Rare Complication

INTRODUCTION: Post-colonoscopy diverticulitis is a rare but potentially significant complication. We report a case of colonoscopy-induced diverticulitis in a patient with no prior history of diverticulitis. CASE DESCRIPTION/METHODS: A 59-year-old female with a past medical history of hypertension, hypothyroidism and gastroesophageal reflux disease presented for a screening colonoscopy. Colonoscopy findings included a few small and large-mouthed diverticula in the sigmoid colon, a 4mm sessile polyp in the sigmoid colon removed with cold biopsy forceps, and non-bleeding grade I internal hemorrhoids. Pathology of the polyp returned as tubular adenoma. Two days post-procedure, she reported worsening lower abdominal pain as well as nausea and was recommended to go to the emergency room. On arrival, she was afebrile and hemodynamically stable. She was noted to have tenderness to palpation along her lower abdomen, greatest in the left lower quadrant. She denied fevers, chills or rectal bleeding. Labs were significant for a white blood cell count of 11.63 × 103/μL (reference range 4.5-11 × 103/μL). CT abdomen/pelvis with IV contrast showed inflamed diverticulum within the sigmoid colon with surrounding inflammatory changes, consistent with uncomplicated sigmoid diverticulitis. She was discharged home with a 10 day course of ciprofloxacin and metronidazole, and was doing well at her follow up visit. DISCUSSION: Although colonoscopy-induced diverticulitis is a rare finding, it is important to consider it as a complication in patients with symptoms after colonoscopy. Potential causes of post-colonoscopy diverticulitis include barotrauma, multiple attempts for intubation, and direct pressure of the scope. Another possible cause is reactivation of silent diverticulitis, with air insufflation unsealing micro-perforations in diverticula. Prior history of diverticulitis is associated with incomplete colonoscopy and can be a risk factor for developing diverticulitis; this is likely due to deformed colonic architecture from prior severe inflammation. Our patient had no prior history of diverticulitis, and presented with diverticulitis two days after her first colonoscopy. More research needs to be done on the risk of post-colonoscopy diverticulitis in those without a prior history of diverticulitis, as the prevalence of this complication is likely higher than reported.

1643 Colonic Malakoplakia: An Exquisitely Rare Cause of Lower GI Bleeding

INTRODUCTION: Malakoplakia is a rare chronic granulomatous disease that may affect many organs. The gastrointestinal tract is the second most common site of involvement (after the urinary tract). The most common sites of colonic involvement are the rectum, sigmoid, and right colon, in descending order of frequency. The pathogenesis of malakoplakia is unknown. The treatment of malakoplakia ranges from antibiotic therapy to surgical resection. Here we describe a case of a 33-year-old man who presented with hematochezia and was noted to have malakoplakia on rectal mass biopsy during colonoscopy. CASE DESCRIPTION/METHODS: A 33-year-old man presented to our clinic due recurrent episodes of painless hematochezia in the setting of warfarin for recent lower extremity deep venous thrombosis. He is a resident of a nursing home due to a complex neurosurgical history which includes resection of a right temporal glioblastoma multiforme tumor followed by chemo and radiation therapy. He also had subsequent craniotomy and ventriculo-peritoneal shunt placement and used oral dexamethasone for recurrent episodes of cerebral edema related to residual brain tumor. Despite stopping warfarin he continued to have rectal bleeding. Colonoscopy showed a frond-like/villous, fungating and polypoid non-obstructing circumferential mass in the rectum. Biopsies showed malakoplakia. After multidisciplinary discussions, a decision was made to continue dexamethasone to minimize cerebral edema and bowel resection was declined by patient’s parents. We opted to use a prolonged course of Ciprofloxacin, however, the patient developed severe urosepsis and unfortunately died. DISCUSSION: First reported by Michaelis and Gutmann in 1902, malakoplakia is derived from the Greek “malakos” (soft) and “plakos” (plaque) and reflects its usual endoscopic appearance as a friable, yellow mucosal lesion. Coliform bacteria in macrophage cytoplasm (von Hansemann histiocytes), and laminated intracytoplasmic inclusion bodies (Michaelis-Gutmann bodies) are characteristic. A decrease in macrophage cyclic GMP activity with resultant impaired bactericidal activity is hypothesized to be the cause of malakoplakia. Macrophage abnormalities and clinical symptoms resolve after discontinuation of glucocorticoids. Antibiotics such as ciprofloxacin have been successful treatments in few case reports. Unfortunately our patient did not have the opportunity to utilize any of these antibiotics prior to his passing.

1566 Pylephlebitis and Intestinal Necrosis: An Unexpected Outcome of a Common Infection

INTRODUCTION: Although rare, pylephlebitis should be included on the differential for any patient with CT imaging showing thrombosis in the portal vasculature, with a recent intraabdominal infection. Although there are not yet guidelines for management of this potential deadly complication, patients who received early antibiotics and anticoagulation have been associated with better outcomes. CASE DESCRIPTION/METHODS: A 59-year-old female presented with worsening abdominal pain two days after being discharged for uncomplicated diverticulitis, for which she was receiving a course of ciprofloxacin and metronidazole. Initial CBC was significant for a leukocytosis of 19.5 K/uL, and CT imaging revealed an inferior mesenteric vein (IMV) thrombosis extending up to her portal vein. She was continued on her antibiotics and started on unfractionated heparin for systemic anticoagulation. Despite these interventions, the patient continued to experience worsening abdominal pain, with physical exam revealing significant rebound tenderness. Interventional radiology (IR) guided aspiration on hospital day (HD) 6 as well as endoscopic aspiration on HD 9 were attempted. However, the location of the infectious process was prohibitively difficult to access. Repeat CT imaging done on HD 10 showed progressive septic thrombophlebitis with evidence of bowel ischemia. She underwent emergent washout with left colectomy and end colostomy. Throughout her admission, her course had been complicated by perforated diverticulitis and candida dubliniensis fungemia. The patient eventually improved and was discharged on HD 29. She was discharged to complete piperacillin-tazobactam (4 weeks of therapy), anidulafungin (6 weeks of therapy) and Coumadin (6 months of therapy). DISCUSSION: Pylephlebitis is a grave condition that can arise from common infections adjacent to the portal venous system. Diagnosis is now commonly made by imaging showing thrombosis in the portal vasculature. The mortality rate is significant, estimated to be 11-25%. Repeat imaging should be considered if there is lack of clinical improvement. Broad spectrum antibiotic therapy is a mainstay of treatment. Lower mortality rates and improved outcomes have been shown in those who were anticoagulated. Complications can be seen in up to 20% of patients, the most common of which are chronic thrombosis or extension of the thrombus, bowel ischemia and abscess formation. Surgery is not required for the initial management but can be used to obtain source control and manage complications.

Ciprofloxacin for BK viremia prophylaxis in kidney transplant recipients: Results of a prospective, double-blind, randomized, placebo-controlled trial.

In kidney transplantation, BK virus infection has historically resulted in high rates of graft dysfunction and graft loss. Unlike other opportunistic infections, no therapies have been shown to prevent BK. The purpose of the current study was to evaluate the safety and efficacy of ciprofloxacin for the prevention of BK viremia in kidney transplant recipients. Two hundred kidney transplant recipients were enrolled in a prospective, randomized, double-blind, placebo-controlled trial comparing a 3-month course of ciprofloxacin (n=133) vs placebo (n=67) for the prevention of BK viremia. The primary endpoint of BK viremia at month 6 posttransplant occurred in 25 (18.8%) patients in the ciprofloxacin group and 5 (7.5%) in the placebo group (P=.03). Higher rates of BK viremia (23.3% vs 11.9%; P=.06) and BK nephropathy (5.8% vs 1.5%; P=.26) remained at 12months in the ciprofloxacin group. Ciprofloxacin use was associated with a significantly higher rate of fluoroquinolone-resistant gram-negative infections (83.3% vs 50%; P=.04). A 3-month course of ciprofloxacin was ineffective at preventing BK viremia in kidney transplant recipients and was associated with an increased risk of fluoroquinolone-resistant infections. Clinical trial registration number: NCT01789203.

Parkinson’s Disease: A Case Report of Motor Symptoms Resolution Following Antibiotic Treatment for Suspected Bacterial Osteomyelitis

Background and case: The vast majority of Parkinson’s disease (PD) cases occur sporadically without any obvious etiological schema. That poses major hurdles to the discovery of effective preventative and treatment strategies. Here we are reporting the case of an 86-year-old Caucasian male, with a 21-year history of PD, who reports complete resolution of PD - related motor symptoms after treatment with antibiotics for suspected bacterial osteomyelitis.Results: After a right leg injury, the patient was prescribed a ten-day course of ciprofloxacin and a four-week course of dicloxacillin for suspected osteomyelitis. After completion of the antibiotics, the patient reported his pervasive motor symptoms as “completely resolved” which to this day have not returned.Conclusion: PD is a progressive, mostly idiopathic, neurodegenerative disorder with effective but limited treatment options and without compelling preventative strategies. Here we identify the first case indicating the resolution of PD-linked motor symptoms following an unrelated treatment course with antibiotics. This raises interesting questions about the use of antibiotics in PD and the potential of an etiological bacterial connection. The microbiome signature of PD is a current ‘hot topic’ of investigation and studies need to continue investigating bacteria as a possible causes of PD and antibiotics as effective treatment modalities.

Chronic Radiation Gastroenteropathy Diagnosed by Small Bowel Capsule Endoscopy: A Case Report

Radiation therapy plays an important role in a vast array of both benign and malignant disease processes. However, gastrointestinal toxicity limits the total radiation dose that can be prescribed. Chronic radiation gastroenteropathy may arise as early as 6 months to as late as several decades after the initial exposure. Microvascular sclerosis, mucosal atrophy, and intestinal wall fibrosis lead to altered intestinal transit, gut dysmotility, malabsorption, and potentially intestinal obstruction, fistulization, and perforation. We present a case of chronic radiation gastroenteropathy diagnosed by small bowel capsule endoscopy. A 56 year old man presented to the gastroenterology clinic for evaluation of chronic refractory iron-deficiency anemia (IDA). He had a history of Hodgkin lymphoma 30 years prior treated at that time with chemoradiation therapy with which he achieved remission; he then suffered from complications of radiation including mild pulmonary fibrosis, cardiomyopathy, coronary artery disease, and myelopathy resulting in paraplegia. As part of the workup for IDA, prior esophagogastroduodenoscopy (EGD) and colonoscopy had been remarkable for diffuse duodenal lymphangiectasias and a benign traversable transverse colon stricture attributed to radiation therapy. At our institution repeat EGD showed a bleeding gastric Dieulafoy lesion treated with bipolar electrocoagulation leading to hemostasis, and repeat colonoscopy was unremarkable except for the colonic stricture. Postprandial bloating, distention, and flatulence responded to a short course of ciprofloxacin, supporting a presumptive diagnosis of small intestinal bacterial overgrowth; recurrent symptoms were treated with a second course of ciprofloxacin and subsequently amoxicillin/clavulanic acid. Given persistent IDA he underwent small bowel capsule endoscopy, which showed mucosal atrophy interspersed with mucosal congestion and erythema as well as diffuse lymphangiectasias throughout the small bowel; these findings were consistent with chronic radiation enteropathy. Despite the decreasing incidence of radiation-induced enteropathy, we continue to encounter patients who present with significant complications after a prolonged latency period. A presumptive diagnosis is often made clinically, although small bowel capsule endoscopy remains a valuable and minimally invasive method to confirm this clinical entity.FigureFigureFigure

Is Acute Hepatitis E Virus (HEV) Infection a Steroid-Responsive Disease?

Introduction: While HEV infection often is self-limited, prolonged infection can put the patient at significant risk for liver injury, and treatment with Ribavirin can have mixed success. The following case represents an occasion in which lab result delay and clinical decision-making led to the improved outcome of a patient with acute HEV infection. Case Report: A 50 Year old South Asian female presented to her primary care physician (PCP) with complaints of diarrhea and fever after returning from a recent trip to Pakistan. This was treated by her PCP with Rifaximin, but the diarrhea continued. Lab results showed ALT and AST levels at 985 and 679, respectively. The patient was started on a course of ciprofloxacin and azithromycin, but her condition did not significantly improve. She was then referred to the hepatology clinic for workup. Labs were repeated, and tests for Hepatitis E and autoantibody titers were ordered. The patient followed up two days later and lab results showed elevated immunoglobulin G levels and a positive anti-Smith autoantibody titer (1:80). Autoimmune hepatitis was suspected and a liver biopsy was ordered. The liver biopsy results showed signs of nonspecific lobular inflammatory infiltration, and an order for Prednisone 60 mg by mouth once daily was added to the management plan while awaiting results of other serologies. The patient was then hospitalized for exacerbation of her condition and arthralgia in her extremities. However, she quickly responded to the course of steroids with marked improvement of her liver enzymes. Upon her next follow-up, steroids were being tapered, and the previously ordered pending lab results had come back positive for HEV IgG and IgM. HEV viral load was 145,000 IU/mL, and her ALT and AST had dropped to 164 and 25, respectively. She was started on Ribavirin 600mg daily as per HEV protocol. Within 2 weeks, viral HEV RNA was undetectable and her liver enzymes returned to within normal limits. Discussion: This patient had undiagnosed Hepatitis E, most likely contracted on a recent trip abroad. The inadvertent use of and response to prednisone suggests that steroids may be an efficacious adjunct to ribavirin in the management of acute Hepatitis E.

A Seven-Day Course of TMP-SMX May Be as Effective as a Seven-Day Course of Ciprofloxacin for the Treatment of Pyelonephritis

BackgroundThe Infectious Diseases Society of America guidelines recommend either 14 days of trimethoprim-sulfamethoxazole (TMP-SMX) or 7 days of ciprofloxacin for the treatment of pyelonephritis. Antibiotic courses of 7 days of TMP-SMX vs 7 days of ciprofloxacin for pyelonephritis have not been previously compared. We evaluated the odds of a subsequent, symptomatic urinary tract infection (UTI) for women with Escherichia coli pyelonephritis receiving a 7-day course of TMP-SMX vs a 7-day course of ciprofloxacin. MethodsWomen ages 16 years and older with E. coli pyelonephritis presenting to 5 health care facilities in the greater Maryland area between 2010 and 2016 receiving either TMP-SMX or ciprofloxacin were included. Patients were excluded if they met any of the following criteria: (a) pregnancy, (b) dialysis dependency, (c) E. coli not susceptible to the treatment prescribed, (d) polymicrobial urine culture, or (e) >48 hours of antibiotic therapy other than TMP-SMX or ciprofloxacin. ResultsOf 272 women meeting eligibility criteria, 81 (30%) and 191 (70%) received 7 days of TMP-SMX and 7 days of ciprofloxacin, respectively. In an adjusted model, the likelihood of a recurrent UTI within 30 days for the TMP-SMX and ciprofloxacin groups was similar (adjusted odds ratio 2.30; 95% confidence interval, 0.72-7.42). ConclusionsOur findings suggest that 7 days of TMP-SMX therapy may result in similar clinical outcomes compared with 7 days of ciprofloxacin for the treatment of pyelonephritis. Considering the frequency of pyelonephritis and risks of antibiotic resistance and associated toxicities, decreasing the duration of antibiotic therapy for pyelonephritis may impact a large number of women.

Atypical Presentation of Achilles Tendon Rupture: MRI Evaluation

Atypical Presentation of Achilles Tendon Rupture: MRI Evaluation

It ain't necessarily so: a surprising lower airway infection

Rossa Brugha (Junior Doctor): A 3-year-old boy with cystic fibrosis (CF) diagnosed on newborn screening (sweat chloride 90 mmol/L, F508del homozygous) attended routine follow-up in the CF clinic. He had...

Infectious Complications Following Prostate Biopsy: A Single Institution Review

Purpose: Determine incidence of fluoroquinolone-resistant bacteria complications among patients following prostate biopsy at New York Medical College, NY.Materials and Methods: Retrospective chart review of 229 consecutive patients receiving prostate biopsy between 2009 and 2013 at New York Medical College, NY. Each was administered a Fleet enema the morning of and a three-day course of ciprofloxacin starting the day before biopsy. Results: The 1.3% (3/229) of patients developed infectious complications following biopsy. Each of the (3/3) species isolated was fluoroquinolone-resistant. Among patients developing infectious complications, all had prior exposure to fluoroquinolones and all infectious complications were fluoroquinolone-resistant.Conclusion: This study highlights the need for confirming the patient’s exposure history with fluoroquinolones and considering another class of antibiotics for patients with prior fluoroquinolone exposure to avoid infectious complications following prostate biopsies.

A Rare Case of Acute Colitis Caused by Syphilis and Shigella Co-infection

A 47-year-old male with a past medical history of HIV on antiretroviral therapy and prior rectal Kaposi's sarcoma developed several months of abdominal discomfort and bright red blood per rectum. The patient had undergone endoscopic evaluation for his symptoms at an outside institution without a determined etiology. He presented to our hospital for worsening abdominal pain and persistent bright red blood per rectum. Stool cultures grew Shigella sonnei group D. He was started on a course of Ciprofloxacin with some improvement in symptoms. Due to his reported high-risk sexual activities, a rapid plasma reagent (RPR) test was obtained, which was positive with a titer of 1:64. A confirmatory fluorescent treponemal antibody absorption test (FTA-ABS) was reactive in the serum. Colonoscopy repeated during the hospitalization revealed a normal terminal ileum, diffuse cecal inflammation with apthous ulceration and moderate mucosal inflammation from the rectum extending proximally to the descending colon. Biopsies were obtained in the cecum and sigmoid colon and, in the setting of a positive RPR and FTA-ABS, specific immunohistochemical staining for spirochetes was performed that demonstrated treponemal microorganisms covering the brush border surface of the mucosal epithelium. These findings were consistent with acute syphilitic colitis. The patient was successfully treated with intramuscular benzathine penicillin G along with counseling of sexual partners. In review of the literature, men who have sex with men have a greater incidence of shigellosis and syphilis than the general population. Further, in the absence of specific immunohistochemical stains for spirochetes, syphilis shares many endoscopic and histologic features of alternative diagnoses and can be mistaken for other opportunistic infections as well as inflammatory bowel disease. This case demonstrates a unique diagnosis of colitis caused by co-infection with shigella and syphilis in a high-risk patient. In the right clinical setting, a high index of suspicion is necessary for the proper endoscopic and histologic diagnosis of syphilitic proctocolitis and other sexually transmitted infections.Figure 1Figure 2Figure 3

Salmonella Colitis as an Unusual Cause of Elevated Lipase

Salmonella infections are a reported, albeit uncommon, cause of acute pancreatitis. However, Salmonella may precipitate elevated serum lipase levels without other signs or symptoms of acute pancreatitis. The following is a case of Salmonella colitis with elevated serum lipase but without clinical pancreatitis. A 50 year old male presented with a one week history of watery, bloody bowel movements, nausea and vomiting associated with fevers, chills, and abdominal pain. Imaging showed diffuse small bowel and colonic thickening consistent with infectious colitis and stool cultures were found be positive for Salmonella enterica. He was treated with a course of Ciprofloxacin. Shortly after discharge, the patient returned to the ED with nausea and vomiting unrelated to oral intake. Though he had minimal abdominal pain, a serum lipase was measured and found to be elevated to 1929 and amylase elevated to 230. The patient denied any history of drinking and an abdominal ultrasound showed no evidence of gallstone pathology. A CT Abdomen/Pelvis showed a normal pancreas without any signs of inflammation. His nausea and vomiting abated without intervention and he was able to tolerate a regular diet. While an elevated serum lipase may typically confirm the diagnosis of acute pancreatitis, elevated lipase levels may also be seen in other disorders. For instance, elevated serum lipase levels have been reported in patients with infectious colitis without clinical pancreatitis, though this is exceedingly rare. In addition, one study demonstrated that serum lipase may be elevated in Salmonella colitis, but may not have clinical significance. This most significant elevation in lipase was seen in Salmonella enterica serovar typhimurium. There are several hypotheses for the enzyme elevations, including increased intestinal inflammation with increased permeability leading to an increase in reabsorption of lipase. There is also some evidence that Salmonella species are present in the bile fluid and gallstone cultures and may directly infect the pancreas via the biliary duct. Regardless of the pathophysiology, physicians need to be aware that elevations in serum lipase and amylase may not always be clinically significant and should note these alternative causes, including Salmonella infections.

FleQ, a Transcriptional Activator, Is Required for Biofilm Formation In Vitro But Does Not Alter Virulence in a Cholesteatomas Model.

Bacterial biofilm formation within cholesteatomas is responsible for increased persistence and tissue destruction and Pseudomonas aeruginosa deficient in biofilm formation (PAO1 ΔfleQ) are less virulent than the parent bacteria. Infected aural cholesteatomas have been demonstrated to be more destructive than uninfected cholesteatomas and infections are more persistent. The chronicity and persistence of infections within cholesteatomas may be because of the presence of biofilm formation. Twenty-seven mutant strains of PAO1 were screened for surface adherence. These strains were also screened for static biofilm formation. The biofilms were quantified by staining with crystal violet. Aural cholesteatomas were then induced in Mongolian gerbils by ligation of the ear canal. At the time of ligation, the ear canals were inoculated with wild-type PAO1 and a biofilm deficient PAO1 ΔfleQ strain of P. aeruginosa. A 7 weeks course of ciprofloxacin (20 mg/kg/day) was started on postoperative day 7. Eight weeks after induction of cholesteatomas, the cholesteatoma size, levels of bone destruction, and levels of bone remodeling were evaluated using microCT imaging. PAO1 ΔfleQ was identified as a poorly adherent and deficient biofilm forming mutant strain of P. aeruginosa. Infected cholesteatomas had more growth, bone destruction and bone remodeling than uninfected cholesteatomas. However, there was no difference observed between cholesteatomas infected with PAO1 (biofilm competent strain) and PAO1 ΔfleQ (biofilm deficient strain). We demonstrate that the biofilm phenotype is not an important virulence factor in cholesteatomas infected with P. aeruginosa.

A 3-month course of ciprofloxacin does not prevent BK virus replication in heavily immunosuppressed kidney-transplant patients

BackgroundIn vitro and retrospective studies of kidney-transplant patients have shown that quinolones can efficiently prevent BK virus (BKV) replication. However, in a prospective study, a 3 month-course of levofloxacin did not decrease the rate of BK viruria in kidney-transplant patients treated with standard immunosuppression. ObjectivesThe aim of this study was to assess the effect of a 3-month course of ciprofloxacin prophylaxis on BKV replication in kidney-transplant patients that had received heavy immunosuppression (plasma exchange or immunoadsorption and rituximab) to achieve desensitization before undergoing HLA- and/or ABO-incompatible (ABOi) transplantation. Study designTwenty-nine patients were given ciprofloxacin (500mg/d) for 3 months, starting immediately after transplantation. The results were compared with results from a previous study where patients had received a similar immunosuppression regimen without ciprofloxacin prophylaxis (n=43). Around 60% of patients had undergone a retransplantation. After transplantation, all patients were given induction therapy, tacrolimus, mycophenolic acid and steroids. BK viruria and viremia were monitored at months 1, 3, 6 and 12 post-transplantation. ResultsThe rates of BK viruria, BK viremia, and BKV-associated nephropathy did not differ between patients who were given or not given ciprofloxacin prophylaxis. These rates were also identical when patients received quinolones at any time within the first year after transplantation compared to those that had not. The rate of bacterial infection was also similar in patients who had or had not received ciprofloxacin. ConclusionThe use of quinolones seemed to not have any beneficial effect in preventing BKV replication in kidney-transplant patients receiving heavy immunosuppression.

A single dose of meropenem is superior to ciprofloxacin in preventing infections after transrectal ultrasound-guided prostate biopsies in the era of quinolone resistance.

To evaluate the efficacy of meropenem single dose before transrectal prostate biopsy, instead of ciprofloxacin in the era of fluoroquinolones resistance. This prospective study included patients with indications for prostatic biopsy from January to December 2014. Those with known resistance in fluoroquinolones or meropenem or with decreased creatinine clearance were excluded. Patients were randomized into two groups, and statistical analysis was carried out. Group A received a 3-day course of ciprofloxacin 500 bid per os starting the day before biopsy. Group B received 1g meropenem intravenously 1h prior to the procedure. Patients were followed up for 15days, and those with lower urinary tract symptoms (LUTS) and fever were called for hospitalization. Urine and blood cultures were obtained. A total of 110 patients, 52-75years old (mean 67.5, median 66) participated in the study, allocated in Groups A and B. After the procedure, 18 patients (32.7%) of Group A reported macroscopic hematuria, while 10 (18.2%) reported rectal blood loss. Nine patients (16.3%) presented because of fever and LUTS. One of them developed septic shock and died in the ICU. Cultures revealed multi-resistant E. coli with high sensitivity to meropenem, and patients were treated accordingly. In Group B, 20 (36.3%) patients presented with macroscopic hematuria and 9 (16.3%) with rectal blood loss. One patient returned to hospital with LUTS and fever. Cultures revealed Klebsiella pneumoniae sensitive to colimycine. A single dose of meropenem prior to prostate biopsy is a safe and effective way to avoid the possible infectious complications in high-risk patients.

Bordetella Bronchiseptica in a Kidney-pancreas Transplant Recipient after Dog Vaccination

Bordetella bronchiseptica is a gram negative coccobacillus that causes infections in animals including dogs,rabbits, and guinea pigs. It’s the causative agent in kennel cough, producing a dry‚ ‘honking’ cough. We report a case of Bordetella bronchiseptica in a kidney and pancreas transplant patient. A 55-year-old gentleman with a history of a living related kidney transplant, pancreas transplant, diabetes, hypertension, hyperlipidemia, and smoking history who presented to the hospital with fever/chills. He underwent pancreas transplantation 3 weeks prior to his current hospitalization. He was immunosuppressed on Prograf, Cellcept. Patient recently had a PICC line in place due to dehydration requiring IV fluids as an outpatient. He had adopted a puppy recently after his wife went back to work for companionship. The puppy had been given live vaccines around the time of transplant. Puppy noted to have been licking the PICC line. Patient denied cough, sore throat, nausea or vomiting. Physical exam revealed blood pressure 117/84 mm/Hg, heart rate 70 beats per minute, respiratory rate 14, temperature 38.3°C, 98% on room air. Auscultation of lungs revealed clear lungs bilaterally. No leukocytosis, normal renal function. CXR revealed no infiltrate, no lymphadenopathy. Blood cultures revealed Bordetella bronchiseptica sensitive to quinolones and trimethoprim-sulfamethoxazole. Patient started on piperacillin/tazobactam. His PICC line was removed. All symptoms gradually resolved with antibiotics over a two week course of Ciprofloxacin. Household dogs and some cats are routinely vaccinated against Bordetella bronchiseptica. Transmission occurs via respiratory droplets or by direct contact. Diagnosis is based on positive cultures or polymerase chain reaction from a patient with a history of exposure to infected animals. Treatment includes aminoglycosides, antipseudomonal penicillins, quinolones, tetracyclines, thirdgeneration cephalosporins, and trimethoprim-sulfamethoxazole. Duration of therapy is based on immune status of patient, however ranges from 2-6 weeks. Immunosuppressed patients should avoid contact with unvaccinated or newly vaccinated especially those with young animals who have received live vaccines.