Recurrent strokes, central nervous system vasculitis, and acquired protein S deficiency secondary to varicella zoster in a child with AIDS.

A child with vertical transmission of human immunodeficiency virus refractory to therapy developed zoster-induced protein S deficiency and recurrent strokes. Extensive carotid arteritis was found postmortem. The carotid tissue was positive for herpes varicella zoster by polymerase chain reaction, as were immunofixation stains of the arterial wall.

The Clinical Presentation of Subcutaneous Phaeohyphomycosis: A Case Series from Yetebon, Ethiopia.

Subcutaneous phaeohyphomycosis is a chronic fungal infection usually found on the lower extremity and feet of agricultural workers in the tropics. It can present with various skin manifestations, verrucous to nodular plaques, and is caused by multiple species of fungi. Laboratory confirmation requires skin samples for pathology and fungal cultures. Cure, often difficult in resource-poor countries, requires months of antifungal therapy. We describe the cases of three men from Ethiopia who were seen and are being treated by American doctors who traveled there on a medical mission.

Outbreak of Trichinella spiralis infections associated with a wild boar hunted at a game farm in Iowa.

BACKGROUND: Rates of trichinellosis have declined significantly in the United States due to improved pork production practices and public awareness of the danger of eating raw or undercooked pork. In April 2011, the Minnesota Department of Health received a report of presumptive trichinellosis in a 50-year-old man with a history of wild boar consumption. A public health investigation was initiated. METHODS: Medical record reviews and patient and family interviews were conducted. Trichinella species serology was performed on patient and family serum samples, and larval identification was attempted on clinical specimens and meat samples. RESULTS: The index patient harvested a wild boar from an Iowa game farm; he processed the meat after returning home and developed gastrointestinal symptoms 2 days later. Four days after his illness onset, all 5 family members consumed a roast from the boar. The index patient sought healthcare 4 times after illness onset before being definitively diagnosed with trichinellosis. Following initiation of albendazole therapy, the index patient developed atrial fibrillation. One additional family member who processed the raw meat was diagnosed with trichinellosis. Trichinella spiralis larvae were identified in wild boar meat samples. CONCLUSIONS: Trichinellosis has long been recognized as a potential hazard of consuming undercooked wild carnivore meat, and historically has been associated with consumption of pork from domestic swine, but may be unfamiliar to practicing clinicians in the United States. Education of hunters and the broader population on the potential for trichinellosis and the importance of proper handling and cooking meat from wild or free-range animals needs to be reinforced.

Blastomycosis diagnosed in a nonhyperendemic area.

INTRODUCTION: Blastomycosis, caused by the dimorphic fungus Blastomyces dermatitidis, is hyperendemic in northern Wisconsin and is unevenly distributed in the rest of the state and contiguous Minnesota. Clinical presentation of this illness has been characterized by localized outbreaks and sporadic cases in endemic areas. METHODS: Using ICD-9 CPT codes, we queried our electronic health record system to identify cases of blastomycosis diagnosed at Gundersen Health System over a 32-year period. Gundersen serves a region outside the hyperendemic area of Wisconsin. Records so identified were reviewed for demographic and clinical features. We attempted to interview patients with a blastomycosis diagnosis from 2002 through 2006. Blastomycosis data also were collected from the states of Wisconsin and Minnesota from 2002 through 2006 and assessed for trends. RESULTS: Thirty-six patients had blastomycosis diagnoses at Gundersen Health System during the study period, as identified by ICD-9 code. Of these, 10 were excluded from further review because they were either miscoded or the code indicated a previous diagnosis. The remaining 26 patients were included in the study. Premorbid conditions included diabetes (38%) and smoking (62%). The mean time from onset of symptoms to the first laboratory specimen positive for B dermatitidis was 51 days. Notably, 73% of these patients were treated initially for bacterial pneumonia. The incidence of blastomycosis in Wisconsin in the review period was 2.0 per 100,000, and the rate in Minnesota was 0.5 per 100,000. Based on the census data in Gundersen Health System's 19-county service area, the incidence of blastomycosis is 0.17 cases per 100,000. CONCLUSION: In this review of blastomycosis cases diagnosed outside the hyperendemic area of northern Wisconsin, diagnosis was often delayed, and 4 patients whose infections might have been treatable died. Although uncommon, blastomycosis needs to be considered in the differential diagnosis in areas outside the hyperendemic area.

Management of neutropenic fever during a transition from traditional hematology/oncology service to hospitalist care.

OBJECTIVES: Increasingly, hospitalists across the United States provide primary inpatient care for almost all subspecialty patients, including hematology and medical oncology. Febrile neutropenia (FN) is a serious condition often seen as a complication of cytotoxic chemotherapy or in patients with underlying bone marrow defects. The purpose of this study was to document the change of inpatient management of a common admission diagnosis during a transition of providers from hematologists/oncologists to the use of hospitalists in a tertiary care medical center, and to compare the appropriateness of treatment and outcomes over a period of 5.5 years of this transition. METHODS: The medical records of all patients with neutropenia at a community-based teaching hospital during a period of conversion from hematologist/oncologist to hospitalist coverage were retrospectively reviewed. Patients with fever and absolute neutrophil counts of less than 500/ microL (.5 x 10(9)/L) on admission were included. Study cases were divided into 3 groups by admission date, roughly demarcating the nascent hospitalist era, the era of transition to hospitalist, and the mature hospitalist era. Management of FN during these eras was compared. RESULTS: Three hundred ninety-nine inpatients were identified as neutropenic. Of these, 184 did not meet case-inclusion criteria. The remaining 215 cases were included in the study. The internal medicine hospitalist service admitted less than 10% of this population in 2003, but by 2007-2008 it admitted over 90%. The use of 4th-generation cephalosporins and carbapenems increased over time (P = .027), and the infectious disease service was consulted more frequently over time (P = .007). Outcomes varied due to changes in underlying disease states, use of hospice services, and changes in the types of patients hospitalized with FN. Morbidity decreased due to the change in the type and nonantibiotic therapy of cases, but inappropriate antimicrobial treatment was unusual, and septic morbidity or mortality related to inappropriate therapy was too rare to compare through these eras. CONCLUSION: Over the 3 eras compared, care of most neutropenic fever patients was transferred from specialists to hospitalists. Care became more uniform, guideline based, and used more infectious disease consultation, and mortality decreased. Complex changes in the types and treatments of cancer, neutropenia therapy, and in the types of patients hospitalized with FN prevent any conclusion of added value for this change in the type of primary provider management.

Successful treatment of brainstem blastomycosis with fluconazole.

The lipid formulation of amphotericin B is the initial drug of choice for central nervous system blastomycosis, but it is costly and associated with significant toxicity. This case report details a patient with primary pulmonary blastomycosis with dissemination to the skin, one joint, and the brainstem that was successfully treated solely with high-dose fluconazole.

Escherichia coli pyomyositis in an immunocompromised host.

BACKGROUND: Pyomyositis due to Escherichia coli (E. coil) is rarely reported in immunocompromised patients with hematological malignancy. CASE REPORT: We present a case report of a 34-year-old man who developed E. coli pyomyositis as a complication of acute myelogenous leukemia (AML). Magnetic resonance imaging (MRI) of the right hip suggested myofascial infection of the gluteal muscles, and a needle muscle aspiration grew E. coli phylogenetic group B2. The patient responded to intravenous piperacillin/tazobactam followed by prolonged oral levofloxacin. CONCLUSION: Pyomyositis should be suspected in all immunocompromised patients complaining of muscle pain and may exhibit signs of localized muscle infection. Appropriate antibiotic therapy targeting fluoroquinolone-resistant E. coli should be considered for initial empiric therapy of pyomyositis in immunocompromised patients.

The differential diagnosis of pulmonary blastomycosis using case vignettes: a Wisconsin Network for Health Research (WiNHR) study.

PURPOSE: Pulmonary blastomycosis is an uncommon but serious fungal infection endemic in Wisconsin. Clinician awareness of the protean presentations of this disease may reduce diagnostic delay. This study addressed the diagnostic accuracy of physicians responding to case vignettes of pulmonary blastomycosis and the primary care differential diagnosis of this disease. METHODS: Eight pulmonary blastomycosis cases were developed from case files. From these, 2 vignettes were randomly selected and mailed to primary care physicians in the Wisconsin Network for Health Research. Respondents were asked to list the 3 most likely diagnoses for each case. RESULTS: Respondents listed Blastomycosis as the most likely diagnosis for 37/227 (16%) case vignettes, and 1 of the 3 most likely diagnoses for 43/227 (19%). When vignettes included patient activity in counties with an annual incidence rate of blastomycosis greater than 2/100,000, compared to counties with lower incidence rates, diagnosis was more accurate (28/61 [46%] vs 15/166 [9%]; P<0.001). Physicians with practice locations in counties with annual blastomycosis incidence rates >2/100,000 listed blastomycosis more commonly than physicians from other counties (16/36 [44%] vs 27/177 [15%]; P<0.001). This difference in accurate diagnosis remained significant in a multivariate model of practice demographics. Based on responses to the vignettes, pneumonia, cancer, non-infectious pulmonary disease, and tuberculosis emerged as the most-frequently noted diagnosis in the differential diagnosis of blastomycosis. CONCLUSION: Blastomycosis was not listed as 1of 3 primary diagnoses in a majority of cases when Wisconsin primary care physicians considered case vignettes of actual pulmonary blastomycosis cases. Diagnosis was more accurate if the patient vignette listed exposure to a higher incidence county, or if the physician practiced in a higher incidence county. In Wisconsin, failure to include blastomycosis in the differential diagnoses of illnesses associated with a wide variety of pulmonary symptoms suspected to represent infectious or non-infectious pulmonary, cardiac, or neoplastic disease, regardless of geographic exposure, could result in excess morbidity or mortality.

The effect of residual osteomyelitis at the resection margin in patients with surgically treated diabetic foot infection.

The appropriate antibiotic treatment of surgically resected diabetic foot osteomyelitis is controversial. We conducted a retrospective cohort study to evaluate the prognostic impact of residual osteomyelitis at the surgical margin of surgically resected diabetic foot osteomyelitis, and to assess the effectiveness of postoperative antibiotic therapy for residual osteomyelitis after surgical resection of infected bone. Of the 111 patients included in the study, 39 (35.14%) had pathologically confirmed margins positive for residual osteomyelitis. The median total duration of antibiotic treatment was 19 (range 10-134) days in patients with positive margins, whereas it was 14 (range 2-63) days in those with negative margins (P = .01). No statistically significant difference (P = .695) was found in the primary outcome of definite failure, defined as pathologically or microbiologically confirmed infection relapse at the proximal amputation site, between 3 (7.69%) of 39 patients with positive margins and 4 (5.56%) of 47 patients with negative margins. A statistically significant difference (P = .001) in the secondary outcome, definite treatment failure, or the need for more proximal amputation was found between 17 (43.59%) of 39 patients with positive margins and 11 (15.28%) of 72 patients with negative margins. Residual osteomyelitis at the pathologic margin was associated with a higher rate of treatment failure, despite the longer duration of antibiotic therapy.

Increased Incidence of Giant Cell Arteritis After Introduction of a Live Varicella Zoster Virus Vaccine.

BACKGROUND: Varicella zoster virus (VZV) has been associated with giant cell arteritis (GCA). The introduction of a live attenuated vaccine against this virus (ZVL) might have changed the incidence of GCA. METHODS: The incidence of GCA was retrospectively measured using 2 matched cohorts seen in a regional health system located in the Midwestern United States: ZVL recipients from the years 2007 through 2015 following the introduction of the vaccine and nonrecipients from the years 2000 through 2015. RESULTS: In the ZVL cohort, a significant increase of GCA was associated with clinical criteria alone for the diagnosis of GCA (hazard ratio [HR], 2.70; 95% CI, 1.48-4.45; P = .004). In addition, using only pathologically confirmed GCA, the same matched cohort comparison analysis also found that ZVL recipients were at significantly higher risk than those who did not receive ZVL (HR, 2.70; 95% CI, 1.48-4.95; P = .001). CONCLUSION: Using a matched cohort, retrospective comparison, ZVL was associated with an increased incidence of GCA.

Antibiotic treatment duration and long-term outcomes of patients with early lyme disease from a lyme disease-hyperendemic area.

BACKGROUND: The length of antibiotic therapy and long-term outcomes in patients with early Lyme disease are incompletely described. We report the long-term clinical outcomes of patients with early localized and early disseminated Lyme disease based on the duration of antibiotic therapy prescribed. METHODS: A retrospective cohort study and follow-up survey of patients diagnosed as having early localized and early disseminated Lyme disease from 1 January 2000 through 31 December 2004 was conducted in a Lyme disease-hyperendemic area. RESULTS: Six hundred seven patients met the study inclusion criteria. Most patients (93%) were treated with doxycycline for treatment durations of 10 days, 11-15 days, or 16 days in 17%, 33%, and 47% of doxycycline-treated patients, respectively. Treatment failure criteria, defined before performing the study, were met in only 6 patients (1%). Although these 6 patients met a priori treatment failure criteria, 4 of these patients' clinical details suggested reinfection, 1 was treated with an inappropriate antibiotic, and 1 developed facial palsy early in therapy. Reinfection developed in 4% of patients. The 2-year treatment failure-free survival rates of patients treated with antibiotics for 10 days, 11-15 days, or 16 days were 99.0%, 98.9%, and 99.2%, respectively. Patients treated with antibiotics for 16 days had lower 36-item Short-Form Health Survey social functioning scores on the follow-up survey. No other differences were found in follow-up clinical status or 36-item Short-Form Health Survey scores by duration of antibiotic treatment. CONCLUSIONS: Patients treated for 10 days with antibiotic therapy for early Lyme disease have long-term outcomes similar to those of patients treated with longer courses. Treatment failure after appropriately targeted short-course therapy, if it occurs, is exceedingly rare.

Use of optical mapping to sort uropathogenic Escherichia coli strains into distinct subgroups.

Optical maps were generated for 33 uropathogenic Escherichia coli (UPEC) isolates. For individual genomes, the NcoI restriction fragments aligned into a unique chromosome map for each individual isolate, which was then compared with the in silico restriction maps of all of the sequenced E. coli and Shigella strains. All of the UPEC isolates clustered separately from the Shigella strains as well as the laboratory and enterohaemorrhagic E. coli strains. Moreover, the individual strains appeared to cluster into distinct subgroups based on the dendrogram analyses. Phylogenetic grouping of these 33 strains showed that 32/33 were the B2 subgroup and 1/33 was subgroup A. To further characterize the similarities and differences among the 33 isolates, pathogenicity island (PAI), haemolysin and virulence gene comparisons were performed. A strong correlation was observed between individual subgroups and virulence factor genes as well as haemolysis activity. Furthermore, there was considerable conservation of sequenced-strain PAIs in the specific subgroups. Strains with different antibiotic-resistance patterns also appeared to sort into separate subgroups. Thus, the optical maps distinguished the UPEC strains from other E. coli strains and further subdivided the strains into distinct subgroups. This optical mapping procedure holds promise as an alternative way to subgroup all E. coli strains, including those involved in infections outside of the intestinal tract and epidemic strains with distinct patterns of antibiotic resistance.

Use of hair nets and face masks to decrease blood culture contamination rates.

Owing to a persistently high blood culture contamination rate of 3.2% exceeding the target rate of <3%, a midwestern United States hospital began a series of 3 additive interventions. After collecting phlebotomist data for approximately 3 months, reporting of individual contamination rates commenced. A specialized trainer reeducated staff with high rates, which resulted in a modest decrease in contamination rates (3.2% to 2.8%, P = 0.23). A second, additional intervention requiring phlebotomists to wear hair nets and face masks resulted in marked improvement from a mean of 2.8% to 1.1% (P < .0001). In a final, third addition, whenever possible, the replacement of nursing staff by phlebotomy staff for blood specimen collection did not result in a significant change in mean contamination (P = 0.81). Overall, the mean contamination rate progressively declined in a stepwise manner from 3.2% to 1.2% (P = .0013), with the greatest decline after adding hair nets and face masks.

An Unusual Subcutaneous Mass in an Otherwise Healthy Patient: A Case Report of Localized Histoplasmosis Diagnosed on Excisional Biopsy.

Patients are commonly referred to general surgery clinics for evaluation of soft-tissue masses of the trunk and extremities. The primary goal of surgical referral is to confirm the presence of a mass, to assess the need for additional imaging and/or testing, and to gauge amenability to surgical biopsy, whether incisional or excisional. This is a case of a 67-year-old woman who was referred to surgery clinic for a small soft-tissue mass near her left elbow that had increased in size and pain over the past year. The mass had been present for several years. After MRI imaging revealed a nonspecific process, an excisional biopsy was performed. Following a careful review of the patient's history, risk factors, and histological results, a diagnosis of localized subcutaneous Histoplasma capsulatum var. capsulatum infection was made. Without signs or symptoms of active, systemic disease, no further treatment was recommended. The patient was provided risk factor counseling for symptoms or signs of active histoplasmosis and outpatient follow-up. Histologically, most masses will return as benign and mesenchymal in origin. However, soft-tissue masses may arise from uncommon etiologies and a broad differential is needed to ensure appropriate management and recommendations.

How should we approach adolescent and adult pertussis?

Previously considered a disease of childhood, pertussis is now also recognized as a significant problem for adolescents and adults; however, diagnosing pertussis remains problematic due to its nonspecific clinical presentation and the time delay, sensitivity/specificity, and expense of testing. To be effective, therapy is best started very early in the illness, when the illness is seldom recognized. Other than chemoprophylaxis in families with a non-immune infant, antibiotic therapy is controversial due to the ubiquitous nature of pertussis, its similarity to other respiratory infections, increased prevalence, prolonged outbreaks, and difficulties in determining true exposures in the general community. If antimicrobial therapy is used extensively for whooping cough prevention, drug reactions and increased bacterial resistance are expected. Likewise, without laboratory confirmation of infection, isolation of individuals is difficult and expensive. Fortunately, 2 new Food and Drug Administration-approved vaccines, 1 for adolescents and 1 for adolescents/adults, are now available. Both have been shown to be safe and to produce protective antibody responses. As vaccination of adolescent and adult groups is expanded, the rising incidence of pertussis in all age groups can be curtailed.

Milkers' nodules complicated by erythema multiforme and graft-versus-host disease after allogeneic hematopoietic stem cell transplantation for multiple myeloma.

We describe a case of cow-transmitted parapoxvirus infection--also known as milkers' nodules--after a hematopoietic stem cell transplantation for multiple myeloma. The infection was complicated by erythema multiforme and acute exacerbation of graft-versus-host disease. Parapoxvirus was confirmed by electron microscopy. The natural history of milker's nodules in immunocompetent hosts is described and compared to that in our immunocompromised patient.

A comparison of two treatment regimens of ceftriaxone in late Lyme disease.

BACKGROUND: The optimal duration of treatment for patients with late Lyme disease is unresolved. METHODS: In a prospective, open label, randomized, multi-center study, a 14 day course of ceftriaxone was compared to 28 days of therapy. Entry criteria included objective abnormalities compatible with late Lyme disease and serologic reactivity to Borrelia burgdorferi. Randomization took place prior to obtaining serologic results. Clinical response was rated as cure; improvement; failure; or not assessable. RESULTS: Of the 201 patients randomized, 21 patients in the 14 day group and 37 in the 28-day group were excluded from the study for failure to meet serologic criteria. Of those who met serologic criteria, 80 patients received 14 days and 63 received 28 days of ceftriaxone. At time of last evaluation, there were 5 treatment failures in the 14 day group and none in the 28 day group (p = 0.07). Clinical cure rates were 76% for the 14 day group and 70% for the 28 day group (p = NS). Therapy was discontinued due to adverse events for a significantly greater proportion of patients in the 28-day group compared to the 14-day group (p < 0.02). CONCLUSIONS: Ceftriaxone for 14 days eradicated the signs and symptoms of late Lyme disease in the majority of evaluable patients. Although there were more failures in the 14-day group than in the 28-day group, this study did not have the power to determine if a clinical subset of patients may benefit from 28 days of therapy.