Systemic Febrile Illness Research Articles

Rat-Bite Fever due to the genus <i>Streptobacillus</i>

<p>Rat-bite fever (RBF) is a zoonotic infection and systemic febrile illness transmitted to humans by <italic>Rattus</italic> spp. contacts following a scratch, bite, or touching excrement, such as urine, feces, and oral secretions. Infection with members of the genus <italic>Streptobacillus</italic> is the most common cause of this infectious disease. In this review article, we updated the knowledge on the RBF caused by the genus <italic>Streptobacillus</italic> based on the isolation and identification methods, virulence factors, clinical signs, differential diagnoses, antibiogram, treatment, geographical distribution, and epidemiology. Moreover, the present paper's comprehensive analysis of over 200 infection cases attributed to this genus, spanning from 1915 to 2023, sheds light on its epidemiology and provides valuable insights for the future.</p>

Detection of Salmonella species by Automated Blood Culture Method in Suspected Cases of Enteric Fever

Background: Enteric fever caused by Salmonella species is a systemic febrile illness that can be fatal since its characterization in 1880. Enteric fever may remain asymptomatic carrier and sometimes fatal that it can be difficult to diagnose based on symptoms alone because they are similar to those of other febrile disorders. In developing countries, enteric fever is common global health problem due to poor standard of personal hygiene, contaminated food, inadequate safe water and sanitation. Methods: This is a cross-sectional study that was conducted in the Microbiology Department of Rajshahi Medical College Hospital for one year from January 2021 to December 2021 to identify Salmonella species by Automated Blood Culture (Fastidious Antibiotic Neutralization method) followed by subculture in MacConkey’s agar, Xylose lysine deoxycholate agar, and Salmonella Shigella agar media in suspected enteric fever cases. This study included suspected cases of enteric fever as determined by the physician who fulfilled the inclusion and exclusion criteria. Results: Among 127 suspected cases of enteric fever 64(50.39%) culture positive bacteria isolated by automated blood culture (FAN) method and out of that Salmonella species 38 (59.37%) and others bacteria 26(40.63%) following subculture in MacConkey’s agar, Xylose lysine deoxycholate agar and Salmonella Shigella agar media. Regarding gender, the majorities (61.4%) of culture-positive patients were male, and the majority (65.35%) came from rural areas. Conclusion: Especially for patients who have received antibiotics, we propose that the automated blood culture approach followed by subculture could be employed as a novel diagnostic method for typhoid fever. TAJ 2023; 36: No-2: 71-76

Review of the post-COVID-19 syndrome associated to acute telogen effluvium

Coronavirus disease 2019 (COVID-19) has impacted our society in numerous ways. So far (November 2022) around 640 million SARS-CoV-2 infections have been confirmed worldwide. It is known that this disease has a main affection at the cardiopulmonary level, however, it affects almost all the organs and systems of the body, including the skin. Post-COVID-19 syndrome occurs in some patients, leaving significant sequelae that impact their quality of life. Among the most common sequelae are: cough, dyspnea, chronic fatigue, hyposmia and dysosmia. In addition to these, other sequelae not related to respiratory syndrome have been reported, such as hair loss, which has been observed in around 20% of post-COVID-19 patients, this could be attributable to acute telogen effluvium (TE). To date, no study has been conducted to determine the relationship of ET in those who have had COVID-19. Acute ET is defined as diffuse, non-scarring hair loss, usually self-limited, lasting for about 6 months. Within its etiology, severe systemic febrile illness, pregnancy, restrictive diets, severe stress and various drugs have been described. It seriously affects the quality of life of patients and is often associated with loss of confidence and low self-esteem.

Imported diseases in travellers presenting to the emergency department after a stay in a malaria-endemic country: a retrospective observational study

BackgroundWe aimed to investigate the aetiology and outcomes of illnesses in patients presenting to an emergency department after travelling to a malaria-endemic country, in order to raise awareness of both tropical and cosmopolitan diseases.MethodsA retrospective chart review was performed for all patients who underwent blood smear testing for malaria at the Emergency Department of the University Hospitals Leuven from 2017 to 2020. Patient characteristics, results of laboratory and radiological examinations, diagnoses, disease course and outcome were collected and analysed.ResultsA total of 253 patients were included in the study. The majority of ill travellers returned from Sub-Saharan Africa (68.4%) and Southeast Asia (19.4%). Their diagnoses fell into three major syndrome categories: systemic febrile illness (30.8%), inflammatory syndrome of unknown origin (23.3%) and acute diarrhoea (18.2%). Malaria (15.8%) was the most common specific diagnosis in patients with systemic febrile illness, followed by influenza (5.1%), rickettsiosis (3.2%), dengue (1.6%), enteric fever (0.8%), chikungunya (0.8%) and leptospirosis (0.8%). The presence of hyperbilirubinemia and thrombocytopenia increased the probability of malaria, with a likelihood ratio of 4.01 and 6.03, respectively. Seven patients (2.8%) were treated in the intensive care unit, and none died.ConclusionSystemic febrile illness, inflammatory syndrome of unknown origin and acute diarrhoea were the three major syndromic categories in returning travellers presenting to our emergency department after a stay in a malaria-endemic country. Malaria was the most common specific diagnosis in patients with systemic febrile illness. None of the patients died.

S2643 Rare Gastrointestinal Bleeding in a Patient With Severe Plasmodium Falciparum Malaria

Introduction: Malaria clinically presents as a systemic febrile illness; the most severe form is caused by Plasmodium Falciparum. In addition to hematologic manifestations such as severe anemia, thrombocytopenia, and coagulopathy, malaria patients uncommonly experience gastrointestinal complications such as GI bleeds, splenic rupture and subacute intestinal obstruction. We report a severe case of P. falciparum malaria complicated by a GI bleed. Case Description/Methods: A 66-year-old male with recent travel to Nigeria and a medical history of hypertension was brought to the ER with altered mental status, abdominal pain and a 25lb weight loss in the last month. In the ED he spiked a fever to 102F, prompting a thorough infectious workup. An LP was remarkable for many RBCs, glucose 81 and protein 47. CSF was negative for meningitis/encephalitis; he did not have EBV, CMV or HIV. Blood and fungal cultures were negative. Due to his recent travel history, our patient had a 5-thin and 2-thick malarial smear which showed P. falciparum malaria ring forms. He was started on cefepime, vancomycin, metronidazole, atovaquone/proguanil. Over the next 12-hours, the patient rapidly deteriorated with a large coffee ground emesis, a hemoglobin drop from 12.1 to 8.6, and a thrombocytopenia from 135 to 15. Hemolysis labs were positive: haptoglobin < 30, LDH 607, reticulocyte 14.6%, fibrinogen 112. Upper endoscopy showed Grade-C esophagitis, an oozing duodenal ulcer and hematin all throughout the stomach wall. Abdominal ultrasound and CT showed no acute intra-abdominal pathologies. With new ongoing hematemesis and melena, he went into progressive septic vs hemorrhagic shock and required vasopressors and stress-dose steroids. Discussion: The hematologic manifestations often seen in malaria rarely lead to massive GI bleeds. Our patient did not use NSAIDS, he was not tested for H. Pylori, and despite the stress of his acute severe illness, he had no other risk factors for duodenal ulceration. High levels of free oxygen radicals and tumor necrosis factor may have played a role in the etiology of his peptic ulcer formation. Malarial hemolysis results from the release of cytokines, macrophage recruitment, causing a cytokine storm and activation of endothelial adhesion molecule type 1, E-selectin, enhancing cytoadherence of parasitized cells, mediating lactic acidemia, shock, gut mucosal damage and increased permeability. Despite aggressive measures, our patient ultimately developed shock and died.

Developing a National Minimum Data Set for Kawasaki Disease Registry in Iran.

BackgroundKawasaki Disease is an acute and self-limited systemic inflammatory and febrile illness, which is the most common cause of acquired heart disease in children in developed countries. The incidence of KD in Asian countries is high. But, data is not available from the Middle East. So, the aim of this study was to develop an MDS to set up a national registry for KD to estimate the burden of disease in Iran.Materials and MethodsThis cross-sectional and descriptive study was conducted in 2020. Literature review, data collection from patients medical records, and expert panel approach were used to design this MDS. Data elements with a Content Validity Ratio (CVR) of more than 0.56 were selected as the MDS of the registry.ResultsOverall, 99 data elements were recognized. Of which, 51 and 48 data elements were verified and rejected, respectively. Moreover, 17 data elements were added as required by experts. Eventually, 68 data elements were chosen as the MDS of the national KD registry of IRAN; of which, 17 and 51 data elements were classified as administrative and clinical data, respectively.ConclusionsThese precise, integrated, and comprehensive developed data elements and the national KD registry will lead to effective disease management and thus, improve the quality of care and, consequently, improve public health.

744. Incidence and Duration of Diagnostic Delays Associated with Dengue Fever

Abstract Background Dengue fever is a prominent emerging arboviral infection in the tropics and subtropics, and an important cause of systemic febrile illness among some international travelers. Signs and symptoms are similar to more common infectious illnesses in temperate climates, and dengue may not be promptly considered when patients seek evaluation. Methods We conducted a retrospective cohort study of patients diagnosed with dengue fever using the IBM MarketScan Research database from 2001-2017. We identified cases of dengue fever where patients were enrolled ≥ 1 year prior to the index diagnosis. All healthcare visits in the year prior to the index diagnosis were collected and we identified visits with signs/symptoms compatible with dengue or a diagnosis made of an illness with similar symptoms (e.g., influenza) before the index dengue diagnosis. We used a time-series change-point analysis to identify the time before diagnosis in which symptoms of dengue became more prominent. We conducted a bootstrap-based simulation analysis to estimate the duration and frequency of missed diagnostic opportunities. Results We identified 4,449 cases of dengue fever that met eligibility criteria. We found that 2,791 (62.7%) had ≥ 1 healthcare visit(s) prior to diagnosis with characteristic symptoms of dengue recorded. Our simulations analysis supports that 32.9% (95% CI: 31.1-35.0) experienced 1 or more missed opportunities for diagnosis. Among these patients, the average duration of diagnostic delay was 8.26 (CI: 6.32-11.38) days and ~21% of patients had a diagnostic delay of 2 or more weeks. Patients with a delayed diagnosis averaged 2.2 (CI 2.11-2.29) healthcare visits which represented missed opportunities. Missed opportunities were more likely during weekend, ED or outpatient visits. Conclusion Dengue fever is not considered in the majority of patients at the time of the initial symptomatic evaluation in the U.S., indicating delays in diagnosis are common. Enhanced education of providers about dengue fever could lead to more prompt diagnosis that should help optimize patient management. Disclosures All Authors: No reported disclosures

Optical coherence tomography angiography (OCTA) of retinal vasculature in patients with post fever retinitis: a qualitative and quantitative analysis

Post fever retinitis is a heterogenous entity that is seen 2–4 weeks after a systemic febrile illness in an immunocompetent individual. It may occur following bacterial, viruses, or protozoal infection. Optical coherence angiography (OCTA) is a newer non-invasive modality that is an alternative to fundus fluorescein angiography to image the retinal microvasculature. We hereby describe the vascular changes during the acute phase of post fever retinitis on OCTA. Imaging on OCTA was done for all patients with post fever retinitis at presentation with 3 × 3 mm and 8 × 8 mm scans centred on the macula and corresponding enface optical coherence tomography (OCT) scans obtained. A qualitative and quantitative analysis was done for all images. 46 eyes of 33 patients were included in the study. Salient features noted were changes in the superficial (SCP) and deep capillary plexus (DCP) with capillary rarefaction and irregularity of larger vessels in the SCP. The DCP had more capillary rarefaction when compared to the SCP. The foveal avascular zone (FAZ) was altered with an irregular perifoveal network. Our series of post fever retinitis describes the salient vascular features on OCTA. Although the presumed aetiology was different in all our patients, they developed similar changes on OCTA. While OCTA is not useful if there is gross macular oedema, the altered FAZ can be indicative of macular ischemia.

Typhoid Fever among Admitted Pediatric Patients in a Tertiary Care Center: A Descriptive Cross-sectional Study.

Typhoid fever, an acute systemic febrile illness caused by Salmonella Typhi & Paratyphi, is an important public health problem in developing countries. It requires frequent observation regarding proper diagnostic protocol and treatment practices. The aim of the study is to find the prevalence of typhoid fever among admitted pediatric patients in a tertiary care center. This is a descriptive cross-sectional study conducted among the admitted patients of pediatric and adolescent medicine of a tertiary care center from August 2016 to May 2018 after obtaining ethical clearance (IRC/609/015). Convenience sampling was used and data was analyzed using the Statistical Package of Social version 11.5. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Among 7450 patients, 151 (2.03%) at 95% Confidence Interval (1.71-2.35) patients were diagnosed with enteric fever of which 85 (56.29%) were male and 66 (43.71%) were female. Common symptoms were fever 151 (100%), and abdominal pain 94 (62.25%). Azithromycin 54 (38.03%) was the most common antibiotic received before presenting to hospital and ceftriaxone 151 (100%) was prescribed to all the patients after admission. Two-third of the patients (96/151) was hospitalized for at least 6 days, with the longest hospital stay of 14 days and shortest of 3 days. Occurrence rate of Typhoid Fever was similar to other studies. Antibiotic susceptibility could not be well established; further surveillance on typhoid fever and the antimicrobial susceptibility pattern is recommended.

Rat bite fever with osteomyelitis and discitis: case report and literature review

BackgroundRat bite fever (RBF) is a rare systemic febrile illness transmitted by rats. Streptobacillus moniliformis is a pleomorphic Gram-negative bacillus which is the usual etiologic organism for rat bite fever in the United States.Case presentationHere we present a case of rat bite fever complicated by vertebral osteomyelitis and discitis. The patient revealed an exposure history of being bitten by pet rats. The patient’s symptoms dramatically improved with a six-week course of cephalexin therapy.ConclusionsIt is important to obtain a thorough zoonotic exposure history and maintain rat bite fever in the differential when considering potential causes of discitis and osteomyelitis.

Surveillance for West Nile Virus Disease - United States, 2009-2018.

Problem/ConditionWest Nile virus (WNV) is an arthropodborne virus (arbovirus) in the family Flaviviridae and is the leading cause of domestically acquired arboviral disease in the contiguous United States. An estimated 70%–80% of WNV infections are asymptomatic. Symptomatic persons usually develop an acute systemic febrile illness. Less than 1% of infected persons develop neuroinvasive disease, which typically presents as encephalitis, meningitis, or acute flaccid paralysis.Reporting Period2009–2018.Description of SystemWNV disease is a nationally notifiable condition with standard surveillance case definitions. State health departments report WNV cases to CDC through ArboNET, an electronic passive surveillance system. Variables collected include patient age, sex, race, ethnicity, county and state of residence, date of illness onset, clinical syndrome, hospitalization, and death.ResultsDuring 2009–2018, a total of 21,869 confirmed or probable cases of WNV disease, including 12,835 (59%) WNV neuroinvasive disease cases, were reported to CDC from all 50 states, the District of Columbia, and Puerto Rico. A total of 89% of all WNV patients had illness onset during July–September. Neuroinvasive disease incidence and case-fatalities increased with increasing age, with the highest incidence (1.22 cases per 100,000 population) occurring among persons aged ≥70 years. Among neuroinvasive cases, hospitalization rates were >85% in all age groups but were highest among patients aged ≥70 years (98%). The national incidence of WNV neuroinvasive disease peaked in 2012 (0.92 cases per 100,000 population). Although national incidence was relatively stable during 2013–2018 (average annual incidence: 0.44; range: 0.40–0.51), state level incidence varied from year to year. During 2009–2018, the highest average annual incidence of neuroinvasive disease occurred in North Dakota (3.16 cases per 100,000 population), South Dakota (3.06), Nebraska (1.95), and Mississippi (1.17), and the largest number of total cases occurred in California (2,819), Texas (2,043), Illinois (728), and Arizona (632). Six counties located within the four states with the highest case counts accounted for 23% of all neuroinvasive disease cases nationally.InterpretationDespite the recent stability in annual national incidence of neuroinvasive disease, peaks in activity were reported in different years for different regions of the country. Variations in vectors, avian amplifying hosts, human activity, and environmental factors make it difficult to predict future WNV disease incidence and outbreak locations.Public Health ActionWNV disease surveillance is important for detecting and monitoring seasonal epidemics and for identifying persons at increased risk for severe disease. Surveillance data can be used to inform prevention and control activities. Health care providers should consider WNV infection in the differential diagnosis of aseptic meningitis and encephalitis, obtain appropriate specimens for testing, and promptly report cases to public health authorities. Public health education programs should focus prevention messaging on older persons, because they are at increased risk for severe neurologic disease and death. In the absence of a human vaccine, WNV disease prevention depends on community-level mosquito control and household and personal protective measures. Understanding the geographic distribution of cases, particularly at the county level, appears to provide the best opportunity for directing finite resources toward effective prevention and control activities. Additional work to further develop and improve predictive models that can foreshadow areas most likely to be impacted in a given year by WNV outbreaks could allow for proactive targeting of interventions and ultimately lowering of WNV disease morbidity and mortality.

Emergence of MDR and XDR Salmonella enterica serovar Typhi from pediatric septicemia patients in Lahore

Background: Typhoid fever is a systemic febrile illness that requires prompt antibiotic treatment. Over 21 million people contract typhoid each year mainly due to fecal contaminated food or water and among these 161,000 die globally. Moreover, in southeast Asia including Pakistan, 3.6 cases of typhoid occurred per 100,000 persons/year. Extensively drug-resistant typhoid fever is spreading in Pakistan, raising fears of antibiotic failure at a global level. Methods & Materials: Blood samples (n = 4543) were collected from children suspected of septicemia from a tertiary care hospital in Lahore, Pakistan. Blood samples were collected aseptically in peads BacT/ALERT plus blood culture bottles and placed in BacT/ALERT for up to 5 days. Positive blood culture bottles were sub-cultured on blood and MacConkey agar. Colonies were observed by morphological characteristics. Biochemical confirmation of isolates was carried out by VITEK 2 compact system using GN card. MIC (μg/mL) was determined against 15 different antibiotics using AST-N204 by VITEK 2 compact system. Results: Of 4543 blood cultures samples, 415 (9.1%) were positive for S. Typhi. Among these, 69.1% were MDR S. Typhi while 41.6% were XDR S. Typhi. The highest prevalence of MDR S. Typhi in Peads emergency (167; 40%) followed by peads OPD (90; 21%) and Peads Medical Ward (78; 11.5%). Antibiogram (μg/mL) showed that patients had MDR and XDR S. Typhi was resistant to ampicillin (90%), ciprofloxacin (73%), co-trimoxazole (72.6%) and cefotaxime (67.6%) and ceftriaxone (65.3%) however, 100% sensitive to meropenem and colistin. Conclusion: The present study concluded that the emergence of MDR and XDR S. Typhi in children is a serious public health concern that causes mortality due to treatment failure.

Identification of co-circulating pathogens that are clinically indistinguishable from Lassa fever during the 2018 Lassa outbreak in Nigeria

Background: The burden of undiagnosed febrile illness in low and middle-income countries is high and infectious diseases remain the leading cause of morbidity and mortality. The aetiology of systemic febrile illness and sepsis are particularly badly described partly because many pathogens cause a similar initial clinical presentation. In early 2018, Nigeria experienced its largest recorded outbreak of Lassa fever (LF). During this period of heightened transmission, there were 1,968 persons who met the clinical case definition for LF. However, only 431 could be laboratory confirmed, while for 1,537 no causative pathogen could be identified. The unprecedented scale of this outbreak prompted the Nigeria Centre for Disease Control (NCDC) and the WHO to reconsider their diagnostic strategy and re-prioritise LF diagnostics. A joint research collaboration between the NCDC and the United Kingdom Public Health Rapid Support Team (UK-PHRST) has worked to address this question. Methods and materials: Archived clinical diagnostic samples collected under the auspices of the Nigerian National Lassa Virus Testing Algorithm taken from patients who met NCDCs case definition for LF during the 2018 LF outbreak in Nigeria were sought and a non-probability sampling technique on consecutive cases who meet the selection criteria (lassa-negative by PCR and malaria-negative by RDT) was employed. RNA extracts were screened TaqMan array card system for 50 pathogens known to occur in West Africa and a subset of TAC+/- samples underwent unbiased metagenomic sequencing to determine which pathogen(s) are co-circulating and potentially mimicking the presentation of LF. Associations between pathogens and selected epidemiological and clinical variables were tested by Chi-square with significance level set at p < 0.05. Results: Results from this study indicate that there was no one specific pathogen responsible for patients developing clinical presentations indistinguishable from LF. Rather, a variety of pathogens (both viral and bacterial) were found to be co-circulating at the time of heightened LF transmission resulting in both single and co-infections (particularly in the immunocompromised). Conclusion: We anticipate that this study will help ensure proper and expedited diagnosis of diseases in the differential diagnosis for LF, helping to target treatment of patients with both LF and non-LF acute febrile illnesses in Nigeria.

A COMPARATIVE STUDY OF WIDAL TEST WITH BLOOD CULTURE IN THE DIAGNOSIS OF TYPHOID FEVER IN FEBRILE PATIENTS ATTENDING GGH, ANANTHAPURAMU.

Introduction Typhoid fever is a systemic prolonged febrile illness caused by certain Salmonella serotypes including Salmonella typhi, S. paratyphi A, S. paratyphi B and S. paratyphi C. 1 Human beings are the only reservoir host for typhoid fever. It is transmitted is by feco-oral contamination of water and food in endemic areas especially by carriers handling food. The World Health Organization (WHO) estimates about 21 million cases of typhoid fever with &gt;600,000 deaths annually. 2 The cases are more likely to be seen because of rapid population growth, increased urbanization, and limited safe water, limited infrastructure and health systems. Aims &amp; Objectives The main aim of this study is to compare the result of Widal test and blood culture in the diagnosis of typhoid fever in febrile patients. Material &amp; Methods: This is a prospective study conducted in the GGH Anantapuramu, for a period of 18 months .i.e. from May 2018 to Oct 2019. Blood samples were collected from 542 febrile patients with symptoms clinically similar to typhoid fever. Blood culture was used to isolate S.typhi and S.paratyphi. Slide agglutination test and tube agglutination tests were used for the determination of antibody titer. An antibody titer of ≥1:80 for anti TO and ≥1:160 for anti TH were taken as a cut of value to indicate recent infection of typhoid fever. Results: A total of the 542 patients were the study population, among which 384 (70.8%) were females, and 158 (29.1%) were males. Widal and blood culture was performed, 11 (2.02%) cases of S. typhi and 5 (0.9%) cases of S. paratyphi were identified using blood culture. The total prevalence of typhoid fever is 2.95%. The specificity, sensitivity, Positive Predictive Value, and Negative Predictive Value of the Widal test with O Ag is 70%, 81.25%, 10.93%, and 96%, respectively, and with H Ag is 40%, 96%, 18.1%, 98.8% respectively.

Clinical and laboratory findings of acute Zika virus infection in patients from Salvador during the first Brazilian epidemic

Several major epidemics of Zika fever, caused by the ZIKA virus (ZIKV), have emerged in Brazil since early 2015, eventually spreading to other countries on the South American continent. The present study describes the clinical manifestations and laboratory findings of patients with confirmed acute ZIKV infection during the first epidemic that occurred in Salvador, Brazil. All included patients were seen at the emergency room of a private tertiary hospital located in Salvador, Brazil from 2015 through 2017. Patients were considered eligible if signs of systemic viral febrile disease were present. All individuals were tested for ZIKV and Chikungunya infection using PCR, while rapid test was used to detect Dengue virus antibodies or, alternatively, the NS1 antigen. A diagnosis of acute ZIKV infection was confirmed in 78/434 (18%) individuals with systemic viral febrile illness. Positivity was mainly observed in blood, followed by saliva and urine. Coinfection with Chikungunya and/or Dengue virus was detected in 5% of the ZIKV-infected patients. The most frequent clinical findings were myalgia, arthralgia and low-grade fever. Laboratory analysis demonstrated normal levels of hematocrit, platelets and liver enzymes. In summary, in acute settings where molecular testing remains unavailable, clinicians face difficulties to confirm the diagnosis of ZIKV infection, as they rely only on clinical examinations and conventional laboratory tests.

Severe recurrent Streptobacillus moniliformis endocarditis in a pregnant woman, and review of the literature

BackgroundRat bite fever is a systemic febrile illness caused by infection with the Gram-negative bacillus Streptobacillus moniliformis following a bite, scratch, or contact with excrement. Only 26 cases of native valve endocarditis have been reported to date. We could find no other reports of severe Streptobacillus endocarditis requiring valve replacement in a young, pregnant patient.Case presentationA pregnant patient sought care for right leg pain, fevers, left upper quadrant pain, generalized weakness, fatigue, and inability to bear weight on her right leg. She had a syncopal episode 9 months earlier, resulting in a mandibular fracture and internal fixation hardware. Her pregnancy was complicated by hyperemesis and weight loss. Her pets included a rescued wild bird, a cat, and four rats. Her parents rescued stray cats, and she recalled multiple cat bites and scratches since childhood. She denied injection drug use. Ultrasound indicated a right popliteal artery thrombus. Transesophageal echocardiogram revealed a 2 cm × 0.7 cm vegetation. Angiography demonstrated multiple splenic infarcts and bilateral renal infarcts. She underwent mitral valve repair. The mitral valve Gram stain demonstrated 2+ Gram-negative rods, rare Gram-positive rods, and moderate white blood cells. Propionibacterium spp. was isolated from the mitral valve tissue on Columbia agar incubated anaerobically. Anaerobic and aerobic cultures of the valve tissue on all other broths and agars remained negative at 14 days. Hematoxylin and eosin stains showed a fibro-inflammatory vegetation. Aggregates of rod-shaped bacteria were identified on Warthin Starry/Steiner stain. Bartonella titers were positive for B. henselae IgG 1:256, IgM < 1:20. Brown-Hopps Gram stain, AFB, and GMS stains for bacterial and fungal microorganisms were negative. Broad range bacterial PCR and sequencing of a segment of 16 s rRNA gene of the valve tissue matched to Streptobacillus sp. (genus level) and most closely related to Streptobacillus moniliformis.ConclusionThis case demonstrates diagnostic and therapeutic challenges associated with a relatively uncommon cause of endocarditis. The diagnosis of rat bite fever was delayed due to symptoms of a concomitant pregnancy. Other confounders included possible alternative sources or co-infections with another zoonosis from multiple pets, and an odontogenic source due to presence of exposed jaw hardware.

Post Fever Uveoretinal Manifestations in an Immunocompetent Individual

Background: Post fever uveoretinal sequelae (PFURS) are the various uveoretinal manifestations seen after a systemic febrile illness in an immunocompetent individual caused by bacteria, viruses, and protozoa. These may be the result of a direct invasion by the pathogen or by indirect mechanism mediated through immune mechanisms. Method: The authors aim to review the ocular manifestations, utility of relevant diagnostic tests, management, and prognosis of PFURS. A comprehensive literature search was conducted on PubMed and Google Scholar databases with the search words “retinitis”, “choroiditis”, “neuroretinitis”, “macular edema”, “maculopathy”, “multifocal retinitis”, “chikungunya”, “dengue”, “West Nile”, “typhoid”, and “rickettsiosis”. Only articles published or translated into English language were considered. The key data were extracted, evaluated, and combined. Results: The authors search yielded 95 articles for the period between 1986 and May 2020. Painless blurring of vision was the most common symptom. Patients can have varied posterior segment manifestations, including vitritis, focal and multifocal patches of retinitis which could be unilateral or bilateral, optic nerve involvement, serous detachment at the macula, macular oedema, and localised involvement of the retinal vessels in the form of beading of the vessel wall, tortuosity, and perivascular sheathing. Conclusion: PFURS presents with a similar morphological pattern irrespective of the aetiology and follows a preset natural course before resolution. Treatment may or may not be required. Treating physicians need to be aware of this important ophthalmic condition even after complete resolution of fever.

An Outbreak of Kawasaki-like Disease in children during SARS-CoV- 2 Epidemic: No Surprise?

Background and aim:Kawasaki disease is an acute systemic febrile illness of unknown aetiology, which usually affects children under 5 years of age. It is well known that Kawasaki disease is one of the most common causes of acquired heart diseases in children in the developed countries. Many studies, have suggested that heterogeneous infectious agents, such as common viruses, may trigger Kawasaki disease in young children with genetic background. Nowadays we are facing a pandemic caused by a Novel Coronavirus named SARS-CoV-2. Consequently, it could be possible that once exposed to this new coronavirus, some children, genetically predisposed, may mount an exaggerated inflammatory response which clinically manifests as Kawasaki Disease.Methods:from January to May 2020 a systematic search was performed on Pubmed for the following search terms: “COVID-19”, “children”, “SARS-CoV-2”, “complications”, “Kawasaki disease”, “cytokine storm”.Results:Usually, infants and children present milder symptoms of SARS-CoV-2 disease with a better outcome than adults. At variance, some children may be genetically disposed to a more robust inflammatory response to SARS-CoV-2, similar to Kawasaki disease. In fact, Kawasaki disease is the result of an abnormal immune response, in susceptible children, to an external trigger such as an infection. Thus, according to the pathogenesis of Kawasaki disease, paediatricians may expect an increase in cases of Kawasaki disease during the COVID-19 pandemic. (www.actabiomedica.it)

Real-time RT-PCR for the detection and quantitation of Oropouche virus

Oropouche virus (OROV) causes an acute, systemic febrile illness, and in certain regions of South America, this represents the second most common human arboviral infection after dengue virus. A new real-time RT-PCR was developed for OROV and reassortant species. The new OROV rRT-PCR proved linear across 6–7 orders of magnitude with a lower limit of 95% detection of 5.6–10.8 copies/μL. Upon testing dilutions of OROV and Iquitos virus reference genomic RNA, all dilutions with >10 copies/μL were detected in both the OROV rRT-PCR and a comparator molecular assay, but the OROV rRT-PCR detected more samples with ≤10 copies/μL (8/14 vs 0/13, respectively, P = 0.002). In a set of 100 acute-phase clinical samples from Paraguay patients with a suspected arboviral illness, no patients tested positive for OROV RNA using either assay. The OROV rRT-PCR provides a sensitive molecular assay for the study of this important yet neglected tropical arboviral infection.

Spectrum of illness among returned Australian travellers from Bali, Indonesia: a 5-year retrospective observational study.

Bali, Indonesia, presents significant infectious and non-infectious health risks for Australian travellers. Understanding this spectrum of illnesses has the potential to assist clinicians in evaluating unwell returning travellers and guide provision of pre-travel advice. To describe the spectrum of illnesses seen in returned travellers from Bali. Using a novel text mining approach, we performed a retrospective, observational study of all adult emergency department presentations to a metropolitan health service in Melbourne, from 2011 to 2015. Outcome measures included demographic, clinical and laboratory features of travel-related illnesses. A total of 464 patients met inclusion criteria. Gastroenteritis (119/464, 26%), systemic febrile illness (88/464, 19%) and respiratory tract infection (51/464, 11%) were the most common diagnoses. Dengue was the most common laboratory-confirmed diagnosis (25/464, 5%). No cases of malaria were identified. Common non-infectious presentations included traumatic injury (47/464, 10%) and animal bites requiring rabies post-exposure prophylaxis (29/464, 6%). A total of 110 patients (24%) was admitted to the hospital; those presenting with systemic febrile illness were more likely to be admitted compared to those presenting with other illnesses (odds ratio 3.42, 95% confidence interval 2.02-5.75, P < 0.001). This is the first study to use a text mining approach to identify and describe emergency department presentations related to diseases acquired in Bali by Australian travellers. Although infections are important causes of illness, trauma and animal bites account for a significant number of hospital presentations. Our findings contribute to the knowledge on the health risks for travellers to Bali, and will assist clinicians in relevant pre- and post-travel evaluations.