Ning-Chi Wang

The Emerging Life-threatening Opportunistic Fungal Pathogen Kodamaea ohmeri: Optimal Treatment and Literature Review

BACKGROUND/PURPOSE The yeast Kodamaea ohmeri rarely causes life-threatening human infections. However, risk factors, laboratory diagnoses, and treatments for K. ohmeri infection have been limited, and the optimal therapy for K. ohmeri infection has not been identified. METHODS Twenty cases of K. ohmeri infection have been reported in the English medical literature. We present two new cases of K. ohmeri fungemia. We investigated the nature and treatment of K. ohmeri infections using minimum inhibitory concentrations of antifungal agents and by comparing the two cases with those described in the literature. RESULTS From March 1998 to December 2008, a total of 22 patients with K. ohmeri infections were studied. Hematological malignancies and diabetes were the most common co-morbidities for K. ohmeri infections, with crude prevalence rates of 27.3% and 18.2%, respectively. The K. ohmeri isolates showed less susceptibility to fluconazole but greater susceptibility to amphotericin B [15/25 isolates (60%) vs. 25/25 isolates (100%), respectively]. Good outcomes (8/9 cases; 88.9%) were found following removal of indwelling catheters and implants. In addition, voriconazole and echinocandins, such as caspofungin and micafungin, also showed excellent minimum inhibitory concentrations against K. ohmeri. CONCLUSION K. ohmeri should not be regarded as a contaminant of blood cultures. Favorable outcomes for this potentially life-threatening infection are promoted by the removal of indwelling catheters; furthermore, outcomes are associated with optimal antifungal regimens, especially voriconazole and echinocandins.

Risk factors and outcomes of cytomegalovirus viremia in cancer patients: a study from a medical center in northern Taiwan.

BACKGROUND Cytomegalovirus (CMV) is a pathogen and can cause life-threatening infection in the patients with malignancies. This study was conducted to investigate the risk factors and outcomes of CMV viremia in patients with malignancies. METHODS Data were collected with retrospective analysis from adults suffering from CMV viremia with underlying malignancies. A total of 107 patients were enrolled in a tertiary medical center in northern Taiwan from March 2008 to December 2009. RESULTS Among the 107 patients who suffered with CMV viremia with an overall mortality rate of 56.1% (60/107), 75 patients (70.1%) had solid organ malignancies and 32 (29.9%) had hematological malignancies. Mechanical ventilation (p=0.048), leukocytosis (p=0.004), and lack of appropriate early treatment (p=0.011) were independent predisposing factors associated with higher mortality rate. CONCLUSIONS CMV viremia predicts high mortality rate in cancer patients, especially in those with mechanical ventilation, leukocytosis, and lack of appropriate early treatment. Appropriate early antiviral therapy is recommended to improve outcomes.

Methicillin-resistant Staphylococcus aureus bacteremia in hemodialysis and nondialysis patients

BACKGROUND/PURPOSE Increased mortality has been reported in patients treated with vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with high minimum inhibitory concentration (MIC) values within the susceptibility range. However, this finding has not been verified in hemodialysis patients, who have much higher invasive MRSA infection rates than nondialysis patients. We aimed at comparing vancomycin MICs between hemodialysis and nondialysis patients, and identifying predictors of high vancomycin MICs and infection-related mortality in hemodialysis patients with MRSA bacteremia. METHODS Patients with MRSA bacteremia from January 2008 through December 2009 were enrolled. Vancomycin MIC was determined for each first isolate using the Etest method. Clinical characteristics and vancomycin MICs were compared between hemodialysis and nondialysis patients. Factors associated with high vancomycin MIC (2 μg/mL) and infection-related mortality in hemodialysis patients were analyzed. RESULTS A total of 162 MRSA bacteremia episodes were identified. Forty-four (27.0%) isolates were obtained from hemodialysis patients and 118 (73.0%) from nondialysis patients. Diabetes (63.3% vs. 39.8%, p = 0.007) and prior vancomycin exposure in 30 days (31.8% vs. 12.7%, p = 0.005) were more prevalent in hemodialysis group than in nondialysis group. A higher prevalence of vancomycin MIC of 2 μg/mL was observed in hemodialysis group in comparison with nondialysis group (11.4% vs. 1.7%, p = 0.016). In following analyses of hemodialysis group, patients with initial presentation of septic shock had a higher risk of vancomycin MIC of 2 μg/mL than nonseptic shock patients (100.0% vs. 38.5% p = 0.014). Infection-related mortality was associated with age, Acute Physiology and Chronic Health Evaluation II (APACHE-II) score >15, presence of septic shock, receipt of mechanical ventilation, and failure to remove source of bacteremia in univariate analysis. CONCLUSION Hemodialysis patients with MRSA bacteremia are more likely to have a high vancomycin MIC (2 μg/mL) compared with nondialysis patients. Infection-related mortality is associated with the patients clinical manifestations, including age, APACHE-II score >15, presence of septic shock, receipt of mechanical ventilation, and failure to remove source of bacteremia. Treatment selection should be tailored according to the patients clinical condition.

Cytomegalovirus Colitis Mimics Amebic Colitis in a Man With AIDS

Opportunistic gastrointestinal infections are common in patients with HIV infection; both amebic colitis and cytomegalovirus (CMV) colitis are common causes of chronic diarrhea. It is difficult to distinguish these 2 diseases by nonspecific clinical symptoms such as diarrhea, abdominal pain, and weight loss. Here we report a case of CMV colitis mimicking amebic colitis with elevated indirect hemagglutination assay antibody titer against Entamoeba histolytica and negative IgM antibody titer against CMV. The diagnosis of CMV colitis was confirmed by eosinophilic nucleoli and inclusion bodies in colon biopsies. The patient recovered after ganciclovir and highly active antiretroviral therapy. Exact diagnoses are important for treating opportunistic infections. Other pathogens should be considered in patients with chronic diarrhea who are refractory to initial treatments. Our case highlights the importance of histopathological diagnosis for chronic diarrhea in patients with HIV infection and the possibility of false-positive results for indirect hemagglutination assay antibody against Entamoeba histolytica despite high titers.

Acute Peritonitis as Presentations of Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome in an HIV-Infected Man

Immune reconstitution inflammatory syndrome (IRIS) is particularly observed after the start of therapy for pathogenic antigens in patients infected with human immunodeficiency virus (HIV) and receiving highly active antiretroviral therapy (HAART). Although tuberculosis (TB)-associated IRIS is the most common form, its presentation as a primary feature of acute peritonitis is extraordinarily rare. We report a 43-year-old man diagnosed with acquired immunodeficiency syndrome and pulmonary TB coinfection. His symptoms, sputum quantity, and chest radiologic appearance improved markedly after 3 weeks of antituberculous therapy, and HAART was initiated on the fourth week. However, acute abdomen with peritoneal signs resulting from the established tuberculous peritonitis developed on the seventh day of HAART. His clinical symptoms resolved after maintenance of HAART and antituberculous regimens. Tuberculous peritonitis must be considered in the differential diagnosis of acute abdomen in HIV-infected patients on antiviral therapy, especially in patients with known underlying TB. Early recognition of IRIS is important when managing HIV-infected patients with opportunistic infections.

Multicenter study of skin rashes and hepatotoxicity in antiretroviral-naïve HIV-positive patients receiving non-nucleoside reverse-transcriptase inhibitor plus nucleoside reverse-transcriptase inhibitors in Taiwan

Objectives Two nucleos(t)ide reverse-transcriptase inhibitors (NRTIs) plus 1 non-NRTI (nNRTI) remain the preferred or alternative combination antiretroviral therapy (cART) for antiretroviral-naive HIV-positive patients in Taiwan. The three most commonly used nNRTIs are nevirapine (NVP), efavirenz (EFV) and rilpivirine (RPV). This study aimed to determine the incidences of hepatotoxicity and skin rashes within 4 weeks of initiation of cART containing 1 nNRTI plus 2 NRTIs. Methods Between June, 2012 and November, 2015, all antiretroviral-naive HIV-positive adult patients initiating nNRTI-containing cART at 8 designated hospitals for HIV care were included in this retrospective observational study. According to the national HIV treatment guidelines, patients were assessed at baseline, 2 and 4 weeks of cART initiation, and subsequently every 8 to 12 weeks. Plasma HIV RNA load, CD4 cell count and aminotransferases were determined. The toxicity grading scale of the Division of AIDS (DAIDS) 2014 was used for reporting clinical and laboratory adverse events. Results During the 3.5-year study period, 2,341 patients initiated nNRTI-containing cART: NVP in 629 patients, EFV 1,363 patients, and RPV 349 patients. Rash of any grade occurred in 14.1% (n = 331) of the patients. In multiple logistic regression analysis, baseline CD4 cell counts (per 100-cell/μl increase, adjusted odds ratio [AOR], 1.125; 95% confidence interval [95% CI], 1.031–1.228) and use of NVP (AOR, 2.443; 95% CI, 1.816–3.286) (compared with efavirenz) were independently associated with the development of skin rashes. Among the 1,455 patients (62.2%) with aminotransferase data both at baseline and week 4, 72 (4.9%) developed grade 2 or greater hepatotoxicity. In multiple logistic regression analysis, presence of antibody for hepatitis C virus (HCV) (AOR, 2.865; 95% CI, 1.439–5.704) or hepatitis B surface antigen (AOR, 2.397; 95% CI, 1.150–4.997), and development of skin rashes (AOR, 2.811; 95% CI, 1.051–7.521) were independently associated with the development of hepatotoxicity. Conclusions The baseline CD4 cell counts and use of NVP were associated with increased risk of skin rashes, while hepatotoxicity was independently associated with HCV or hepatitis B virus coinfection, and development of skin rashes in antiretroviral-naïve HIV-positive Taiwanese patients within 4 weeks of initiation of nNRTI-containing regimens.

Pathological fracture of the right distal radius caused by Enterobacter aerogenes osteomyelitis in an adult.

A pathological fracture is a break in a diseased bone caused by weakening of the bone structure by a pathological process with no identifiable trauma. Acute bacterial osteomyelitis that results in pathological fractures in the extremities is rare in adults. To our knowledge, we report the first case of Enterobacter aerogenes osteomyelitis of the right distal radius, complicated with a pathological fracture, in a 79-year-old man with diabetes, which was diagnosed by radiological, microbiological, and histopathological examinations. He recovered well after an 8-week course of antibiotics and surgical debridement. This highlights the fact that radial osteomyelitis should be included in the differential diagnosis when an elderly diabetic patient with no history of trauma presents with pain in the forearm.

Evolution of hepatitis A virus seroprevalence among HIV-positive adults in Taiwan.

Objectives The study aimed to describe the seroprevalence of hepatitis A virus (HAV) in HIV-positive adult patients in Taiwan between 2012 and 2016 and to examine the evolution of HAV seroprevalence between 2004–2007 and 2012–2016. Methods Clinical information and data of anti-HAV antibody results were collected from 2,860 antiretroviral-naïve HIV-positive Taiwanese aged 18 years or older who initiated combination antiretroviral therapy at 11 hospitals around Taiwan between 2012 and 2016 (2012–2016 cohort). A multivariate logistic regression model was applied to identify independent variables associated with HAV seropositivity. Comparisons of HAV seroprevalences and associated clinical characteristics were made between this 2012–2016 cohort and a previous cohort of 1580 HIV-positive patients in 2004–2007 (2004–2007 cohort). Results Of the 2,860 HIV-positive patients between 2012 and 2016, the overall HAV seropositivity rate was 21.2% (605/2860), which was independently associated with an older age (adjusted odds ratio [AOR], per 1-year increase, 1.13; 95% confidence interval [95% CI], 1.11–1.15) and co-infection with hepatitis B virus (AOR 1.44; 95% CI, 1.08–1.93). Residence in southern Taiwan (AOR 0.49; 95% CI, 0.34–0.72) was inversely associated with HAV seropositivity. The overall HAV seroprevalence in the 2012–2016 cohort was significantly lower than that in the 2004–2007 cohort (21.2% vs 60.9%, p<0.01). The decreases of HAV seropositivity rate were observed in nearly every age-matched group, which suggested the cohort effect on HAV seroepidemiology. However, among individuals aged 25 years or younger, the HAV seropositivity rate increased from 3.8% (2/52) in the 2004–2007 cohort to 8.5% (50/587) in the 2012–2016 cohort, with 95.4% (560/587) being MSM in this age group of the latter cohort. Conclusions HAV seroprevalence has decreased with time among HIV-positive adults in Taiwan. The cohort effect has increased the number of young HIV-positive patients that are susceptible to HAV infection in a country without nationwide childhood vaccination program against HAV.

A rare skin presentation of Penicillium marneffei infection in an AIDS patient.

Penicillium marneffei is an opportunistic fungal pathogen in HIV disease. We report the case of a patient with AIDS who presented with general weakness and generalized skin rashes. No specific allergic history or recent medication were reported. The skin lesions disappeared after adequate antifungal therapy. A blood culture obtained from the patient confirmed the presence of P. marneffei, infection which is characterized by cutaneous umbilicated lesions in AIDS patients. We report this case on account of the unusual skin presentation.

Community-onset Bacteremic Urinary Tract Infections Caused by Extended-spectrum Beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae

There is an in increase in community-onset bacteremic urinary tract infections (UTIs) caused by Escherichia coli and Klebsiella pneumoniae. Among these, extended-spectrum beta-lactamase (ESBL)-producing E. coli and K. pneumoniae (ESBL-EK) are the most prevalent in Taiwan. Methods: This study was conducted retrospectively from January 2003-June 2008 and 22 patients were enrolled. Diagnosis was based on the findings of at least one positive blood culture disclosing the same pathogen as urine culture on admission. Results: The proportion of patients with indwelling urinary catheters was 41.0% and the proportion for patients from healthcare facilities was 50%. Mean Acute Physiology and Chronic Health Evaluation Ⅱ scores were 22.1±6.3. The rate of intensive care unit (ICU) admission was 27.3%. The mortality rate was 4.5%. The mean hospital stay was 14.5±7.9 days. Up to 72.7% of 22 patients received inappropriate antibiotic therapy. The mean expenditure on antibiotics was 533.2±370.2 USDs. Conclusions: Among the patients, the proportions of male gender patients, patients with urinary catheter indwelling and residents from healthcare facilities were high. Though the majority of them received inappropriate antibiotic treatment, the mortality rate was low.