Susceptibility of nucleotide-binding oligomerization domain 2 mutations to Whipple's disease.

OBJECTIVES: Whipple's disease (WD) results from infection of the bacteria Tropheryma whipplei (TW). This disease is characterized by macrophage infiltration of intestinal mucosa and primarily affects Caucasian males. Genetic studies of host susceptibility are scarce. Nucleotide-binding oligomerization domain containing protein 2 (NOD2) is an innate immune sensor, resides mainly in monocytes/macrophages and contributes to defense against infection and inflammatory regulation. NOD2 mutations are associated with autoinflammatory diseases. We report the association of NOD2 mutations with TW and WD for the first time. METHODS: A multicenter, retrospective study of three patients with WD was conducted. Patients received extensive multidisciplinary evaluations and were cared for by the authors. NOD2 and its association with infection and inflammation were schematically represented. RESULTS: All patients were Caucasian men and presented with years of autoinflammatory phenotypes, including recurrent fever, rash, inflammatory arthritis, gastrointestinal symptoms, and elevated inflammatory markers. All patients underwent molecular testing using a gene panel for periodic fever syndromes and were identified to carry NOD2 mutations associated with NOD2-associated autoinflammatory disease. Despite initially negative gastrointestinal evaluations, repeat endoscopy with duodenal tissue biopsy ultimately confirmed WD. After initial ceftriaxone and maintenance with doxycycline and/or hydroxychloroquine, symptoms were largely controlled, though mild relapses occurred in follow up. CONCLUSION: Both NOD2 and TW/WD are intensively involved in monocytes/macrophages. WD is regarded as a macrophage disease. NOD2 leucin rich repeat-associated mutations in monocytes/macrophages cause functional impairment of these cells and consequently may make the host susceptible for TW infection and WD, especially in the setting of immunosuppression.

Cryptogenic Liver Abscess Caused by a K1 Serotype Klebsiella pneumoniae Isolate.

Hypervirulent Klebsiella pneumoniae (hvKp) is a common cause of pyogenic liver abscesses in Asia but is quite uncommon in North America. Among the cases described in North America, only occasional reports have described molecular strain typing to confirm the K1 strain as the causative agent. We report a 56-year-old Hispanic female with no previous intra-abdominal pathology and no recent travel, who presented with subacute abdominal pain and developed bacteremia and monomicrobial pyogenic liver abscess due to a community-acquired K1 serotype K. pneumoniae isolate. In this case, the infection was recognized early, so the patient was successfully treated with percutaneous drainage and prolonged antibiotic therapy. Hvkp can cause severe invasive disease with high morbidity and mortality, and the recent emergence of multidrug resistance in these strains poses a serious threat to public health. In addition, the isolation of a K1 K. pneumoniae strain from a cryptogenic liver abscess in a Hispanic patient with no epidemiologic risk factors raises concern for a wider spread of the hypervirulent strain beyond Asian populations. Therefore, a high index of suspicion for hvKp infection in the Hispanic population can be crucial as the hypervirulent strain is likely to cause severe metastatic infection with significant morbidity and mortality.

Candidiasis and Mechanisms of Antifungal Resistance.

Candidiasis can be present as a cutaneous, mucosal or deep-seated organ infection, which is caused by more than 20 types of Candida sp., with C. albicans being the most common. These are pathogenic yeast and are usually present in the normal microbiome. High-risk individuals are patients of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), organ transplant, and diabetes. During infection, pathogens can adhere to complement receptors and various extracellular matrix proteins in the oral and vaginal cavity. Oral and vaginal Candidiasis results from the overgrowth of Candida sp. in the hosts, causing penetration of the oral and vaginal tissues. Symptoms include white patches in the mouth, tongue, throat, and itchiness or burning of genitalia. Diagnosis involves visual examination, microscopic analysis, or culturing. These infections are treated with a variety of antifungals that target different biosynthetic pathways of the pathogen. For example, echinochandins target cell wall biosynthesis, while allylamines, azoles, and morpholines target ergosterol biosynthesis, and 5-Flucytosine (5FC) targets nucleic acid biosynthesis. Azoles are commonly used in therapeutics, however, because of its fungistatic nature, Candida sp. evolve azole resistance. Besides azoles, Candida sp. also acquire resistance to polyenes, echinochandins, and 5FC. This review discusses, in detail, the drug resistance mechanisms adapted by Candida sp.

Mycobacterium avium-avium-associated typhlitis mimicking appendicitis in an immunocompetent host.

Mycobacterium avium-intracellulare complex (MAC) primarily causes respiratory infection in patients with underlying lung disease or disseminated disease in immunocompromised patients. We report a unique case of MAC disease in the terminal ileum of a healthy patient, mimicking appendicitis. This case emphasizes the need to further explore MAC pathogenesis in immunocompetent hosts.

Aspergillus osteomyelitis: review of 12 cases identified by the Prospective Antifungal Therapy Alliance registry.

A review of 12 patients with proven Aspergillus osteomyelitis was undertaken between July 2004 and October 2007. Aspergillus fumigatus was most commonly identified (n = 9). Voriconazole was commonly administered (11/12; 91.7%), and 9 (75.0%) underwent surgery. Seven (58.3%) responded to treatment, and 12-week mortality was 25.0% (3/12). Survival was improved with surgical intervention (P = 0.05).

Hyposplenism: a comprehensive review. Part II: clinical manifestations, diagnosis, and management.

In the first part of this review, we described the physiological basis of splenic function and hypofunction. We also described the wide spectrum of diseases that can result in functional hyposplenism. In the second part of this review, we will be discussing the clinical picture, including complications, diagnostic methods, and management of hyposplenism.