IDCases最新文献

Background

Melioidosis is one of the emerging infections in India and is often neglected due to lack of awareness among clinicians. The diseases usually present as multifocal or focal abscesses with bacteremia, yet the isolated septic monoarthritic complicated with septic venous thrombosis is a rare presentation.

Case

This case report describes a 48-year-old male business executive with diabetes and alcoholism who developed septic arthritis caused by Burkholderia pseudomallei and no clear history of exposure to the organism. The patient initially experienced fever, chills, fatigue, reduced urine output, and signs of early sepsis. Despite initial improvement with fluid therapy and antibiotics, the patient's fever persisted. Meticulous clinical examination revealed signs of inflammation and movement restriction in the left shoulder which letter on became obvious and the main complaints of patient. Blood cultures confirmed the presence of B. pseudomallei. Imaging showed septic arthritis, osteomyelitis, lymphadenitis, and venous thrombosis in the left shoulder. Surgical debridement was performed, and the tissue cultures showed the growth of the same pathogen. This led to significant clinical improvement and with prolonged course of antibiotics, complete resolution of symptoms and normal joint function was achieved.

Conclusion

This case report serves to highlight the rare and atypical presentation of Melioidosis and the importance of suspecting this infection in nonendemic regions underscoring the probable impact of climate change. Early diagnosis, effective source control measures and prolonged antibiotic therapy, emerges as pivotal factors contributing to favorable outcomes in such cases.

The area under the concentration-time curve (AUC)/minimum inhibitory concentration (MIC) – guided approach is recommended for vancomycin therapeutic drug monitoring in severe methicillin-resistant Staphylococcus aureus (MRSA) infection. However, evidence regarding the efficacy of vancomycin AUC-guided strategies for the treatment of systemic infections is limited. This case report describes the successful treatment of MRSA meningitis, with vancomycin using a higher AUC/MIC target. A 61-year-old woman who underwent ventriculoperitoneal (VP) shunt placement for subarachnoid hemorrhage, developed MRSA meningitis due to shunt infection. Vancomycin was administered intravenously, with concurrent monitoring of serum and cerebrospinal fluid (CSF) vancomycin concentrations and AUC/MIC. On post-operative day (POD) 24 of VP shunt placement, the vancomycin trough concentration and AUC/MIC were 12.0 μg/mL and 515, respectively, with persistently positive CSF culture. On POD 28, the trough concentration and AUC/MIC were 18.6 μg/mL and 610, respectively. There were no major adverse events, and CSF culture turned negative on POD 30. The vancomycin CSF-to-serum ratio was approximately 41 %. For patients with MRSA meningitis, we suggest an optimal therapeutic range with a vancomycin AUC/MIC target near the upper limit of the therapeutic window.

Scedosporium, a widespread filamentous fungus found in diverse environments, has experienced a rise in cases due to escalating malignancies and chronic immunosuppression. Clinical manifestations span mycetoma, airway involvement, and various infections, with osteomyelitis being a notable complication. We present a case of a 77-year-old female initially displaying cutaneous Scedosporium signs, which progressed to osteomyelitis. The patient, with a history of trauma, chronic low dose steroid use, and underlying conditions, presented with a foot injury caused by her dog. Despite initial management, worsening symptoms led to the identification of Scedosporium. A comprehensive approach involving debridement, antimicrobial therapy, and reduction of immunosuppression resulted in clinical improvement. The rarity of zoonotic transmission, diagnostic challenges, and antifungal efficacy are also discussed. The patient's positive trajectory emphasizes early diagnosis, targeted treatment, and vigilance in managing immunosuppression. An adaptable treatment protocol is proposed based on risk factors. Considering the rising opportunistic fungal infections and delayed culture results, initiating empirical antifungals based on clinical judgment and regional prevalence is vital for favorable outcomes.

There is indirect evidence signifying a potential link between tuberculosis and Takayasu’s arteritis (TAK); however, the exact mechanism and relationship between TKA and Mycobacterium tuberculosis (TB) remain to be elucidated. This case intends to highlight the association between TB and TKA, as early detection can avoid devastating consequences.

Introduction

Coronaviruses have been suspected to be associated with neurological manifestations in patients with respiratory tract infections. Corona Virus disease (COVID-19) develop seizures as a consequence of hypoxia, metabolic derangements, organ failure, or even cerebral damage that may happen in people with COVID-19. There is scarce data about the development of seizures after recovery from acute COVID-19 illness, especially in those who have had a mild disease.

Case

A thirty three year old male patient with recent history of mild COVID-19 disease, with no known comorbidities, no history of substance abuse, presented with history of transient loss of consciousness. On examination had no lateralising signs, tongue bite was present. Inflammatory markers were found to be raised. MRI brain showed no significant abnormality. EEG done showed bilateral intermittent slowing.

Conclusion

Post COVID-19 infection, the post-infectious inflammatory response can give rise to many neurological complication, seizure being one among them, as noted in our patient.

Two atypical cases of infectious mononucleosis in two teenagers with initially negative serology and non-evocative blood examinations are reported. The first patient had recently traveled to Africa, and Epstein-Barr virus negative serology led us to make many extensive investigations. The second patient complained of asthenia for a month, and PET/CT was performed to suspicion of lymphoma. PET scan revealed hypermetabolic lymph nodes in the supradiaphragmatic and subdiaphragmatic stations, along with¹⁸F-FDG uptake in the spleen and pharynx, raising more suspicion of lymphoma. Fortunately, Epstein-Barr virus DNA testing was performed and turned positive in both cases, and Epstein-Barr virus serology subsequently became positive. Diagnosing EBV infection can be challenging in rare cases, as EBV-specific serology may be negative in the early stages and confounding factors may be present. Therefore, Epstein-Barr virus DNA testing should be considered early in the diagnostic algorithm to prevent unnecessary investigations in similar cases.

Lomentospora prolificans is a rare, filamentous fungus, that causes a disseminated infection in immunocompromised individuals. Disseminated infections caused by the fungus are difficult to diagnose early. It is resistant to multiple antifungal agents and has a high mortality rate. We encountered a case in which the involvement of this fungus was indicated by a history of antifungal prophylaxis and an elevated serum 1,3-beta-D-glucan (BDG) level. A 76-year-old female with myelodysplastic syndrome that developed into overt leukemia was administered oral posaconazole as antifungal prophylaxis. She was admitted to the hospital to determine the cause of her fever, where no new abnormalities other than an elevated serum BDG level were observed. Unfortunately, the patient died due to acute respiratory failure on the same day of admission. The day after her death, L. prolificans was detected in a blood culture taken upon her admission. L. prolificans should be suspected based on the history of antifungal prophylaxis and an elevated serum BDG level, as these are risk factors for infection by this pathogen. Blood cultures are useful to provide a diagnosis. If treated early, before it is detected in culture, the mortality rate can be decreased.

Toscana virus (TOSV) is an emerging cause of central nervous system (CNS) infections, especially in endemic countries during summer. Cerebrospinal fluid (CSF) is usually clear, with < 500 leukocytes/mm³, normal glucose (> 60 % serum glucose) and normal (< 45 mg/dL) to slightly increased protein levels. Here we present two cases of TOSV meningitis with misleading CSF characteristics observed at Santa Maria Annunziata Hospital (Bagno a Ripoli, Florence, Italy). Case 1 presented with signs and symptoms of meningitis. CSF was opalescent on macroscopic examination, with 1192 cells/mm³, hypoglycorrhachia (30 % serum glucose) and hyperproteinorachia (228.0 mg/dL). TOSV meningitis was confirmed with serology. Case 2 presented with headache, vomiting and mild neck stiffness. CSF was slightly turbid, with 1092 cells/mm³, normal glucose (61 % serum glucose) and slightly increased protein (77.0 mg/dL) levels. TOSV meningitis was confirmed with serology and molecular test on CSF. We performed a literature review including cases of TOSV neuroinvasive infections in which CSF characteristics were reported. Pleocytosis > 500 cells/mm³ was reported in 12/62 (19.4 %) patients, hypoglycorrhachia in 3/62 (4.8 %) patients, mild hyperproteinorachia (45 - 75 mg/dL) in 7/62 (11.3 %) patients and severe hyperproteinorachia (> 75 mg/dL) in 40/62 (64.5 %) patients. TOSV should be considered in the differential diagnosis of CNS infections in endemic areas during the warm season even when CSF examination shows atypical results.

Tuberculous meningitis (TBM) is a potentially life-threatening form of tuberculosis (TB) that affects the central nervous system. Its management in patients with concomitant chronic liver disease (CLD) presents unique challenges due to altered drug metabolism with potentially impaired spinal fluid drug penetration and hepatotoxicity. The standard regimen for TBM includes isoniazid (INH) and rifampin (RIF), and Pyrazinamide (PZA) which are metabolized by the liver and may cause hepatotoxicity, which can exacerbate preexisting liver disease. Thus, careful consideration is required to balance therapeutic efficacy with potential drug-induced hepatotoxicity. Regular monitoring of liver function tests and clinical response is essential to minimize adverse effects and optimize treatment outcomes. Further research is needed to establish evidence-based guidelines for the tailored management of TBM in this vulnerable patient subset. Overall, the treatment of TBM in patients with severe liver disease should be individualized and closely monitored.

Ecthyma grangrenosum is an unusual condition, mostly related to Pseudomonas septicemia. Ecthyma-like skin lesions caused by cutaneous phaeohyphomycosis are extremely rare. Here, we report a case of a 20-year-old Thai man, previously healthy, presenting multiple ecthyma-like skin lesions in both arms and both legs for 2 months. Physical examination revealed ill-defined erythematous plaque with central necrotic crust at both arms and both legs. Tissue biopsy showed a neutrophil collection identified by GMS stain revealing septate hyphae organisms in the vascular lumen. The skin culture was positive for Curvularia lunata, while the final diagnosis was cutaneous phaeohyphomycosis caused by Curvularia lunata. He was empirically treated with amphotericin B and then voriconazole. Itraconazole was administered as a definitive regimen, resulting in complete resolution after 2 months of treatment. Cutaneous phaeohyphomycosis is also an uncommon cause of ecthyma-like lesions and should be considered for investigation when initial results do not demonstrate a bacterial etiology.