Bonnie Prokesch

Primary osteomyelitis caused by hypervirulent Klebsiella pneumoniae

Klebsiella pneumoniae is the most clinically relevant species of this genus, known to cause both community-acquired and nosocomial infections worldwide. In the past two decades, a distinct hypervirulent strain of K pneumoniae, characterised by its hypermucoviscous phenotype, has emerged as a clinically significant pathogen responsible for highly invasive infections. We present a case of osteomyelitis due to hypervirulent K pneumoniae reported in the USA. Genomic testing of the K pneumoniae isolate was performed due to the striking clinical presentation of the infection as well as the hypermucoid nature of the isolates, raising the suspicion for possible infection with the hypervirulent strain. Whole-genome sequencing and additional PCR testing demonstrated the isolate to be a K1 serotype, sequence type 23 strain expressing rmpA and rmpA2. Given the multiple reports of this pathogen causing invasive infections, clinicians should be aware of the possible presentation of metastatic and severe infection, including osteomyelitis, due to the hypervirulent strain of K pneumoniae not typical of classic K pneumoniae variants. In this Grand Round, we review the clinical features of hypervirulent K pneumoniae and its link to invasive infections, and discuss the need for improved awareness and identification of the pathogen.

Thromboangiitis obliterans involving the temporal artery

Introduction Thromboangiitis obliterans (TO) is a nonatherosclerotic, inflammatory segmental vascular disease typically seen in young male smokers, involving primarily smalland medium-sized vessels of the distal extremities (1). The first case of TO was described by von Winiwarter in 1879, and, in 1908, Leo Buerger explained the pathologic findings in 11 amputated extremities. Although more than 100 years have passed since the vasculitis was recognized and the pathology fully explained, the cause of TO remains unclear. Nonetheless, the use of or exposure to tobacco has been found to be essential to the onset and progression of the disease. Diagnosis is often one of exclusion, but can be made based on bilateral extremity digital necrosis in a heavy smoker and in the absence of scleroderma. Typically, echocardiography is done to rule out a proximal source of emboli, and angiography is done to look for segmental occlusive lesions, or “corkscrew collaterals”; however, these findings are not pathognomonic for TO and may also be seen in atherosclerosis. The physical examination findings, along with the clinical history of tobacco use, an examination with negative results for other sources of thrombi, and a suggestive angiographic picture allow for a diagnosis of TO. Rarely is a biopsy performed. In the case described below, TO was confirmed by temporal artery biopsy showing the classic pathologic features in a patient presenting with typical signs and symptoms of the disease.

Nail gun attempted suicide and traumatic ventricular perforations

A 57-year-old male walked into the emergency department within 24 h of shooting himself with a nail gun as a suicide attempt. He was hemodynamically stable and reported chest pain. Although …

Letermovir successfully used for secondary prophylaxis in a heart transplant recipient with ganciclovir-resistant cytomegalovirus syndrome (UL97 mutation)

Letermovir was approved by the Food and Drug Administration (FDA) in November 2017 for use in adult cytomegalovirus (CMV)‐seropositive allogeneic stem cell transplant (SCT) recipients for primary prophylaxis of CMV infection and disease. We report off‐label use of letermovir for secondary prophylaxis of genotype‐confirmed ganciclovir‐resistant cytomegalovirus (CMV) syndrome (UL 97 mutation [C603W]) in a heart transplant recipient initially treated with intravenous cidofovir followed by foscarnet, both discontinued due to unacceptable toxicities.

What’s in a name? The heterogeneous clinical spectrum and prognostic factors in a cohort of adults with hemophagocytic lymphohistiocytosis

PURPOSE Hemophagocytic lymphohistiocytosis (HLH) in adults is rare but frequently fatal. Diagnosis is often delayed and treatment approaches vary significantly in contrast to the protocol-driven approach typically used in pediatric HLH. To improve care of these complex patients, this study retrospectively examined the prevalence, clinical characteristics, therapies and outcomes of adult HLH patients at two large tertiary care centers. METHODS Adult patients with HLH confirmed by retrospective review of electronic medical records using HLH2004 criteria during admissions to the University of Texas Southwestern and Parkland Memorial Hospitals between June 2007 and June 2017 were studied. RESULTS Of 31 patients included, 67.7% were male with mean age of 46 years. Average time from admission to diagnosis was 10.5 days. 48% of patients had malignancy, with T-cell lymphoma being most common. Infections were seen in 70%. Autoimmune disorders were found in 9.6%. In total, 13 patients survived (44.8%). Median survival was 8 months with increased mortality in malignancy-associated HLH (median 0.56 months versus 36.5 months, p < 0.001). T-cell lymphoma carried a worse prognosis than other malignancies. Central nervous system disease, hypoalbuminemia, elevated bilirubin, elevated soluble interleukin 2 receptor, and elevated lactate dehydrogenase, were also associated with poor survival. Treatment varied significantly. No individual treatment improved survival. CONCLUSION This study corroborates prior limited data in adult HLH patients regarding poor survival, particularly in malignancy-associated HLH. Earlier recognition of this disease and a multidisciplinary approach to streamline diagnosis and optimize treatment are needed to improve outcomes in adult HLH patients.

Bacteremia and septic arthritis due to a nontoxigenic strain of Clostridium difficile in a patient with sickle cell disease

Abstract A 22-year-old female with sickle cell disease presented with fevers, bilateral knee pain, and lethargy. Laboratory data revealed a leukocytosis and lactic acidosis. Blood and synovial fluid cultures grew a non-toxin-producing strain of Clostridium difficile. This case highlights the fact that nontoxigenic Clostridium difficile can cause significant disease.

Successful treatment of persistent Burkholderia cepacia complex bacteremia with ceftazidime-avibactam

ABSTRACT We report our clinical experience treating a 2-month-old infant with congenital diaphragmatic hernia who experienced prolonged bacteremia with Burkholderia cepacia complex (Bcc) despite conventional antibiotic therapy and appropriate source control measures. The infection resolved after initiation of ceftazidime-avibactam. Whole-genome sequencing revealed that the isolate most closely resembled B. contaminans and identified the mechanism of resistance that likely contributed to clinical cure with this agent. Ceftazidime-avibactam should be considered salvage therapy for Bcc infections if other treatment options have been exhausted.

A 60-year-old man with necrotic skin lesions after heart transplantation.

American Journal of Transplantation 2014; 14: 2664–2666 American Journal of Transplantation Images in Transplantation – Continuing Medical Education (CME) Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal-based CME activity, chosen to educate participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 CreditTM per article at their own pace. This month’s feature article is titled: “A 60-Year-Old Man With Necrotic Skin Lesions After Heart Transplantation.” Accreditation and Designation Statement This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services, the American Society of Transplant Surgeons and the American Society of Transplantation. Blackwell Futura Media Services is accredited by the ACCME to provide continuing medical education for physicians. Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Statement of Need Prompt diagnosis via skin biopsy is critical for initiation of treatment in a timely fashion, as certain disseminated infections are often fatal in immunosuppressed patients. Clinicians must consider the diagnosis of rare cutaneous manifestations of infection in all transplant patients presenting with painless, necrotic purpuric skin lesions. Purpose of Activity This activity is designed to meet the educational needs of the learner by helping improve knowledge and competence regarding timely evaluation, prompt diagnosis, and optimal treatment of infectious skin lesions in immunosuppressed patients. Identifi cation of Practice Gap Transplant recipients are at risk for rare invasive infections associated with high morbidity and mortality that can present with cutaneous lesions. Transplant providers need to be aware of the potential risks for these infections and understand how to diagnose them in a timely manner. Learning Objectives Upon completion of this educational activity, participants will be able to: • Compare the risk factors for development of disseminated infections in transplantation patients. • Develop a differential diagnosis of a purpuric and necrotic skin lesion in a transplant recipient. • Describe the possible presentations of invasive infection in transplant recipients. • Identify the appropriate way to best diagnose an infection with cutaneous manifestations in a timely manner in immunocompromised patients. • Recognize specifi c fi ndings related to certain types of fungal infections on pathology specimens that have been stained with hematoxylin and eosin and lactophenol cotton blue stains. Target Audience This activity has been designed to meet the educational needs of physicians and surgeons in the fi eld of transplantation. Disclosures No commercial support has been accepted related to the development or publication of this activity. Blackwell Futura Media Services has reviewed all disclosures and resolved or managed all identifi ed confl icts of interest, as applicable. Editor-in-Chief Allan D. Kirk, MD, PhD, FACS, has no relevant fi nancial relationships to disclose. Editors Sandy Feng, MD, PhD, has no relevant fi nancial relationships to disclose. Douglas W. Hanto, MD, PhD, has no relevant fi nancial relationships to disclose. Authors Bonnie C. Prokesch, MD, Dominick Cavuoti, DO, Jade B. Le, MD, and David E. Greenberg, MD, have no relevant fi nancial relationships to disclose.