Management of acute cholecystitis.

PURPOSE OF REVIEW: Various aspects of the management of acute calculous cholecystitis, including type and timing of surgery, role of antibiotics, and nonoperative management, remain controversial. This review focuses on recently published studies addressing the timing of cholecystectomy, use of cholecystostomy tubes, and role of antibiotics in this condition. RECENT FINDINGS: In most cases, the diagnosis of acute cholecystitis can be initially confirmed with an abdominal ultrasound. Early laparoscopic cholecystectomy (within 24-72 h of symptom onset) is better than delayed surgery (>7 days) for most patients with grade I and II diseases. Percutaneous cholecystostomy and novel endoscopic gallbladder drainage interventions may be used as a temporizing measure or as definitive therapy in those who are too sick to undergo surgery. Studies are conflicting as to whether antibiotics are required for the treatment of uncomplicated cases. SUMMARY: Cholecystectomy remains the only definitive therapy for acute cholecystitis. Current guidelines recommend treatment on the basis of disease severity at presentation. Antibiotics and a variety of minimally invasive nonsurgical interventions, although not definitive, play an adjunctive role in the management of the disease.

Laryngeal tuberculosis in the United States of America: a forgotten disease.

Laryngeal tuberculosis (TB) was a common manifestation of TB in the early twentieth century, but now represents only 1% of all cases. Most modern case series of laryngeal TB originate outside the USA. We report a case of laryngeal TB from our institution and review other US cases published between 1970 and 2012. One hundred twenty-seven cases were identified. The mean patient age was 49 y and 28% were female. The mean duration of symptoms was 19 weeks. Dysphonia and weight loss were the most common manifestations, seen in 96% and 47% of cases, respectively. These symptoms were usually attributed to malignancy initially. Most cases involved the vocal cords. Eighty-six percent of cases had underlying pulmonary involvement. Mortality was 3%. In the USA, laryngeal TB is rarely suspected and often confused with malignancy. This infection should be considered in patients with unexplained dysphonia and weight loss.

Recognizing the roles of fever in host survival and in medical intervention in infectious diseases.

Fever has roles both in host defense against infectious challenges and in guidance of medical intervention. These roles remain insufficiently acknowledged and considered by both health care providers and patients and their families. This review cites reports in support of both roles and provides recommendations regarding the clinician's approach to fever, as well as points relevant for education of patients and their families.

Intra-abdominal fungal infections.

PURPOSE OF REVIEW: The clinical spectrum of intra-abdominal fungal infections has not been systematically analyzed in the literature. RECENT FINDINGS: Even though intra-abdominal fungal infections have been recognized with increasing frequency in the recent years, most clinical experience is limited to case reports or uncontrolled case series. These infections are more common than clinically recognized disease. The clinical presentation varies broadly depending on the organism and host's immune status, but it is frequently severe, difficult to treat, and associated with significant morbimortality. Predisposing factors, clinical characteristics, and advances in the management are discussed. SUMMARY: Intra-abdominal fungal infections are increasingly important in clinical practice. Early recognition and a combined treatment approach, usually consisting of surgical intervention and systemic antifungal therapy, are required for improved outcomes.

Five-year outbreak of community- and hospital-acquired Mycobacterium porcinum infections related to public water supplies.

Mycobacterium porcinum is a rarely encountered rapidly growing Mycobacterium (RGM). We identified M. porcinum from 24 patients at a Galveston university hospital (University of Texas Medical Branch) over a 5-year period. M. porcinum was considered a pathogen in 11 (46%) of 24 infected patients, including 4 patients with community-acquired disease. Retrospective patient data were collected, and water samples were cultured. Molecular analysis of water isolates, clustered clinical isolates, and 15 unrelated control strains of M. porcinum was performed. Among samples of hospital ice and tap water, 63% were positive for RGM, 50% of which were M. porcinum. Among samples of water from the city of Galveston, four of five households (80%) were positive for M. porcinum. By pulsed-field gel electrophoresis (PFGE), 8 of 10 environmental M. porcinum were determined to belong to two closely related clones. A total of 26 of 29 clinical isolates subjected to PFGE (including isolates from all positive patients) were clonal with the water patterns, including patients with community-acquired disease. Fifteen control strains of M. porcinum had unique profiles. Sequencing of hsp65, recA, and rpoB revealed the PFGE outbreak clones to have identical sequences, while unrelated strains exhibited multiple sequence variants. M. porcinum from 22 (92%) of 24 patients were clonal, matched hospital- and household water-acquired isolates, and differed from epidemiologically unrelated strains. M. porcinum can be a drinking water contaminant, serve as a long-term reservoir (years) for patient contamination (especially sputum), and be a source of clinical disease. This study expands concern about public health issues regarding nontuberculous mycobacteria. Multilocus gene sequencing helped define clonal populations.

Recovery of replication-competent residual HIV-1 from plasma of a patient receiving prolonged, suppressive highly active antiretroviral therapy.

The clinical significance of persistent residual viremia in patients on prolonged highly active antiretroviral therapy (HAART) is not clear. Moreover, it remains to be demonstrated whether residual viremia consists of viruses capable of spreading infection in vivo upon termination of therapy. Using residual viral RNAs (vRNAs) isolated from a HAART-treated patient's plasma, we cloned full-length viral genomes and found that most of them could produce infectious, replication-competent HIVs when transfected into TZM-bl cells, suggesting that residual viruses produced in the absence of therapy can initiate fresh cycles of infection and spread in host cells. The data further indicate that residual viremia may pose a major concern with regard to the emergence of drug-resistant HIVs during periods of low adherence to therapy.

Treatment Considerations in an HIV Elite Controller.

HIV elite controllers naturally suppress viral loads below limits of detection and evidence lack of evolution of infection for prolonged periods. The role of antiretroviral therapy (ART) in these individuals is controversial. Though recent data suggest that ART may decrease immune activation and prevent complications such as development of accelerated cardiovascular disease (CVD); treatment has not clearly demonstrated a benefit on clinical outcomes (e.g., HIV disease progression, CVD events, mortality). We describe a 49-year-old female HIV elite controller who presented with asymptomatic HIV infection for 26 years and review recent literature on the role of ART in this population.

Persistent Infection Versus Type 2 Immunological Reaction in Lepromatous Leprosy.

The distinction between persistent infection and immunologic reactions in leprosy is often difficult but critically important since their management is different. We present the case of a 51-year-old Vietnamese female who presented in 2015 with areas of erythema and skin infiltration on face and chest, as well as edema on her hands and feet. Skin biopsy was consistent with lepromatous leprosy. She was treated with rifampin, clarithromycin, and levofloxacin for 2 years. Her lower extremity edema was attributed to type 2 immunological reaction for which she was started on prednisone and methotrexate, but she was lost to follow-up for 19 months. She presented with new skin lesions and pain on her extremities. New biopsies revealed an intense neutrophilic infiltrate in the dermis and acid-fast bacilli focally within cutaneous nerve twigs. As compared with the initial biopsy, the inflammatory infiltrates were diminished and the bacilli had a degenerating appearance. These findings were consistent with type 2 immunological reaction. The patient was treated with thalidomide with improvement in the appearance of the skin lesions. A follow-up biopsy showed lack of neutrophilic infiltrates and decreased number of bacilli. This case illustrates the importance of differentiating between persistent infection and immunologic reactions in leprosy. Clinicians should be aware of these complications. A high index of suspicion and accurate interpretation of skin biopsy results are essential for appropriate diagnosis.

Lemierre's Syndrome Due to Methicillin-Resistant Staphylococcus aureus.

Lemierre's syndrome is an uncommon and potentially fatal complication of oropharyngeal and facial infections. It involves an associated septic thrombophlebitis, bacteremia, and septic emboli. Traditionally, compromise of the internal jugular vein has been described in conjunction with an infection caused by anaerobes, especially, Fusobacterium necrophorum. In recent years, however, variant forms have been appearing, including other vessel compromise and other etiologic agents. We present the case of Lemierre's syndrome in a 31-year-old male with facial vein thrombosis, septic emboli to the lungs, and bacteremia caused by methicillin-resistant Staphylococcus aureus. We hope that this case will raise awareness about variant presentations and promote a timely diagnosis and appropriate treatment of this potentially fatal infection.

Immune reconstitution inflammatory syndrome presenting as pericarditis and pericardial effusion.

Immune reconstitution inflammatory syndrome (IRIS) affects 30-43% of HIV and tuberculosis (TB) co-infected patients after starting highly active antiretroviral therapy (HAART). Pericarditis and pericardial effusion are rare manifestations of IRIS. We report a case of HIV-TB related IRIS that developed pericardial involvement. This complication resolved after treatment with ibuprofen. Antituberculous treatment and HAART were not interrupted.

Mycobacterium-avium-intracellulare complex immune reconstitution inflammatory syndrome in HIV/AIDS presenting as osteomyelitis.

We report a case of osteomyelitis due to Mycobacterium avium-intracellulare complex (MAC) in an AIDS patient shortly after the initiation of antiretroviral therapy with subsequent immune reconstitution inflammatory syndrome (IRIS). He improved after surgical debridement and treatment with clarithromycin, ethambutol, rifabutin, and low-dose corticosteroids. Antiretroviral therapy was not interrupted. MAC should be suspected in IRIS-related complications such as osteomyelitis.

Disseminated Histoplasmosis in Early Human Immunodeficiency Virus Infection.

Early human immunodeficiency virus (HIV) infection leads to transient immunosuppression followed by a quasi-homeostatic state with slow progression towards AIDS. Histoplasmosis has never been reported in early HIV. We present a case of disseminated histoplasmosis with documented recent seroconversion and review the literature regarding other opportunistic infections in early HIV.

Central nervous system pseudallescheriasis after near-drowning.

BACKGROUND: Clinical characteristics of central nervous system (CNS) pseudallescheriasis after near-drowning have not been systematically analyzed. METHODS: Review of cases reported in the English-language literature. RESULTS: Sixteen patients were identified. The average period between the near-drowning episode and onset of clinical manifestations was 37 days. Common manifestations included fever, altered mental status, headache, seizures, and hemiparesis. All patients developed brain abscesses; however, imaging studies were normal at presentation in 6 patients. Cerebrospinal fluid neutrophilic pleocytosis, elevated protein, and decreased glucose were commonly observed. Most patients were treated with surgical resection and systemic amphotericin B or miconazole. Voriconazole was used in 2 patients. Twelve patients (75%) died. The average time between the near-drowning episode and death was 12 weeks. Four survivors received prompt treatment. CONCLUSIONS: CNS pseudallescheriasis after near-drowning is highly lethal. Early diagnosis and aggressive medical and surgical interventions may improve survival.

Central Nervous System Histoplasmosis in Acquired Immunodeficiency Syndrome.

BACKGROUND: Involvement of the central nervous system (CNS) by Histoplasma capsulatum in AIDS is uncommon and not easily recognized. MATERIALS AND METHODS: CNS histoplasmosis cases from our institution were identified by a retrospective chart review from 2004-2014. A thorough literature search was performed for additional cases and their characteristics were compared. Clinical findings, treatment and outcomes are discussed. RESULTS: A total of 5 cases from our institution were identified. They had a clinical presentation that included classic signs of meningitis, often with evidence of disseminated involvement, and was typically severe with important neurological impairment. These cases were treated with antifungal agents, including a lipid amphotericin B formulation and azole drugs, but eventually 3 experienced nonresolution of their disease likely because of lack of adherence to therapy and died from their infection. The clinical presentation, treatment and outcome of these cases did not significantly differ from cases found in the review of the literature. CONCLUSIONS: Clinicians practicing in endemic areas should be aware of this rare but serious form of histoplasmosis. The recognition of 5 cases of CNS histoplasmosis in AIDS patients from a single institution suggests that histoplasmosis should be included in the differential diagnosis of the CNS complications of AIDS.

Candida glabrata endophthalmitis treated successfully with caspofungin.

A 39-year-old man with Candida glabrata endophthalmitis was successfully treated with a 28-day course of intravenous caspofungin. Presence of underlying renal insufficiency and infection with a drug-resistant strain precluded use of amphotericin B or fluconazole. Intravitreal administration of antifungals and vitrectomy were not required. The role of caspofungin in Candida endophthalmitis is discussed.

Clinical characteristics of linezolid-resistant Staphylococcus aureus infections.

Case reports have previously identified linezolid resistance in 6 clinical isolates of Staphylococcus aureus. We describe an additional case and discuss clinical characteristics of these patients. Invasive procedures, deep organ involvement, and presence of foreign material were predominant in these cases. Resistance followed prolonged (>21 days) linezolid therapy in most cases. The development of resistance to linezolid should be taken into account when selecting this drug as a therapeutic option.

Intravenous Foscarnet With Topical Cidofovir for Chronic Refractory Genital Herpes in a Patient With AIDS.

Few case reports have documented the use of topical cidofovir for refractory genital herpes simplex virus (HSV) ulcers in human immunodeficiency virus (HIV) infected patients. This drug formulation lacks a standardized concentration or even a procedural outline as to how it should be compounded. We aim to discuss the utilization of topical cidofovir in addition to presenting a procedural means of compounding it for treatment of refractory genital HSV ulcers. Our patient completed 21 days of intravenous foscarnet and 13 days of topical cidofovir with clinical improvement in the penile and scrotal ulcers. Genital herpes is a concern in patients with HIV because it generally manifests as a persistent infection. Physicians should be aware that when patients fail to respond to the conventional treatment regimens for genital HSV in a timely manner, other options are available, such as topical cidofovir as an adjuvant to systemic antivirals.

Deep sternal wound infection caused by group g streptococcus after open-heart surgery.

We report the first case of deep sternal wound infection caused by group G Streptococcus after open-heart surgery. The patient's clinical presentation was nonspecific and his diagnosis was delayed. Surgical debridement and a 4-week course of intravenous antibiotics consisting of sequential penicillin plus gentamicin/ceftriaxone led to recovery. Group G Streptococcus should be suspected as an important postoperative pathogen.

Antigen negative gastrointestinal histoplasmosis in an AIDS patient.

PATIENT: Female, 51 FINAL DIAGNOSIS: Gastrointestinal histoplasmosis Symptoms: Abdominal pain • nausea • vomiting MEDICATION: - Clinical Procedure: - Specialty: Gastroenterology and Hepatology. OBJECTIVE: Adverse events of drug therapy. BACKGROUND: Gastrointestinal involvement in patients with disseminated histoplasmosis is considered common since the organism is identified in the GI tract of approximately 70-90% of autopsy cases. This infection is rarely recognized by clinicians due to its non-specific symptoms. Lesions may occur anywhere in the GI tract but most commonly affects the terminal ileum. PATIENTs present with GI bleeding, intestinal obstruction, ulcerations, masses, and peritonitis. Serum and urine serological antigens are useful for diagnosis because they are positive in over 90% of patients with disseminated disease but may be falsely negative in patients with localized GI involvement. Although histopathology and tissue cultures are specific, limitations include insensitivity and need for invasive procedures. Antifungal agents include intravenous amphotericin B for severe or unstable disease and oral itraconazole for stable disease. CASE REPORT: A 51-year-old HIV positive female presented with abdominal pain, nausea and vomiting. A CT scan of the abdomen revealed circumferential narrowing around a segment of the sigmoid colon with the cecum demonstrating irregular thickened walls. A biopsy of an obstructing duodenal mass found on endoscopy revealed granulomatous inflammation and budding yeasts consistent with Histoplasma spp. She was started on intravenous liposomal amphotericin B and after 2 weeks switched to itraconazole oral solution. Urine and serum histoplasma antigens sent out 2 weeks after antifungal treatment were negative. CONCLUSIONS: This case report illustrates the importance of recognizing gastrointestinal histoplasmosis in AIDS patients presenting with non-specific GI symptoms.