Norman Beatty

Kissing Bug (Triatoma spp.) Intrusion into Homes: Troublesome Bites and Domiciliation

Kissing bugs (Triatoma spp.) frequently enter homes and bite human and pet occupants. Bites may lead to severe allergic reactions and, in some cases, death. Kissing bugs are also vectors of Trypanosoma cruzi, the cause of Chagas disease. In general, modern houses in the United States are not conducive to domiciliation of kissing bugs (bugs living out their entire life within the home with the presence of eggs, nymphs, adults, and exuviae). Construction features such as concrete foundations, solid walls and ceilings, window screens, tight thresholds for doors and windows, and other measures impede bug entry into homes, and air conditioning reduces the need for open doors and windows. Where Chagas disease is endemic in Mexico and Central and South America, homes often have thatch roofs, adobe walls, and open doors and windows. We investigated numerous instances of kissing bug intrusions into homes in Southern Arizona, California, and Louisiana and documented the reactions to kissing bug bites. Our work confirms the importance of modern home construction in limiting kissing bug intrusions. Older homes, especially those lacking modern screening, caulking, and weather stripping to reduce air leakage, may be subject to kissing bug intrusions and domiciliation. We describe a community in Southern Arizona where domiciliation of homes by Triatoma recurva is common. We also provide recent data regarding kissing bug bites and allergic reactions to the bites.

A rare case of Mycobacterium abscessus subspecies abscessus prosthetic valve endocarditis and the clinical importance of inducible erm(41) gene testing

A 56-year-old man with a history of injection drug use and two prior episodes of native valve infective endocarditis presented with dyspnoea on exertion. Our preliminary work-up revealed bacteraemia with reported growth of ‘Mycobacterium abscessus group’ on multiple blood cultures. The patient was later found to have eustachian valve and prosthetic pulmonic valve endocarditis. Initially, he responded to standard antimycobacterial therapy for rapidly growing mycobacteria (RGM) with supporting laboratory susceptibilities. However, he later developed refractory disease and persistent bacteraemia in the setting of these alleged susceptible antibiotics. Further molecular testing revealed a functional and inducible erm(41) gene which confers macrolide resistance. A subspecies analysis of the M abscessus group revealed the subspecies to be abscessus. We present a challenging case of M abscessus subsp. abscessus bacteraemia and prosthetic valve endocarditis with further discussion on treatment and management of this infection along with the taxonomic complexity of this ubiquitous RGM.

Skin Manifestations of Primary Vibrio vulnificus Septicemia

A 55-year-old man from the southwest United States (Tucson, AZ) presented with altered sensorium. He has a history of alcohol-induced liver cirrhosis. Family members reported thepatient had complainedof abdominal discomfort, watery nonbloody diarrhea, malaise, and leg discoloration earlier that day. He had not traveled outside of the United States for more than 20 years. Vitals were significant for hypotension, tachycardia, tachypnea, and hypothermia (35.4 C). Pertinent physical examination findings revealed scleral icterus, abdominal distension, and cutaneous ecchymosiswith scatteredhemorrhagic appearingbullae locatedonboth lower extremities (Figure 1A and 1B). Laboratory investigations uncovered a white blood cell count 1.2 × 10 cells/mL, platelet count 31×10 cells/mL, international normalized ratio 2.1, total bilirubin 5.1 mg/dL, serum bicarbonate 7 mMol/L, blood urea nitrogen 66 mg/dL, creatinine 6.6 mg/dL, and lactic acid 13.0 mMol/L. The Gram stain of the bullae aspirate (Figure 1C) and blood (Figure 1D) revealedGram-negative bacilli with a curved appearance. Growth from all sampled sources identified the culprit microorganism as Vibrio vulnificus. Despite aggressive supportive care in the medical intensive care unit and broadspectrum antibiotics, the patient unfortunately died from multiorgan failure. Vibrio vulnificus is a Gram-negative halophilic bacilli endemic to coastal regions of warm temperate climates. Gram staining will often reveal a short, slim, and curved Gramnegative bacillus under light microscopy. Vibrio vulnificus is a potentially lethal pathogen and the leading cause of seafoodrelated death in the United States. High rates of infection are reported in Taiwan, South Korea, Japan, andGulf ofMexico of the United States. Exposure to V. vulnificus occurs either through direct contact with a contaminated water source or seafood (handling or ingestion) which can lead to gastroenteritis, skin and soft tissue infection (often necrotizing), or septicemia. Our patient was lacking any contact with a salt FIGURE 1. (A) Cutaneous bullae with hemorrhagic appearing fluid of bilateral lower extremities. (B) Cutaneous ecchymosis appearing prior to developing bullae

Polymicrobial Pituitary Abscess Predominately Involving Escherichia coli in the Setting of an Apoplectic Pituitary Prolactinoma

Pituitary abscess is a rare intracranial infection that can be life-threatening if not appropriately diagnosed and treated upon presentation. The most common presenting symptoms include headache, anterior pituitary hypofunction, and visual field disturbances. Brain imaging with either computed tomography or magnetic resonance imaging usually reveals intra- or suprasellar lesion(s). Diagnosis is typically confirmed intra- or postoperatively when pathological analysis is done. Clinicians should immediately start empiric antibiotics and request a neurosurgical consult when pituitary abscess is suspected. Escherichia coli (E. coli) causing intracranial infections are not well understood and are uncommon in adults. We present an interesting case of an immunocompetent male with a history of hypogonadism presenting with worsening headache and acute right eye vision loss. He was found to have a polymicrobial pituitary abscess predominantly involving E.   coli in addition to Actinomyces odontolyticus and Prevotella melaninogenica in the setting of an apoplectic pituitary prolactinoma. The definitive etiology of this infection was not determined but an odontogenic process was suspected. A chronic third molar eruption and impaction in close proximity to the pituitary gland likely led to contiguous spread of opportunistic oral microorganisms allowing for a polymicrobial pituitary abscess formation.

A 20-year experience with nocardiosis in solid organ transplant (SOT) recipients in the Southwestern United States: A single-center study

Nocardiosis is a life‐threatening opportunistic infection. Solid organ transplant (SOT) recipients are at higher risk (incidence 0.04%‐3.5%) of developing nocardiosis. Rate of nocardiosis in the Southwestern US may be high due to environmental factors.

Significance of bacteriuria in patients with end-stage renal disease on hemodialysis

The significance of bacteriuria in patients with end-stage renal disease (ESRD) on hemodialysis (HD) is unclear. It is not known whether treatment of asymptomatic bacteriuria is associated with lower rates of urinary tract infection or readmission. Adult patients with ESRD on HD were retrospectively evaluated to assess factors associated with the recurrence of bacteriuria and readmission. We included 68 patients in the analysis. There were 20 patients (29.4%) with urinary symptoms. All symptomatic patients received antibiotic therapy, whereas half of the asymptomatic patients received antibiotics. Antibiotic use was not associated with lower rates of readmission or the recurrence of bacteriuria.

Evidence of Likely Autochthonous Transmission of Chagas Disease in Arizona

A healthy 16-year-old girl born and raised in Tucson, AZ, had screening and confirmatory testing revealing Chagas disease; clinical evaluation established that she had the indeterminate form of chronic Chagas disease with evidence of likely autochthonous transmission. Trypanosoma cruzi DNA was detected by conventional polymerase chain reaction in Triatoma rubida captured at her home.

Influenza vaccine availability at urgent care centers in the state of Arizona

HIGHLIGHTSUrgent care centers are an emerging source of ambulatory healthcare in the United States.Influenza vaccination is not routinely available at these facilities in Arizona.This is the first study to investigate influenza vaccination at urgent care centers. &NA; We surveyed urgent care centers (UCCs) in the state of Arizona to determine whether they offered the influenza vaccine during the 2016–2017 influenza season. Overall vaccine availability was 80.3% at these facilities. During this season, one‐third of the UCCs offered influenza vaccination to children 6 months or older; approximately two‐thirds offered influenza vaccination to children and young adults 16 years or older. This is the first study of influenza vaccine availability at UCCs.

Appropriateness of a Rapid Multiplex Gastrointestinal Panel in the Investigation of Suspected Infectious Diarrhea After Implementation at an Academic Medical Center

Abstract Background The BioFire FilmArray™ Gastrointestinal (GI) Panel is a 1 hour multiplex real-time PCR test that can detect the presence of 22 GI pathogens (viral, bacterial, and parasitic) known to cause infectious diarrhea. Our tertiary-care academic medical center implemented the GI Panel for all cases of suspected infectious diarrhea replacing the previous conventional testing once utilized to detect GI pathogens. Since its implementation we have not had any criteria for ordering this test to aid healthcare providers. Methods The aim of this IRB approved, retrospective investigation was to determine the appropriateness of ordering the GI panel at our academic institution. Cases were randomly selected, stratified by age group and result (specific pathogens or negative result) from May 2015 through April 2016 in the post-implementation period (n = 400 of 1117 total tests). We developed appropriateness criteria for ordering the GI panel which included: passage of at least 3 unformed stools in 24 hours plus one or more enteric symptom (nausea, vomiting, abdominal pain/cramps, tenesmus, fecal urgency, moderate to severe flatulence), and one of the following: grossly bloody diarrhea (dysenteric), persistent diarrhea (14 – 30 days), worsening or relapsing diarrhea, fever ≥ 101 F°, severe diarrhea > 10 bouts in 24hrs, immunosuppression, pregnancy, food handler, infant < 1 year and their care takers, age ≥ 65 years old, concern for disseminated GI infection, with no previous GI panel testing in the past 30 days. Results Overall appropriateness of GI panel testing based off our generated criteria was 36% (n = 144/400). This included all tests ordered in the outpatient clinics, emergency department, inpatient medical/surgical wards, and intensive care units. Conclusion Currently there is not a well-established standard criteria for ordering the GI panel for investigating suspected infectious diarrhea. After implementation at our academic tertiary-care medical center the GI panel was used inappropriately in most cases without a criteria for ordering in place to aid clinicians. Educating healthcare providers about appropriate testing indications is being performed. Further studies are needed to assess if our generated criteria will lead to decreased costs and unnecessary testing. Disclosures All authors: No reported disclosures.

Hematophagous Ectoparasites of Cliff Swallows Invade a Hospital and Feed on Humans

We describe a hospital infestation by 2 hematophagous ectoparasites of cliff swallows that nested in the window eaves. Breaks in window seals allowed entry of swallow ticks and swallow bugs. These pests emerged in large numbers in patient rooms, hallways, and stairwells; 17% of the ticks fed on humans.