Clinical Infection in Practice最新文献

Mycobacterium xenopi, a nontuberculous mycobacterium (NTM), presents a significant diagnostic challenge in clinical practice, particularly in immunocompromised individuals. We report a case of M. xenopi infection in a liver transplant recipient on immunosuppressive medication. A 67-year-old male presented with chronic cough, anemia, and significant weight loss. Imaging studies revealed extensive pulmonary involvement with cavitations. More definitively, an acid-fast bacilli (AFB) bronchoalveolar lavage culture as well as an acid-fast bacilli (AFB) sputum culture confirmed M. xenopi infection. Treatment initiation with multiple antimicrobial agents was guided by susceptibility testing and published recommendations by the Infectious Disease Society of America and the American Thoracic Society guidelines from 2020 (Kurz, et al., 2020). This case emphasizes the importance of considering non-tubercular bacterial infections, particularly M. xenopi, in the differential diagnosis of respiratory symptoms in immunocompromised hosts. In addition to the case report, this paper provides a comprehensive review of the epidemiology, risk factors, clinical manifestations, diagnostic challenges, and treatment strategies for M. xenopi infections.

Non-tuberculous mycobacteria (NTM) are mycobacterial species other than Mycobacterium tuberculosis complex (MTB) and the organisms that cause leprosy. They can cause pulmonary, central nervous system, lymph-node, joint, catheter-related as well as disseminated infection. NTM pulmonary disease (NTM-PD) occurs when NTM infection causes progressive inflammatory lung damage. NTM-PD is increasing in both incidence and prevalence. Mycobaterium szulgai, is an uncommon, slow-growing NTM. M. szulgai primarily causes pulmonary infections which present like MTB pulmonary infections. Due to low prevalence there are no standardised treatment guidelines for the management of M. szulgai infection.

We describe a case of M. szulgai pulmonary infection in diabetic man in his fifties who presented with productive cough, dyspnoea, weight loss, fatigue and night sweats. Computed tomography (CT) showed three thick walled cavities in the right lung, with consolidation, emphysema and adenopathy, thought to be reactive. Sputum samples were positive for acid alcohol fast bacilli (AAFB) but MTB PCR testing was negative. Sputum culture grew M. szulgai. He was treated with on Rifampicin, Isoniazid, Ethambutol and Azithromycin for 13 months. The patient improved significantly following initiation of anti-mycobacterial treatment.

The patient’s clinical presentation, radiological findings of upper lobe cavitating lesions, and characteristics; male, over 50 years old, immunosuppressed with underlying lung disease, are similar to most reported cases. M. szulgai can rarely infect immunocompetent hosts. Evidence to guide therapy is lacking. Treatment duration in the literature varies from six months to 39 months. Resistance to isoniazid has been reported and an isolate with both rifampicin and ethambutol resistance documented. Consensus guidelines recommend that NTM should be treated for at least 12 months from the first negative sputum culture. A combination of at least three susceptible drugs should be used, with rifampicin, ethambutol and azithromycin or clarithromycin recommended first line.

Background

There are wide varieties of clinical manifestations of Tuberculosis (TB). Extrapulmonary tuberculosis (EPTB) patients usually come with an atypical presentation, are difficult to suspect, and frequently involve sites that are very hard to access, and invasive procedures are usually required for diagnosis. We are presenting five cases of atypical presentations of TB here.

Case reports

The first case presented acute flaccid paraparesis with right loin pain, ultimately diagnosed as tubercular psoas abscess inducing acute inflammatory demyelinating polyneuropathy. The second case presented with hematemesis, dysphagia, weight loss, and a rare case of esophageal TB was diagnosed. The third case presented with painful multiple bony lytic lesions and was diagnosed as a case of multifocal skeletal TB. The fourth case presented multiple abscesses at different skin sites, leading to a diagnosis of metastatic tubercular abscesses. The fifth case was an elderly female who presented with right hip joint pain, eventually diagnosed as tubercular hip arthritis.

Conclusion

EPTB is a great mimicker and has been a challenging medical condition due to the divergence of presentations. High clinical suspicion and vigilance can lead to an early diagnosis and survival of patients.

Demands on infection services have significantly increased over recent years, covering a diverse and broad range of clinical activities (Lawrence et al, 2021). This has not been accompanied by a corresponding increase in resources. The term Infection Specialist equally covers a broad and diverse range of specialities, and what is defined as one type of clinical infection review/consult may differ between infection specialists and infection services. This has also made it difficult to accurately capture clinical activity. Documentation of clinical activity may also be challenging, and also prevent accurate capture of the amount and type of activity being undertaken.

This document aims to provide a standardised description of the different types of clinical infection reviews. It aims to guide referrers to the minimum information required to optimise each type of review, to optimise the consultation. There are also suggested tools which may help infection services document and capture their clinical activity.

Objectives

Enteric fever remains a common diagnosis in returned travellers to the UK, the majority of which require hospital admission. Increased resistance to antibiotics has complicated the management and rates of vaccine uptake remain unclear.

Methods

We performed a retrospective study of culture-confirmed cases of enteric fever from blood samples in patients admitted to University Hospitals Birmingham, UK, between January 2010 and June 2022 to assess antimicrobial susceptibility, treatment outcomes and vaccination uptake.

Results

In total, 108 patients were identified during the time period (S.typhi n = 57 [53 %]; S.paratyphi n = 51 [47 %]). Nearly all (93 % [100/108]) had returned from South Asia. There was no evidence of typhoid vaccination pre-travel for most patients (n = 96 [89 %]) in both groups. Over half of patients with S.typhi had microbiologically positive stool samples compared to just over 20 % of the S. paratyphi group (20/36 [55 %] vs 5/23 [22 %], p = 0.015). Three cases of ceftriaxone resistant enteric fever occurred.

Conclusion

Enteric fever remains a frequent presentation to a non-endemic setting with close links to high-endemic regions such as South Asia. Vaccination uptake among local populations could be improved. Few cases of ceftriaxone-resistant enteric fever were seen which is a consideration for improved antimicrobial stewardship.

Introduction

Neuropathy, particularly commonly seen in the form of benign osteomyelitis, is a leading cause of wound formation and severe bone deformity. Leprosy, a chronic disease caused by Mycobacterium leprae and Mycobacterium lepromatosis, initially presents with asymptomatic infections that can remain so for 5 to 20 years. Hansen’s disease, caused by Mycobacterium leprae, presents a disease spectrum influenced by the patient’s immune response, ranging from tuberculoid to lepromatous.

Case presentation:

In this case study, maggot therapy was utilized as a novel method to address the wound. This study aimed to heal a wound and prevent amputation in a 76-year-old leprosy patient with osteomyelitis of the metatarsophalangeal joint. Diagnosed with leprosy at 45, he presented numbness in his legs up to the waist and hand, indicating neuropathy. The condition, linked to inadequate joint care, led to osteomyelitis. The patient sought treatment due to a wound in the metatarsophalangeal area.

Laboratory tests, wound cultures, and imaging studies revealed positive results for osteomyelitis, prompting consideration of leg amputation. However, preservation of the leg without amputation through joint and bone osteotomy was successfully achieved, demonstrating an alternative to amputation in select cases.

Conclusion

This study underscores the importance of tailored and multidisciplinary approaches in addressing challenging wound healing issues in patients with leprosy. It emphasizes the significance of individualized care and the potential benefits of integrating diverse therapeutic interventions to achieve successful outcomes.