Iron in airway macrophages and infective exacerbations of chronic obstructive pulmonary disease.

BACKGROUND: Excess pulmonary iron has been implicated in the pathogenesis of lung disease, including asthma and COPD. An association between higher iron content in sputum macrophages and infective exacerbations of COPD has previously been demonstrated. OBJECTIVES: To assess the mechanisms of pulmonary macrophage iron sequestration, test the effect of macrophage iron-loading on cellular immune function, and prospectively determine if sputum hemosiderin index can predict infectious exacerbations of COPD. METHODS: Intra- and extracellular iron was measured in cell-line-derived and in freshly isolated sputum macrophages under various experimental conditions including treatment with exogenous IL-6 and hepcidin. Bacterial uptake and killing were compared in the presence or absence of iron-loading. A prospective cohort of COPD patients with defined sputum hemosiderin indices were monitored to determine the annual rate of severe infectious exacerbations. RESULTS: Gene expression studies suggest that airway macrophages have the requisite apparatus of the hepcidin-ferroportin axis. IL-6 and hepcidin play roles in pulmonary iron sequestration, though IL-6 appears to exert its effect via a hepcidin-independent mechanism. Iron-loaded macrophages had reduced uptake of COPD-relevant organisms and were associated with higher growth rates. Infectious exacerbations were predicted by sputum hemosiderin index (ß = 0.035, p = 0.035). CONCLUSIONS: We demonstrate in-vitro and population-level evidence that excess iron in pulmonary macrophages may contribute to recurrent airway infection in COPD. Specifically, IL-6-dependent iron sequestration by sputum macrophages may result in immune cell dysfunction and ultimately lead to increased frequency of infective exacerbation.

Rothia santali sp. nov., endophytic bacteria isolated from sandalwood (Santalum album L.) seedling.

A novel, mustard yellow-pigmented aerobic bacterial strain designated AR01T was isolated from hypocotyl tissue of a sandalwood seedling from Bangalore, India. The 16S rRNA gene of strain AR01T had the highest 98.97% sequence similarity with Rothia halotolerans YIM 90716T (KCTC 19172) followed by Rothia kristinae PM 129T (NBRC 15354T) (97.31%) and Rothia koreensis P31T (JCM 15915) (97.11%), respectively. The strain AR01T was coccoid-shaped, non-motile, non-spore forming, oxidase negative and catalase positive. The strain AR01T has a genome size of 3.31 Mb containing 2993 protein-coding genes including 48 tRNA and 10 rRNAs spread across 84 contigs. The genomic DNA G + C content was 71.77 mol%. The calculated dDDH was 31.10% and the OrthoANI value was 85.27% when compared with its closest related type strain Rothia halotolerans YIM 90716T. The predominant cellular fatty acids were C16:0 iso, C15:0 anteiso and C17:0 anteiso. The strain AR01T contains major polar lipids including diphosphatidylglycerol and phosphatidylglycerol. The distinct physiological, biochemical characteristics and genotypic relatedness indicated that AR01T represents a novel species of the genus Rothia, for which the name Rothia santali sp. nov. (Type strain AR01T = MCC 4800T = JCM 35593T) is proposed.

An early experience on the effect of solid organ transplant status on hospitalized COVID-19 patients.

We compared the outcome of COVID-19 in immunosuppressed solid organ transplant (SOT) patients to a transplant naïve population. In total, 10 356 adult hospital admissions for COVID-19 from March 1, 2020 to April 27, 2020 were analyzed. Data were collected on demographics, baseline clinical conditions, medications, immunosuppression, and COVID-19 course. Primary outcome was combined death or mechanical ventilation. We assessed the association between primary outcome and prognostic variables using bivariate and multivariate regression models. We also compared the primary endpoint in SOT patients to an age, gender, and comorbidity-matched control group. Bivariate analysis found transplant status, age, gender, race/ethnicity, body mass index, diabetes, hypertension, cardiovascular disease, COPD, and GFR <60 mL/min/1.73 m2 to be significant predictors of combined death or mechanical ventilation. After multivariate logistic regression analysis, SOT status had a trend toward significance (odds ratio [OR] 1.29; 95% CI 0.99-1.69, p = .06). Compared to an age, gender, and comorbidity-matched control group, SOT patients had a higher combined risk of death or mechanical ventilation (OR 1.34; 95% CI 1.03-1.74, p = .027).

Comparison in Outcome of Patients with Post TB-Destroyed Lung and COPD Admitted with Respiratory Failure.

INTRODUCTION: The term post TB sequelae is usually used to describe the destructive lung parenchymal changes due to pulmonary tuberculosis, which occur over years, and cause chronic airway obstruction as well as restriction. Furthermore, post TB sequelae and COPD are common causes of acute exacerbation with respiratory failure in Indian setting. AIM OF THE STUDY: To compare the outcome of patients with post TB sequelae and COPD admitted with respiratory failure Methodes: 62 Post TB sequelae and 79 COPD patients admitted in respiratory failure were treated as per standard ICU protocols. Outcome of these patients in these groups were compared with respect to mortality, morbidity and requirement of type ventilatory support. RESULTS: It was observed that duration of stay, morbidity and mortality in these groups was comparable and difference was not statistically significant. CONCLUSION: The presentation and outcome of COPD and Post TB destroyed lung patients is similar, so Post TB Destroyed lung patients should be treated as per COPD guidelines.

COVID-19 in kidney transplant recipients.

There is minimal information on coronavirus disease 2019 (COVID-19) in immunocompromised individuals. We have studied 10 patients treated at 12 adult care hospitals. Ten kidney transplant recipients tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction, and 9 were admitted. The median age was 57 (interquartile range [IQR] 47-67), 60% were male, 40% Caucasian, and 30% Black/African American. Median time from transplant to COVID-19 testing was 2822 days (IQR 1272-4592). The most common symptom was fever, followed by cough, myalgia, chills, and fatigue. The most common chest X-ray and computed tomography abnormality was multifocal patchy opacities. Three patients had no abnormal findings. Leukopenia was seen in 20% of patients, and allograft function was stable in 50% of patients. Nine patients were on tacrolimus and a mycophenolic antimetabolite, and 70% were on prednisone. Hospitalized patients had their antimetabolite agent stopped. All hospitalized patients received hydroxychloroquine and azithromycin. Three patients died (30%), and 5 (50%) developed acute kidney injury. Kidney transplant recipients infected with COVID-19 should be monitored closely in the setting of lowered immunosuppression. Most individuals required hospitalization and presenting symptoms were similar to those of nontransplant individuals.

Weight-adjusted Intravenous Reslizumab in Severe Asthma with Inadequate Response to Fixed-Dose Subcutaneous Mepolizumab.

RATIONALE: Clinical benefits of fixed-dose 100-mg subcutaneous (SC) mepolizumab in prednisone-dependent patients are modest when sputum eosinophilia is not adequately controlled. OBJECTIVES: This study compared treatment response of weight-adjusted intravenous (IV) reslizumab in patients previously treated with 100-mg SC mepolizumab. METHODS: Ten prednisone-dependent patients with asthma (sputum eosinophils >3% and blood eosinophils >300 cells/µl), who had previously received mepolizumab (100 mg SC dosed every 4 wk [Q4W]) for at least 1 year, received two infusions of placebo (Q4W) followed by four infusions of 3.0 mg/kg reslizumab Q4W in a single-blind, placebo-controlled sequential trial. Primary outcomes were reduction of eosinophils in sputum and blood. Additional outcomes included FEV1, asthma control questionnaire, eosinophil peroxidase, IL-5, sputum and blood innate lymphoid cells group 2, eosinophil progenitor cells, and autoimmune responses. MEASUREMENTS AND MAIN RESULTS: IV reslizumab attenuated sputum eosinophils by 91.2% (P = 0.002), blood eosinophil counts by 87.4% (P = 0.004), and sputum eosinophil peroxidase levels by 65.5% (P = 0.03) compared with placebo. Attenuation of both local and systemic eosinophilia was associated with statistically significant improvements in FEV1 (P = 0.004) and asthma control questionnaire five-question instrument scores (P = 0.006). Decrease in percent sputum eosinophil was greater with reslizumab (by 42.7%) compared with mepolizumab (by 5.0%) and this was associated with greater improvement in asthma control questionnaire (P = 0.01; analysis of covariance of Δ between before and after treatment, mepolizumab vs. reslizumab, adjusted for baseline prednisone). Changes in sputum IL-5 and anti-eosinophil peroxidase IgG after anti-IL-5 therapy were predictors of response. CONCLUSIONS: Weight-adjusted IV reslizumab was superior to fixed-dose SC mepolizumab in attenuating airway eosinophilia in prednisone-dependent patients with asthma, with associated improvement in asthma control. Clinical trial registered with www.clinicaltrials.gov (NCT 02559791).

Multiplexed Recombinase Polymerase Amplification Assay To Detect Intestinal Protozoa.

This work describes a proof-of-concept multiplex recombinase polymerase amplification (RPA) assay with lateral flow readout that is capable of simultaneously detecting and differentiating DNA from any of the diarrhea-causing protozoa Giardia, Cryptosporidium, and Entamoeba. Together, these parasites contribute significantly to the global burden of diarrheal illness. Differential diagnosis of these parasites is traditionally accomplished via stool microscopy. However, microscopy is insensitive and can miss up to half of all cases. DNA-based diagnostics such as polymerase chain reaction (PCR) are far more sensitive; however, they rely on expensive thermal cycling equipment, limiting their availability to centralized reference laboratories. Isothermal DNA amplification platforms, such as the RPA platform used in this study, alleviate the need for thermal cycling equipment and have the potential to broaden access to more sensitive diagnostics. Until now, multiplex RPA assays have not been developed that are capable of simultaneously detecting and differentiating infections caused by different pathogens. We developed a multiplex RPA assay to detect the presence of DNA from Giardia, Cryptosporidium, and Entamoeba. The multiplex assay was characterized using synthetic DNA, where the limits-of-detection were calculated to be 403, 425, and 368 gene copies per reaction of the synthetic Giardia, Cryptosporidium, and Entamoeba targets, respectively (roughly 1.5 orders of magnitude higher than for the same targets in a singleplex RPA assay). The multiplex assay was also characterized using DNA extracted from live parasites spiked into stool samples where the limits-of-detection were calculated to be 444, 6, and 9 parasites per reaction for Giardia, Cryptosporidium, and Entamoeba parasites, respectively. This proof-of-concept assay may be reconfigured to detect a wide variety of targets by re-designing the primer and probe sequences.

[Massive hookworm infection as a cause of intestinal bleeding and severe anemia]. / Infección masiva por Ancylostoma duodenale como causa de hemorragia intestinal y anemia severa.

Overt gastrointestinal bleeding caused by hookworm infection is rarely reported. We present a 34 year old male with lower gastrointestinal bleeding with evidence of massive hookworm infection on colonoscopy and discuss the need to consider hookworm infection as a possible etiology of gastrointestinal bleed in endemic areas.

Noninvasive intestinal amebiasis: Entamoeba histolytica colonization without invasion.

PURPOSE OF REVIEW: Entamoeba histolytica infection remains a major cause of morbidity and mortality worldwide. Although research with the organism began in the late nineteenth century, our understanding of the natural history of the infection remains incomplete and is heavily based on expert opinion. Most persons infected with E. histolytica are carriers with the organism colonizing the large intestine. Host defense mechanisms that prevent invasive diseases are poorly understood. A timely review could lead to renewed interest. RECENT FINDINGS: We herein review 2012 and 2013 publications related to the epidemiology, diagnosis, management and potential mechanisms that enable noninvasive E. histolytica colonization without invasion. SUMMARY: There are several publications that advance our knowledge in the first three categories listed above, but studies of mechanisms for noninvasive E. histolytica colonization are glaringly few.

Optimizing surveillance of low-risk metabolic dysfunction associated steatotic liver disease using transient elastography.

BACKGROUND: Most people with metabolic dysfunction-associated steatotic liver disease (MASLD) lack significant fibrosis and are considered low-risk. Surveillance strategy for low-risk MASLD remains uncertain. AIM: Identify which low-risk subjects can avoid follow-up vibration-controlled transient elastography (VCTE) within 1 year. METHODS: Retrospective analysis of two independent low-risk MASLD cohorts (baseline liver stiffness [LS] < 8kPa) with routine 6-12 months follow-up VCTE. The primary outcome was LS ≥ 8kPa on follow-up, requiring referral and further work-up according to current guidance. Predictors of the primary outcome on univariate and multivariate logistic regression were incorporated into a decision algorithm, and validated in an independent cohort. RESULTS: Of 206 subjects in the derivation cohort, 96 were low-risk. After a median of 10 months, 24 (25%) low-risk subjects had LS ≥ 8kPa. Baseline LS ( P  < 0.01) and ALT change from baseline ( P  = 0.02) (multivariate AUROC = 0.84 [0.74-0.94]) predicted the primary outcome, and were incorporated to a two-step decision algorithm. Low-risk subjects with baseline LS < 5.5 kPa can avoid repeating VCTE in a year, while those with LS > 6.8 kPa require one. For intermediate baseline LS (5.5-6.8kPa), repeat VCTE is only indicated when ALT increase > 6 U/L. The algorithm had 92% negative predictive value, 78% specificity, and 78% accuracy in the derivation cohort. In the validation cohort (n = 64), it had 91% NPV, 72% specificity, and 71% accuracy. CONCLUSION: In low-risk MASLD, a simple algorithm combining baseline LS and ALT change can be used to safely avoid a repeat VCTE in a year.

A Cross-Sectional Study on Sedentary Lifestyle Among Budding Doctors: Silent Killer?

Background Internship is the time period when young doctors learn to balance between professional and personal lives. If they have good awareness and practice of any kind of physical activity during this period, it will help them to continue it forward. This enables them to educate and inspire people and patients around them. The main objectives of this study were to assess patterns of physical activity among medical interns and to understand the factors preventing physical activity among them. Methodology This cross-sectional survey was carried out among interns of a tertiary care hospital in western Maharashtra from July 2022 to September 2022. Ethical clearance was obtained before starting data collection. The survey was administered to those who fulfilled the inclusion criteria. The questionnaire was adopted from the Global Physical Activity Questionnaire. The data collected were entered into Microsoft Excel (Microsoft Corporation, Redmond, WA) and analysis was done using MedCalc v.18.2.1 (MedCalc Software Ltd, Ostend, Belgium). Results A total of 220 interns were enrolled in the survey, of which 13 were removed due to incomplete data and 28 interns did not participate in the study. Finally, 179 interns were included for analysis in the study. The response rate was 87.27%. The mean age of participants was 23.12 years. The study population consisted of 72 (40.22%) males and 107 (59.78%) females. Among participants, 33 interns (18.44%) were involved in vigorous activity during work, and 108 interns (60.34%) were involved in moderate physical activity during work. The median time of a sedentary lifestyle was 300 minutes per day and was more common among males. Cumulatively busy working schedules and exam preparation were the important reasons for reduced physical activity. Conclusion There is a gap in the practice of physical activity among interns. A sedentary lifestyle was more prevalent among male interns than in female interns. The main constraints were demanding working hours and the pressure of competitive exams. Medical students will become doctors in the future who can advise their patients on healthy lifestyle habits. We recommend that it is necessary to promote physical activity in medical schools and to reinforce the importance of physical exercise in the medical curriculum.

Temperate phage-antibiotic synergy across antibiotic classes reveals new mechanism for preventing lysogeny.

A recent demonstration of synergy between a temperate phage and the antibiotic ciprofloxacin suggested a scalable approach to exploiting temperate phages in therapy, termed temperate phage-antibiotic synergy, which specifically interacted with the lysis-lysogeny decision. To determine whether this would hold true across antibiotics, we challenged Escherichia coli with the phage HK97 and a set of 13 antibiotics spanning seven classes. As expected, given the conserved induction pathway, we observed synergy with classes of drugs known to induce an SOS response: a sulfa drug, other quinolones, and mitomycin C. While some ß-lactams exhibited synergy, this appeared to be traditional phage-antibiotic synergy, with no effect on the lysis-lysogeny decision. Curiously, we observed a potent synergy with antibiotics not known to induce the SOS response: protein synthesis inhibitors gentamicin, kanamycin, tetracycline, and azithromycin. The synergy results in an eightfold reduction in the effective minimum inhibitory concentration of gentamicin, complete eradication of the bacteria, and, when administered at sub-optimal doses, drastically decreases the frequency of lysogens emerging from the combined challenge. However, lysogens exhibit no increased sensitivity to the antibiotic; synergy was maintained in the absence of RecA; and the antibiotic reduced the initial frequency of lysogeny rather than selecting against formed lysogens. Our results confirm that SOS-inducing antibiotics broadly result in temperate-phage-specific synergy, but that other antibiotics can interact with temperate phages specifically and result in synergy. This is the first report of a means of chemically blocking entry into lysogeny, providing a new means for manipulating the key lysis-lysogeny decision.IMPORTANCEThe lysis-lysogeny decision is made by most bacterial viruses (bacteriophages, phages), determining whether to kill their host or go dormant within it. With over half of the bacteria containing phages waiting to wake, this is one of the most important behaviors in all of biology. These phages are also considered unusable for therapy because of this behavior. In this paper, we show that many antibiotics bias this behavior to "wake" the dormant phages, forcing them to kill their host, but some also prevent dormancy in the first place. These will be important tools to study this critical decision point and may enable the therapeutic use of these phages.

Enhancer-targeted CRISPR-Activation Rescues Haploinsufficient Autism Susceptibility Genes.

Autism Spectrum Disorder (ASD) is a highly heritable condition with diverse clinical presentations. Approximately 20% of ASD's genetic susceptibility is imparted by de novo mutations of major effect, most of which cause haploinsufficiency. We mapped enhancers of two high confidence autism genes - CHD8 and SCN2A and used CRISPR-based gene activation (CRISPR-A) in hPSC-derived excitatory neurons and cerebral forebrain organoids to correct the effects of haploinsufficiency, taking advantage of the presence of a wildtype allele of each gene and endogenous gene regulation. We found that CRISPR-A induced a sustained increase in CHD8 and SCN2A expression in treated neurons and organoids, with rescue of gene expression levels and mutation-associated phenotypes, including gene expression and physiology. These data support gene activation via targeting enhancers of haploinsufficient genes, as a therapeutic intervention in ASD and other neurodevelopmental disorders.

Association between body mass index and liver stiffness measurement using transient elastography in patients with non-alcoholic fatty liver disease in a hepatology clinic: a cross sectional study.

Background: Transient elastography (TE) is an FDA approved, non-invasive tool to estimate liver stiffness measurement (LSM) in patients with non-alcoholic fatty liver disease (NAFLD). Our aim was to analyze if body mass index (BMI) would predict the severity of liver stiffness using TE scores. Methods: We performed a cross-sectional study of patients with NAFLD who presented to the hepatology clinic between January 2019 through January 2021. Fibrosis severity was divided into the following categories: F0 to F1 (2-7 kPa), F2 (>7 to 10 kPa), F3 (>10 to 14 kPa) and F4 (>14 kPa). We used ordered logistic regression models to determine the odds ratio (OR) and 95% confidence interval (CI) of having a higher LSM severity compared to lower associated with BMI. Models were adjusted for patient demographics and comorbidities. Results: Among 284 patients, 56.7% were females, and the median (interquartile range, IQR) age was 62 [51-68] years and BMI 31.9 (28.1, 36.2) kg/m2; 47% of patients were in the F0 to F1 stage, 24% F2, 16% F3, and 13% F4. The correlation between BMI and TE score was 0.31 (P<0.001). With 1 kg/m2 increase in BMI there was 1.10 times higher odds of having a higher LSM severity (adjusted OR, 1.10; 95% CI: 1.05-1.14). Compared to patients with BMI <25 kg/m2, the adjusted OR (95% CI) of having a higher fibrosis stage was 1.82 (0.61-5.44), 5.93 (2.05-17.13), and 8.56 (2.51-29.17) for patients with BMI of 25 to <30, 30 to <40, and ≥40 respectively. Conclusions: BMI correlates with the severity of LSM using TE scores in NAFLD patients even after adjusting for potential confounding variables. This suggests TE as an appreciable study for liver stiffness even in obese individuals.

People's Perspective on Out-of-Pocket Expenditure for Healthcare: A Qualitative Study From Pune, India.

Background Out-Of-Pocket Expenditure (OOPE) directly reflects the burden of health expenses that households bear. Despite the availability of social security schemes providing healthcare benefits, a high proportion of Indian households are still incurring OOPE. In order to recognize the reasons behind OOPE, a comprehensive understanding of people's attitudes and behavior is needed. Methodology By purposive sampling, 16 in-depth interviews were conducted using an interview guide in the catchment area of urban and rural health centers of a tertiary healthcare hospital. Interviews were conducted in Marathi and Hindi and were audio tape-recorded after taking informed consent. The interviews were transcribed and translated into English, followed by a thematic analysis. Results Although most participants knew that government hospitals provide facilities and experienced doctors, inconvenience and unsatisfactory quality deter them from utilizing government facilities. A few had experiences with government schemes; almost all concur that the formality and procedure of claiming insurance are cumbersome and all have had bad experiences. Cost of medications and consultation accounted for the majority of the healthcare expenditures. While some participants had benefitted from insurance, few regretted not enrolling in one. Conclusion The awareness regarding government schemes was derisory. Government-financed health insurance schemes and their utilization are crucial to reducing OOPE. Efforts should be made to increase accessibility to public healthcare services. Nevertheless, there is potential to redress the barriers to improve scheme utilization.

Simultaneous Liver-Kidney Transplantation.

End-stage kidney disease (ESKD) after liver transplantation is associated with high morbidity and mortality. This increase in mortality can be offset by performing a kidney transplant at the time of the liver transplant in select cases. Accordingly, Margreiter and colleague; s performed the first simultaneous liver-kidney (SLK) transplant in 1983. The number of SLK transplants has increased by more than 300% since then. In 1990%, 1.7% of all liver transplants in the United States were SLK transplants which increased to 9.9% by 2016. This steep increase was likely due to the implementation of the model of end-stage liver disease (MELD) scoring system in 2002, which is heavily weighted by serum creatinine.

Immensely High Creatine Kinase Levels in a Case of Rhabdomyolysis Due to Legionnaires' Disease in a Patient on Tofacitinib: A Case Report and Literature Review.

A 58-year-old female patient presented with altered mental status, diarrhea, and fever. She was hospitalized for acute kidney injury [AKI] and a patchy right lower lobe infiltrates on chest X-ray. Subsequent testing revealed rhabdomyolysis and a positive urinary Legionella antigen test. Creatinine kinase [CK] level peaked at 512,820 U/L and was managed with aggressive intravenous hydration and appropriate antibiotic treatment. With clinical signs of resolution of pneumonia, the CK level declined rapidly, however renal function returned to baseline only after 2 months requiring hemodialysis in the meantime. The patient was also on tofacitinib which can rarely contribute to rhabdomyolysis. Legionella infection can cause severe rhabdomyolysis and AKI. Timely diagnosis of Legionella-associated rhabdomyolysis, and prompt treatment with aggressive IV hydration and appropriate antibiotics is required to prevent morbidity and mortality.

The effect of race coefficients on preemptive listing for kidney transplantation.

Background: Race coefficients of estimated glomerular filtration rate (eGFR) formulas may be partially responsible for racial inequality in preemptive listing for kidney transplantation. Methods: We used the Scientific Registry of Transplant Recipients database to evaluate differences in racial distribution of preemptive listing before and after application of the Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) race coefficients to all preemptively listed non-Black kidney transplant candidates (eGFR modulation). Odds of preemptive listing were calculated by race, with Black as the reference before and after eGFR modulation. Variables known to influence preemptive listing were included in the model. Results: Among 385 087 kidney-alone transplant candidates from 1 January 2010 to 2 December 2020, 118 329 (30.7%) candidates were identified as preemptively listed (71.7% White, 19% Black, 7.8% Asian, 0.6% multi-racial, 0.6% Native American and 0.3% Pacific Islander). After eGFR modulation, non-Black patients with an eGFR ≥20 mL/min/1.73 m2 were removed. Compared with Black candidates, the adjusted odds of preemptive listing for White candidates decreased from 2.01 [95% confidence interval (95% CI) 1.78-2.26] before eGFR modulation to 1.18 (95% CI 1.0-1.39; P = 0.046) with the MDRD and 1.37 (95% CI 1.18-1.58) with the CKD-EPI equations after adjusting for race coefficients. Conclusions: Removing race coefficients in GFR estimation formulas may result in a more equitable distribution of Black candidates listed earlier on a preemptive basis.

Hemorrhagic pneumonia and upper lobe pulmonary cavitary lesion caused by Streptococcus pyogenes.

A 33-year-old previously healthy man from Mexico who presented with massive hemoptysis, fevers, chills and found to have cavitary lesions in the right upper lobe of lung was highly suspicious for tuberculosis. The patient was treated with vancomycin, ceftriaxone, azithromycin and placed on isolation for suspected tuberculosis. Sputum AFB stains were negative and blood cultures grew Group A Streptococcus [GAS]. Antibiotics were narrowed down to ampicillin-sulbactam and the patient was discharged with significant clinical improvement. Strep A pyogenes is a rare cause of cavitary hemorrhagic pneumonia but is associated with high mortality. Clinical suspicion and early diagnosis are crucial in saving the patient.

Parasitic necrotizing pneumonia in an immunocompetent patient in United States.

A 59-year-old Baltimore native female, with a history of asthma and no history of travel outside of the USA, presented with productive cough and shortness of breath. Computed tomography scan showed left upper lobe consolidation of the lung with multiple tiny cavitations. She was empirically treated without improvement. Later, strongyloides were found in the sputum gram stain and she was treated with ivermectin. Pulmonary strongyloidiasis has been mainly described in patients who are immunosuppressed and have a history of travel to endemic areas, both of which were absent in our patient. Our case underlines the importance of considering strongyloides necrotizing pneumonia as a differential diagnosis of community-acquired pneumonia even in immunocompetent patients in the USA, especially if not responding to empiric treatment.