Healthy Immunocompetent Patient Research Articles

Uncommon case of isolated conjunctival histoplasmosis: A rare clinical entity

We report an unusual case of isolated conjunctival histoplasmosis in a healthy immunocompetent patient. A 62-year-old male presented with a gradually progressing, painless, fleshy mass in both eyes for 2 months. On examination, a diffuse, raised, vascularized, and nontender mass was noted on the entire bulbar conjunctiva. On incisional biopsy, the histopathologic report confirmed a causative agent of Histoplasma capsulatum. He was then treated with topical itraconazole and intravenous amphotericin B, the lesion exhibited signs of regression. When confronted with an unusual conjunctival mass, it is imperative to do a detailed microbiological and histopathological work-up of a patient.

Diagnostic Difficulty in Pseudotumoral Form of Pulmonary Tuberculosis: A New Case

The pseudotumoral form of tuberculosis is rare in healthy immunocompetent patients. This form can mimic benign and malignant tumors. The diagnosis is confirmed by bacteriological and/or different histological samples. In this specific case, the patient presented with cough, left chest pain, fatigue and fever. The chest computerized tomography (CT) scan revealed an inhomogeneous mass that initially appeared to be a primary tumor. However, further investigation was required to establish an accurate diagnosis. Histopathological examination of the biopsy samples obtained through bronchoscopy did not indicate any evidence of neoplasia. Bronchoalveolar lavage (BAL) was positive for Mycobacterium tuberculosis, and real-time PCR for detecting M. tuberculosis was positive. Two transparietal punctures were performed and histological analysis revealed nonspecific inflammation. Pulmonary TB was diagnosed and a therapeutic regimen was prescribed with good clinical, biological and radiological improvement. This case emphasizes the diagnostic challenges associated with the pseudotumoral form of tuberculosis. It highlights the importance of considering tuberculosis in the differential diagnosis, even when the radiographic images and clinical history suggest an alternative diagnosis, particularly in areas where tuberculosis is endemic.

P.031 A Rare Canadian Case of Cervical Pyomyosistis Presenting as Occipital Neuralgia

Background: Pyomyositis is an infectious disease usually encountered in tropical regions. It typically occurs in immunocompromised hosts and most commonly affects lower limb muscles. Our patient was a healthy Canadian with an atypical presentation of cervical pyomyositis. Methods: We report a case of a healthy 22-year old woman presenting to the emergency department with unprovoked severe bilateral cervico-occipital pain and nuchal rigidity. She remained afebrile. Review of the literature was conducted to search for similar presentations. Results: A Computed Tomography scan of the head and neck demonstrated the presence of a ring enhancing lesion in the semispinalis capitis muscle extending from the occiput to the C4 level. The abscess was surgically drained and cultures grew staphylococcus aureus. The patient rapidly improved on intravenous antibiotics. Literature review revealed this to be the first Canadian case of cervical pyomyositis. Conclusions: Cervical pyomyositis can be complicated by local destruction of the vertebrae, septic shock, endocarditis, septic emboli, brain abscess or rhabdomyolysis. Early diagnosis and source control is necessary to reduce the risk of morbidity. Therefore, it is important to consider this rare disease in the differential diagnosis of cervicalgia even in healthy immunocompetent patients.

S1928 Seeing the Forest for the Trees: Not All Colitis Is IBD

Introduction: Gastrointestinal involvement by Epstein-Barr virus (EBV) infection is rare, and almost always occurs in states of immunodeficiency or chronic inflammation. We present a case of EBV colitis in a healthy immunocompetent patient. Case description/methods: A 33-year-old man presented with 3 weeks of bloody diarrhea, fatigue, malaise, and weight loss. On exam, he had tender cervical lymphadenopathy. Labs showed leukocytosis of 19.2 K/UL (64% lymphocytes), hemoglobin of 11.5 g/dL, and elevated CRP of 23.8 mg/L. Liver enzymes were elevated, with ALT of 156 U/L, AST of 125 U/L, and alkaline phosphatase of 220 U/L. Albumin (4 g/dL) and platelets (221 K/UL) were normal. Tests for HIV, viral hepatitis, and stool bacteria, ova, and parasites were negative. Computed tomography showed splenomegaly, enlarged intraabdominal lymph nodes, and diffuse colon wall thickening with hyperemia. Colonoscopy revealed patchy ulcers, friability, and erythema in the colon, with normal intervening mucosa and terminal ileum. He was referred to the Inflammatory Bowel Disease (IBD) service, and initial pathology showed mild active chronic pancolitis. Due to symptom severity, he was started on IV methylprednisolone 20 mg twice daily and rapidly improved in 2 days. Final pathology showed positive EBV-encoded small RNA (EBER) in situ hybridization (50 cells/hpf) without evidence of an underlying lymphoproliferative disorder. Serologies showed acute EBV infection (IgM+, IgG-, PCR viral load 341 IU/mL), and liver biopsy showed EBV hepatitis. Infectious Disease (ID) agreed with supportive therapy. He was discharged on 5 days of prednisone 40 mg daily. On 1-week follow up, he was asymptomatic off steroids. Repeat colonoscopy will be performed in 3 months. Discussion: Acute EBV infection classically presents with lymphadenopathy, splenomegaly, and constitutional symptoms. EBV colitis is exceedingly rare in immunocompetent patients, especially in the absence of lymphoma, with only 3 published case reports. Our case highlights the importance of maintaining a holistic approach to arrive at a unifying diagnosis. EBV in colon biopsies is not always pathologic; serologies are needed to determine active or latent infection. Coordinating with ID is prudent. Management is typically supportive, given the self-limited course; the role of corticosteroids and antivirals remains unclear. Repeat colonoscopy with biopsies to evaluate mucosal healing and to rule out underlying IBD is recommended.Figure 1.: Figure 1A. 4.3 x 3.5 cm mass anterior to a large sigmoid diverticulum with Hounsfield units of 22-36 (red arrow). Hounsfield units of lipomas range from 30 to 70. Figure 1B. 4 cm pedunculated polyp 20 cm from the anal verge. Figure 1C. Microscopy depicting submucosal mass with mature white adipose tissue (red arrow).

A case of disseminated Cryptococcus neoformans in a non HIV patient

Background: Cryptococcus neoformans predominantly causes significant infections in immunocompromised individuals, of which 80–90% occur in people infected with human immunodeficiency virus (HIV). The clinical manifestations can vary from asymptomatic colonization of the respiratory airways to dissemination of infection into any part of the human body. Disseminated cryptococcal infection especially noncutaneous cryptococcal abscess in immunocompetent host is uncommon. We report a case of disseminated Cryptococcus neoformans with soft tissue and pulmonary involvement in an otherwise healthy immunocompetent patient diagnosed by culture of the abscess. Case Description: Mr S, 72 y old Malay man, no known medical illness, a farmer at palm oil plantation in Benut, Johor, presented with progressive anterior chest wall swelling for 1 week duration associated with fever. CECT thorax showed left upper lobe and right chest wall abscess complicated with septic arthritis and osteomyelitis. The swelling was incised and pus was drained. Histopathological examination showed numerous encapsulated yeast like organism with thick capsule. Culture from tissue and pus of this patient grew Cryptococcus neoformans var grubii. Patient was treated as disseminated Cryptococcus neoformans and responding well to Amphotericin B. Discussion: Cryptococcal infections are common in immunosuppressed and relatively rare among immunocompetent population. In this case, the culture of the pus grew Cryptococcus neoformans serotype A (var. grubii) identified by Malditof. This variant of Cryptococcus is most commonly isolated from AIDS patient. The pathogenesis of cryptococcosis is rely on status of host defences, virulence strain and size of the inoculums. The mode of transmission in this case as he is a farmer, most likely from inhalation and direct of inoculation of the pathogen. Conclusion: Absence of immunosuppression should not be a reason to exclude cryptococcosis from the differential diagnosis when patient presents with an abscess.

Panton-Valentine Leukocidin-positive Staphylococcus aureus: a potentially significant pathogen in cystic fibrosis

Staphylococcus aureus is an important pathogen within the context of cystic fibrosis lung disease. Case reports have identified a strong association between the toxin Panton-Valentine Leukocidin (PVL) and lethal necrotizing pneumonia in healthy immunocompetent patients. PVL+ strains of Staphylococcus aureus have also been identified in patients with cystic fibrosis. We describe a further case of pneumonia in a patient with cystic fibrosis, and outline potential transmission of the organism from healthy family members to this patient. We review the evidence regarding the pathogenicity of PVL toxin with a special reference to patients with cystic fibrosis. We outline current concerns regarding the potential transmission of the organism and possible treatment strategies.

Isolated Renal Mucormycosis in a Healthy Immunocompetent Patient: Atypical Presentation and Course

Isolated renal mucormycosis is rarely identified and has been described in only a handful of cases. We hereby report a case of isolated renal mucormycosis with an atypical presentation in an immunocompetent patient with no identifiable risk factors. A 30-year-old nondiabetic male presented with a poorly functioning right kidney with minimal constitutional symptoms. The patient underwent a right simple nephrectomy. Histopathology revealed necrotizing xanthogranulomatous pyelonephritis with mucormycosis. The postoperative period was uneventful and the patient was managed without any antifungal administration. We hereby emphasize that renal mucormycosis can affect immunocompetent healthy adults without any previously known risk factors and that asymptomatic patients with no evidence of fungemia or disseminated disease can be managed without administration of intravenous amphotericin.

An instructive case of CNS histoplasmosis in an immunocompetent host

Histoplasma capsulatum is a dimorphic endemic fungus which infects both immunocompetent and immunocompromised hosts. Isolated CNS histoplasmosis is a rare presentation with increased risk in individuals with impaired cellular immunity, however not all patients with this condition are immunocompromised. We report a case of isolated CNS histoplasmosis in an otherwise healthy immunocompetent patient who was initially treated with Liposomal Amphotericin B followed by oral Voriconazole and later Itraconazole with significant improvement in clinical status.

Disseminated Cryptococcosis in an Immunocompetent Patient: A Case Report

Cryptococcus neoformans is ubiquitous encapsulated yeast found throughout the world. It predominantly causes significant infections in immunocompromised individuals, of which 80–90% occur in people with human immunodeficiency virus (HIV) infection. Disseminated cryptococcal infection is uncommon and almost always occurs in HIV-infected patients. Disseminated disease, especially noncutaneous cryptococcal abscess in immunocompetent hosts, is exceedingly rare. We report a case of disseminated cryptococcosis with soft tissue, pulmonary, and cerebral involvement in an otherwise healthy immunocompetent patient initially diagnosed by fine needle aspiration cytology (FNAC).

Periorbital necrotising fasciitis following cutaneous herpes zoster

Necrotising fasciitis is a rare severe infection of the soft tissues and deep fascia, which is associated with a significant level of mortality. Involvement of the head and neck is uncommon, and necrotising fasciitis of the periorbital area even rarer. We present a case of bilateral periorbital necrotising fasciitis following shingles in an otherwise healthy immunocompetent patient.

Central nervous system aspergillosis in an immunocompetent patient

Aspergillus sp. is a fungus that is very common in nature and may cause invasive disease with high mortality, especially in immunosuppressed patients. Here we present a case of central nervous system (CNS) aspergillosis in a previously healthy immunocompetent patient. A 23-year-old female was admitted to hospital with the complaints of headache, blurred vision, and double vision. In her cranial magnetic resonance imaging, abscess and paranchymal edema were observed in the left frontal lobe, and biopsy was performed with endoscopic nasal operation. The pathology result was consistent with aspergillus infection. It should be remembered that although CNS aspergillosis generally occurs in immunosuppressed patients, it may also rarely be diagnosed in immunocompetent individuals.

Interferon-λ in immunocompetent individuals with a history of recurrent herpes labialis

Herpes labialis (HL) is the most common manifestation of recurrent oral herpes simplex virus type-1 (HSV-1) infection. Between 20% and 40% of the population is affected by recurrent HL. The biological basis for the difference between HSV-1-infected individuals who do and who do not suffer recurrences, has long been investigated. Interferon (IFN)-alpha and IFN-lambda are essential for antiviral immunity, but the precise role of IFN-lambda in vivo is not yet well understood. Healthy immunocompetent patients with or without a history of recurrent HL were recruited from the Policlinico of the University of Rome Tor Vergata (Rome, Italy), and HSV-1-seronegative individuals were recruited from the Department of Experimental Medicine of the University of Rome Tor Vergata, between July 2007 and December 2008. Participants were interviewed by medically trained investigators and underwent a blood test. Peripheral blood mononuclear cells (PBMCs) were obtained from heparinized blood of patients and stimulated in vitro with intact HSV-1 strain F1 (1 plaque-forming unit/cell). PBMC supernatants were assayed for IFN-alpha, IFN-gamma and IFN-lambda production by ELISA at 24 and 48 h after viral challenge. PBMC from patients with a history of recurrent HL produced markedly lower levels of IFN-lambda and marginally lower levels of IFN-alpha and IFN-gamma than those from the history-negative HSV-1-seropositive controls. Among individuals with HL recurrences, those with more frequent and severe manifestations showed a significant trend towards lower levels of IFN-lambda production. A reduced IFN-lambda response might correlate with the development of recurrent HSV-1 infection in immunocompetent individuals. Testing for IFN-lambda response might be useful to predict individual patterns of antiviral response, contributing to more successful therapeutic or prophylactic interventions.

Non-traumatic nasal septal abscess in an immunocompetent patient

Nasal septal abscess is an uncommon condition. Most commonly it is secondary to nasal trauma, which leads to haematoma, and subsequent abscess formation. There are other less common causes like sinusitis, dental infections and furunculosis. Non-traumatic nasal septal abscess has also been reported in immunocompromised individuals. We report a case of non-traumatic, spontaneous nasal septal abscess, in a healthy immunocompetent patient with no evidence of sinusitis or other localized infections. Using Medline and Google.co.uk search applications, there has been one previous report of such a condition. We stress the importance of excluding nasal septal abscess in patients presenting with nasal obstruction especially with signs of toxaemia.

Non-traumatic nasal septal abscess in an immunocompetent patient

Nasal septal abscess is an uncommon condition. Most commonly it is secondary to nasal trauma, which leads to haematoma, and subsequent abscess formation. There are other less common causes like sinusitis, dental infections and furunculosis. Non-traumatic nasal septal abscess has also been reported in immunocompromised individuals. We report a case of non-traumatic, spontaneous nasal septal abscess, in a healthy immunocompetent patient with no evidence of sinusitis or other localized infections. Using Medline and Google.co.uk search applications, there has been one previous report of such a condition. We stress the importance of excluding nasal septal abscess in patients presenting with nasal obstruction especially with signs of toxaemia.

Near-Fatal Multiple Organ Dysfunction Syndrome Induced byPlasmodium malariae

To the Editor: We report a case of Plasmodium malariae–related multiple organ dysfunction syndrome (MODS) in a healthy immunocompetent patient. Despite extensive investigation, P. malariae was the only pathogen identified. The patient’s isolates had a combination of mutant alleles that could possibly explain the severity of the infection.

Near-Fatal Multiple Organ Dysfunction Syndrome Induced byPlasmodium malariae

To the Editor: We report a case of Plasmodium malariae–related multiple organ dysfunction syndrome (MODS) in a healthy immunocompetent patient. Despite extensive investigation, P. malariae was the only pathogen identified. The patient’s isolates had a combination of mutant alleles that could possibly explain the severity of the infection.

Disfiguring molluscum contagiosum in a HIV-positive patient responding to antiretroviral therapy

Molluscum contagiosum (MC) is caused by a double stranded DNA virus belonging to the pox virus family. MC lesions are usually pearly, dome shaped, small, discrete lesions with central umbilication. In HIV-positive patients atypical varieties are found. They may be large or nonumbilicated. Individual papules may join to form the agminate variety. This form is rare. Lesions of MC in healthy immunocompetent patients may occur at any part of the body including face, trunk, and limbs. Sexually active adults have lesions usually on the genitalia, pubis, and inner thigh, rarely on the face and scalp. We present a case of agminate MC occurring in a patient with acquired immunodeficiency disease responding to highly active antiretroviral therapy.