Alwyn Rapose

Listeria grayi bacteremia in a heart transplant recipient

Abstract: Bacteria belonging to the genus Listeria have been isolated from food products of animal, plant, and fish origin, and are associated with infections in immunocompromised hosts, pregnant women, and infants. The species Listeria grayi has rarely been reported as a human pathogen. It has a unique antibiotic sensitivity profile. We describe a case of L. grayi bacteremia in a heart transplant recipient. The organism demonstrated a reduced sensitivity to ampicillin. The patient was successfully treated with a combination of vancomycin and ciprofloxacin.

Immune Reconstitution Inflammatory Syndrome Presenting as Pericarditis and Pericardial Effusion

Immune reconstitution inflammatory syndrome (IRIS) affects 30–43% of HIV and tuberculosis (TB) co-infected patients after starting highly active antiretroviral therapy (HAART). Pericarditis and pericardial effusion are rare manifestations of IRIS. We report a case of HIV-TB related IRIS that developed pericardial involvement. This complication resolved after treatment with ibuprofen. Antituberculous treatment and HAART were not interrupted.

Prostate abscess: MRSA spreading its influence into Gram-negative territory: case report and literature review

Prostate abscess is a rare complication of an ascending urinary tract infection (UTI). Its incidence has reduced secondary to routine and early use of antibiotics for treatment of UTIs. Prostate abscess has been reported in patients with uncontrolled diabetes, prolonged indwelling urinary catheters, prostate biopsy or other instrumentation of lower urinary tract. Prostate abscess is most commonly associated with Gram-negative bacteria. Staphylococcus aureus is rarely implicated and has been reported in patients with underlying risk factors like long-term or uncontrolled diabetes, intravenous drug abuse or bacteraemia. We present a rare case of prostate abscess due to methicillin resistant S aureus without obvious risk factors.

Naltrexone-induced Nicolau syndrome masquerading as cutaneous abscess

Nicolau syndrome—also known as Embolia Cutis Medicamentosa—is a rare complication of intramuscular and subcutaneous injections manifesting as necrosis of skin and the underlying tissues. The exact pathogenesis is uncertain. There are several hypotheses including direct damage to the end artery, cytotoxic effects of the implicated drug or additives in the injectable preparations. Naltrexone is a long-acting opioid antagonist used primarily in the management of alcohol and opioid dependence. The patient received intramuscular naltrexone for treatment of alcoholism. A week later, she presented with what appeared to be cellulitis at the site of injection. It progressed in spite of antibiotics and mimicked an abscess. Attempted incision and drainage however yielded no pus. Deep tissue necrosis was seen and histopathology was consistent with Nicolau syndrome. As per our knowledge, this is the first reported case of naltrexone associated Nicolau syndrome that masqueraded as a buttock abscess.

Fatal Enterococcus durans aortic valve endocarditis: a case report and review of the literature.

Most enterococcal endocarditis is caused by Enterococcus faecalis and Enterococcus faecium. Enterococcus durans is a rare member of non-faecalis, non-faecium enterococcal species and is found in the intestines of animals. E durans endocarditis is a very rare infection—only two cases of endocarditis in humans have been reported in the literature—and usually associated with good outcomes when treated with appropriate antibiotics. We report the first case of fatal E durans endocarditis. This patient had end-stage liver disease with associated compromised immune status that likely contributed to the progression of disease in spite of appropriate antibiotic coverage and clearance of bacteraemia.

'Non-resolving' pneumonia.

A 47-year-old man presented with symptoms of fever and productive cough secondary to a left upper lobe pneumonia. He had received more than three courses of antibiotics over a 2-year period. Review of serial radiographic exams including chest x-ray and CT scans revealed consolidation of the left upper lobe. Lack of response to antibiotics prompted invasive testing with bronchoscopy which revealed a growth in the left main bronchus. Histopathology revealed squamous cell carcinoma.

Colon cancer and enterococcus bacteremia co-affection: A dangerous alliance

Adenocarcinoma of the colorectal region is one of the leading causes of cancer-related mortality in the USA and hence an important public health concern. Enterococci are emerging as an important cause of infection in the elderly. While translocation of enteric bacteria into the bloodstream is a known phenomenon in patients with infectious, inflammatory or infiltrative conditions of the bowel, a causative link between Enterococcus bacteremia and colorectal cancer has not been established in medical literature. We report the case of a patient presenting with E. faecalis bacteremia who was also diagnosed with infiltrating adenocarcinoma of the rectum. We discuss a possible relationship between these two conditions.

The evaluation of Clostridium difficile infection (CDI) in a community hospital

INTRODUCTION Clostridium difficile is a serious reemerging pathogen in Europe and North America. C. difficile infection (CDI) has been of concern over the last decade in view of its significant morbidity and mortality, as well as the high health care costs involved with each case. Although multiple risk factors are known to be associated with CDI, a number of patients develop severe infection even in the absence of known risk factors. CDI is diagnosed by the detection of the toxin A/B in stools by enzyme immunoassay (EIA) or by polymerase chain reaction (PCR). There is conflicting literature regarding whether any particular group of antibiotics is associated with higher risk for CDI. There is also a tendency to perform repeated stool tests for toxin A/B if the first test is negative. We evaluated 100 consecutive hospitalized patients who tested positive for C. difficile over a one-year period. METHODS We performed a retrospective analysis of 100 consecutive patients with CDI admitted to our hospital between July 2008 and June 2009. Patient records were reviewed for risk factors, treatment, and clinical outcomes. We also evaluated the number of stool tests performed for the detection of C. difficile and fecal leukocyte testing in each patient. RESULTS The majority of the patients were more than 60 years of age (87%). Forty-four percent of patients presented from a nursing facility. More than 50% were on Proton Pump Inhibitors (PPIs) at the time of admission. Co-morbidities in our patients included malignancy in 28%, diabetes mellitus in 25%, and chronic renal disease in 23%. Most of the patients had multiple co-morbidities. Patients who had taken antibiotics in the previous six months constituted 74% of the total study population. A beta-lactam alone or in combination with other antibiotics was prescribed in 48%, quinolones in 13% and clindamycin in 4% of patients. Stool samples were tested only once in 53% of patients and twice or more in 43%. Metronidazole was the initial therapy in 86% of patients. Intensive care unit stay was required in 33% of patients. Seventeen percent died during their hospitalization. CONCLUSIONS Elderly patients are especially vulnerable to CDI when exposed to antibiotics, and higher mortality and morbidity is observed in this age group. PPI use was common in our patients. Metronidazole was used as the first line agent in the majority of patients. We also determined a tendency to test for the C. difficile toxin in more than one stool sample. All of these practices need to be modified based on the current guidelines.

Human papillomavirus and genital cancer

Human papillomavirus (HPV) is one of the most common sexually transmitted infections world-wide. Low-risk HPV-types are associated with genital warts. Persistent infection with high-risk HPV-types is associated with genital cancers. Smoking and HIV infection have consistently been associated with longer duration of HPV infection and risk for genital cancer. There is an increasing incidence of anal cancers, and a close association with HPV infection has been demonstrated. Receptive anal sex and HIV-positive status are associated with a high risk for anal cancer. Two HPV vaccines are now available and offer protection from infection by the HPV-types included in the vaccine. This benefit is maximally seen in young women who were uninfected prior to vaccination.

Herpes zoster encephalopathy or acyclovir neurotoxicity: a management dilemma

This is a case report of a 69-year-old morbidly obese woman who presented with mental status changes after she was treated with acyclovir for shingles. The predominant symptoms were word-finding difficulties and visual hallucinations. Complicating her presentation was acyclovir-induced acute renal injury causing her creatinine level to rise up to 7.4 mg/dL. Acyclovir was discontinued on the suspicion of acyclovir neurotoxicity. Even though PCR for varicella zoster virus in the cerebrospinal fluid was positive, acyclovir was not restarted and the patient continued to improve and returned to her baseline.