Tasaduq Fazili

Actinomyces meyeri infection: Case report and review of the literature

Actinomyces meyeri is an uncommon cause of actinomycosis. We present a patient with pneumonia and empyema due to A. meyeri. The patient underwent open thoracotomy with decortication and was discharged home on a twelve-month course of oral penicillin. Review of the English literature revealed thirty-two cases of infection due to A. meyeri. The majority of patients were male, and a significant number had poor dental hygiene and a history of alcoholism. More than other Actinomyces species, A. meyeri causes pulmonary infection and has a predilection for dissemination. Prognosis is favorable with prolonged penicillin therapy combined with surgical debridement, if needed.

Klebsiella pneumoniae Liver Abscess: An Emerging Disease☆

ABSTRACT Most of the cases of Klebsiella pneumoniae liver abscess reported early on were from Asia, predominantly Taiwan, with a significant number of patients being middle aged diabetic men, and developing metastatic complications, especially endophthalmitis. The entity is now being increasingly recognized in the United States. In this article, the authors review those reported cases, and also the literature regarding the pathophysiology of this intriguing syndrome.

Role of procalcitonin in guiding antibiotic therapy.

PURPOSE The role of procalcitonin in guiding antibiotic therapy is reviewed. SUMMARY Procalcitonin is a prohormone for calcitonin, which is secreted by the parafollicular cells of the thyroid gland. The biological activity of procalcitonin is significantly different from calcitonin and is believed to be part of the complex inflammatory cascade of the immune system. Procalcitonin has been shown to be elevated in bacterial infections but not in viral infections or other inflammatory conditions. The first published study that suggested that procalcitonin levels increased in the presence of bacterial infection was conducted in France in the early 1990s. Numerous studies have been conducted using procalcitonin-guided therapy to reduce antibiotic use. These studies were performed in one of three clinical settings: outpatient primary care (two multicenter, noninferiority studies of patients with upper- and lower-respiratory-tract infections), emergency room and inpatient (five studies in patients with chronic obstructive pulmonary disease, exacerbation, bronchitis, or community-acquired pneumonia), and the intensive care unit (ICU) (two studies in medical ICU patients and two in postoperative ICU patients with infection or sepsis). Based on the findings of these studies, a cutoff value of 0.25 μg/L in non-ICU patients or of 0.5 μg/L in ICU patients seems appropriate for making a decision about the initiation and discontinuation of antibiotic therapy. In patients with a significantly elevated baseline procalcitonin level, a subsequent drop of >80% appears to be reasonable for discontinuing antibiotics. CONCLUSION Published evidence supports the use of procalcitonin as a biomarker of bacterial infection that can be used to reduce antibiotic exposure.

An 86-year-old man with septic arthritis of the knee

Department of Medicine/Infectious Disease, State University of New York Upstate University, Syracuse, New York, USA Correspondence: Dr Tasaduq Fazili, Department of Medicine/Infectious Disease, State University of New York Upstate Medical University, 725 Irving Avenue, Syracuse, New York 13104, USA. Telephone 315-464-9360, fax 315-464-9361, e-mail fazilit@upstate.edu Case presentation An 86-year-old man with a medical history significant for an aortic valve replacement and pacemaker insertion >20 years previously developed a stress fracture of the left leg, which was placed in an immobilizer cast. One week later, he developed progressive left knee swelling and was admitted to the hospital. A physical examination was significant only for a grade 2 (of 6) systolic murmur over the aortic area, and mild swelling and tenderness of the left knee. The surrounding skin was not erythematous. He exhibited leukocytosis with a white blood cell count of 15.1×109/L. An aspirate of joint fluid from the left knee revealed a white blood cell count of 12.9×109/L with 82% neutrophils. A Gram-stained smear of the joint fluid revealed many white blood cells with no bacteria. Culture of this aspirate for bacteria and fungi was negative. A bone scan showed increasing uptake in the left tibia, suggestive of osteomyelitis. The patient was discharged on four weeks of ceftriaxone (2 g intravenously once per day) for presumed bacterial septic arthritis/osteomyelitis. He presented three weeks later with increasing left knee pain and swelling. A joint washout of the knee and surgical debridement of the proximal tibia was performed. A Gram stain (Figure 1) and modified acid-fast stain (Figure 2) of the joint fluid are shown.

Cardiobacterium Hominis Endocarditis of Bioprosthetic Pulmonic Valve:Case Report and Review of Literature

Cardiobacterium hominis is a gram-negative rod and is an uncommon cause of infective endocarditis. Here we report the first published case description of C. hominis endocarditis of the pulmonic valve homograft in a patient who had previously undergone the Ross procedure.

Pott's Disease Caused by Mycobacterium bovis Following Intravesical BCG Therapy for Bladder Cancer

Abstract Background Bacillus Calmette-Guerin (BCG) are attenuated strains of Mycobacterium bovis, which is part of the Mycobacterium tuberculosis complex. BCG is used for bladder cancer therapy. Case/Methods 80 year old man presented with severe back pain, paraplegia, urine retention. Past history included rheumatoid arthritis, bladder cancer. He was diagnosed with recurrent bladder cancer (T1, high grade lamina propria superficial invasion) in June 2016 (previously diagnosed 14 years ago, treated with BCG). Patient had transurethral resection of tumor in August 2016, after which he got 6 weekly cycles of intravesical BCG. He underwent cystoscopies with no evidence of residual disease. No history of concurrent illness during therapy. He was initially admitted 1 month ago with back pain: MRI showed thoracic (T6-T7) epidural abscess, vertebral osteomyelitis/diskitis; he underwent T6-T7 hemilaminectomies, drainage of abscess, cord decompression. Operative cultures were initially negative. He was discharged with empiric broad spectrum antibiotics. Repeat MRI during this admission showed extensive inflammation at T6-T7: diskitis, osteomyelitis, epidural abscess, more non enhancing material in the disc space, progressive edema in pedicles and lamina, worse cord compression. Neurosurgery evaluated patient: deemed to be poor surgical candidate given his extensive comorbidities, advanced age. His operative AFB cultures turned positive 4 weeks after surgery (MTB complex by DNA probe). Therapy started with Isoniazid, Rifampin, Ethambutol, Pyridoxine, Dexamethasone. The isolate was sent to state lab: whole genome sequencing showed M. bovis BCG strain. Susceptibility testing is pending. Discussion/Results BCG therapy of superficial bladder cancer is a recommended treatment modality. Early infectious complications occur within 3 months, late infections after 1 year. In >2000 patients treated with BCG, infectious complications occurred in <5%. Potts disease following BCG therapy is rare but has been described; the time of onset can be from 14 days to 12 years after therapy. Conclusion In patients treated with BCG for bladder cancer, clinicians must have a high index of suspicion for infectious complications, as early initiation of therapy yields better outcomes. Disclosures All authors: No reported disclosures.

Mycobacterium goodii Related Breast Implant Infection: First Case and Literature Review

A 46-year-old Caucasian female was diagnosed with invasive lobular carcinoma of the left breast. She underwent mastectomy and placement of a silicone breast implant as a single-stage procedure. Two weeks after surgery, she developed erythema and drainage to the postoperative site, necessitating removal of the breast implant. Operative cultures grew Mycobacterium goodii. She was successfully treated with a three month course of moxifloxacin and doxycyline. M. goodii should be in the differential of postoperative wound infections, including breast implants. Correspondence to: Aakriti Pandita, SUNY Upstate Medical University, Internal Medicine, 750 E Adams st, Syracuse, NY 13202, USA, Tel: 646 634 1562; E-mail: pandita.aakriti@gmail.com

A 45-Year-Old Man with Cough and a Cavitary Lung Lesion

45-year-old man with no significant medical history was admitted to hospital with a four-month history of intermittent fever and a predominantly dry cough. Approximately one month before admission, he started developing worsening cough with scant expectoration and pleuritic left-sided chest pain. His symptoms persisted and he presented for admission. On examination, the patient appeared chronically ill and nontoxic. His vital signs were stable except for mild tachycardia, with a heart rate in the low one hundreds. Examination of the mouth revealed him to be partially edentulous with poor orodental hygiene, although there was no evidence of dental abscesses. A chest examination revealed diminished breath sounds to the left infraaxillary area. His laboratory results were significant for mild leukocytosis (white blood cell count 13×10 9 /L) and mild anemia (hemoglobin level 90 g/L). Kidney and liver function tests were within normal limits. A chest radiograph showed a left perihilar infiltrate. An axial computed tomography (CT) scan of the chest showed a patchy infiltrate to the posterior upper lung with a central air cavity measuring 2.9 cm × 0.7 cm and a small left-sided pleural effusion (Figure 1). The patient was placed on moxifloxacin and clindamycin and a procedure was performed. What is your diagnosis? Diagnosis The patient did not improve clinically after 10 days of antibiotic therapy and was taken to the operating room for an open left thoracotomy with decortication and drainage of the empyema. The Gram stain of the pleural fluid culture showed branching, Gram-positive rods (Figure 2) and cultures yielded Actinomyces meyeri. The patient’s antibiotic regimen was switched to intravenous penicillin, three million units every 4 h. He was treated with intravenous penicillin for a twoweek course in the hospital and was discharged home to complete a 12-month course of oral penicillin, 500 mg every 6 h. Discussion