Catherine F. Decker

Disseminated Mycobacterium marinum infection in a patient with rheumatoid arthritis receiving infliximab therapy

Tumor necrosis factor-α inhibitors are important adjunctive therapies for rheumatologic diseases. These agents increase the risk for granulomatous disease. We present a case of a woman with severe rheumatoid arthritis on infliximab who developed multiple nodular skin lesions. Biopsies grew Mycobacterium marinum. New lesions developed through therapy, necessitating surgical debulking.

Rhabdomyolysis and Pandemic (H1N1) 2009 Pneumonia in Adult

To the Editor: A 56-year-old man came to the emergency department (ED) of Malcolm Grow Medical Center at Andrews Air Force Base in suburban Maryland, USA, just outside Washington, DC. He had a history of several days of cough, fever, and malaise; was a nonsmoker; was overweight (body mass index 28 kg/m2); and did not have chronic pulmonary disease. Radiographs showed bilateral pulmonary infiltrates, and he was hypoxemic. Two weeks previously, the patient had begun receiving therapy for recurrent multiple myeloma (lenalidomide and high-dose dexamethasone). He was intubated at the time of initial visit to the ED for influenza symptoms, and broad-spectrum antimicrobial drugs were administered (vancomycin 1,000 mg every 12 h, piperacillin-tazobactam 4.5 gm every 6 h, and levofloxacin 750 mg 1×/d). Initial nasopharyngeal wash was negative for influenza A and B antigen by enzyme immunoassay; serum creatine kinase was 271 U/L (reference range 38–174 U/L).

Rocky Mountain Spotted Fever

ocky Mountain spotted fever (RMSF) is both the most serious and the most ommonly reported rickettsial infection in the USA. The causative organism s Rickettsia rickettsii, which is a member of the spotted fever group. R. ickettsii are small, aerobic, obligate intracellular, Gram-negative coccobailli. The disease name is derived from its origins in the Rocky Mountains. nitially known as “black measles,” RMSF was first recognized in the Snake iver Valley of Idaho and the Bitterroot Valley of western Montana in the ate 1890s. In 1906, a medical team led by Howard Taylor Ricketts etermined the role of ticks in disease transmission. Today, most cases in the SA occur in the mid-Atlantic and southern states (Fig 1). RMSF also has een found in Canada and in Central and South America. RMSF is a systemic mall-vessel vasculitis. Clinical presentations range from benign to life hreatening. Early recognition and prompt treatment are keys to reduce ortality from this intriguing illness.

MRSA: An Evolving Pathogen

ethicillin-resistant Staphylococcus aureus (MRSA) infections have reently become the focus of intense media attention. MRSA has emerged as major health problem that is no longer confined to the health care etting. Reports of MRSA infections occurring in community settings eg, day care centers, schools, sports teams) along with reports of deaths n healthy children and adults have heightened public awareness of RSA. In turn, the lay press has labeled MRSA as the “super bug,” hich killed more people in the United States in 2005 than AIDS. The ear of infection frequently prompts worried patients to seek medical ttention. It has become such a concern to the American public that state egislatures in Maryland, Illinois, Pennsylvania, and New Jersey have roposed measures to target MRSA control, including the mandated use f surveillance cultures to screen hospitalized patients for MRSA and ublic reporting of MRSA infections. MRSA infections are not only a ignificant cause of morbidity and mortality, but they also place a large conomic strain on our health care system. It is becoming increasingly mportant that primary care physicians be aware of the epidemiology, linical presentation, and treatment of MRSA.

Ehrlichioses: Anaplasmosis and Human Ehrlichiosis

uman ehrlichiosis and anaplasmosis are acute febrile tick-borne rickettial diseases caused by organisms of the closely related genera Ehrlichia nd Anaplasma. Over the past 20 years, Ehrlicha has become increasingly ecognized as an emerging zoonotic infection since it was first found to ause human disease in 1986. The most common agents of human ick-borne ehrlichiosis include Anaplasma phagocytophlium, Ehrlichia haffenenis, and Ehrlichia ewingii. The more commonly recognized nfections include anaplasmosis (human granulocytic anaplasmosis HGA]) and human ehrlichiosis (human monocytic ehrlichiosis HME]). The causative agents of HME and HGA are small, Gramegative, obligate intracellular bacteria that have tropism for specific eukocytes. HME has an affinity for monocytes and HGA preferentially nfects granulocytes. Ehrlichieae replicate within vacuoles in these eukocytes forming microcolonies called morulae, derived from Latin ord “Morus” for mulberry, which allows the organisms to avoid hagocytosis to facilitate their survival. Morulae can be visualized by ight microscopy of Giemsaor Wright-stained peripheral smears. pidemiology GA

Other Tick-Borne Illnesses: Tularemia, Colorado Tick Fever, Tick Paralysis

Tularemia, caused by the small, aerobic Gram-negative coccobacillus rancisella tularensis, is a zoonotic disease found largely in the Northern emisphere. It has also been referred to by many other names, including eerfly fever, rabbit fever, hare fever, meat-cutter’s disease, and market an’s disease. The organism can be transmitted by inhalation or tick or iting fly vectors. Most cases of tularemia are associated with inhalation f the organism via direct exposure (direct inoculation) to infected nimals’ carcasses or animal products (especially rabbits) during hunting r food processing; however, cases do occur via bite of a tick or fly. It is ne of the most infectious pathogens known; less than 10 organisms may ause disease. Its high degree of infectivity and the ability of this rganism to be aerosolized have caused concern for its use as a powerful ioterrorism weapon. pidemiology

Respiratory Tract Infections in Athletes

The average adult experiences between 2 to 5 upper respiratory infections (URTIs) a year, which is a leading cause of physician visits and missed days of work. URTIs are one of the most common medical conditions affecting athletes. Athletes are often in close contact with others in team locker rooms, at practice, or during travel, all of which increase their risk of infection. In addition, the stress of training, traveling, competition, and environmental exposure suppresses the athlete’s immune system.

Chlamydia trachomatis infections

For more than 20 years, chlamydial infections, caused by the obligate intracellular bacteria Chlamydia trachomatis (CT), have been the most frequently reported bacterial sexually transmitted infection (STI) in the United States. Young age is a strong predictor of CT infection, particularly prevalent in individuals younger than 25 years. Infections caused by CT are often asymptomatic in both men and women so routine screening is essential for the detection of infection. Its asymptomatic nature facilitates transmission between partners. When symptomatic, women may present with cervicitis that can progress to pelvic inflammatory disease if untreated and may lead to serious consequences such as ectopic pregnancy or infertility. Men may present with urethritis, or less commonly epididymitis. Nucleic acid amplification testing (NAAT) is the detection strategy of choice for both symptomatic infections and for routine screening, which is recommended for all sexually active women younger than 25 years of age, as well as, older women in higher-risk groups based on sexual practices. When CT is detected, azithromycin or doxycycline are first-line treatments, and partner testing and treatment is also essential.

When to Suspect Tick-Borne Illness

Catherine F. Decker, MD, FACP, FIDSA hen a patient develops a febrile illness, particularly during the summer onths, the index of suspicion for tick-borne illness should always be igh in those who live in or travel (within 2 weeks) to areas where ick-borne diseases are endemic, such as the microfoci of the Northeastern S, Western Wisconsin, and Nantucket. In addition to travel, other mportant clinical history includes recent tick exposure, specific recretional or occupational exposures to tick-infested habitats, or similar llness in family members or coworkers, all of which may be critical nformation in the diagnosis of tick-borne illnesses. Outdoor activities, whether recreational (camping, hunting, walking ogs, gardening) or occupational, during April and September, particuarly in areas with high uncut grass, weeds, and low brush, can increase he risk for tick bites. The absence of history of tick bite or attachment hould not dissuade a physician from considering the diagnosis of ick-borne illness. Some may not recall tick exposure but might describe pruritic erythematous or ulcerated cutaneous lesion. Clusters of illnesses are frequently attributed to a viral infection when ore than 1 family member or coworker is affected; however, temporally nd geographically related clusters of tick-borne illnesses have been well eported. Some examples of such clusters include reports of family lusters of Rocky Mountain spotted fever (RMSF), ehrlichiosis among esidents of golf communities, and soldiers on field maneuvers.

Skin and Soft Tissue Infections in the Athlete

Skin and soft tissue infections (SSTIs) are a very common problems in athletes. Whether caused by bacteria, viruses, or fungi, many of these skin infections may be contagious, lead to team outbreaks, and have an impact on the athlete’s eligibility to compete. Although the skin functions as a protective barrier, frequent skin trauma along with the athlete’s contact with equipment and other players predisposes them to the development of skin infections. While most of these skin conditions are relatively easy to treat, more recently the emergence of methicillin-resistant Staphylococcus aureus (MRSA) has become a recurrent and potentially serious problem among athletes. This review focuses on the recognition, management, and return to play guidelines for the skin infections that most commonly afflict athletes. Cutaneous Bacterial Infections Methicillin-Resistant Staphylococcus aureus. Historically, clinicians could be confident that a healthy patient presenting with a skin or soft tissue infection was likely infected with either methicillin-susceptible S. aureus (MSSA) or Streptococcus pyogenes (beta-hemolytic Group A streptococcus). Unfortunately, that is no longer the case and community-associated MRSA must now be considered a potential pathogen. MRSA, once considered a health care associated organism, has evolved into an important cause of community-associated SSTIs, currently accounting for more than half of all SSTI-related S. aureus infections in the outpatient setting. 1-3 While many patients with community-associated MRSA have no risk factors, the established risk factors include poor hygiene, overcrowded living conditions, skin-skin contact between individuals, sharing contaminated personal items, and trauma, all of which play a large role in disseminating the organism. 3,4 Outbreaks have occurred in athletes engaged in contact sports, including wrestlers, football players, rugby players, and fencers. 5-7 Specifically, among competitive sports, the following risk factors have