History Of Fever Research Articles

CANCER RATIO-BASED DIAGNOSTIC TOOL IN IDENTIFYING MALIGNANT PLEURAL EFFUSION: SENSITIVITY, SPECIFICITY AND CLINICAL INSIGHTS

Background: Malignant pleural effusion (MPE) is a common cause of exudative lymphocytic pleural effusion. Although pleural fluid evaluation is routinely performed, cytology or histopathology remains the gold standard for MPE diagnosis. The cancer ratio (CR), calculated by comparing serum LDH to pleural fluid ADA levels, has shown promise in diagnosing MPE. However, no studies have investigated its utility in the Thai population, which has a high tuberculosis prevalence.
 Objectives: This study aimed to evaluate the diagnostic accuracy of the CR in MPE diagnosis, compare clinical and pleural fluid parameters between MPE and nonMPE cases, determine the appropriate CR cut-off for the Thai population and develop a prediction score for prediagnosing MPE.
 Results: Between July 2021 and December 2022, patients presenting exudative lymphocytic pleural effusion were included in the study. Demographics, symptoms, radiographic findings and pleural fluid parameters were collected and cytology/histopathology served as the reference test. CR performance was assessed using receiver operating characteristic curves, and a prediction score was developed using multivariable logistic regression analysis. Among 122 patients, 46.7% received a diagnosis of MPE. The CR exhibited a sensitivity of 87.7% and specificity of 72.3% (AUC 0.83) with a cut-off level >10. Patients with MPE showed longer symptom duration, lower fever and massive pleural effusion, which were more common in MPE than nonMPE cases. A prediction score incorporating symptom duration, fever history, effusion amount and CR demonstrated superior diagnostic performance for MPE (AUC 0.94) compared with the CR alone.
 Conclusion: The CR can effectively differentiate MPE from nonMPE among patients with exudative lymphocytic pleural effusion. A cut-off level >10 is recommended for diagnosing MPE in the Thai population. Combining clinical, radiologic and CR data may aid in prediagnosing MPE; however, further research is needed for validation.

LE (lupus erythematosus) Cell in Pleural fluid Cytology

During the COVID-19 (coronavirus disease) pandemic, a middle-aged woman was brought to the emergency department after experiencing sudden difficulty breathing after a two-week history of fever and cough. A contrast-enhanced computerised tomography (CECT) scan revealed minimal pericardial and pleural effusions on the left side. A pleural effusion was tapped using ultrasound guidance and sent to the cytopathology laboratory. A cytological examination revealed numerous lupus erythematosus (LE) cells, resulting in a diagnosis of lupus pleuritis. J Bangladesh Coll Phys Surg 2023; 41(4): 348-349

A multi-platform approach to identify a blood-based host protein signature for distinguishing between bacterial and viral infections in febrile children (PERFORM): a multi-cohort machine learning study

Differentiating between self-resolving viral infections and bacterial infections in children who are febrile is a common challenge, causing difficulties in identifying which individuals require antibiotics. Studying the host response to infection can provide useful insights and can lead to the identification of biomarkers of infection with diagnostic potential. This study aimed to identify host protein biomarkers for future development into an accurate, rapid point-of-care test that can distinguish between bacterial and viral infections, by recruiting children presenting to health-care settings with fever or a history of fever in the previous 72 h. In this multi-cohort machine learning study, patient data were taken from EUCLIDS, the Swiss Pediatric Sepsis study, the GENDRES study, and the PERFORM study, which were all based in Europe. We generated three high-dimensional proteomic datasets (SomaScan and two via liquid chromatography tandem mass spectrometry, referred to as MS-A and MS-B) using targeted and untargeted platforms (SomaScan and liquid chromatography mass spectrometry). Protein biomarkers were then shortlisted using differential abundance analysis, feature selection using forward selection-partial least squares (FS-PLS; 100 iterations), along with a literature search. Identified proteins were tested with Luminex and ELISA and iterative FS-PLS was done again (25 iterations) on the Luminex results alone, and the Luminex and ELISA results together. A sparse protein signature for distinguishing between bacterial and viral infections was identified from the selected proteins. The performance of this signature was finally tested using Luminex assays and by calculating disease risk scores. 376 children provided serum or plasma samples for use in the discovery of protein biomarkers. 79 serum samples were collected for the generation of the SomaScan dataset, 147 plasma samples for the MS-A dataset, and 150 plasma samples for the MS-B dataset. Differential abundance analysis, and the first round of feature selection using FS-PLS identified 35 protein biomarker candidates, of which 13 had commercial ELISA or Luminex tests available. 16 proteins with ELISA or Luminex tests available were identified by literature review. Further evaluation via Luminex and ELISA and the second round of feature selection using FS-PLS revealed a six-protein signature: three of the included proteins are elevated in bacterial infections (SELE, NGAL, and IFN-γ), and three are elevated in viral infections (IL18, NCAM1, and LG3BP). Performance testing of the signature using Luminex assays revealed area under the receiver operating characteristic curve values between 89·4% and 93·6%. This study has led to the identification of a protein signature that could be ultimately developed into a blood-based point-of-care diagnostic test for rapidly diagnosing bacterial and viral infections in febrile children. Such a test has the potential to greatly improve care of children who are febrile, ensuring that the correct individuals receive antibiotics. European Union's Horizon 2020 research and innovation programme, the European Union's Seventh Framework Programme (EUCLIDS), Imperial Biomedical Research Centre of the National Institute for Health Research, the Wellcome Trust and Medical Research Foundation, Instituto de Salud Carlos III, Consorcio Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Grupos de Refeencia Competitiva, Swiss State Secretariat for Education, Research and Innovation.

Successful Management of Retropharyngeal Lymphangioma with Stridor Using Sirolimus: A Case Report.

Lymphatic malformations (LMs) are one of the congenital malformations of the lymphatic system in the body. The patient usually presents with head and neck swelling, airway compression, and/or airway obstruction. The diagnosis of retropharyngeal LMs can be challenging due to their rare occurrence. We report a case of a five-month-old boy diagnosed with retropharyngeal LMs. He presented with a three-day history of fever, cough, and stridor and was initially treated for acute bronchiolitis. A lateral neck radiograph revealed prevertebral widening, suggesting retropharyngeal collection. The patient's condition worsened, requiring intubation in the operating room and proceeding with aspirations and drainage. However, the symptoms recurred after a few days, necessitating re-intubation, repeated aspirations and drainage procedures. The patient was intubated, and the neck's magnetic resonance imaging (MRI) confirmed retropharyngeal LMs. An elective tracheostomy was performed and was treated with sirolimus. The patient had a successful tracheostomy decannulation and showed no recurrence during follow-up.

Surgical emphysema and pneumothorax: Unfamiliar combination in Ehlers-Danlos syndrome

A 53-year-old gentleman presented with sudden onset swelling over the neck for the past 5 days. It was associated with dyspnoea on exertion. He was a known patient of Ehlers-Danlos syndrome since sixteen years of age. Initially, the swelling appeared over the neck which gradually progressed over to the anterior chest wall and the nape of the neck. There was no history of trauma, fever, surgery or similar complaints in the past. He was a known smoker. On examination, there was diffuse subcutaneous emphysema over the neck, and the anterior chest wall (Figure 1). Skin crepitus was present. The skin was hyper-extensile, fragile and easily stretchable (Figure 1). The patient was vitally stable. On rigid laryngoscopy, bilateral vocal cords were mobile. We admitted the patient and performed a CT scan of the neck and chest to assess the extent of the emphysema. CT scan confirmed an extensive subcutaneous emphysema over the neck, extending posterior to the oesophagus. There were multiple emphysematous bullae over the apical region of the right lung and an area of pneumothorax just in the vicinity of the bullae (Figure 2). The patient was planned for incision and evacuation of the air. A horizontal incision was given over the most prominent part of the swelling and the air was milked out gently. An Intercostal Chest Drain (ICD) was inserted and the condition was closely monitored. The recovery was uneventful. He was discharged after seven days of hospital stay.

Differential diagnosis of bulging scalp: beyond cephalohematoma and subgaleal hematoma

A 30-day-old infant was brought to the pediatric emergency room with a bulge in the scalp in the parieto-occipital region, mobile and without associated phlogistic signs. He had no history of fever or any other complaints. The mother reported that the bulge appeared at 20 days of life and showed progressive growth. There was no history of trauma. The boy was born at term by cesarean delivery due to cephalopelvic disproportion.
 For initial evaluation, skull X-ray and cerebral ultrasound were performed (Figure 1). A magnetic resonance imaging and tomography of the brain were also performed (Figure 1). 
 Faced with the diagnostic challenge, neurosurgery proceeded with drainage of the collection and biopsy of the galea. No malignant cells were found and the biopsy only found an inflammatory change. Given these findings, the diagnosis of delayed subaponeurotic fluid collection (DSFD) was made. There was no recurrence of the collection and the patient had a good evolution.
 DSFD are a rare condition, which occurs spontaneously between the 4th and 18th week of life, and makes the differential diagnosis with cephalohematoma, caput succedeneum and subgaleal hematoma [1]. Its pathophysiology is not fully elucidated; however, most reports share a similar history of prolonged or instrumented delivery [1,2]. Patients are otherwise healthy and with no history of trauma [2].
 The management of DSFD is conservative and the natural history is spontaneous resolution within 1 to 2 months [1,2].

Perinephric and psoas abscesses leading to empyema: An unusual tuberculosis presentation

Tuberculous psoas abscess usually results from tuberculous spondylitis but may also develop from direct spread or via hematogenous route [1]. Our case involves direct spread from an adjacent perinephric abscess with associated thoracic extension from suspected direct erosion or a diaphragmatic defect. We present a case of pleural empyema arising from abdominal tuberculous abscesses. This is an 11-year-old male who initially presented with a three-week history of cough, intermittent fever, and dyspnea. Congenital diaphragmatic hernia was first suspected at the emergency department when an opacified left hemithorax with cystic lucencies was noted. Further imaging of the chest and upper abdomen was done in our institution revealing large left perinephric and psoas abscesses with intra-thoracic extension resulting in empyema thoracis and necessitans. Culture of the abscess fluid yielded no growth but GenExpert tested positive for M. tuberculosis. Tuberculosis remains a major illness in developing countries and has a multitude of infection sites and clinical presentation. Our case presented as an ascending thoracic extension of a perinephric and psoas abscess, likely from a diaphragmatic defect. The absence of spinal involvement proves its renal origin. The importance of CT scan is highlighted in medically-confounding cases such as this one.

Transitional meningioma benign who grade 1 tumor-A case and review of the literature

Transitional meningioma (TM) is an uncommon benign meningioma. Transitional meningioma is a WHO grade I meningioma characterized by the coexistence of meningothelial cells and fibrous architectural patterns. A35 year female presented with history of intermittent fever, headache of 1 month duration. And since last 2 days with altered level of consciousness and vomiting.: MRI of the brain was performed using TI weighted spin echoI2 weighted turbo spin echo and turbo Fluid-attenuated inversion recovery: FLAIR diffusion sequences. It showed a large, lobulated, enhancing lesion in right fronto-temporal region, along right greater wing of sphenoid suggestive of meningioma. Surgical excision of tumor was done. On histopathology showed a benign tumor consists of meningothelial and fibrous proliferation. The meningothelial cells were arranged in fascicles, with the fibroblastic tumor in syncytial pattern. The nuclei were round, uniform without nucleoli. The chromatin was fine and open. The tumor cells were spindle having abundant pink cytoplasm, indistinguishable cell membranes and bland nuclear features. Mitotic figures and atypia were absent .Scattered Psammoma bodies were noted. Histopathological diagnosis was gives as benign WHO grade 1 tumor- transitional meningioma.Due to enhanced and improved imaging, histopathological techniques the increased incidence of meningiomas is observed and it will be helpful for better outcomes of patients. We are presenting this case of transitional meningioma benign tumor WHO grade1for its clinical, radioimaging and histopatholgical findings.

Paediatric thoracic actinomycosis presenting as back swelling: A case report

Presentation: A seven years old girl presented with a three-day history of cough and fever, and several weeks of back pain, anorexia and weight loss. Examination was significant only for a tender, non-erythematous swelling to the right mid-back measuring ten centimetres in length. Diagnosis and treatment: Investigations on admission included neutrophilia and elevated inflammatory markers. Chest radiograph demonstrated a confluent area of opacification within the right peripheral lower zone with a small pleural effusion. CT reported two large enhancing and infiltrative lesions in the right thorax and the right posterior lower ribs, and disseminated lymphadenopathy. Microbiology and histology of a tissue sample were conclusive for actinomycosis israelii. She had a full recovery following a nine month course of oral amoxicillin. Discussion: Invasive actinomycosis is rare, and a high clinical suspicion and thorough investigation is warranted with invasive pneumonia and atypical associated symptoms. Keywords: Actinomycosis; Pneumonia; Chest wall mass; non-accidental injury.

A rare case of a massive unilocular typhoid splenic abscess in Sri Lanka: A Case Report

Splenic abscesses are commonly reported in patients with immunosuppression, abnormalities in the spleen due to trauma or haemoglobinopathies and diabetes. Typhoid fever causing isolated splenic abscess is a rarity. We report a case of a splenic abscess in a previously well patient without any predisposing risk factors and previous illness clinically suggestive of typhoid fever.A 22-year-old Sri Lankan woman was admitted to a tertiary care hospital in Sri Lanka with a 2-week history of high-grade fever with chills and rigors, and abdominal fullness. Palpation revealed a large firm mass in the left upper quadrant which was confirmed as a massive spleen on ultrasonography. Contrast CT of the abdomen showed a large hypodense lesion within the spleen. A drain was inserted radiologically which drained a purulent fluid. Culture of the drain fluid grew Salmonella ser. Typhi. She made an excellent recovery with antibiotics.Typhoid is a rare but reported cause of splenic abscesses. It could occur even in patients with no apparent risk factors. Early diagnosis and treatment lead to an excellent clinical outcome.

Anakinra and hepatotoxicity in pediatric rheumatology: a case series

BackgroundAnakinra is a recombinant interleukin-1 (IL-1) receptor antagonist used in systemic juvenile idiopathic arthritis (sJIA), refractory Kawasaki disease (KD) and cryopyrin-associated autoinflammatory syndrome (CAPS). Anakinra associated hepatotoxicity, while rare, has been described in several cases in daily practice. ​In this case series the authors describe three pediatric patients with this side effect in the setting of severe macrophage activation syndrome (MAS) in KD and sJIA.Case presentationThe first patient was a 12-year-old boy who presented with fever, maculo-papular exanthema and polyarthralgia. Tonsillitis, distal limb induration and tender cervical lymph nodes were observed. Erythrocyte-sedimentation rate (ESR), C-reactive protein (CRP), ferritin (11,975 ng/mL), D-dimers (5,98 mg/L FEU) and soluble CD25 (3645 pg/mL) levels were elevated. Exclusion of sepsis / toxic shock syndrome warranted introduction of IV methylprednisolone and immunoglobulin (IG IV), with partial response. A MAS secondary to KD was assumed, and anakinra 2 mg/kg/day was introduced. Twenty days later he developed new-onset nausea and severe cyto-cholestasis, normalizing after 2 months of drug discontinuation. Posterior onset of polyarthritis and evanescent lead to a final diagnosis of sJIA. The second patient was a 2-year-old boy with a 10-day history of fevers, generalized rash, hepatosplenomegaly and strawberry tongue. Leucocytosis with neutrophilia and elevated CRP were observed. Initial treatment with IVIG in the setting of incomplete KD was ineffective. Mild anaemia, leukopenia and very high serum ferritin (maximum 26,128 ng/mL) ensued. Presumptive sJIA associated MAS was treated with IV methylprednisolone and anakinra 2 mg/kg/day, with prompt response. Four weeks later transaminitis was detected, and temporary anakinra suspension led to normalisation of laboratorial values. The third case related to a 4-year-old boy presenting with fever, maculopapular rash and cervical lymphadenopathy. CRP and ESR were elevated, and KD was diagnosed. IVIG and methylprednisolone were initiated with clinical worsening, warranting for anakinra introduction at 2 mg/kg/day. After three weeks, liver enzymes progressively elevated, resolving on 2 weeks of anakinra discontinuation.ConclusionsTo the best of our knowledge, this is the first case series describing anakinra associated hepatotoxicity in pediatric patients with rheumatic diseases other than sJIA, bringing additional insight to therapeutic monitoring in patients undergoing this treatment.

FRI559 An Uncommon Association Of Two Common Etiologies Of Hyperthyroidism

Abstract Disclosure: C. Chew: None. Introduction: Subacute thyroiditis and Graves’ disease are two common etiologies of hyperthyroidism. Association of these two diseases in patient presented with recurrent hyperthyroidism has rarely been reported. Case Report: A 35 years old women, with no known medical illness, was referred to Endocrine Clinic for painful anterior neck swelling associated with palpitation for 2 weeks. The symptoms were preceded by 3 days history of sore throat and mild fever She denied other symptoms of hyperthyroidism. Her last menses was 3 weeks prior. On physical examination, she was tachycardic with heart rate of 115 beats per minute. Her blood pressure was 135/90 mmHg and she was afebrile. There was a tender and diffusely enlarged goiter. However, there were no signs of thyroid eye disease and other signs of hyperthyroidism. Examinations of her throat, lung, abdomen, cardiovascular system and neurological system were unremarkable. There was also absence of lymphadenopathy. She denied family history of thyroid disease. Results of laboratory investigations were suggestive of hyperthyroidism secondary to subacute thyroiditis: Free T4 52 pmol/L (8-16), TSH <0.01 mIU/L (0.45-4.50), TRAb 0.8 IU/L (0-1.0) and ESR 108 mm/hr (1-10). The technetium scan showed mildly enlarged gland with decreased uptake of Tc-99m tracer suggestive of thyroiditis. She was treated with Ibuprofen and Propranolol, and her symptoms improved. At 6 weeks follow up, her thyroid function normalized with Free T4 of 13 pmol/L (8-16), TSH of 1.28 mIU/L (0.45-4.50). However, she complained of weight loss and palpitation at 6 months follow up. Examination revealed a small painless diffuse goiter and she was tachycardic with heart rate of 115 beats per minute. Thyroid function test confirmed recurrence of hyperthyroidism: free T4 45.8 pmol/L (8-16) and TSH <0.01 mIU/L (0.45-4.50). Elevated TSH receptor antibody (TRAb) level at 16.8 IU/L confirmed the diagnosis of Graves’ disease. Carbimazole was then started. Discussion: Subacute thyroiditis and Graves’ disease are two common etiologies of hyperthyroidism. The incidence of association of these two diseases had been reported to be rare at 0.15% in patients with Graves’ disease and 0.76% in patients with subacute thyroiditis (1). The postulated mechanism of the association is that the release of thyroid antigens and corresponding activation of the immune system due to viral invasion of the thyroid gland in subacute thyroiditis may cause the subsequent Graves’ disease (1,2). Conclusion: Graves’ disease should be suspected in patient with persistent or recurrent hyperthyroidism after an episode of subacute thyroiditis although it is rare. Reference: 1. Nakano Y et al. Graves’ disease following subacute thyroiditis. Tohoku J. Exp. Med. 2011; 225:301-309. 2. Bartalena L et al. Graves’ disease occurring after subacute thyroiditis. Report of a case and review of the literature. Thyroid. 1996; 4:345-348. Presentation: Friday, June 16, 2023

Seasonal Trends with the Comparison of Venous and Capillary Blood for Diagnosis of Malaria among Children in Karachi, Pakistan.

More than 250 million people are infected by malaria parasites annually while around one million children less than 5 years of age die every year due to malaria. We aimed to assess the seasonal trends and usefulness of capillary and venous blood for rapid diagnosis of malaria. This cross-sectional study of 18 months duration was conducted at the National Institute of Child Health (NICH), Karachi. All patients reporting fever as chief complaint were recruited as study subjects. A semi-structured questionnaire was used to collect demographic information, presenting complaints, awareness of caregivers regarding malaria, preventive measures and history of malaria fever. Three ml Venous (2-3ml) as well as peripheral blood (3-4 drops) samples of all patients were collected for microscopy and rapid diagnostic tests (RDTs). Out of total 477 patients with fever Venous and Capillary Blood RDTs methods detected 33(6.9%) and 30(6.3%) as the malaria positive while Venous and Capillary Blood Microscopy detected 30(6.1%) and 32(6.7%) cases respectively. Plasmodium Vivax infection was the most prevalent (87.9%) and majority (39.39%) of the cases occurred in the quarter, July to September. July to September is the peak season for malaria and P. Vivax (87.9%) is the predominant strain in Karachi. Venous and capillary blood are equally useful for malaria diagnosis however, convenience and less invasiveness may justify the preference of capillary blood over venous blood for early diagnosis of malaria.

Simultaneous tubercular meningitis and ethmoidal sinus tuberculoma mimicking as Foster Kennedy syndrome

A 35-year-old male presented with gradual-onset progressive loss of vision in the left eye of 2 months duration. There was history of fever, weight loss, and headache. Comprehensive ocular examination revealed disc edema in the right eye and optic atrophy in the left eye. Further radiologic, histopathologic, and cerebrospinal fluid study led to a diagnosis of tubercular meningitis and ethmoidal sinus tuberculoma compressing the left optic nerve. The clinical picture mimicked Foster Kennedy syndrome. This case highlights the importance of ancillary investigations in the form of radiologic and histopathologic studies in arriving at the final correct diagnosis.

Strongyloidiasis masquerading as Addison’s disease

Abstract A 20-year-old man presented with complaints of weight loss of 25 kg, anorexia, vomiting, and generalized darkening of complexion for 6 months. He complained of abdominal discomfort, fullness, and pain after meals, followed by vomiting. There was no history of diarrhea, fever, night sweats, or jaundice. The stools were not bulky or oily. He was hospitalized before, but nothing significant was found except for mucosal thickening in the stomach and duodenum in gastroscopy. His chest X-ray, thyroid function tests, plasma glucose, and abdominal sonography were found normal during the previous admission. Serology for HIV was nonreactive. Family history was noncontributory. The patient had no addictions. The patient was shifted to the endocrine ward with a suspected diagnosis of Addison’s disease. The patient looked cachexic, with sunken eyes and coarse hair. However, serum 8 a.m. cortisol was normal. But vitamin B12 was low. The patient belonged to a rural background and was going to fields for defecation. His stool examination showed larvae of Strongyloides. After antihelminthic drugs, he showed improvement in appetite and regained 24 kg of weight in the next 4 months. Skin complexion also became normal.

Hypercalcemia of unusual etiology: A case report

Abstract A 71-year-old lady, known to have diabetes and hypertension, was evaluated for a history of fever and tiredness for a few weeks. She had drug-induced hypokalemia due to chlorthalidone that she was taking for hypertension, and it was corrected. Further investigations revealed hypercalcemia of 11.3 mg/dL, which rose to 14.4 mg/dL in a few days. Parathyroid hormone level was low. Her respiratory evaluation showed granulomatous features in the lungs in PET-CT scan and GeneXpert for tuberculosis in urine, and bronchoalveolar lavage fluid was positive, suggestive of disseminated tuberculosis. Her serum calcium was reduced with zoledronic acid given for emergency treatment of hypercalcemia and reached a normal level within 6 days and was maintained within normal limits by 3 weeks of starting antituberculosis treatment. This is a case of tuberculosis-induced hypercalcemia.

Relevance and challenges of neuroimaging for childhood tuberculous meningitis diagnosis in a resource-constraint country: A case report and literature review

Objective: Tuberculous meningitis (TBM) may be an undiagnosed cause of childhood mortality or neurologic sequelae. Cranial computed tomography (CT) scan remains a relevant diagnostic and prognostic tool amidst negative cerebrospinal fluid or sputum findings for tuberculous meningitis (TBM) diagnosis. Delays in diagnosis and treatment increase morbidity in resource-constraint countries.
 Case report: A seven-year-old boy was referred with three weeks history of fever, progressive body weakness, aphasia and unconsciousness (three days). He had right cranial nerve III palsy, generalized hypertonia, and hyperreflexia in right lower limbs. All tuberculosis tests were negative except the cranial CT findings of leptomeningeal enhancement with basilar involvement and evidence of obstructive hydrocephalus. He was managed with anti-tuberculous drugs, prednisolone, ventriculoperitoneal shunt, and physiotherapy, and made a significant recovery after a year of anti-tuberculosis treatment.
 Conclusion: The cranial CT scan findings facilitate TBM diagnosis for which prompt treatment commencement is crucial for a good outcome.

Community acquired pneumonia due to Klebsiella pneumoniae and Burkholderia pseudomallei co-infection in a diabetic patient: a case report

A 63-year-old diabetic man from Sherpur district, presented with 20-day history of fever and productive cough without any haemoptysis. Initially he was diagnosed as having pneumonia caused by Klebsiella pneumoniae and had been receiving sensitive antibiotic without satisfactory improvement. Clinical evaluation later revealed that, he was febrile, tachycardic, tachypneic and anaemic. Chest examination findings were consistent with consolidation at right upper chest. Further diagnostic work-up confirmed pneumonia due to co-infection by Klebsiella pneumoniae and Burkholderia pseudomallei. He tested positive for SARS-CoV-2 infection. Antibiotic was revised and his response to treatment was satisfactory till the latest follow-up. This case is reported to stress the importance for searching causes for non-resolution of pneumonia. BIRDEM Med J 2023; 13(3): 152-154

C5 (Clinical Case) Coccobacillary Meningitis and Septic Embolic Infarcts in an Ex-Preterm Infant: An Unexpected Pathogen

Abstract Introduction/Background Pasteurella multocida causes life-threatening zoonotic invasive infections in immunocompromised individuals and those at extremes of age (neonates and elderly). Bacteremia, meningitis, and endocarditis are serious complications that are associated with up to 25-30% mortality. Case Description A 7-week-old ex-34-week preterm female infant presented with a one-day history of fever, irritability, and poor feeding without exposure to sick contacts. Household contacts included a constantly drooling Shi Tzu dog. Examination revealed an irritable, febrile infant with a bulging fontanelle and scant purulent eye discharge. No focal neurological deficits, skin rashes or murmurs were appreciated. Empiric antibiotics were initiated following a full work-up for sepsis. Cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis with 7608 x106L nucleated cells (95% neutrophils), protein 7360 mg/L, glucose <0.2 mmol/L and gram-negative coccobacilli. Blood and CSF cultures grew Pasteurella multocida, prompting a switch to crystalline penicillin. An echogenic mitral valvular mass was identified in the absence of underlying cardiac defects. Head imaging confirmed ventriculitis with multiple small infarcts. No sequelae of abscess, hydrocephalus or hearing loss were demonstrated after the completion of 6 weeks of penicillin therapy. Discussion Haemophilus influenzae, serotype b, is the typical cause of coccobacillary meningitis in a 7-week-old infant. In addition to non-b serotypes, non-typeable species which cause conjunctivitis may also cause invasive disease in young infants. The resultant growth of P. multocida from cultures was, therefore, unexpected, particularly given there were no preceding animal bites or scratches. In vulnerable hosts, this pathogen can be transmitted across skin or mucous membranes after close animal contact, such as licking and sniffing. The constant drooling and spraying of saliva from the pet dog, a flat-faced breed known to have stenotic nares and chronic nasal secretions, likely provided an opportunity for mucosal contamination. This infant’s young age, prematurity, and exposure to a flat-faced dog placed her at high risk for Pasteurellosis, which manifested as complicated meningitis and endocarditis. Conclusion Pasteurella infections most often arise as local infections following an animal bite or scratch, are rare but important causes of life-threatening severe coccobacillary invasive infection, even without preceding trauma, in young infants. Families of at-risk individuals who own pets should have adequate education about zoonotic infections that address risk factors, including animal breed and behaviour, presenting features and preventive strategies to reduce the potential for serious morbidity and even mortality.

Shooting Your Own Foot: A Case Report on Autoimmune Encephalitis Following a Viral Trigger

Aims: The aim of this case report is to highlight the frequently overlooked association between Anti-NMDA Receptor Encephalitis and a preceding Herpes Simplex Viral Encephalitis trigger, the clinical settings under which to suspect this autoimmune disease, the need for appropriate workup to clinch the diagnosis and the necessity of speedy initiation of immunotherapy, in a disease where timely treatment is paramount.
 Presentation of Case: A middle aged woman presented with a history of fever and syncope, followed by slurring of speech, quadriparesis, seizures and altered sensorium. She was diagnosed with HSV-1 Encephalitis on basis of CSF studies and MRI brain. Despite a timely 28-day course of intravenous acyclovir therapy, she showed incomplete clinical recovery. A serum and CSF autoantibody panel was performed, which clinched a diagnosis of Anti-NMDA Receptor Encephalitis. A course of steroids and IVIg was given and the patient was discharged after showing clinical improvement.
 Discussion: Anti-NMDA Receptor Encephalitis is an autoimmune encephalitis characterized by complex neuropsychiatric features and presence of IgG antibodies against NR1 subunit of NMDA receptor detectable in CSF and serum. It is associated with various malignancies, chiefly ovarian teratomas, and with HSV-1 viral encephalitis. Diagnosis involves autoantibody detection in CSF or serum and first line treatment is with steroids, IVIg or plasma exchange, and tumour resection.
 Conclusion: Prompt diagnosis of Anti-NMDA receptor encephalitis is crucial as it enables treatment with timely immunosuppression and tumour resection. This disease must be suspected in adults or children presenting with subacute onset of neuropsychiatric symptoms, with CSF lymphocytic pleocytosis and presence of autoantibodies to NMDA receptor in CSF or serum. Early treatment is associated with good outcomes.