Disseminated Nocardia cyriacigeorgica Infection Disguised as a Metastatic Adrenal Gland Malignancy in a Healthy Patient.

Nocardia, typically recognized as an uncommon opportunistic pathogen affecting immunocompromised individuals, has also been documented in various case reports involving infections in immunocompetent hosts. Transmission occurs through inhalation or inoculation into compromised skin. Subsequently, it can lead to disseminated infection via hematogenous spread, affecting nearly any organ with a particular affinity for the central nervous system. Dissemination to the adrenal glands is extremely rare, with only a few cases reported. In this report, we present a rare case of disseminated Nocardia cyriacigeorgica, initially resembling a metastatic adrenal gland malignancy in an otherwise healthy individual. The patient presented with non-specific symptoms, had multiple sets of negative blood cultures, clinical findings suggestive of an underlying adrenal gland malignancy, and lacked identifiable risk factors for Nocardia, creating a significant diagnostic challenge. Additionally, we review the existing literature on nocardiosis involving the adrenal glands. This case marks the third reported instance of a Nocardia cyriacigeorgica adrenal gland abscess in the literature.

Morphological differences between the lesser and the greater omenta in albino rats.

BACKGROUND: Publications report that all mammals have two omenta, namely, lesser omentum and greater omentum. Basically, these organs, which share the same name except for the adjective "lesser" or "greater," should not differ from each other. However, no clear description of the structure of the lesser omentum, as well as comparative morphological analysis between the lesser and greater omenta have been found in the literature, which necessitates a thorough investigation. Therefore, the aim of our study was to analyze the morphofunctional differences between the greater and lesser omenta in albino rats. METHOD: The experiment involved 20 mature male albino rats, weighing 298,28±7,36 grams. The material for our study were preparations of lesser and greater omenta, fixed in 10 % of neutral buffered formalin. Paraffin sections were stained with hematoxylin-eosin and Van Gieson stain. RESULTS: The findings of the study showed that the greater omentum in albino rats, unlike other derivatives of the omentum (ligaments and mesenteries), represents a free extension (mostly from the greater curvature of the stomach), in the form of an "apron," into a specific depth of the peritoneal cavity, duplicating the serous membrane. This duplication is characterized by the composition of two structurally interdependent formations. These include vascular-fatty arcades, associated with lymphoid nodules known as milky spots, and binding serous-reticular membranes. The findings of the study of the lesser omentum have established that in all cases it is located beneath the liver and becomes visualized only after hepatolifting. It is presented in the form of two ligaments: hepatoduodenal and hepatogastric, which contain two main structured formations, which we called vascular-fatty spurs, between these spurs, serous-reticular membranes are located. CONCLUSION: despite having similar names, the lesser omentum, a derivative of the peritoneum, is fundamentally different. As it is well known, the lesser omentum is represented by ligaments that extend from the liver hilus to the lesser curvature of the stomach and the duodenum. Due to this arrangement, the lesser omentum lacks the mobile activity characteristic of the greater omentum, which plays a crucial role in rapid response to damage in the gastrointestinal tract. Despite sharing the same names, both formations differ in shape, morphological structure, development and function.

Stenotrophomonas maltophilia-associated odontogenic cerebral abscess in an immunocompetent patient: A case report.

Key Clinical Message: Stenotrophomonas maltophilia can cause rare odontogenic brain abscesses in immunocompetent patients, highlighting the importance of considering uncommon pathogens in central nervous system infections. With only three reported cases of cerebral abscesses and one pituitary abscess caused by this microorganism, tailored diagnostic methods and individualized treatment regimens are crucial for accurate management. Abstract: Brain abscesses present diagnostic and therapeutic challenges, with Stenotrophomonas maltophilia infections being exceptionally rare in the central nervous system. We present a case of odontogenic brain abscesses caused by S. maltophilia in an immunocompetent patient, highlighting the rarity and complexity of such infections. A 66-year-old male presented with spatial-temporal disorientation and left-sided weakness. Radiological investigations revealed an expansive lesion in the right posterior frontal region. A craniotomy and drainage were performed, identifying S. maltophilia in the purulent material. The patient responded well to tailored antibiotic therapy. S. maltophilia-related central nervous system infections are infrequent, emphasizing the need for a heightened clinical suspicion in atypical cases. This case contributes to the literature, emphasizing the importance of a multidisciplinary approach for successful diagnosis and management.

CMV neuroretinitis in an immunocompetent patient: a unique case report.

Aim: To report a case of cytomegalovirus (CMV) neuroretinitis observed in an immunocompetent patient. Materials and methods: The patient presented with a complaint of diminution of vision in both eyes (BE) and had a traumatic cataract in the right eye (RE). Fundus examination of the left eye (LE) revealed an active white, fluffy lesion with an overlying retinal hemorrhage patch with a macular star. The diagnosis of CMV neuroretinitis was established, and the patient commenced treatment with valganciclovir. Results: The patient exhibited no underlying risk factors. Subsequently, a positive response to oral valganciclovir treatment was observed. Discussion: Cytomegalovirus (CMV) neuroretinitis is typically associated with immunocompromised individuals, such as those with HIV/AIDS. The patient's presentation with a traumatic cataract in the right eye and a distinctive fundus appearance in the left eye posed a diagnostic challenge. The absence of common risk factors for CMV infection necessitated a thorough examination and consideration of rare infectious etiologies. The positive response to valganciclovir reinforces its efficacy in managing CMV-related ocular conditions. This case emphasized the necessity for ophthalmologists to maintain a high index of suspicion for CMV and other unusual pathogens when faced with neuroretinitis in patients who do not present with typical systemic immunosuppressive conditions. Early diagnosis and appropriate antiviral therapy prevent potential complications and preserve vision in such atypical presentations. Conclusion: This case underscores the importance of considering rare infectious agents in immunocompetent patients when encountering neuroretinitis, particularly in the absence of typical symptoms or signs of the disease. Abbreviations: CMV = Cytomegalovirus, BE = Both eyes, RE = Right eye, LE = Left eye, CBC = Complete Blood Count, ESR = Erythrocyte Sedimentation Rate, VDRL = Venereal Disease Research Laboratory, FTA-ABS = Fluorescent Treponemal Antibody Absorption, PPD = Purified Protein Derivative, ANA = Anti-Nuclear Antibodies, RF = Rheumatoid Factor, ACE = Anti Converting Enzyme, Ig G = Immunoglobulin G, HSV = Herpes simplex virus.

Epstein-Barr Virus (EBV)-Associated Myopericarditis Provoking Severe Heart Failure in an Immunocompetent Young Male.

Myopericarditis, a rare inflammatory condition affecting the heart and its surrounding layers, can lead to serious consequences if not promptly diagnosed and treated. A recent case involved a 28-year-old man with no significant medical history who developed severe chest pain and was diagnosed with myopericarditis induced by the Epstein-Barr virus (EBV). The patient's symptoms, imaging, and lab test results suggest myopericarditis. Initially, he was treated with non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine, and upon discharge, he continued with NSAIDs, as well as guideline-directed medical therapy, including an angiotensin-converting enzyme inhibitor, beta blocker, and SGLT2 inhibitor. Close follow-up with the cardiology and heart failure programs was planned. This case highlights the rare occurrence of this condition in individuals with a healthy immune system.

Unmasking the Culprits: A Case of Epstein-Barr Virus-Associated Hemophagocytic Lymphohistiocytosis Presenting With Mouth Ulcers and Nosebleeds.

Hemophagocytic lymphohistiocytosis (HLH) is an aggressive syndrome of excessive immune activation. It usually occurs in children, mainly during the first year of life. Primary hemophagocytic lymphohistiocytosis is more common and usually occurs in immunocompromised patients. Secondary hemophagocytic lymphohistiocytosis, on the other hand, is less common, especially in immunocompetent patients. Here, we intend to present a case of a 55-year-old male patient who had no known immune deficiency, presented with epistaxis, and was found to have Epstein-Barr virus (EBV)-induced hemophagocytic lymphohistiocytosis.

Atypical cutaneous manifestations of methicillin resistant Staphylococcus aureus infections in two immunocompetent pediatric patients: Case reports and review of the literature.

Although many clinical variants of Staphylococcus aureus infection are well-recognized, atypical presentations may mimic other conditions. We describe two cases of atypical S. aureus infections in pediatric patients: a S. aureus infection presenting with a vesicopustular rash mimicking varicella zoster virus and a case of multifocal panniculitis. Both of these cases were specifically caused by methicillin-resistant S. aureus (MRSA). Additional cases of atypical S. aureus infections and presenting features from the current literature are also discussed.

Purulent Streptococcus intermedius Pericarditis in the Setting of Histoplasma Mediastinal Lymphadenitis: A Case Report and Literature Review.

Purulent pericarditis is a rare and potentially life-threatening condition characterized by infection of the pericardial space. We describe a case of purulent bacterial pericarditis in a 41-year-old male with no significant medical or surgical history who had concomitant pulmonary Histoplasma infection. Streptococcus intermedius was the bacteria directly responsible for the pericardial infection, though co-infection with histoplasmosis likely predisposed him to develop purulent pericarditis. We hypothesize histoplasmosis caused mediastinal lymphadenopathy, facilitating contact between a necrotic lymph node and the pericardium and contiguous suppuration of bacteria to the pericardial space. We treated S. intermedius and Histoplasma capsulatum with ceftriaxone and amphotericin B, respectively. Additionally, the patient presented in cardiac tamponade requiring emergent pericardiocentesis and drain placement. His course was also complicated by pericardial constriction. Cardiac magnetic resonance confirmed this, showing inflamed pericardium and abnormal septal motion with inspiration, and he had symptoms refractory to antimicrobials and anti-inflammatories. As such, he required pericardiectomy. This case demonstrates maintaining suspicion for secondary infectious foci as a contributor to the pathogenesis of purulent pericarditis is important, as pulmonary histoplasmosis played a pivotal role in allowing S. intermedius to spread to the pericardium but was not the primary infection. It also highlights the multifaceted evaluation and management of purulent pericarditis, highlighting the role of echocardiography and emergent pericardial drainage if cardiac tamponade is present, the importance of targeted antimicrobial therapy, the superior ability of cardiac magnetic resonance to identify pericardial constriction as a sequela of purulent pericarditis, and indications for pericardiectomy.

Neurobrucellosis presenting as an infected cerebellopontine cistern epidermoid cyst.

Neurobrucellosis is a rare complication of brucella infection which presents as meningitis, meningoencephalitis, subdural empyema, brain abscess, myelitis, and radiculo- neuritis. We report the first case of neurobrucellosis presenting as an infected cerebellopontine cistern epidermoid cyst in a young immunocompetent male who presented with fever and acute raised intracranial pressure. MRI brain showed an extra-axial mass in the right cerebellopontine angle cistern with peripheral rim enhancement and diffusion restriction. Emergency surgery unveiled a well-encapsulated lesion containing thick pus and keratinous material, confirming an infected epidermoid cyst. Intriguingly, the culture revealed Brucella infection, but the source of the infection remained unclear.

Histoplasmosis in non-immunosuppressed patients from an endemic area in northeastern Brazil.

Differently from immunocompromised patients, very little information is available in the literature regarding the clinical presentation, epidemiology, and outcomes of histoplasmosis in non-immunosuppressed individuals living in endemic areas. This retrospective case series study was carried out by reviewing the medical records of non-immunocompromised patients with histoplasmosis, residents in a hyperendemic area in northeastern Brazil, between 2011 and 2022. Thirty HIV-negative patients were identified with histoplasmosis, and 19 cases met the inclusion criteria: ten patients had acute pulmonary histoplasmosis (APH), one had chronic pulmonary histoplasmosis (CPH), two had progressive disseminated (PD) presentation, and six had the chronic disseminated (CD) form. The median age of our sample was 32.7 years old [IQR: 24 - 45]. Most of the patients were male (male-to-female ratio=15:4) and resided in the state capital (n=9). The majority had a previous history of exposure to well-known risk factors for Histoplasma infection. The lung images of APH were characterized by nodules, enlarged hilar/mediastinal lymph nodes, and patches, and three patients were initially treated empirically for pulmonary tuberculosis; one death was registered. The chronic pulmonary form of histoplasmosis was diagnosed in one patient only after the symptoms persisted despite specific treatment. The primary clinical manifestations of the CD form were enlarged lymph nodes, with histopathology being the main diagnostic method. The cases were detected as isolated occurrences and not as an outbreak, suggesting that exposure to Histoplasma can be more widespread than presumed. Despite the self-limiting nature of the disease, death can occur even in previously heath patients.

This study aimed to describe the presentation of histoplasmosis outside the context of immunosuppression, including the diagnostic methods, epidemiology, and main radiological and clinical features. A better understanding of the various forms of this disease will help improve case management.

A retrospective observational study on disseminated herpes zoster in immunocompetent patients.

INTRODUCTION: Disseminated herpes zoster (DHZ) is a severe infection associated with high incidences and mortality rates in immunocompromised patients. Although studies have shown its occurrence in immunocompetent patients, its epidemiology, clinical presentation, and treatment outcomes in this cohort remain unknown. Thus, this study aimed to examine the clinical presentation, treatment, complications, and outcomes of DHZ in immunocompetent patients and compare these findings with previous studies. METHODS: We included 20 immunocompetent patients of DHZ at our institution and reviewed 42 previously published cases. We then investigated the clinical features, predisposing factors, laboratory findings, treatment, and outcomes of all cases including in-hospital mortality, neurological dysfunction at discharge, and postherpetic neuralgia. We compared DHZ-immunocompetent patients to DHZ-immunocompromised patients. RESULTS: Patients had a median age of 71.5 years and were predominantly male. The trigeminal area was the most common site of initial rash, with a mean dissemination time of 6.5 days. Pain was the most common symptom, followed by fever (approximately 40 % of cases); acyclovir was the most used treatment. Additionally, the in-hospital mortality was 0 %, neuropathy at discharge was observed in approximately 10 % of patients, and postherpetic neuralgia was present in approximately 40 % of patients. In the immunocompromised cases, the mortality rate was 12 %, which was higher than in our cases; however, the rates of neuropathy and postherpetic neuralgia were lower. CONCLUSIONS: This study provides new insights into the clinical presentation, treatment, and outcomes of DHZ cases in immunocompetent patients, highlighting its tendency for residual neurological damage despite having low mortality rates.

Isolation of Clavispora lusitaniae from the Oral Cavity of Immunocompetent Young Adults from the North of Mexico.

The human oral cavity is normally colonized by microorganisms including bacteria, fungi, archaea, viruses and protozoa. The aim of this study was to determine the frequency of Candida spp., in de oral cavity in a group of medical students from the north of Mexico. Oral sample were obtained from 240 healthy students. The specimens were analyzed by traditional microbiology cultures and DNA sequencing. Candida spp., grew in Sabouraud dextrose agar from 57 samples and subsequently were isolated and phenotyped. The definitive identification to the species level was done by sequence analysis. The yeasts were identified as follow: 28 Clavispora lusitaniae, 20 Candida albicans, 5 Pichia kudriavzevii and 4 Candida parapsilosis. Our findings revealed that 23.75% of the healthy population has a potential pathogen in their mouth. Surprisingly, C. albicans is not the predominant yeast; instead other non-Candida species are the colonizers of the oral cavity as normal microbiota. C. lusitaniae is considered an emerging opportunistic pathogen in immunosuppressive patients. This paper pretends to highlight the presence of this yeast in the oral cavity in immunocompetent young adults. Supplementary Information: The online version contains supplementary material available at 10.1007/s12088-023-01145-x.

An Unusual Case of Lynch Syndrome.

Lynch syndrome is the most common cause of hereditary colorectal cancer. It usually develops asymptomatically until symptoms related to colorectal carcinoma appear, such as gastrointestinal bleeding, abdominal pain, and changes in bowel habits and/or stool characteristics. Oftentime, when these clinical signs and symptoms are not present, the diagnosis becomes challenging. We present the clinical case of a 69-year-old woman, adopted, with no known previous history, who presented to the emergency department with low back pain, without irradiation, that had been going on for three days, associated with inflammatory signs in the right hip region. There were no urinary or sensory alterations and no recent trauma. She was initially discharged with antibiotherapy with the diagnosis of hip cellulitis. As the symptoms continued and the inflammation spread to the right lower limb, she returned to the emergency department. A CT scan revealed an abscess (17 cm) in the right buttock, complicated by necrotizing fasciitis due to fistulization from a tumor in the right colon. She underwent an exploratory laparotomy, which identified a neoplasm of the ascending colon, adherent to the abdominal wall, in the right lumbar region. Right hemicolectomy and drainage of the right buttock/thigh abscess were performed. The histology was compatible with invasive adenocarcinoma, with high-grade dysplasia but well differentiated, pT3G1N0. The immunohistochemistry was suggestive of Lynch syndrome.

Herpes Zoster in a 13-Year-Old Male Without Prior Varicella Infection.

Herpes zoster (HZ) typically presents following reactivation of latent varicella-zoster virus (VZV) in adult and geriatric patients with a history of prior varicella infection. Primary VZV infection in patients compliant with vaccine schedules and without any immunocompromising condition is rare, with reactivation leading to HZ being even rarer. This case report details one such example involving a 13-year-old immunocompetent and fully immunized male with HZ despite no history of VZV infection, as well as possible explanatory mechanisms for this uncommon presentation. This case report contributes to a growing body of literature on atypical HZ presentations in pediatric populations without any history of prior VZV infection or exposure.

Modeling human gastric cancers in immunocompetent mice.

Gastric cancer (GC) is a major cause of cancer-related mortality worldwide. This cancer is determined by multiple (epi)genetic and environmental factors; can occur at distinct anatomic positions of the stomach; and displays high heterogeneity, with different cellular origins and diverse histological and molecular features. This heterogeneity has hindered efforts to fully understand the pathology of GC and develop efficient therapeutics. In the past decade, great progress has been made in the study of GC, particularly in molecular subtyping, investigation of the immune microenvironment, and defining the evolutionary path and dynamics. Preclinical mouse models, particularly immunocompetent models that mimic the cellular and molecular features of human GC, in combination with organoid culture and clinical studies, have provided powerful tools for elucidating the molecular and cellular mechanisms underlying GC pathology and immune evasion, and the development of novel therapeutic strategies. Herein, we first briefly introduce current progress and challenges in GC study and subsequently summarize immunocompetent GC mouse models, emphasizing the potential application of genetically engineered mouse models in antitumor immunity and immunotherapy studies.

Challenging Diagnosis of Streptococcus intermedius-Associated Empyema in an Immunocompetent Adult: A Case Report and Literature Review.

The significance of Streptococcus intermedius in infectious diseases, especially pleural infections, is gaining recognition. While traditional risk factors like dental procedures and immunosuppression remain pivotal in differential diagnosis, there is an emerging recognition of unconventional clinical presentations and risk factors linked to infections by S. intermedius. This shift compels medical professionals to broaden their diagnostic and therapeutic strategies, underscoring the intricate and evolving nature of managing infections associated with this opportunistic bacterium. We describe the case of a 48-year-old immunocompetent woman with untreated hypertension who experienced a 15-day episode of right-sided chest pain, which worsened with a sudden onset of dyspnea, yet her daily activities remained unaffected. Physical examination suggested a pleuropulmonary syndrome due to significant pleural effusion, with a computed tomography (CT) scan of the lungs revealing about 50% effusion on the right side. Laboratory tests indicated elevated inflammatory markers. Ultrasound-guided thoracentesis extracted purulent fluid compatible with empyema, necessitating the placement of a pleural drain and multiple pleural cavity lavages using alteplase, which led to the removal of substantial infected fluid. Culture of the pleural fluid identified S. intermedius, which was pansusceptible. Treatment with intravenous ceftriaxone was administered, resulting in a favorable clinical outcome. This case highlights the critical nature of recognizing atypical clinical presentations and managing complex bacterial infections in the pleural space.

Disseminated Cutaneous Histoplasmosis and Its Recurrence in an Apparently Immunocompetent Patient.

Histoplasmosis is a fungal infection caused by the fungus Histoplasma capsulatum. It can manifest in various ways, ranging from pulmonary to disseminated presentations. Most of the disseminated cases are seen in immunocompromised patients; here, we present an unusual case of an 81-year-old Mexican male with a history of cave exposure in his childhood, with 75 years of incubation period of the disease, who developed disseminated cutaneous histoplasmosis with no evident immunocompromising conditions. We considered the hypotheses of transient immunosuppression, CD4+ T lymphocytopenia, and immune senescence as the cause of this manifestation. The present case is also notable for its recurrence following therapy. This report underscores the challenges in diagnosing histoplasmosis in immunocompetent individuals and highlights the importance of long-term treatment and follow-up.

Cryptococcal Pleuritis in an Immunocompetent Patient: A Case Report and Literature Review.

Cryptococcosis, primarily an opportunistic infection, often occurs in immunocompromised patients but can also affect immunocompetent individuals. Cryptococcosis typically manifests in the lungs, but pleurisy is rare, particularly in immunocompetent patients. This report details a case of cryptococcal pleuritis in a 74-year-old immunocompetent male with a history of heart failure, presenting initially with pleural effusion. Diagnostic challenges arose due to the initial absence of intrapulmonary lesions. The diagnosis was eventually established through a surgical biopsy and tissue culture, revealing Cryptococcus neoformans. This case underscores the complexity of diagnosing cryptococcal infections, particularly in immunocompetent patients, and highlights the need for considering cryptococcosis in differential diagnoses of lymphocyte-predominant exudative pleural effusions.

Unravelling lung adenocarcinoma in an immunocompetent patient with endobronchial aspergilloma: A case report.

Inhalation of Aspergillus spp. can cause a wide spectrum of lung diseases. Endobronchial aspergilloma is an uncommon clinical entity that occurs because of Aspergillus spp. overgrowth in the airway lumen. We present a 73-year-old gentleman with a rare dual pathology of endobronchial aspergilloma and endobronchial adenocarcinoma. He initially presented with prolonged cough, dyspnoea, and haemoptysis. Bronchoscopy revealed an obstructed right main bronchus by a necrotic mass whereby histological examination showed evidence of Aspergillus spp. infection. The lesion however persisted despite treatment with anti-fungal agents. Repeated bronchoscopy and biopsy eventually unravelled an underlying endobronchial adenocarcinoma. He received chemotherapy but ultimately passed away 3 months later.