Recent Foreign Travel Research Articles

Enteroaggregative Escherichia coli in mid-Norway: A prospective, case control study.

The use of molecular methods has led to increased detection of Enteroaggregative Escherichia coli (EAEC) in faecal samples. Studies have yielded conflicting results regarding the clinical relevance of this finding. The objective of this study was to investigate the prevalence of EAEC in faecal samples from patients with diarrhoea and healthy controls and describe characteristics of EAEC positive persons. From March 1st, 2017 to February 28th, 2019, we investigated all consecutive faecal samples from patients with diarrhoea received at the laboratory and collected faecal samples from randomly invited healthy controls from mid-Norway. Real-time multiplex PCR was used for detection of bacterial, viral, and parasitic pathogens. We registered sex, age, urban versus non-urban residency, and travel history for all participants. Statistical analyses were performed with Pearson chi-squared test, Kruskal-Wallis test, and Mann-Whitney U test. We identified EAEC in 440 of 9487 (4.6%) patients with diarrhoea and 8 of 375 (2.2%) healthy controls. The EAEC prevalence was 19.1% among those with diarrhoea and recent foreign travel and 2.2% in those without travel history independent of diarrhoea. Concomitant pathogens were detected in 64.3% of EAEC-positive patients with diarrhoea. The median age was 28.5 in those with EAEC-positive diarrhoea and 38 in those with EAEC-negative diarrhoea (p <0.01). In patients with diarrhoea, travel was reported in 72% of those with EAEC and concomitant pathogens, and 54% and 12% in those with only EAEC and no EAEC, respectively (p <0.01). EAEC was a common detection, particularly in patients with diarrhoea and recent international travel, and was found together with other intestinal pathogens in the majority of cases. Our results suggest that domestically acquired EAEC is not associated with diarrhoea. Patients with EAEC-positive diarrhoea and concomitant pathogens were young and often reported recent travel history compared to other patients with diarrhoea.

Rare Sighting of an Unstable Hemoglobin Variant [ Β11 (A8) Val → Asp]: Hemoglobin Windsor

Hemoglobin (Hb) is the major blood oxygen carrier where Hb subunits bind oxygen via the heme iron buried within a hydrophobic pocket that faces the outside of HbA tetramers. Iron must be in its reduced (ferrous, Fe2+) state for Hb to bind oxygen. Oxidized or metHb (ferric, Fe3+) cannot bind oxygen and is relatively unstable. Globin mutations that alter amino acids within the ligand pocket lead to changes in affinity for oxygen, and increased rates of metHb formation and heme loss. We present the case of a patient with a rare variant “Hb Windsor” which has only been described once in the literature. The patient is a 20-year-old Mexican male with a history of hepatitis B presenting with three days of fevers, chills, nausea and vomiting. The patient reported a diagnosis of hepatitis at the age of eight in Mexico and with jaundice all his life. He had no prior hospitalizations or blood transfusions. He denied any unusual food ingestions or recent foreign travel. In the emergency room, the patient was hypoxic with a SpO2 73% and tachypneic which improved with supplemental oxygen. On physical examination, the patient was jaundiced with scleral icterus and the spleen was easily palpable to the midline. CT scan confirmed splenomegaly measuring 20 cm. Labs showed a white blood count 21.6 nl, hemoglobin 4.2 g/dl, platelet count 33 nl, lactate dehydrogenase 13 unit/L and reticulocyte count 24%, total bilirubin 16 mg/dl, direct bilirubin 4 mg/dl and methemoglobin 20.9%. The patient was administered methylene blue and transfused two units of packed red blood cells with hemoglobin increasing to 7.1 g/dl. HIV, hepatitis B and C, direct antiglobulin test, and G6PD testing were negative. The peripheral smear showed numerous nucleated red cells, increased polychromasia with red cells showing numerous microspherocytes, microanthocytes, and bubbled cells with significant basophilic stippling. No fragmented cells were present. The clinical history and lab findings suggested a chronic hemolytic anemia, and the peripheral smear suggested a possible hemoglobinopathy. Hemoglobin electrophoresis by high performance liquid chromatography showed an unknown hemoglobin of 22.5%. Isoelectric focusing showed Hb A 71.9%, F, Hb A2 4.6%, Hb F 0.3%, and an abnormal band of 23% in the hemoglobin M range. Specimens were sent for DNA sequencing and a point mutation in the beta chain was found leading to a valine to aspartate substitution in the A8 position. Protein analysis showed a valine is substituted with aspartic acid in the ligand pocket which is the unstable varian Hb Windsor. This substitution in the base of the heme pocket results in instability of the hemoglobin molecule and an increase in oxygen affinity. The residues lining the heme pocket function as a hydrophobic basket from the heme iron, preventing its oxidation to the ferric state. Valine, which occupies position A8 is a hydrophobic amino acid. However, in Hb Windsor, the valine is substituted by aspartic acid, a polar molecule. The hydrophilic nature of aspartic acid, a polar molecule, may disrupt the hydrophobic nature of the heme pocket. The valine at position A8 also acts as a contact with the H helix which is lost in Hb Windsor leading to decreased Hb stability. These substitutions cause heme iron to auto-oxidize which results in methemoglobinemia. Hb M has iron in the ferric state (Fe3+) and is unable to carry oxygen which produces cyanosis. Our patient was found to be hypoxic requiring oxygen supplementation and found to have methemoglobinemia. We present a rare case of a hemoglobin variant Hb Windsor in a Mexican adult which has only been previously documented in a nine-month-old Anglo-Saxon infant. This variant seems to be a spontaneous de novo mutation as both patients had no family history of anemia. It is hypothesized that the hemolysis was precipitated by oxidative stress of an acute infection in the setting of an unstable hemoglobin. The patient was found to have stable hemoglobin of 12 g/dl and methemoglobin of 4.9% in follow up several years later.

P11 A case of Mycobacterium marinum infection in a patient with rheumatoid arthritis recently initiated on adalimumab

P11 A case of <i>Mycobacterium marinum</i> infection in a patient with rheumatoid arthritis recently initiated on adalimumab

P22 Will the real scleroderma please stand up?: a case of a rare scleroderma mimic in ED

P22 Will the real scleroderma please stand up?: a case of a rare scleroderma mimic in ED

Vocal Cord Icterus in Acute Liver Failure

A 63-year-old Caucasian man presented with new-onset jaundice associated with worsening fatigue and weight loss. He denied abdominal pain, recent foreign travel, the use of new medications/paracetamol, sick contacts, or behaviors that would increase his risk of viral hepatitis. Socially, he lived with his wife, drank alcohol occasionally, and was a nonsmoker. He was previously fit and well, and took no regular medications. There was no medical or family history of note.

Candida auris Isolates Resistant to Three Classes of Antifungal Medications - New York, 2019.

Candida auris is a globally emerging yeast that causes outbreaks in health care settings and is often resistant to one or more classes of antifungal medications (1). Cases of C. auris with resistance to all three classes of commonly prescribed antifungal drugs (pan-resistance) have been reported in multiple countries (1). C. auris has been identified in the United States since 2016; the largest number (427 of 911 [47%]) of confirmed clinical cases reported as of October 31, 2019, have been reported in New York, where C. auris was first detected in July 2016 (1,2). As of June 28, 2019, a total of 801 patients with C. auris were identified in New York, based on clinical cultures or swabs of skin or nares obtained to detect asymptomatic colonization (3). Among these patients, three were found to have pan-resistant C. auris that developed after receipt of antifungal medications, including echinocandins, a class of drugs that targets the fungal cell wall. All three patients had multiple comorbidities and no known recent domestic or foreign travel. Although extensive investigations failed to document transmission of pan-resistant isolates from the three patients to other patients or the environment, the emergence of pan-resistance is concerning. The occurrence of these cases underscores the public health importance of surveillance for C. auris, the need for prudent antifungal prescribing, and the importance of conducting susceptibility testing on all clinical isolates, including serial isolates from individual patients, especially those treated with echinocandin medications. This report summarizes investigations related to the three New York patients with pan-resistant infections and the subsequent actions conducted by the New York State Department of Health and hospital and long-term care facility partners.

2376 Diffuse Large B-Cell Lymphoma Presenting With Typical Features of HCC on Liver Imaging: A Diagnostic Conundrum

INTRODUCTION: Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. HCC can be solely diagnosed on cross-sectional imaging (CT or MRI) if a lesion meets the diagnostic criteria according to the Liver Imaging Reporting and Data System (LI-RADS), which has above 90% specificity. HCC commonly metastasizes to lungs, regional lymph nodes, kidney, bone marrow and adrenals but metastases to the spleen are rare. We present a case of liver masses with typical HCC characteristics on liver MRI which was ultimately proven to be diffuse large B-cell lymphoma (DLBCL) on liver biopsy. CASE DESCRIPTION/METHODS: 38-year-old Vietnamese male with no past medical history was admitted with significant weight loss, fatigue and abdominal discomfort. He did not have a history of high risk behaviors or recent foreign travel. Physical exam revealed hepatomegaly. On labs, CBC was normal, T-bili 0.7, Alk Phos 147, AST 89, ALT 50, Albumin 3 g/dL, INR 1.1, creatinine 0.7. HBV serology was positive for HBsAg, anti-HBc and anti-HBe and was negative for HBeAg. HBV DNA was 497 IU/ml. HIV, HCV and HDV serology were negative. CT abdomen showed numerous liver lesions, largest of which was 10.4 cm and a single 8.1 cm splenic lesion. MRI showed several large, rounded and well-circumscribed liver lesions demonstrating arterial hyperenhancement, washout and pseudocapsule consistent with diagnosis of HCC (LI-RADS 5). MRI confirmed a single lesion on spleen (Figure 1), suspicious for metastasis. Tumor markers (AFP, CEA, CA 19-9) were within normal range. Lactate dehydrogenase (LDH) was 1200. Given elevated LDH and a spleen lesion, liver biopsy was done which showed high grade DLBCL (Figure 2). Systemic staging tests did not reveal any other tumor sites. Patient was started on tenofovir and chemotherapy with excellent response (Figure 3). DISCUSSION: Liver biopsy is rarely required to diagnose HCC if certain diagnostic criteria are met on cross sectional imaging, even without significantly elevated AFP. Extranodal lymphoma with liver and spleen involvement can present with lab and imaging abnormalities which can mimic HCC, as in our case. Markedly elevated LDH and spleen lesion raised suspicion for a different diagnosis. Undiagnosed or untreated advanced DLBCL can limit survival to a few months while hepatic involvement can also cause liver failure. In conclusion, a biopsy should be considered for liver lesions diagnosed as HCC on cross sectional imaging when atypical features, in our case elevated LDH and spleen lesion, are present.

Effect of Augmented Antimicrobial Prophylaxis and Rectal Swab Culture–guided Targeted Prophylaxis on the Risk of Sepsis Following Transrectal Prostate Biopsy

BackgroundSepsis is a severe complication following transrectal ultrasound-guided prostate biopsy (TRUSPBx). Ciprofloxacin is commonly used for prophylaxis; however, there is an increasing incidence of resistant enteric organisms worldwide. ObjectiveTo investigate the effect of a targeted prophylactic antimicrobial regimen based on rectal swab cultures in reducing the rate of sepsis. Design, setting, and participantsA total of 1012 patients were included. Group A (609 patients) received an empirical prophylactic antimicrobial regimen of gentamicin, metronidazole, and ciprofloxacin. Targeted antimicrobial prophylaxis was introduced due to significant ciprofloxacin and gentamicin resistance in patients admitted with sepsis following TRUSPBx. The remaining 403 patients (Group B) had rectal swab cultures performed prior to biopsy. Patients with organisms resistant to ciprofloxacin or gentamicin received a targeted prophylaxis regimen of fosfomycin, amikacin, and metronidazole. Outcome measurements and statistical analysisWe retrospectively collected and analysed data on sepsis and bacteraemia for all patients as well as data on rectal swab culture, recent foreign travel, and recent antibiotic use for patients in Group B. Results and limitationsIn group A, 12 (2.0%) patients developed sepsis following TRUSPBx, while in group B, 9 (2.2%) patients developed sepsis despite targeted prophylaxis (p=0.82). Patients with ciprofloxacin-resistant rectal flora had a significantly higher rate of sepsis (9.1% vs 1.1%; p=0.003). There was a reduction in patients admitted with bacteraemia and severe sepsis between group A (1.2%) and group B (0.3%) which did not reach statistical significance (p=0.16). In group B, 55 of 403 (13.6%) patients had ciprofloxacin-resistant rectal flora, while 66 (16.4%) had organisms resistant to both ciprofloxacin and gentamicin. A recent foreign travel history was associated with an increased incidence of ciprofloxacin-resistant rectal flora (23.6% vs 10.8%; p=0.007). The main limitations of our study include its retrospective nature and potential under-reporting of less severe infectious complications. ConclusionsRectal swab cultures identify patients with ciprofloxacin-resistant rectal flora who have an eight-fold risk of sepsis. Targeted antimicrobial prophylaxis may not be beneficial in reducing the sepsis rate when compared with augmented empirical prophylaxis. In an era of increasing antimicrobial resistance, transperineal prostate biopsies should be considered to reduce the risk of infective complications. Patient summaryPerforming rectal swab culture prior to transrectal prostate biopsy can help identify patients at risk of developing sepsis despite targeted prophylactic antibiotics.

Think pyomyositis!

AbstractUncontrolled diabetes is associated with increased risk of infections. An uncommon but rather serious infection is pyomyositis which is a purulent infection of the skeletal muscle. Delay in recognition and diagnosis can lead to serious complications.We report the case of a 44‐year‐old male patient with a background of uncontrolled diabetes who presented with bilateral thigh pain and progressive leg weakness over three weeks. He had no other comorbidities and he denied any recent trauma or foreign travel. On examination he had multiple hard lumps in both thighs and blood results showed leucocytosis and raised inflammatory markers. Magnetic resonance imaging (MRI) showed multiple bilateral thigh abscesses. The diagnosis of pyomyositis was made and drains were inserted into the two largest abscesses. Simultaneously, he was started on antibiotics based on the drained fluid culture and sensitivity. On drainage of the abscesses and completion of eight weeks of antibiotics, he gradually regained the lower limbs' power and the thigh pain resolved. His recovery was aided by the better control of diabetes with insulin therapy.Pyomyositis is mainly encountered in tropical areas. Non‐tropical pyomyositis is more common in immunocompromised patients and patients with uncontrolled diabetes. It requires a high index of suspicion because of its indolent presentation that may mimic other pathologies like cellulitis, diabetic amyotrophy, septic arthritis and deep vein thrombosis. MRI is the best diagnostic tool to differentiate pyomyositis from these disorders. Early diagnosis and intervention with drainage of the abscesses and appropriate antibiotics prevent serious complications and improve the outcome. Copyright © 2017 John Wiley &amp; Sons.

Local genes for local bacteria: Evidence of allopatry in the genomes of transatlantic Campylobacter populations.

The genetic structure of bacterial populations can be related to geographical locations of isolation. In some species, there is a strong correlation between geographical distance and genetic distance, which can be caused by different evolutionary mechanisms. Patterns of ancient admixture in Helicobacter pylori can be reconstructed in concordance with past human migration, whereas in Mycobacterium tuberculosis it is the lack of recombination that causes allopatric clusters. In Campylobacter, analyses of genomic data and molecular typing have been successful in determining the reservoir host species, but not geographical origin. We investigated biogeographical variation in highly recombining genes to determine the extent of clustering between genomes from geographically distinct Campylobacter populations. Whole‐genome sequences from 294 Campylobacter isolates from North America and the UK were analysed. Isolates from within the same country shared more recently recombined DNA than isolates from different countries. Using 15 UK/American closely matched pairs of isolates that shared ancestors, we identify regions that have frequently and recently recombined to test their correlation with geographical origin. The seven genes that demonstrated the greatest clustering by geography were used in an attribution model to infer geographical origin which was tested using a further 383 UK clinical isolates to detect signatures of recent foreign travel. Patient records indicated that in 46 cases, travel abroad had occurred <2 weeks prior to sampling, and genomic analysis identified that 34 (74%) of these isolates were of a non‐UK origin. Identification of biogeographical markers in Campylobacter genomes will contribute to improved source attribution of clinical Campylobacter infection and inform intervention strategies to reduce campylobacteriosis.

Self-assessment

A 10 year old Caucasian girl is referred by her General practitioner to the paediatric ambulatory unit with an 8 week history of persistent swelling and redness of her left knee. There is no history of trauma or recent foreign travel. There are no other systemic symptoms except she feels tired sometimes. She complains of intermittent pain lasting for up to a week. There is no family history of note. General examination was unremarkable except for minimal pallor. She walks with an antalgic gait, and her left knee is red and swollen with restricted movements and a small joint effusion. There is no leg length discrepancy.

Increase of prostate biopsy-related bacteremic complications in southern Finland, 2005-2013: a population-based analysis.

The most severe manifestations of prostate biopsy complications are bacteremic infections. These complications are increasing alarmingly. A retrospective cohort study of 17 183 transrectal prostate biopsies performed at the Helsinki and Uusimaa hospital district in southern Finland during 2005-2013. Biopsies were linked to a database of positive blood cultures, yielding 111 bacteremic cases, and yearly bacteremia rates were determined. By multiple regression analysis, demographic risk factors of the whole biopsy cohort for developing bacteremia or fluoroquinolone (FQ)-resistant bacteremia were studied. Clinical risk factors for bacteremia caused by an FQ-resistant organism and for serious bacteremic outcomes were studied by univariate and multivariate analyzes. The average bacteremia rate was 0.7% (111 of 17 183 biopsies) and an increase was observed from 0.5% in 2005 (95% confidence interval (CI): 0.3-0.9) to 1.2% in 2012 (95% CI 0.8-1.8); 53.2% were caused by an FQ-resistant organism. In univariate regression analysis, previous biopsy sessions and increasing calendar year of biopsy associated with the risk of developing bacteremia (odds ratio (OR) 1.232, 95% CI: 1.020-1.488, P=0.030 and OR 1.164, 95% CI: 1.079-1.255, P<0.001, respectively), but only increasing calendar year of biopsy remained statistically significant (OR 1.155, 95% CI: 1.070-1.247, P<0.001) in multivariate analysis. Foreign travel within 3 months was associated with FQ resistance in multivariate analysis (OR 7.158, 95% CI: 1.042 to infinite, P=0.045). The study failed to show any significant clinical risk factors for serious bacteremic outcomes (requiring intensive care, developing deep infection foci or death). The postbiopsy bacteremia rate doubled during the study period and half of the cases were caused by FQ-resistant organisms. Recent foreign travel increased the risk for FQ resistance. Future research efforts should be aimed at better identifying risk factors, targeted prophylaxis and reducing the need for biopsies.

The prevalence of ESBL-producing Enterobacteriaceae in a nursing home setting compared with elderly living at home: a cross-sectional comparison.

BackgroundThe aim of the study was to investigate the prevalence of faecal carriage of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae among residents living in nursing homes and to compare it with a corresponding group of elderly people living in their own homes.MethodsA total of 160 persons participated in the study between February and April 2014, 91 were residents in nursing homes (n = 10) and the remaining 69 were elderly living in their own homes. In addition to performing faecal samples, all participants answered a standardized questionnaire regarding known risk factors for ESBL-carriage.ResultsThere was no significant difference between the groups, as 10 of the 91 (11 %) residents from nursing homes were ESBL-carriers compared with 6 of 69 (8,7 %) elderly living in their own homes. There was no significant difference between the groups. The total prevalence was 10 %. A univariate analysis revealed that the only studied risk factor significantly associated with ESBL-carriage was recent foreign travel (p = 0,017). All ESBL-positive isolates were Escherichia coli and there was a high degree of co-resistance to other antibiotics. All isolates (n = 17) were susceptible to imipenem and amikacin.ConclusionResidents of nursing homes as well as elderly living in their own homes have high rates of faecal carriage of ESBL-producing bacteria. These findings may affect the choice of empirical antibiotic treatment of severe infections in older adults.

Importance of a Thorough Physical Examination

A 73-year-old white female presented for management of her tophaceous gout, pyoderma gangrenosum, and chronic back pain. On exam, there was an incidental finding of reticular, reddish-brown, non-tender, macular, non-blanching discoloration on her entire back, with a few superficial erosions (see Figure). The patient did not know the duration of her rash. It was neither pruritic nor painful. She denied arthralgia, fever, chills, or other constitutional symptoms. She did not have a history of insect bites, recent foreign travel, falls, or trauma. She frequently used a heating pad to alleviate her chronic back pain. Complete blood count, comprehensive metabolic panel, urine analysis, and inflammatory markers were within normal limits.

A “Q”uizzical Cause of Abnormal LFTs

Introduction: Q fever is a rare cause of abnormal liver function tests (LFT) in an urban population. The disease is characterized by sudden onset of fevers, chills, headaches, myalgia, and pneumonitis or hepatitis. In North America, acute Q fever usually presents as atypical pneumonia. We present a case of Q fever in a patient who presented with jaundice, anorexia, and intermittent fevers. Case Report: A 62-year-old Nepalese man with past medical history of diabetes presented with fatigue and 3 weeks of fevers. On admission, he was febrile to 102°F and found to have ALT 81U/L, AST 103U/L, alkaline phosphatase 298U/L, and total bilirubin 7.7mg/dL with direct component 6.1mg/dL. Synthetic function was preserved with INR 1.2 and platelets of 246THOU/uL. Albumin of 2.8g/dL and pre-albumin of 3mg/dL signified severe malnutrition. The patient denied abdominal pain or change in bowel pattern, but reported nausea and vomiting for 2 days. He denied recent foreign travel, sick contacts, or new medications. Imaging studies revealed fatty liver with an edematous gallbladder and splenomegaly, but no pancreatic mass or biliary obstruction. Urine drug test, acetaminophen, alcohol, and salicylate levels were normal. Viral hepatitis panel was negative, including HIV, CMV, EBV, and HSV. Autoimmune work-up was unremarkable, and he was previously treated for latent TB. There was no leukocytosis, but his fevers persisted despite negative infectious work-up, including brucellosis. Subsequently, the patient underwent liver biopsy, which revealed non-necrotizing granulomas in the background of mild steatohepatitis. Special stains were negative for iron, copper, acid-fast bacilli, and fungal organisms. Finally, after a prolonged hospitalization, the patient was found to have positive Coxiella burnetti serologies confirmed by PCR. He was started on doxycycline, and his fevers and LFT improved. Upon further review, the family admitted to recently consuming freshly slaughtered and skinned goat meat from their local goat farm. Discussion: Acute Q fever is a worldwide zoonosis caused by a Gram-negative bacterium Coxiella burnetti, and is spread by inhalation of bacteria from air contaminated by cattle, sheep, or goat feces, urine, or placenta. It is endemic in the Netherlands and Middle East, and less commonly seen in the United States. Given the nonspecific nature of clinical manifestations of acute Q fever, its diagnosis requires a high index of suspicion. It is usually self-limited, and in most cases, diagnosed retrospectively. Treatment with doxycycline of symptomatic patients has been shown to shorten illness and reduce risk of progression to chronic disease.

G446(P) An Unusual cause of Chronic Cough in a 15 year old girl

AimsCoughing is one of the most common paediatric presentations both in primary and secondary care. We present an unusual cause of chronic cough in a teenager.MethodA 15 year old girl...

Inequalities in the incidence of infectious disease in the North East of England: a population-based study

The objective of this study was to measure the association between deprivation and incidence of 21 infectious diseases in the North East of England (2007-2011). We used count regression models with the Index of Multiple Deprivation and population/landscape data for small areas (~1500 persons). Deprivation significantly predicted incidence (P < 0·05) for 17 infectious diseases. The direction of association was broadly consistent within groups: increased incidence with increased deprivation for all three bloodborne viruses, 2/3 invasive bacterial diseases, 4/5 sexually transmitted infections (STI) and tuberculosis (TB); decreased incidence with increased deprivation for 5/6 infectious intestinal diseases (IID) and 2/3 vaccine-preventable diseases. Associations were removed for all but one IID (E. coli O157 infection) after accounting for recent foreign travel. Hepatitis C virus, TB and STI are priority infections for reduction of inequalities associated with deprivation in the North East of England.

Safety of Injecting Insulin Through Clothes: A Case of Mycobacterium immunogenum Cutaneous Infection and Review of the Literature

L.S., a 47-year-old white woman with type 1 diabetes, a bleeding diathesis, and iron deficiency anemia, was referred to an infectious diseases physician for assessment of a painful, nonhealing skin lesion. Before the referral, her primary care physician had treated her with several courses of oral antibiotics, including cephalexin, clindamycin, and amoxicillin, without improvement. She denied a history of preceding trauma, recent foreign travel, or exposure to aquatic animals or hot tubs. When questioned about whether the lesion was at the site of insulin injection, she stated this was possible because she had injected insulin at various locations through her clothes since adolescence, as instructed. On physical examination, the patient appeared well. Her skin examination was significant for a 5-cm erythematous, tender nodule on the anteromedial aspect of her right thigh (Figure 1). No drainage from the lesion or evidence of surrounding cellulitis was found. There was no associated lymphadenopathy, and the remainder of her physical examination was unremarkable. Routine laboratory tests, including leukocyte count with differential, platelets, electrolytes, creatinine, and liver enzymes, were within normal ranges. Her A1C was elevated at 10.8%. Histology of the biopsied lesion demonstrated nonspecific inflammation with negative stains for acid-fast bacilli (AFB) and fungi. Cultures, however, were positive for mycobacteria spp. after an extended incubation period of 63 days (compared to the conventional incubation period of 49 days). 16S rRNA sequencing identified the organism as Mycobacterium immunogenum . The antimicrobial agents the organism was susceptible to were limited to clarithromycin and tigecycline, with intermediate sensitivity to amikacin. The organism was resistant to ciprofloxacin, doxycycline, cefoxitin, imipenem, cotrimoxazole, and linezolid. 1. How did this …

Streptococcus suisMeningitis in Swine Worker, Minnesota, USA

To the Editor: Streptococcus suis is a major bacterial pathogen in swine worldwide. Historically, cases in humans have occurred sporadically, mostly in Asia (1,2). However, an outbreak in China involved 215 human cases and 39 deaths (3). Only 3 human cases of S. suis disease were documented in the United States before 2011: 2 domestically acquired cases in New York and Hawaii, and 1 case in a person in California who was probably exposed in the Philippines (4). We describe a case of S. suis disease in a swine worker in Minnesota, USA. The case-patient was a previously healthy 60-year-old man (truck driver). On December 14, 2011, severe headache and chills developed, which he attributed to the onset of influenza. He had a history of migraine headaches, and used prescription medications to treat his headache. However, on December 15, he awoke with a severe headache that was unresponsive to treatment. Despite having to stop his truck several times because of the severe headache, he successfully completed his delivery route. Early on December 16, his wife drove him to a nearby emergency department after he did not respond to ordinary commands. The patient had reduced coordination and behaved aggressively. His blood pressure was 92/52 mm Hg. He underwent intubation for 24 hours for airway protection, and a lumbar puncture was performed. Cerebrospinal fluid (CSF) had a leukocyte count of 10,501 cells/μL (99% neutrophils), a protein level of 509 mg/dL, and a glucose level of 38 mg/dL. A few gram-positive diplococci were observed in CSF. Complete blood count showed a leukocyte count of 14,800 cells/μL (92% neutrophils), a hemoglobin level of 14.1 g/dL, and a platelet count of 157,000/μL. Streptococcus suis was isolated from CSF and 2 of 4 blood cultures. Identification of S. suis was confirmed by using 16S rRNA gene sequencing at the Minnesota Department of Health. The patient was given decadron, ceftriaxone, ampicillin, vancomycin, and acyclovir. During hospitalization, antimicrobial drugs were tapered until he received only ceftriaxone. Major symptoms were severe headache and nausea. He was discharged in good condition on day 10 of hospitalization and then completed a 14-day course of ceftriaxone. There are 35 known serotypes of S. suis (1). Of these serotypes, serotype 2 is most commonly identified in infected swine and humans (2). The S. suis isolate from this patient was identified as serotype 2 by coagglutination test at the International Reference Laboratory at the Universite de Montreal (5). The sequence type was identified by PCR as type 25, a common type in North America (6,7). The isolate was positive by PCR for the gene encoding virulence-associated factor muraminidase-released protein and negative for genes encoding virulence-associated extracellular factor and suilysin (8). The isolate was genotyped by enterobacterial repetitive intergenic consensus PCR and compared with 750 swine isolates in the University of Minnesota Veterinary Diagnostic Laboratory database (9). The obtained fingerprint matched that of 15 S. suis isolates from swine meningitis cases in Minnesota and Indiana during 2006–2010. The patient worked for a trucking company that transports swine throughout the Midwest. His daily work required traveling to swine farms in Minnesota and making occasional trips to South Dakota and Iowa. His job was to load slaughter-weight swine into the truck and deliver them to regional slaughterhouses. Approximately 1 month before illness onset, he reported moving swine from a farm on which the farmer reported pneumonia, a rare yet reported manifestation of S. suis infection in swine. The patient reported always wearing coveralls, boots, and gloves while loading and unloading swine, but he wore a dust mask only occasionally. He had no recent foreign travel and no skin breaks. However, absence of open wounds has been noted in previous case-patients (10). The reported incubation period for S. suis infection in humans ranges from hours to weeks, and open wounds are associated with shorter incubation periods (2). Case-patients in the United States reported known risk factors, including handling ill swine or slaughtering and processing swine for meat (4). In this instance, the patient only loaded and unloaded slaughter-weight swine from his truck. He reported transporting swine that had pneumonia, which is common in finishing stages of swine production. However, although S. suis can cause pneumonia, this disease in finishing swine is probably caused by other common pathogens such as Pasteurella multocida, Mycoplasma hyopneumoniae, influenza virus, and porcine reproductive and respiratory syndrome virus. A definitive source of infection for this patient was not identified. This case demonstrates a rare but potentially under-recognized occupational hazard for workers in the swine industry in the United States.

Rare Presentation of Sarcoidosis

Patient: A 54-year-old Caucasian woman with no history of smoking or drinking, no recent trauma, and no occupational exposure to irritants. No known allergies. No history of recent foreign travel. Current Chief Complaint: Dyspnea and chest pain. Past Medical History: Patient presented in 2002 with epigastric pain and fullness after consumption. Tests showed abnormal liver function tests (LFTs). A liver biopsy was non-conclusive. She was referred to the gastroenterologist, who felt that though her LFTs were abnormal, they have been static. Another liver biopsy was not warranted. The patient continued to have abnormal LFTs even though her symptoms improved until February 2006, when she developed pruritus and right upper quadrant (RUQ) pain. In 2003 the patient started presenting with symptoms of hypothyroidism, as she presented with depression weight gain. Testing revealed increased thyroid-stimulating hormone (TSH) and low T3 and T4. The patient began thyroxine. The patient has had severe left knee pain and common extensor pain (tennis elbow) since 2006. Pruritus and night sweats started in 2006 and persisted on and off. Atypical angina, transient ischemic attacks (TIA), left arm weakness, dysarthria, amaurosis fugax-like symptoms (appeared on only 1 occasion), left-sided facial droop, and numbness, began in June 2007 and persisted. Dyspnea has worsened since 2005. No conclusive diagnosis has been reached. Drug Allergies: Aspirin and Salbutamol Current Medications: Prednisolone (7.5 mg daily), Azathioprine (50 mg once daily), Ursodeoxycholic Acid, Atorvastatin, Thyroxine (75 mcg daily), Bisoprolol, Irbesartan, Alendronate, Warfarin, Ventolin. Family History: No significant family history. Social History: Health care assistant. Non-smoker. No alcohol intake. Married and lives with spouse. Physical Exam Vital Signs: Blood pressure, 130/77; temperature, 36.8; weight, 72.6 kgs; BMI, 29. No lymph node enlargement. Chest was clear on auscultation. Normal heart sounds. 1. What are the patient’s most striking (a) clinical, (b) radiological, (c) …