History Of Intravenous Drug Abuse Research Articles

Atypical cause of fever in advanced pregnancy

Although miliary tuberculosis (TB) is uncommon in pregnancy, it is difficult to diagnose when present and is often associated with a maternal history of intravenous drug abuse, malignancy, alcoholism, or human immunodeficiency virus (HIV) infection. TB in pregnancy can present with non-pulmonary symptoms, making the diagnosis and treatment challenging. We report a case of military TB in a lady with advanced pregnancy who presented with fever and cough without any history of exposure to TB patient. There was no history of alcoholism, intravenous drug abuse, or any other risk factors. Sputum for acid-fast bacilli stains and HIV screening were negative. The patient was started on anti-TB treatment after blood investigations ruled out other causes of fever and chest radiograph was suggestive of miliary TB. Confirming the diagnosis of miliary TB is an arduous process requiring a high index of suspicion. During pregnancy, histopathologic examination of tissue biopsy and GeneXpert may facilitate making an early diagnosis of extrapulmonary TB.

Needle Embolization: Suspecting Needle Migration in Intravenous Drug Abusers.

Thirteen million people inject drugs globally, making intravenous drug abuse a substantial concern worldwide. While intravenous drug users occasionally report the breaking of a needle into the skin or subcutaneous tissue, central needle migration remains a rare but potentially devastating complication. A 27-year-old man with a history of intravenous drug abuse presented to the emergency department with the sudden onset of left-sided neck pain, chills, and subjective fever with a history of needle breaking in his left neck 3weeks earlier while using heroin. A computed tomography scan of his chest revealed a needle lodged in the right ventricle with associated mediastinitis and mass effect on the left brachiocephalic vein, and a left internal jugular thrombus. Broad-spectrum antibiotics were initiated. This patient was managed nonsurgically for several reasons and was discharged on hospital day 12 with oral antibiotics. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intravenous drug abusers commonly use cervical veins when their peripheral vasculature has become sclerosed. This puts intravenous drug users at increased risk for intravascular embolization. Due to varied symptomology-chest pain, dyspnea, fever, or asymptomatic-and timelines-days, weeks, or months-after reported needle fragmentation, this remains a complex and likely underdiagnosed condition. Case reports describe serious complications of intracardiac needle embolization, such as cardiac perforation, constrictive pericarditis, septic endocarditis, dysrhythmias, granulomas, venous thrombosis, empyema, acute or delayed spontaneous pneumothorax, osteomyelitis, and valvular damage. In this complicated patient population, clinicians should consider needle retention and relocation in patients who report needle breaking or in those who present with chest pain, dyspnea, or fever among other complaints.

A Rare Case of Rib Osteomyelitis in an Intravenous Drug Abuser

Osteomyelitis (OM) is one of the most common invasive bacterial infections. Rib osteomyelitis is a rare disease that occurs in ~1% or less of all osteomyelitis. It can result from direct inoculation from traumatic wounds, by spreading from adjacent tissue affected by cellulitis or septic arthritis, or through hematogenous seeding. We present a case of a 32-year-old female with a history of Intravenous drug abuse who presented with localized left-sided chest pain. A CT thorax contrast study was obtained that showed edema around the anterior aspects of the left 3rd to fifth ribs and involves the inferior border of the pectoralis muscle with buckling of the left 4th rib with fluid density in the fascial planes. Subsequently, an MRI was done that revealed the pathological fracture of the anterior aspect of the left forth rib with evidence of osteomyelitis of the left 4th and 5th ribs, as well as early insufficiency fracture of the left fifth rib. Blood cultures were negative. She was treated conservatively with empiric antibiotics due to lack of seeding and bacteremia.

SAT-495 1-α-Hydroxylase Activity-Mediated Hypercalcemia Associated with Ovarian Dysgerminoma

Background: Humoral hypercalcemia of malignancy is classically associated with increased tumor production of parathyroid hormone-related peptide (PTHrP). While 1,25 dihydroxy vitamin D (1,25D) mediated hypercalcemia has been demonstrated with a range of granulomatous disorders and lymphomas, there have only been 11 cases reported in ovarian dysgerminomas, of which only 2 were in adults. Ovarian dysgerminoma is the most common ovarian malignancy in childhood but is much more infrequent in adults. We present a case of a rare ovarian malignancy in an adult woman with an even more rare presentation of 1,25D mediated hypercalcemia. Case: A 23 year old African American female with a history of intravenous drug abuse was admitted for dilation and curettage for suspected molar pregnancy. Her operative course was complicated by uterine perforation requiring diagnostic laparoscopy which revealed a large, firm, irregular left ovarian mass concerning for malignancy. Laboratory findings were pertinent for calcium 13.4mg/dl (8.5-10.5), albumin 3.5g/dl (3.5-5.0), creatinine 1.61mg/dl (0.6-1.2), phosphorus 4.0mg/dl (2.5-4.5), alkaline phosphatase elevated at 170 Units/L (25-125) and appropriately suppressed PTH of 4 pg/ml (10-65). Previous calcium levels were all normal. Additional work-up revealed normal PTHrP, 25-OH Vitamin D 14.2 mg/dl (20-50) and high-normal 1,25 dihydroxy vitamin D at 76pg/ml (19.9-79.3). Tumor markers β-hCG, LDH, α-fetoprotein, and CA 19-9 were all elevated. CT scan of the abdomen and pelvis characterized the lesion to be a heterogenous 16.5 x 10.0 x 18.3 cm pelvic mass. The patient was initially given intravenous isotonic fluids and 4mg of intravenous zoledronic acid which decreased calcium to 10mg/dl. Biopsy of the mass performed during initial laparoscopy confirmed the suspected diagnosis of ovarian dysgerminoma. A left salpingo-oophorectomy was performed and the patient developed mild hypocalcemia post-operatively to a nadir of 6.7mg/dl (adjusted for albumin: 7.7) requiring calcium supplementation. The 1,25D level on post-operative day 2 was low at 9.1 pg/ml. Surgical pathology demonstrated metastatic ovarian dysgerminoma with para-aortic lymph node involvement. Conclusion: Our case demonstrates an unusual case of humoral hypercalcemia of malignancy. Exogenous 1-α-hydroxylase expression has been reported exceedingly rarely in solid tumors other than lymphomas. While we were unable to stain the tumor for 1-α-hydroxylase, the abrupt drop in 1,25D and calcium levels post resection strongly support our diagnosis. To our knowledge, our patient is the second oldest patient reported in literature to have 1,25D mediated hypercalcemia associated with an ovarian dysgerminoma.

Secondary Discitis Masquerading as Treatment Failure of Primary Discitis: Case Report and Review of the Literature.

Vertebral osteomyelitis often presents with localized back pain at the site of infection and elevated inflammatory markers. It can generally be treated conservatively with antibiotics targeted at the causative microorganism, but failure of medical treatment often necessitates surgical debridement. There are no reports in the literature that describe a secondary infection masquerading as treatment failure of the primary infection. We present a case of a 29-year-old male with a history of intravenous drug abuse who was treated with antibiotics for methicillin-sensitive Staphylococcus aureus T6-7 discitis/osteomyelitis. The patient later returned with worsened back pain and was initially thought to have experienced failure of medical therapy, but instead was found to have a secondary discitis at a different level, with biopsy-proven different microorganism (Enterobacter cloacae). This case illustrates the possibility of secondary discitis masquerading as treatment failure of the primary discitis. Repeat imaging and biopsy of the new lesion avoided a surgical procedure in this patient.

JUST ANOTHER CASE OF ENDOCARDITIS

Endocarditis complications can include heart failure and embolic phenomena. In patients with hypoxia and increased right atrial pressures, right to left shunt should be considered. A 28 year old female with history of intravenous drug abuse presented 26 weeks pregnant with fever and dyspnea. Blood

Quadruple valve infective endocarditis presenting with suspected Austrian syndrome: a case report and a case series of quadruple valve infective endocarditis

ObjectivesAustrian syndrome comprises the triad of pneumonia, meningitis, and endocarditis secondary to Streptococcus pneumonia. We present what we believe to be the first reported case of Austrian syndrome with quadruple heart valve involvement and review the literature detailing cases of quadruple valve infective endocarditis. Case presentation and resultsA case is presented of a patient with radiographic evidence of a left lower lobe pneumonia. Sequential transthoracic followed by transesophageal echocardiogram done to evaluate the presence of a cardiac murmur revealed the presence of quadruple valve vegetations. Multiple blood cultures were persistently negative. The patient went on to develop seizures secondary to proven meningitis. Microbiological diagnosis was eventually established through positive Streptococcus pneumoniae antigen (Alere BinaxNOW®) from cerebrospinal fluid, establishing a presumptive clinical diagnosis of Austrian syndrome. A computerized PubMed search for reports of quadruple valve infective endocarditis and their references was collated.A total of 22 patients were found, including our patient. The median age of presentation was 47.5 years. Five patients had a history of intravenous drug abuse, another 5 had underlying congenital heart disease, and 1 had both. Two patients (9.1%) had 2 microorganisms isolated. Staphylococcus aureus and Streptococcus viridans (3 cases, 13.6% each) were the most commonly implicated microorganism. Heart failure was the commonest complication, afflicting 11 patients (50.0%). Ten patients (45.5%) underwent surgery. Overall case fatality rate was 50.0%. Cardiac surgery was of statistical significance in predicting survival (P = 0.009). ConclusionQuadruple valve endocarditis is associated with a high mortality rate, and cardiac surgery may be protective.

Management of Duodenal Varix With Coiling

We present a case of a 65-year-old male with past medical history of intravenous drug abuse, ETOH abuse and dependence, chronic HCV, and decompensated liver cirrhosis. He presented to our facility with complaints of bright red blood per rectum for one day, reporting approximately 6 episodes of large volume liquid red stool. Upon arrival to hospital, he had several episodes of hematochezia with hemodynamic instability. SBP was 80 and HR 110. Initial labs revealed a hemoglobin of 6.0 g/dl, HCT of 19%, MCV: 79.1u3, platelet count of 118 k/mm3, INR of 1.7, BUN of 14, and Cr of 0.53. His calculated MELD-Na at the time was 14. Patient was admitted to ICU and he was started on a protonix and octreotide drip, and transfused 2 units of PRBC. EGD was performed which revealed bright red blood in duodenum, and a serpiginous vessel in the duodenum which was believed to be a varix, with stigmata of recent bleed(white nipple sign). Varix was not actively bleeding at the time of endoscopy. Decision was made to send patient for urgent TIPS. However, after TIPS, the patient rebled, requiring 4 more units of PRBC. Doppler study of TIPS, revealed a patent TIPS shunt. Given the continued bleeding he was sent to interventional radiology, for coil embolization of the varix which ultimately resolved the bleeding. Duodenal varix bleeding is an uncommon cause of gastrointestinal bleeding in patients with portal hypertension but can cause severe and potentially fatal bleeding. Duodenal variceal bleeding can be treated surgically or non-surgically. Treatment of duodenal variceal bleeding includes endoscopic sclerotherapy, endoscopic ligation, and trans jugular intrahepatic portosystemic shunt (TIPS). Given the low incidence there is not one uniform means of treating duodenal varices. In patients that are poor surgical candidates TIPS procedure is generally safest, but it too has complications such as hepatic encephalopathy and restenosis of the stent which is common with incidence of 55-70%. Surgical options such as variceal ligation, duodenectomy have high rebleeding rates and usually require further interventions. Other options such as shunt surgery carry up to a 30% mortality and require good hepatic function which in most patients is compromised. Coil embolization has not been adequately studied or performed. We present a case of a patient with a large duodenal varix that was refractory to TIPS, and was eventually coiled with complete cessation of bleeding.2500_A Figure 1. EGD, showing large duodenal varix2500_B Figure 2. Large Varix shown under fluoroscopy2500_C Figure 3. Duodenal Varix status post coiling

Total hip arthroplasty following illicit drug abuse

The role of illicit drug abuse in total joint arthroplasty is largely unknown and is likely underestimated. Patients with drug addictions often suffer from septic osteoarthritis or a necrosis of the femoral head. Purpose of the study was to evaluate the operative management and clinical outcome of total hip replacement in patients with a history of intravenous drug abuse. This retrospective study included 15 patients with a history of intravenous drug abuse who underwent total hip arthroplasty. A total of 6 females and 9 males with an average age of 34.3years were identified. Ten patients presented an acute bacterial coxitis (Coxitis-group) and five an aseptic osteonecrosis of the femoral head (Osteonecrosis-group). Ten patients with a bacterial coxitis underwent a two-staged total hip arthroplasty (THA), with temporary insertion of a drug-eluting spacer. Five patients with a necrosis of the femoral head were primarily treated with THA. All patients developed multiple re-infections after insertion of a drug-eluting spacer or THA. Only two patients finally achieved a THA without infection in the period of 3.9years follow-up. The other 13 patients underwent a Girdlestone arthroplasty (7 patients) or total joint replacement with a chronic fistula (6 patients). THA in patients with illicit drug abuse shows a low success rate. Following septic osteoarthritis or osteonecrosis in drug-addicted patients, we recommend a two-stage procedure with temporary insertion of a drug-eluting spacer. THA might follow only under strict premises.

Foreign Body Aspiration in the Left Bronchial Tree: Apropos of Two Cases

Foreign body aspiration (FBA) is a potentially life-threatening event. The most common site of aspiration is the right main bronchus. We present the cases of two patients with a history of intravenous drug abuse, both with foreign bodies logded in the left upper lobar bronchus (ULB) probabily aspirated during a period of unconsciousness, immediately after drug injection. We believe that the position in which individuals were injected was possibly related to the location of the object. J Med Cases. 2018;9(4):112-113 doi: https://doi.org/10.14740/jmc3025w

INFECTIVE ENDOCARDITIS WITH PROSTHETIC VALVE DEHISCENCE AND EMBOLIZATION: A RARE OCCURRENCE

Due to increased morbidity and mortality, prosthetic valve infective endocarditis (IE) with dehiscence requires urgent intervention. Early identification may prevent embolization. A 27-year-old female with a history of intravenous drug abuse and tricuspid valve (TV) replacement was admitted after

Alterations in the gut microbiota of patients with acquired immune deficiency syndrome.

Acquired immune deficiency syndrome (AIDS), caused by infection with human immunodeficiency virus (HIV), is associated with gastrointestinal disease, systemic immune activation and changes in the gut microbiota. Here, we aim to investigate the gut microbiota patterns of HIV‐infected individuals and HIV‐uninfected individuals in populations from South China. We enrolled 33 patients with HIV (14 participants treated with highly active antiretroviral therapy [HAART] for more than 3 months; the remaining 19 individuals had not received treatment) and 35 healthy controls (HC) for a cross‐sectional comparison of gut microbiota using stool samples. Gut microbial communities were profiled by sequencing the bacterial 16S rRNA genes. Dysbiosis was more common among patients with AIDS compared with healthy individuals. Dysbiosis was characterized by decreased α‐diversity, low mean counts of Bacteroidetes, Faecalibacterium, Prevotella, Bacteroides vulgatus, Dialister and Roseburia inulnivorans, and high mean counts of Proteobacteria, Enterococcus, Streptococcus, Lactobacillus, Lachnociostridium, Ruminococcus gnavus and Streptococcus vestibularis. Increased abundance of Bacilli was observed in homosexual patients. Proteobacteria were higher among heterosexual patients with HIV infections. Tenericutes were higher among patients with history of intravenous drug abuse. Restoration of gut microbiota diversity and a significant increase in abundance of Faecalibacterium, Blautia and Bacteroides were found in patients receiving HAART compared to those who did not receive. HIV infection‐associated dysbiosis is characterized by decreased levels of α‐diversity and Bacteroidetes, increased levels of Proteobacteria and the alterations of gut microbiota correlate with the route of HIV transmission. The imbalanced faecal microbiota of HIV infection is partially restored after therapy.

Bilateral Renal Hypoperfusion Following Motor Vehicle Accident.

Renal hypoperfusion noted on abdominal computed tomography (CT) scan without any underlying comorbid condition is a rare finding. Most reported cases of renal hypoperfusion have an association with an underlying cardioembolic problem, such as atrial fibrillation, endocarditis, cardiomyopathies, or artificial valve thrombi. We present a case of transient renal hypoperfusion evident on abdominal CT scan following blunt trauma. An 18-year-old male without any significant past medical history presented to the emergency department with the complaint of abdominal pain. The patient reported history of motor vehicle accident 1 week prior to his presentation. He was a front seat passenger wearing a seatbelt when the car went into a ditch. Airbags were deployed and the patient briefly lost consciousness. He presented 1 week later with complaints of generalized abdominal pain, more on the left side that started a few days after his accident, nonradiating, constant, 4/10 intensity. He denied dysuria, hematuria, groin pain, fever, chills, nausea, vomiting, abdominal pain, diarrhea, constipation, decreased oral intake, joint pain, leg swelling, or redness. He denied any medication use or any history of intravenous drug abuse. There was no reported family history of kidney disease or blood clots. Initial laboratory tests, including complete blood count, basic metabolic panel, erythrocyte sedimentation rate, and urinalysis were unremarkable except trace protein on the urinalysis. Contrast-enhanced CT of the abdomen showed multiple, confluent, focal areas of hypoperfusion of the renal parenchyma bilaterally. Given the CT findings of bilateral renal hypoperfusion, the patient was admitted to the hospital and an extensive workup was performed to rule out cardioembolic etiology. Echocardiogram, renal ultrasound, magnetic resonance angiogram of the abdomen, vasculitis panel, and hypercoagulable workup was unremarkable. The CT findings of renal hypoperfusion were considered secondary to transient hypoperfusion from blunt trauma. Abdominal pain resolved with nonsteroidal anti-inflammatory drugs and he was discharged to home. Follow-up abdominal CT scan with contrast obtained a few months later showed normal kidneys with resolution of previously noted renal hypoperfusion. Our case highlights a benign incidental finding of bilateral renal hypoperfusion following motor vehicle accident (with airbag injury), which resolved on follow-up imaging. On literature search, such CT scan findings of transient renal hypoperfusion of unclear significance have not been previously reported. Even though our patient underwent extensive workup to rule out cardioembolic etiology, it may be reasonable to forego such workup following blunt abdominal trauma.

Dynamic Course of Serratia marcescens Pulmonic Valve Endocarditis Resulting in Submassive PE and Valve Replacement.

This report illustrates a case of a 42-year-old male with a history of intravenous drug abuse who presented with septic shock. Diagnostic studies, including a transthoracic echocardiogram, chest computed tomography angiography, transesophageal echocardiogram, and blood cultures ultimately revealed Serratia marcescens pulmonic valve infective endocarditis that was treated with intravenous antibiotics. In addition to the rare form of endocarditis and bacterium involved, this case brings into awareness the dynamic nature of the hospital course that requires vigilance in responding to hypotensive episodes for consideration of pulmonary embolism. Surgical valve replacement was opted for due to such a complication in addition to the large size of the vegetation, 2.5 cm.

Total knee arthroplasty in patients with a history of illicit intravenous drug abuse.

Injection drug users are at high risk for both infection with blood-borne pathogens, namely, human immune deficiency virus (HIV), hepatitis-B, -C virus, various bacterial infections, as well as early primary and secondary joint degeneration. When total knee arthroplasty (TKA) is anticipated the risk of septic complications is a major concern. The purpose of this study was to assess the clinical and radiographic outcome of patients with a history of intravenous drug use after total knee arthroplasty. The primary outcome was revision rate. Secondary outcomes were the Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Society Score (KSS) and radiographic loosening. We retrospectively reviewed the records of 1,692 TKA performed or revised in our institution. Data of 18 TKA in 12 patients (11 male, 1 female; average age 42, range 23-62years) with a history of intravenous opioid abuse were available for final analysis. The mean follow up was 125 (range 25-238) months. Seven patients required revision surgery due to periprosthetic joint infection after 62 months (range 5-159): one two staged revision, three arthrodesis and three amputations. The median prosthesis survival was 101 (95%-CI 48-154) months. Total knee arthroplasty in patients with a history of intravenous drug abuse is associated with major complications, including above-the-knee amputation. If permanent abstinence from intravenous drug abuse is doubtful, other therapeutic options including primary arthrodesis should be considered.

A Case Series of HCV Genotype 1a Infection Patients With HIV Co-infection Treated With 8 Weeks of Ledipasvir-Sofosbuvir

HIV (human immunodeficiency virus) co-infection in hepatitis C virus (HCV) patients increases the risk of liver fibrosis and hepatic decompensation. The current American Association For The Study of Liver Disease (AASLD) guidelines recommend a 12-week course of Ledipasvir-Sofosbuvir for HCV/HIV co-infection. We present a case series of four HCV patients with HIV co-infection treated with 8 weeks of therapy. A total of seventy-seven patients with HCV and HIV co-infection were seen in our clinic between May 2014 to May 2017. Four patients (n=4) with HCV genotype 1a and HIV co-infection were effectively treated with 8 weeks of Ledipasvir-Sofosbuvir. SVR was achieved after initial 4 weeks of therapy, and viral load continued to be undetectable at 8,12,16,24 and 28 weeks post treatment. All patients were African American. Three patients had history of intra-venous drug abuse and one out of three patients was actively using cocaine. One patient was a homosexual male. At the time of initiation of therapy all patients were immune to hepatitis A and B. HCV viral load was below 1 million IU/ml for 3 patients and 3602676 IU/ml for one patient. Fibrosure testing revealed stages F2(n=1) and F3(n=3). All patients were concurrently treated for HIV with antiretroviral therapy including Efavirenz / Emtricitabine / Tenofovir (n=3) and Emtricitabine/Rilpivirine/Tenofovir (n=1). Ledipasvir-sofosbuvir for 8 weeks with intensive monitoring of medication compliance provides a safe and highly effective treatment for patients co-infected with HCV genotype 1a and HIV. A shorter duration of therapy can lead to signficant cost reduction in treatment and improve compliance for particular HCV/HIV co-infected patients. Prospective trials with a large number of patients are needed to identify the type of patients, which might benefit from shorter courses of therapy.

Prevalence of HAV Ab, HEV (IgG), HSV2 IgG, and Syphilis Among Sheltered Homeless Adults in Tehran, 2012.

Background: This study investigated the prevalence for hepatitis A virus (HAV), hepatitis E virus (HEV), herpes simplex virus type 2 (HSV2) and syphilis among homeless in the city of Tehran. Methods: In this cross-sectional study, 596 homeless were recruited in Tehran. A researcher-designed questionnaire was used to study demographic data. Using enzyme-linked immunoassay, and rapid plasma reagin (RPR) test, we evaluated the seroprevalence of HAV anti-body, HEV IgG, herpes, HSV2 IgG, and syphilis among sheltered homeless in Tehran. The associations between the participant’s characteristics and infections were evaluated using logistic regression and chi-square. Results: A total of 569 homeless, 78 women (13.7%) and 491 men (86.3%) were enrolled into the study from June to August 2012. Their age mean was 42 years and meantime of being homeless was 24 months. Seroprevalence of syphilis, HEV IgG, HSV2 IgG and HAV Ab was 0.55%, 24.37%, 16.48%, and 94.34%, respectively. History of drug abuse was reported in 77.70%; 46.01% of them were using a drug during the study and 26.87% of them had history of intravenous drug abuse. Among people who had intravenous drug abuse, 48.25% had history of syringe sharing. Conclusion: The prevalence of HAV, HEV and HSV2 were higher than the general population while low prevalence of syphilis was seen among homeless peoples who are at high risk of sexually transmitted infection (STD). Our findings highlighted that significant healthcare needs of sheltered homeless people in Tehran are unmet and much more attention needs to be paid for the health of homeless people.

An Outbreak of Endogenous Fungal Endophthalmitis Among Intravenous Drug Abusers in New England

Intravenous drug abuse (IVDA) is a known risk factor for endogenous fungal endophthalmitis (EFE), a severe intraocular infection caused by hematogenous seeding of mycotic organisms to the eye. Reporting significant increases in heroin-related deaths since 2014, the New England region is in the midst of an opioid crisis that has led to a substantial increase in patients at risk for this vision-threatening disease. To present an update on characteristics, management, and visual outcomes in patients with EFE. Medical records review was initiated on July 1, 2016, evaluating all patients with EFE referred to New England Eye Center at Tufts Medical Center, a tertiary care ophthalmology practice distributed throughout Massachusetts, from May 1, 2014, to May 1, 2016. Patients with a history of IVDA and culture-proven or clinical evidence of fungal endophthalmitis were included. Intravenous drug use. Patient demographics, comorbidities, presenting symptoms and vision, vitreoretinal findings, treatment regimens, culture data, and final visual acuities. Ten patients (5 women) with IVDA-related EFE were identified between May 1, 2014, and May 1, 2016-an increase from 3 patients treated from May 2012 to April 2014. The mean (SD) patient age was 34 (11) years (range, 24-60 years). Presenting visual acuities ranged from 20/25 to hand motion. The most common presenting symptoms were floaters (n = 8), reduced vision (n = 6), and pain (n = 5). Initial treatment included systemic antifungals in all patients and intravitreal antifungals in 9 eyes. Five patients required pars plana vitrectomy for worsening vitritis. The most commonly isolated pathogen was Candida albicans in 20% of the patients. Final visual acuity ranged from 20/40 to 20/300. The data provided in this report suggest that EFE represents severe end organ damage associated with IVDA and portends poor visual outcomes. Health care professionals must maintain a high suspicion for EFE, as patients are typically ambulatory on presentation without systemic signs of infection.

Septic Arthritis of the Wrist: Incidence, Risk Factors, and Predictors of Infection

Septic arthritis of the wrist can result in permanent damage to the joint, making timely diagnosis crucial to initiate empiric antibiotics and surgical intervention. Although septic arthritis is routinely included in the differential diagnosis of atraumatic wrist pain, the incidence is unknown. Unlike large joints, there is no consensus on cell count values considered pathognomonic for wrist septic arthritis. The goal of this retrospective study was to determine the incidence of wrist septic arthritis and to identify the clinical, serum, and joint fluid values that predict infection. The records of patients who presented to a single urban hospital with a swollen, painful wrist without trauma during a 10-year period were reviewed. For patients who had a joint fluid analysis, the records were examined for history as well as demographic and laboratory data. Joint fluid analysis consisted of cell count, Gram stain, and cultures. Of 892 patients who met the inclusion criteria, 1.5% had wrist septic arthritis. Variables associated with septic arthritis included serum white blood cell count above 11,000/µL, core temperature above 100.4°F within 24 hours of aspiration, history of intravenous drug abuse, and smoking. No joint cell count analysis predicted septic arthritis, although patients with septic wrists had an elevated joint white blood cell count above 97,000/µL. Wrist septic arthritis is uncommon; however, objective factors can help identify patients at risk. Because joint cell count analysis cannot reliably predict a septic wrist, priority for joint aspirations with limited fluid should be given instead to Gram stain, culture, and crystal analysis. [Orthopedics. 2017; 40(3):e526-e531.].

Seroprevalence of hepatitis B virus, hepatitis C virus and human immunodeficiency virus in the western region of Nepal

Background and aims: The hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are associated with major public health concerns. The aim of the study was to determine the seroprevalence of HBV, HCV and HIV in the western region of Nepal.Methods: This was a cross-sectional observational study, in which 15,791 patients, attending to Manipal Teaching Hospital, Pokhara, Nepal, were investigated for HBV, HCV and HIV from June 2013 to March 2016; demographic and biochemical profile were studied among the patients with positive test results.Results: Among 15,791 patients [male 6614 (41.9%) and female 9177 (58.1%)], HBV was found in 180 (1.1%), HCV in 52 (0.3%) and HIV in 77 (0.5%). The HBV was found in 63.9% of males and 36.1% of females, HCV in 67.3% of males and 32.7% of females, and HIV in 61% of males and 39% of females which showed that males had more positivity of HBV (P<0.001), HCV (P<0.001) and HIV (P 0.001) than that of female. The HBV was found more in 20-29 years age group (27.2%), HCV in 30-39 years (32.7%), and HIV in 40-49 years (28.6%), with all having p<0.001. Among the patients of HBV, HCV and HIV, the mean values of total bilirubin were 1.4 mg/dl, 0.8 mg/dl and 2.6 mg/dl, Aspartate Transaminase 75.9 U/L, 54.3 U/L and 92.7 U/L, Alanine Transaminase 54.6 U/L, 55.5 U/L and 56.1 U/L, and Alkaline Phosphatase 124.2 U/L, 109.2 U/L and 107.2 U/L, respectively. The majority of patients with HCV had a history of intravenous drug abuse and HIV had concomitant alcoholic liver disease.Conclusion: The HBV was more prevalent followed by HIV and HCV in the western region of Nepal with more prevalence seen in males than in females. Regular screening of HBV, HCV and HIV among the selected patients can help detecting many new cases in Nepal.Journal of Advances in Internal Medicine 2016;05(01):6-10