Lucia Siracusa

Disseminated tuberculosis in a patient treated with a JAK2 selective inhibitor: a case report

BackgroundPrimary myelofibrosis is a myeloproliferative disorder characterized by bone marrow fibrosis, abnormal cytokine expression, splenomegaly and anemia. The activation of JAK2 and the increased levels of circulating proinflammatory cytokines seem to play an important role in the pathogenesis of myelofibrosis. Novel therapeutic agents targeting JAKs have been developed for the treatment of myeloproliferative disorders. Ruxolitinib (INCB018424) is the most recent among them.Case presentationTo our knowledge, there is no evidence from clinical trials of an increased risk of tuberculosis during treatment with JAK inhibitors. Here we describe the first case of tuberculosis in a patient treated with Ruxolitinib, a male with a 12-year history of chronic idiopathic myelofibrosis admitted to our Institute because of fever, night sweats, weight loss and an enlarging mass in the left inguinal area for two months.ConclusionTreatment with Ruxolitinib may have triggered the reactivation of latent tuberculosis because of an inhibition of Th1 response. Our case highlights the importance of an accurate screening for latent tuberculosis before starting an anti-JAK 2 treatment.

Vitamin D and Osteoporosis in HIV/HCV Coinfected Patients: A Literature Review

Vitamin D deficiency further increases the risk of osteoporosis in HIV-positive patients coinfected with hepatitis C virus (HCV); however, it is still unclear whether HCV-related increased fracture risk is a function of the severity of liver disease. The aim of this review was to identify studies on associative vitamin D deficiency patterns in high-risk populations such as HIV/HCV coinfected patients. We did this by searching MEDLINE and EMBASE databases, from inception to August 2014, and included bibliographies. The final 12 articles selected are homogeneous in terms of age but heterogeneous in terms of sample size, participant recruitment, and data source. Most of the HIV/HCV coinfected patients have less than adequate levels of vitamin D. After reviewing the selected articles, we concluded that vitamin D deficiency should be regarded as a continuum and that the lower limit of the ideal range is debatable. We found that vitamin D deficiency might influence liver disease progression in HIV/HCV coinfected patients. Methodological issues in evaluating vitamin D supplementation as a relatively inexpensive therapeutic option are discussed, as well as the need for future research, above all on its role in reducing the risk of HCV-related fracture by modifying liver fibrosis progression.

Rhabdomyolysis associated with the co-administration of daptomycin and pegylated interferon α-2b and ribavirin in a patient with hepatitis C

Rhabdomyolysis is a rare adverse effect reported with daptomy-cin use. Here we report the first case of creatinine phosphokinase (CPK) elevation with rhabdomyolysis developing during the co-administration of daptomycin and pegylated interferon a-2b and ribavirin. We describe the case of a patient with a history of intravenous drug abuse and hepatitis C admitted to our division because of fever and pain in the right gluteal region. The patients general condition was poor, but his physical examination was unremarkable, except for the presence of a right gluteal abscess. The patient had been taking pegylated interferon a-2b and ribavirin for 5 months without reporting side effects. On admission, liver function tests were within normal limits, serum CPK level was slightly elevated (518 U/L; normal values 39 –308 U/L), lactate dehydrogenase (LDH) was 580 U/L (normal values 240–480 U/L), serum creatinine was 1.6 mg/dL and estimated CL CR was 124.8 mL/min. The white blood cell (WBC) count showed neutrophil leucocytosis (WBC 11 580 cells/mm 3 , 87.1% neutrophils) and a low platelet count (72 000 cells/mm 3). All other laboratory findings were within normal limits. Hepatitis C virus (HCV) RNA viral load was undetectable. Blood cultures were performed. The patient was started on empirical antibiotic therapy with levofloxacin (750 mg once daily intravenously) and piperacillin/ tazobactam (4.5 g every 6 h intravenously). Due to lack of improvement of symptoms and fever after 48 h, levofloxacin was switched to daptomycin (500 mg daily intravenously). The second dose was administered, by mistake, 4 h before it should have been. Five days after admission, after only two doses of daptomycin, the patient suddenly complained of weakness and diffuse aches in the proximal thighs and arms. Serum CPK levels were very high (12 933 U/L) and further elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT), 371 and 67 IU/L, respectively, were also noted. A urine drug screen was performed to rule out damage related to illicit substance use, and the results were negative. Blood cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). Suspecting daptomycin-induced rhabdomyolysis, treatment was switched to linezolid (600 mg twice daily intravenously) and meropenem (1 g every 8 h intravenously). The patient was hydrated (2 L/day) to preserve renal function, and this was strictly monitored throughout the course; urinalysis was positive for myoglobin. Although daptomycin had been interrupted, CPK levels and AST/ALT levels continued to increase for 5 days after and on the …

A case of Brucella endocarditis in association with subclavian artery thrombosis

Brucellosis is a common zoonosis, endemic in Mediterranean countries, and caused by bacteria of Brucella genus. Brucellosis is a systemic infection and the clinical presentation varies widely from asymptomatic and mild to severe disease. Cardiovascular complications are extremely rare. We present a case of arterial thrombosis in a previously healthy young patient with Brucella endocarditis. Careful attention must be paid to any sign or symptom of thrombosis in patients affected by brucellosis, regardless of the presence of endocarditis and cardiovascular risk factors.

Candida glabrata meningitis and endocarditis: a late severe complication of candidemia

We report an unusual case of Candida glabrata meningitis and endocarditis in a young Caucasian woman with a prosthetic aortic valve and suffering from a dissecting thoraco-abdominal aortic aneurysm. C. glabrata was isolated from culture of the cerebrospinal fluid. Candida infection of the central nervous system is an uncommon manifestation of disseminated infection due to Candida species. Our case report also highlights the intrinsic resistance of C. glabrata to azoles.

Probable disseminated Mycobacterium abscessus subspecies bolletii infection in a patient with idiopathic CD4+ T lymphocytopenia: a case report

IntroductionRapidly growing mycobacteria are opportunistic pathogens in patients with underlying risk factors. Mycobacterium abscessus subsp. bolletii is a newly recognized member of rapidly growing mycobacteria, isolated from respiratory tract and cutaneous infections.Case presentationWe describe a case of chronic disseminated infection caused by M. abscessus subsp. bolletii in a 38-year-old Sri Lankan man with idiopathic CD4+ T lymphocytopenia. Idiopathic CD4+ T lymphocytopenia is a rare cause of immunodysfunction that, similar to human immunodeficiency virus infection, causes a depletion of CD4+ T lymphocytes. M. abscessus subsp. bolletii infection was diagnosed by culture isolation from two sputum samples.ConclusionsTo the best of our knowledge this is the first report of M. abscessus subsp. bolletii disseminated infection in a patient affected by idiopathic CD4+ T lymphocytopenia. In contrast to previous reports, the isolate of M. abscessus subsp. bolletii presented intermediate resistance to clarithromycin and was susceptible to cefoxitin and imipenem.

Myocarditis in Mediterranean spotted fever: a case report and a review of the literature

Introduction: Mediterranean spotted fever (MSF) is a tick-borne acute febrile disease caused by Rickettsia conorii. Most cases follow a benign course, with a case fatality rate of 3–7 % among hospitalized patients. Complications are described mainly in adult patients and include hepatic, renal, neurological and cardiac impairment. Among cardiac complications, pericarditis, myocarditis and heart rhythm disorders are uncommon complications in MSF and only a few cases have been reported in the literature. Case Presentation: We describe a new case of acute myocarditis complicating MSF in an immunocompetent adult patient without risk factors for severe MSF. Conclusion: Myocarditis is an uncommon but severe complication of MSF. Clinicians should be aware of a possible cardiac involvement in patients with MSF. Close monitoring and an aggressive approach are essential to reduce mortality rates of MSF.

A case of spotted fever rickettsiosis in a human immunodeficiency virus-positive patient.

Mediterranean spotted fever (MSF) due to Rickettsia conorii conorii is an acute febrile disease endemic in Italy, where about 400 cases are reported every year, transmitted to humans by the brown dog tick. Nearly half of Italian MSF cases occur in Sicily (Colomba et al., 2006). However, in recent years other tick-borne spotted fever group rickettsiae such as Rickettsia conorii israelensis, Rickettsia conorii caspia, Rickettsia slovaca, Rickettsia massiliae, Rickettsia aeschlimannii, Rickettsia akari and Rickettsia sibirica mongolitimonae have been documented to cause infection in humans in the Mediterranean basin. All of these agents, although causing milder illnesses than R. conorii, cross-react with R. conorii, thus requiring care in interpretation of serological tests. MSF in an immunocompetent host is typically characterized by fever, skin rash and a black eschar at the site of the tick bite (‘tache noire’). Here, we describe a case of spotted fever rickettsiosis with a benign course in a human immunodeficiency virus-positive patient.

A case of visceral leishmaniasis and pulmonary tuberculosis in a post-partum woman

Visceral leishmaniasis due to Leishmania infantum is a vector-borne zoonotic disease transmitted by sand fly bites endemic in rural or periurban areas of the Mediterranean basin. Pregnancy is accompanied by changes in immune response, mainly a decrease in cellular immunity and a proportional increase in humoral immunity. These physiological events result in increased risk of infection by pathogens whose immunity is based on a T-helper 1 predominant response. We describe a case of visceral leishmaniasis and pulmonary tuberculosis diagnosed in a post-partum woman four days after delivery. The diagnosis of leishmaniasis should be considered in pregnant women with fever and haematologic abnormalities in endemic regions or if a history of exposure in endemic areas is reported.