Disseminated Tuberculosis With an Atypical Cutaneous Manifestation in a Hematopoietic Cell Transplant Patient in the Early Posttransplant Period: Case Report and Review of the Literature.

We describe an unusual case of posttransplant tuberculosis reactivation in a man who underwent allogeneic hematopoietic cell transplant. Concomitant with disseminated adenovirus infection, reactivation of tuberculosis manifested as disseminated, nonfollicular pustules on day +49. Skin biopsy was obtained on day +50. Initial histopathologic evaluation did not suggest mycobacterial infection, but tissue stain showed acid-fast organisms, which were subsequently identified as Mycobacterium tuberculosis. Shortly after the cutaneous presentation of tuberculosis, the patient died on day +52. Our case is among a paucity of reports describing tuberculosis reactivation in hematopoietic cell transplant patients in the early posttransplant period. It highlights the difficulty of diagnosing contemporaneous systemic infections, and it presents a rare and atypical cutaneous manifestation of tuberculosis in a hematopoietic cell transplant patient. Our case and review of the literature emphasize the need for further research to elucidate risk factors associated with early posttransplant reactivation of tuberculosis, and the importance of remaining vigilant for active tuberculosis in hematopoietic cell transplant patients with epidemiologic risk factors.

Diagnostic and therapeutic challenges of treating opportunistic fungal cellulitis: a case series.

BACKGROUND: Cellulitis is an infection most commonly caused by bacteria and successfully treated with antibiotics. However, certain patient populations, especially the immunocompromised, are at risk for fungal cellulitis, which can be misidentified as bacterial cellulitis and contribute to significant morbidity and mortality. CASE PRESENTATIONS: We describe three cases of opportunistic fungal cellulitis in immunosuppressed patients that were initially mistaken for bacterial infections refractory to antibiotic therapy. However, atypical features of cellulitis ultimately prompted further diagnostics to identify fungal cellulitis and allow initiation of appropriate antifungals. We discuss: (1) a 52-year-old male immunosuppressed hematopoietic cell transplant recipient with Fusarium solani cellulitis on his right lower extremity that was treated with amphotericin B and voriconazole with full resolution of the cellulitis; (2) a 70-year-old male lung transplant recipient with Fusarium solani cellulitis on his left lower extremity that ultimately progressed despite antifungals; and (3) a 68-year-old male with a history of kidney transplantation with suspected Purpureocillium lilacinum cellulitis on his left lower extremity ultimately treated with posaconazole with resolution of the skin lesions. CONCLUSIONS: Fusarium solani and Purpureocillium lilacinum are important pathogens causing opportunistic fungal cellulitis. These cases remind providers to be vigilant for fungal cellulitis when skin and soft tissue infection does not adequately respond to antibiotics and atypical features of cellulitis are present.

Skull base osteomyelitis in patients with head and neck cancer: Diagnosis, management, and outcomes in a case series of 23 patients.

BACKGROUND: Skull base osteomyelitis (SBO) is an infection of the central cranial bones, most commonly resulting from contiguous spread of infection from adjacent head and neck structures. SBO is a well-recognized complication of treatment of head and neck cancer (HNC) that results in significant morbidity. METHODS: We conducted a retrospective chart review of HNC patients diagnosed with SBO. RESULTS: SBO was commonly diagnosed with nasal endoscopy showing mucosal breakdown between the naso/oropharynx and skull base and with characteristic changes on CT/MRI. Culture data were often polymicrobial, inclusive of naso/oropharyngeal flora, but half of the patients additionally had antibiotic-resistant or atypical pathogens. The mean duration of antimicrobial therapy was 117 +/- 94 days. Recurrent SBO was found in half of the patients, associated with Pseudomonas aeruginosa and with persistent defects in the mucosa abutting the skull base. CONCLUSIONS: Diagnosis and management of SBO in HNC patients are challenging. Recommendations to aid in clinical care are proposed. LEVEL OF EVIDENCE: 4, case series.

Multilocular Thymic Cyst in a Patient with Untreated HIV/AIDS: Case Report and Review of the Literature.

BACKGROUND: Multilocular thymic cysts (MTCs) in adults with human immunodeficiency virus (HIV) are rarely reported. CASE PRESENTATION: We describe a case of symptomatic MTC in a male with untreated HIV. A presumptive diagnosis was established based on radiographic imaging and biopsy. Pathologic diagnosis and exclusion of malignancy were ultimately confirmed following thymectomy. In conjunction with starting antiretroviral therapy, the patient recovered well post-operatively with a resolution of his presenting symptoms. CONCLUSION: Our case report and review of the literature serve to highlight MTCs as an important clinical entity occurring in persons with HIV.

Reactivation of Chagas Disease in a Patient With an Autoimmune Rheumatic Disease: Case Report and Review of the Literature.

Reactivation of Chagas disease has been described in immunosuppressed patients, but there is a paucity of literature describing reactivation in patients on immunosuppressive therapies for the treatment of autoimmune rheumatic diseases. We describe a case of Chagas disease reactivation in a woman taking azathioprine and prednisone for limited cutaneous systemic sclerosis (lcSSc). Reactivation manifested as indurated and erythematous cutaneous nodules. Sequencing of a skin biopsy specimen confirmed the diagnosis of Chagas disease. She was treated with benznidazole with clinical improvement in the cutaneous lesions. However, her clinical course was complicated and included disseminated CMV disease and subsequent septic shock due to bacteremia. Our case and review of the literature highlight that screening for Chagas disease should be strongly considered for patients who will undergo immunosuppression for treatment of autoimmune disease if epidemiologically indicated.

Concurrent Trypanosoma cruzi and Cytomegalovirus Reactivation in an Immunosuppressed Patient With Limited Cutaneous Systemic Sclerosis.

Chagas disease, a multisystem infection caused by the protozoan Trypanosoma cruzi, is primarily found in Latin America. In recent years, prevalence has increased in the United States, where reactivation is the most common clinical scenario. Here, we describe cutaneous reactivation of T. cruzi in a patient with limited cutaneous systemic sclerosis on immunosuppression therapy who simultaneously presented with cytomegalovirus reactivation. Histopathology showed parasitized histiocytes in the superficial and deep dermis. Occasional epidermal keratinocytes were also parasitized, and rare organisms were also seen in the walls of blood vessels. Also noted were viral cytopathic changes within the vascular endothelium, and immunostaining confirmed cytomegalovirus. In this report, we describe the difference in cutaneous findings between reactivated and acute Chagas disease, and we also review the histopathologic features that help distinguish T.cruzi from other intracellular organisms.

Estradiol regulates large dense core vesicles in the hippocampus of adult female rats.

Previous work has shown that the steroid hormone estradiol facilitates the release of anticonvulsant neuropeptides from inhibitory neurons in the hippocampus to suppress seizures. Because neuropeptides are packaged in large dense core vesicles, estradiol may facilitate neuropeptide release through regulation of dense core vesicles. In the current study, we used serial section electron microscopy in the hippocampal CA1 region of adult female rats to test three hypotheses about estradiol regulation of dense core vesicles: (1) Estradiol increases the number of dense core vesicles in axonal boutons, (2) Estradiol increases the size of dense core vesicles in axonal boutons, (3) Estradiol shifts the location of dense core vesicles toward the periphery of axonal boutons, potentially lowering the threshold for neuropeptide release during seizures. We found that estradiol increases the number and size of dense core vesicles in inhibitory axonal boutons, consistent with increased neuropeptide content, but does not shift the location of dense core vesicles closer to the bouton periphery. These effects were specific to large dense core vesicles (>80 nm) in inhibitory boutons. Estradiol had no effects on small dense core vesicles or dense core vesicles in excitatory boutons. Our results indicate that estradiol suppresses seizures at least in part by increasing the potentially releasable pool of neuropeptides in the hippocampus, and that estradiol facilitation of neuropeptide release involves a mechanism other than mobilization of dense core vesicles toward sites of release.