Tai Chin Hsieh

Caspofungin salvage therapy in Pneumocystis jirovecii pneumonia

Pneumocystis jirovecii pneumonia (PJP) is a severe complication and leading cause of death among human immunodeficiency virus (HIV)-infected patients. Although trimethoprim/sulfamethoxazole (TMP/SMZ) is well known for its effectiveness as empiric and target therapy, it is also associated with various side effects (including skin rash, leukopenia, hepatitis, and diarrhea). The clinical evidence of the synergistic activity of caspofungin to TMP/SMZ or salvage treatment of PJP remains controversial to date. Here, we report an HIV-infected patient complicated with PJP who had skin rash and leukopenia after TMP/SMZ treatment for 6 days. Consequently, the treatment regimen was replaced with caspofungin. The patient was discharged from the hospital in good condition after 14 days of caspofungin salvage therapy. A 46-year-old male patient was admitted to the hospital for high fever and dyspnea, representing a fresh case of HIV infection with very low CD4 count (36/mL). His chest radiograph showed bilateral interstitial infiltration of lung fields (Figure 1A), and the computed tomography scan revealed bilateral diffuse ground-glass infiltrates (Figure 1B). A bronchoalveolar lavage specimen analyzed by Gomori methenamine silver staining revealed a cluster of P. jirovecii cysts. The patient was initially administered with TMP/SMZ (160/800 mg, q6h) intravenously. He received oral prednisolone (30 mg daily) as adjunctive therapy for PJP. The patient’s white blood cell count decreased from 5700/ mL to 3200/mL, and skin rash developed on the 7 admission day. The TMP/SMZ treatment was discontinued, and caspofungin was administered at a loading dose of 70 mg intravenously and a maintenance dosage of 50 mg daily. The patient received caspofungin therapy for a total of 14 days, and the subsequent chest X-ray (Figure 1C) demonstrated a significant improvement. The patient received HAART (highly active antiretrovirus therapy) regimen with combivir (lamivudine/zidovudine) þ stocrit (efavirenz) at the time of caspofungin therapy. His CD4 count recovered

Breakthrough disseminated cryptococcosis during micafungin therapy

Echinocandins are not active against basidiomycetous yeasts, such as Cryptococcus neoformans, Trichosporon, and Rhodotorula species, and zygomycosis. We present a patient with renal failure and candidemia, who developed a breakthrough fungal infection with cryptococcemia and cryptococcuria while receiving micafungin therapy.

Role of vancomycin in the treatment of bacteraemia and meningitis caused by Elizabethkingia meningoseptica

Elizabethkingia meningoseptica, a Gram-negative pathogen once deemed clinically insignificant, tends to cause infections among low-birth-weight infants and immunocompromised patients. Previously, vancomycin was reported to cure several patients with bacteraemia caused by E. meningoseptica. Nevertheless, some laboratory investigations also showed considerable discordance between in vitro vancomycin susceptibility results obtained by the disk diffusion and broth microdilution methods against clinical E. meningoseptica isolates as determined using the criteria for staphylococci recommended by the Clinical and Laboratory Standards Institute (CLSI). In this review, the PubMed database (1960-2017) was searched for studies that reported mainly cases with E. meningoseptica bacteraemia or meningitis treated with vancomycin alone or with regimens that included vancomycin. In addition, the in vitro synergy between vancomycin and other agents against isolates of E. meningoseptica was reviewed. Elizabethkingia meningoseptica bacteraemia appears not to universally respond to intravenous (i.v.) vancomycin-only therapy, especially in patients who require haemodialysis. If i.v. vancomycin is the favoured therapy against E. meningoseptica meningitis, the addition of ciprofloxacin, linezolid or rifampicin might be an option to effectively treat this difficult-to-treat infection. Further clinical studies are needed to determine the clinical efficacy of these combination regimens for the treatment of E. meningoseptica meningitis.

Starch dust explosion and flame burn injury in a patient complicated with severe cellulites caused by non-O1 Vibrio cholerae

Invasive nonepidemic Vibrio cholerae (NEVC) infections after burns injury are rare. We read with great interest the article in the Journal of Microbiology, Immunology and Infection by Chen et al, reporting that a neutropenic immunocompromised patient who denied a history of participating in water activities and suffered from urinary tract infection caused by V. cholerae nonserogroup O1. Here, we report a burn injury patient participating color party in a dried swimming pool (fresh water) in June 2015. Unfortunately he suffered from starch dust explosion and a burn wound of left upper arm infected with V. cholerae Non O1 (Figure 1). The severe cellulites caused by this unusual pathogen were successfully treated with ciprofloxacin therapy. On the night of June 28, 2015, a tragic fire accident occurred in Formosa Water Park situated near Tan-Shui River and the coastal areas in the northern Taiwan. More than 500 young people were injured with various degrees of thermal burn in the starch dust explosion. A 19-year-old male patient was admitted to Taipei municipal Wan-Fang Hospital for second to third degree burns of the extremities involving 30% of the total body surface area. The patient was admitted to the burn unit immediately and managed under stringent infection control measures. Empirical antibiotic therapy with cefazolin 1 g intravenously (IV) q. 6 hours and gentamicin 80 mg IV q. 8 hours was administered. On the 4 admission day, the skin and soft tissue revealed swelling, redness, discoloration, and pus collection on the left arm (Figure 1). The patient received surgical debridement and culture work up. Pus and tissue culture of the burn wound both isolated V. cholera non-O1 by laboratory tests. Antibiotic testing of the isolate showed that it was susceptible to ampicillin, chloramphenicol, sulfamethoxazole/trimethoprim, and ciprofloxacin, but resistant to cefazolin and gentamicin. Because the patient

Vertebral tuberculosis complicated with retropharyngeal, parathoracic, and huge iliopsoas abscess, successfully treated with image-guided percutaneous drainage

Tuberculous retropharyngeal, parathoracic, and iliopsoas abscess is a rare entity, and was regarded as secondary to vertebral tuberculosis. Because of its deep location and insidious course, it has always been a diagnostic and therapeutic challenge. We report a case of vertebral tuberculosis complicated with multiple para-spinal deep abscesses. The magnetic resonance imaging (MRI) and computed tomography (CT) scans confirmed the image diagnosis (Figures 1A and 1B), and microbiologic culture of the abscess grew Mycobacterium tuberculosis. After receiving antituberculosis medicine and CT-guided percutaneous drainage, the patient’s condition improved. The antituberculosis drugs in conjunction with percutaneous drainage under image guidance are an effective therapy in such a patient. A37-year-oldmanpresented toourhospitalwitha1-month history ofmiddle back pain, dysphagia, and a low-grade fever. The patient had a history of psoriasis vulgaris without medication. He did not have a history of diabetes mellitus, malignancy, or did not take any other immunosuppressive agents. His wife, of Vietnamese descent, had a history of pulmonary tuberculosis 4 years prior, and she had received a total of 6 months of antituberculosis treatment. His initial laboratory evaluation showed leukocytosis (white blood cell count of 10,720 cells/mm) with predominant neutrophils (81.6%) and elevated levels of C-reactive protein (12.44 mg/dL). Chest radiograph revealed a barely-visible bilateral paraspinal soft-tissue component along the spine column. Plain abdomen X-ray showed obliteration of the right psoas shadow. Ultrasonography disclosed an homogenous bulky fluid collection measuring 10 8.5 cm in the right psoas muscle. CT scan showed a huge abscess measuring 8.5 9.2 20 cm in the right psoas muscle and 4.0 2.9 5.4 cm in the left psoas muscle (Figure 1B). Subsequently, MRI analysis confirmed multiple vertebral

Co-occurrence of Leriche syndrome and antiphospholipid syndrome in a man with refractory ulcers of the lower limbs

Leriche syndrome is a rare variant of atherosclerotic occlusive disease characterized by total occlusion of abdominal aorta and/or common iliac arteries. The antiphospholipid syndrome is a prothrombotic disorder that can affect both venous and arterial thrombosis. Co-occurrence of antiphospholipid syndrome and Leriche syndrome is extremely rare. Here, we report a male patient with refractory ulcers of the right foot; he received antibiotic therapy and surgical debridement during hospitalization, however, the ulcer wound did not heal well. The results of image study and laboratory data finally proved the above syndromes. A 52-year-old male patient complained of chronic ulcer wound of the right foot without any trauma history. He also had claudication of the legs, body weight loss with a body mass index of 17.6 kg/m, and erectile dysfunction for many years. The physical examination revealed that his bilateral femoral pulses were absent. The extremities showed bilateral lower legs muscle atrophy, and an ulcer wound with peripheral tissue gangrene on the right foot and barely palpable pulses of bilateral dorsalis pedis arteries. He received empiric antibiotic therapy with oxacillin 2 g intravenous drip q. 6 hours and gentamicin 80 mg intravenous drip q. 12 hours for 7 days, and received local surgical debridement. The aerobic and anaerobic culture all revealed negative finding, however, the ulcer wound still did not heal. Computed tomography and angiography showed total occlusion of infrarenal abdominal aorta (Figure 1), and bilateral common iliac arteries with subsequent collateral circulation. Many small collaterals vessels were reconstituted in the bilateral lower extremities. Antiphospholipid antibodies detected by enzyme-linked immunosorbent assay showed 640 RU/mL (positive), and the anticardiolipin immunoglobulin G detected by lupus

A cluster of Streptococcus suis meningitis in a family who traveled to Taiwan from Southern Vietnam

Streptococcus suis is an emerging zoonotic pathogen, and infection is easily misidentified. The first human case in Taiwan was reported in a swine farmer in 1994. Hsueh et al reported six isolates of Streptococcus acidominimus using commercial identification systems but later identified them as S. suis using 16S rRNA gene sequencing analysis. We also identified S. suis meningitis (initially misdiagnosed as S. acidominimus infection) in two members of a family who traveled from Southern Vietnam to Taiwan. An 80-year-old woman who had hypothyroidism treated regularly with thyroxin presented to our emergency