Challenges in Managing Treatment-Resistant Mpox Complicated by Severe Superinfection.

Though typically self-limiting, severe mpox infections have been treated with antiviral medications, most notably tecovirimat. Various reports exist of mpox progression despite tecovirimat treatment. Treatment resistance can be due to acquired mpox strain mutations, most often occurring in an immunocompromised host. We present the case of a male with AIDS who developed disseminated treatment-resistant mpox infection complicated by superimposed bacterial and fungal infections. His orthopoxvirus polymerase chain reaction result remained positive despite treatment with 4 weeks of oral tecovirimat and 3 doses of intravenous cidofovir. Poor response to antiviral therapy was likely due to his underlying immunocompromised state; however, strain resistance cannot be ruled out given that the patient had started but not completed a 14-day course of tecovirimat 8 months prior, at the time of initial mpox diagnosis. Patients with mpox who are immunocompromised may require extended and additional treatment beyond the standard 14 days of tecovirimat, such as cidofovir, brincidofovir, or intravenous vaccina immune globulin.

Identification and infection control response to Candida auris at an academic level I trauma center.

Candida auris, an emerging fungal pathogen with significant morbidity and mortality, can be difficult for health care facilities to identify, isolate, and control. We present our identification and infection control response to Candida auris at a 695-bed academic level I trauma center in Florida.

Balamuthia mandrillaris Encephalitis Presenting as a Symptomatic Focal Hypodensity in an Immunocompromised Patient.

We present the case of a 61-year-old woman with a history of orthotopic heart transplant who was hospitalized with new-onset headache. Magnetic resonance imaging (MRI) of the brain revealed T2 hyperintense signal involving the left occipital lobe with leptomeningeal enhancement and mild vasogenic edema. Initial neurologic examination was normal; however, after 7 days she developed imbalance, visual disturbances, night sweats, bradyphrenia, alexia without agraphia, and right hemianopsia. Brain MRI showed enlargement of the left occipital mass and worsening edema. Stereotactic needle biopsy showed nondiagnostic necrosis. The patient continued to deteriorate despite dexamethasone. Cerebrospinal fluid (CSF) suggested infection, and cytomegalovirus CSF polymerase chain reaction (PCR) was positive. The patient received vancomycin, imipenem, and ganciclovir. After obtaining a positive serum beta-D-glucan (Fungitell), amphotericin was added. Despite best medical efforts, the patient died. Postmortem broad-range PCR sequencing of the brain tissue was positive for rare amoeba Balamuthia mandrillaris.

The Time for Action Is Now: The Impact of Timing of Infectious Disease Consultation for Staphylococcus aureus Bacteremia.

This retrospective cohort study was performed to compare clinical outcomes between patients with Staphylococcus aureus bacteremia who received an early versus late infectious disease consultation. Early consultation resulted in significantly greater adherence to quality care indicators and shorter hospital stays.

Monkeypox-induced proctitis: a case report of an emerging complication.

PURPOSE: At the outset of the 2022 human monkeypox virus outbreak, the World Health Organization described the self-limited disease as a rash illness associated with nonspecific symptoms such as fever, myalgias, and lymphadenopathy. Historically, the infection caused by this zoonotic virus has presented with rashes primarily on the face, palms, and soles of feet. However, emerging case report literature from the 2022 recent outbreak highlighted more atypical presentations ranging from ocular manifestations to myocarditis. CASE DESCRIPTION: We present a case of a 32-year-old African American male with a past medical history of poorly controlled acquired immunodeficiency syndrome and external hemorrhoids that presented for worsening rectal pain. The patient was afflicted with diffuse skin lesions even present on his hemorrhoids. Initial imaging significant circumferential rectal thickening consistent with proctitis. Subsequent polymerase chain reaction testing confirmed active monkeypox infection, and a 14-day course of twice daily tecovirimat 600 mg was initiated to treat disseminated monkeypox infection. After improved pain control and starting antiviral treatment, the patient was discharged two days later. CONCLUSION: As more cases of monkeypox-associated proctitis emerge, clinicians should keep this disease in their differential due to the growing atypical presentations that have diverged from previous patterns to avoid the risk of misdiagnosing another sexually transmitted infection. Additionally, appropriate medical management is still not definitive and requires further development of evidence-based protocols to treat such patients.

Right hip gonococcal septic arthritis treatment with successful transition to oral fluoroquinolone.

We present a case of gonococcal septic arthritis of the right hip diagnosed via synovial fluid cultures. Antimicrobial susceptibility testing of the synovial fluid demonstrated susceptibility to tetracycline, ciprofloxacin, cefixime and ceftriaxone. Our patient was initially treated with ceftriaxone and was successfully de-escalated to oral levofloxacin to complete the treatment. This case is interesting given the rarity of disseminated gonococcal infections in the 21st century and that most clinical isolates of Neisseria gonorrhoeae are increasingly resistant to fluoroquinolones.

A Case Report of Melioidotic Prostatic Abscess in a Traveler.

A 48-year-old man who had returned from Panama 5 weeks prior presented with fever, dysuria, hematuria, flank pain, and suprapubic pain and was found to have a prostatic abscess. Abscess fluid obtained during transurethral drainage grew Burkholderia pseudomallei. Blood cultures remained negative, and imaging did not show any other visceral abscess. This presentation of primary prostatic melioidosis is extremely rare in this region.

Fungemia due to Aureobasidium pullulans.

Aureobasidium pullulans is a yeast-like dematiaceous fungus ubiquitous in nature. It is a rare cause of skin and soft tissue infection, peritonitis, and catheter-related fungemia in certain human hosts. We report a case of recurrent A. pullulans catheter-related fungemia that was successfully treated with caspofungin, posaconazole, and catheter removal.

An Eye-Opening Presentation of Syphilis.

Syphilis has been called "the great masquerader." In this case report, we present a case of an HIV-negative patient with left eye redness and decreased vision. Syphilitic anterior uveitis as a complication of neurosyphilis was subsequently diagnosed and the patient showed marked improvement with treatment.

Strongyloidiasis Infection As the Cause of Pancreatitis.

Strongyloidiasis is endemic to socioeconomically disadvantaged tropics and subtropics, primarily as an asymptomatic carriage. It is seen in developed nations among the underprivileged. We describe a case of an Asian immigrant with eosinophilia, common bile duct stricture, cholangitis, and pancreatitis with Strongyloides spp. found on duodenal biopsy in the setting of steroid exposure.

Accelerated right heart failure due to lung resection in the setting of chronic respiratory failure.

A 68-year-old woman with a past medical history of chronic obstructive pulmonary disease and squamous cell carcinoma of the lung with recent right upper and middle lobectomy was admitted for dyspnea and volume overload. She was diagnosed with right-sided heart failure (RHF) through clinical, laboratory, and echocardiographic means. In the setting of chronic respiratory failure, the recent right lung lobectomy was deemed to be the inciting factor of the RHF. The mechanism by which RHF occurs in this situation is multifactorial, and it is essential to undergo pre-operative risk stratification and post-operative monitoring to avoid emergent events. .

Bartonella Endocarditis: A Missed Diagnosis in Medical Practice.

Here, we present the case of a 52-year-old patient who presented with fever, chills, and weight loss. Further workup revealed Bartonella endocarditis of the aortic valve. After six weeks of antibiotics, a follow-up transthoracic echocardiogram showed a decrease in the size of vegetation. Serologic testing based on epidemiologic history should be obtained for the workup of blood culture-negative endocarditis.

Miliary Histoplasmosis in a Renal Transplant Patient.

Solid organ transplant (SOT) recipients are at increased risk of opportunistic infections due to significant T-cell immune dysfunction. The incidence of clinical disseminated histoplasmosis is rare, and its variable clinical presentation and response to therapy make it challenging to treat with resultant high mortality. A high index of clinical suspicion is necessary, especially in non-endemic areas. We report our clinical experience treating a 63-year-old renal transplant patient on immunosuppressive therapy with late-onset acute miliary histoplasmosis initiated on liposomal amphotericin B (L-AmB).

Pseudoseptic Arthritis in a Patient With Psoriasis.

A 42-year-old male with a history of untreated psoriasis and a previous episode of presumed left knee septic arthritis developed sudden onset of left knee pain, swelling, and a moderate effusion. The pathogen could not be isolated despite extensive inflammation seen in synovial fluid (SF) and synovial tissue biopsy. Whether this is culture-negative septic arthritis or pseudo-septic arthritis is the enigma, given the limited sensitivity of current available SF microbiologic testing. We present a challenging and stimulating case with no current guidelines for an optimal empiric antibiotic regimen or anti-inflammatory therapy.

Elusive Enterobacter cloacae causing pacemaker endocarditis.

An 80-year-old patient was admitted for fever, chills, and chest wall pain. He had a past medical history significant for heart failure with a cardiac resynchronization therapy pacemaker implantation. Extensive workup revealed Enterobacter cloacae endocarditis of the pacemaker leads and the mitral valve, a rare etiology with an unidentified source in our patient. He was managed with a rather unconventional method which proved to be successful. This case sheds light on non-HACEK (other than Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kingella spp). gram-negative organisms, and particularly E. cloacae, as uncommon causes of endocarditis with elevated mortality, and discusses potential treatment modalities.

A Pseudo-Infarction Pattern in the Setting of Esophageal Malignancy.

A 57-year-old African American male was admitted for workup of unintentional weight loss. He was found to have an esophageal squamous cell carcinoma. Electrocardiogram (ECG) readings demonstrated deep Q waves in leads V1-V2 with T wave flattening, which raised concern for a septal infarct. Myocardial infarction (MI) was subsequently ruled out through clinical, imaging, and laboratory analysis. The ECG findings were deemed as a pseudo-infarct pattern in the setting of squamous cell carcinoma of the esophagus.

Methicillin-resistant Staphylococcus aureus (MRSA) sepsis complicated by warm autoimmune haemolytic anaemia secondary to antimicrobial therapy.

A 61-year-old Caucasian woman presented to the emergency room complaining of left-sided chest pain and altered mentation for 3 days. Her medical history included liver cirrhosis and coronary artery disease. On admission, she was found to have methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. Due to a decline in mental status, a lumbar puncture was performed and cerebrospinal fluid cultures grew MRSA. She was treated initially with vancomycin. Ceftaroline was later added, due to the high burden of disease and difficulty in clearing her infection. After initiation of ceftaroline, bacteraemia cleared and mental status improved, however, she developed haemolytic anaemia. Ceftaroline was stopped and vancomycin continued. Staphylococcal meningitis is a rare occurrence, estimated at a rate of only 1%-10% of all bacterial meningitis cases. Ceftaroline seems to be a suitable option for disseminated MRSA infection, including MRSA meningitis, when the clinical response to vancomycin is inadequate. Further studies are warranted in order to establish adequate dosing while avoiding adverse effects.

Kaposi sarcoma with musculoskeletal manifestations in a well-controlled HIV patient.

We present here a case of relapsed HIV-related Kaposi Sarcoma (KS), manifesting as a plantar ulcer with underlying bone involvement in a patient with well-controlled HIV. Radiographic and magnetic resonance imaging of the patient's right foot showed bone destruction suggestive of osteomyelitis. However, when a bone biopsy was done, this was consistent with KS, without any signs of bone infection. Patient was initially diagnosed with KS four years prior. He was successfully treated at the time with doxorubicin, radiation therapy, and began HIV therapy. At the time of the KS recurrence, his HIV viral load was undetectable and his CD4 count was over 900 cells/uL (CD4 percentage of 42%). Musculoskeletal (MSK) involvement in KS is a rare manifestation of this disease. The argest series of skeletal KS in people living with HIV by Papanastasopoulos at el. showed a prevalence of only 1.1%. The radiological features of MSK-KS are generally lytic osseous lesions, but presentations may differ. Bone biopsy remains the gold standard for diagnosis, as many other infectious and neoplastic processes can mimic MSK-KS radiographically. In the era of highly active antiretroviral therapy, people living with HIV who are diagnosed with MSK-KS appear to have a substantially improved survival rate than previously described.

Trivalvular infective endocarditis secondary to Granulicatella adiacens and Peptostreptococcus spp.

We present a case of a 42-year-old Caucasian man that came to our facility complaining of dyspnea and subjective fevers and was found to have infective endocarditis. His blood cultures initially grew Peptostreptococcus spp and he was started on penicillin and gentamicin. Repeat blood cultures, drawn 48 h later, became positive for Granulicatella adiacens. Vancomycin was added at this point, given reports of growing penicillin resistance of Granulicatella spp. Transthoracic echocardiogram showed multiple vegetations on the aortic, mitral and tricuspid valves. The patient's final antibacterial regimen consisted of intravenous penicillin G 24 million units daily and vancomycin (goal trough of 15-20) for a total of 6 weeks. The first 2 weeks of his regimen also included gentamicin. The patient was not considered for valve replacement surgery given concern for continued use of illicit intravenous drugs. Peptostreptococcus species are anaerobic, non-spore forming, gram-positive cocci, thought to generally have a subacute clinical presentation. Granulicatella genus is nutritionally deficient bacteria which require a supplemented media in order to grow. Both of these bacteria are present in the mouth and gastrointestinal flora. The rate of infective endocarditis from anaerobic species has been reported up to 16%, which includes multiple species. While on nutritionally deficient bacteria are reported to be involved on infective endocarditis in the range of 3-8%. Antimicrobial resistance is on the rise for both of these species, which makes the appropriate choice of antimicrobials quite important.