Anaerobiospirillum succiniciproducens prosthetic joint infection.

Anaerobiospirillum succiniciproducens is a rare anaerobic pathogen that is implicated in sporadic cases of bacteremia and diarrhea, usually in immunocompromised patients. We describe a case of prosthetic joint infection in a 71 year old male who presented with right hip pain. Anaerobic cultures from tissue specimen grew a spiral-shaped gram-negative rod, identified as A. succiniciproducens by 16S rRNA gene sequencing. The patient was treated successfully with IV cefoxitin for 6 weeks. To our knowledge this is only the third reported case of prosthetic joint infection due to A. succiniciproducens.

Extraintestinal Clostridium difficile infection: Scrotal abscess.

Clostridium difficile infection is one of the most common causes of healthcare-associated morbidity and mortality. ExtraintestinalC. difficile infection is extremely rare; though a variety of infections involving different organs have been reported. We report the first case of scrotal abscess due toC. difficile in an 84 year old male following left inguinal herniorrhaphy. Patient underwent surgical drainage of scrotal abscess and was successfully treated with culture directed antibiotic therapy.

Gastric antral vascular ectasia: case report and review of the literature.

Gastric antral vascular ectasia is the source of up to 4% of nonvariceal upper gastrointestinal bleeding. It can present with occult bleeding requiring transfusions or with acute gastrointestinal bleeding. It is associated with significant morbidity and mortality and has been associated with such underlying chronic diseases as scleroderma, diabetes mellitus, and hypertension. Approximately 30% of cases are associated with cirrhosis. We report two cases of gastric antral vascular ectasia with two strikingly different endoscopic appearances. We further describe the clinical, endoscopic, histologic, and therapeutic aspects of this entity.

Targeting cytomegalovirus-infected cells using T cells armed with anti-CD3 × anti-CMV bispecific antibody.

Human cytomegalovirus (CMV) reactivation and infection can lead to poor outcomes after allogeneic stem cell transplantation. We hypothesized that anti-CD3 activated T cells (ATCs) armed with chemically heteroconjugated anti-CD3 × polyclonal anti-CMV bispecific antibody (CMVBi) will target and eliminate CMV-infected cells. Arming doses of CMVBi as low as 0.01 ng/10(6) ATCs was able to mediate specific cytotoxicity (SC) directed at CMV-infected target cells significant above unarmed ATCs at mutiplicities of infection (MOI) between 0.01 and 1. At effector-to-target ratios (E:T) of 25:1, 12.5:1, 6.25:1, and 3.125:1, armed ATCs significantly enhanced killing of CMV-infected targets compared with unarmed ATCs. At an MOI of 1.0, the mean % SC directed at CMV-infected targets cells for CMVBi-armed ATCs at E:T of 3.12, 6.25, and 12.5 were 79%, 81%, and 82%, respectively; whereas the mean % SC for unarmed ATCs at the same E:T were all <20%. ATCs, Cytogam(®), or CMVBi alone did not lyse uninfected or CMV-infected targets. Co-cultures of CMVBi-armed ATCs with CMV-infected targets induced cytokine and chemokine release from armed ATCs. This nonmajor histocompatibility complex restricted strategy for targeting CMV could be used to prevent or treat CMV infections after allogeneic stem cell transplantation or organ transplantation.

Diagnosis, treatment, and prevention of anal cancer.

Rare in the general population, anal cancer has reached epidemic proportions among HIV-infected men who have sex with men (MSM). These cancers are human papillomavirus (HPV)-associated, usually HPV type16, and are analogous to cervical cancer. At present, the rates of anal cancer in this group are 10-fold higher than that of cervical cancer occurring in women in the general population. Although there are no national guidelines for screening for anal intraepithelial dysplasia (AIN), many large HIV clinics are now performing anal cytologic screening in their at-risk patients. This paper outlines the current approach to screening for AIN and its management.

Aerococcus Urinae Endocarditis: A Case Report and Literature Review.

A 75-year-old male, with a past medical history of chronic kidney disease stage 3 (CKD3) and a recent diagnosis of bilateral hydronephrosis and Foley catheter placement, presented to the emergency department for fever. Blood cultures grew Aerococcus urinae. Transthoracic echo (TTE) demonstrated thickened aortic valve leaflets with perforation, multiple echo densities, and severe aortic regurgitation. The patient developed decompensated congestive heart failure and cardiogenic shock. En route to surgery for emergent aortic valve replacement, the patient lost pulse and was resuscitated. The patient was subsequently transferred to the ICU where the family decided to initiate comfort care measures. This case highlights the importance and necessity of the prompt diagnosis and treatment of infective endocarditis and makes the reader aware of uncommon and rare organisms, such as Aerococcus urinae, as potential etiologies.

Recurrent urinary tract infections in kidney transplant recipients.

Urinary tract infections (UTIs) are the most common infectious complication after kidney transplantation (KT). Recurrent UTIs after KT can contribute to increased morbidity and may also be associated with graft loss and mortality. Though several risk factors like female gender, diabetes mellitus, presence of ureteric stents, native kidney disease with urological malformations and re-transplantation have been associated with recurrent UTIs after KT, vesicoureteric reflux appears to be a unique risk factor in this patient population. The emergence of drug-resistant pathogens as causative agents for post-transplant recurrent UTIs poses a significant therapeutic challenge. The use of pathogen-specific antibiotic therapy guided by culture and sensitivity data is warranted. The optimal duration of antimicrobial therapy for recurrent UTIs in renal transplant recipients remains uncertain.

Swallow syncope: a case report and review of the literature.

Swallow or deglutition syncope is a relatively rare syndrome. It is a vagally mediated syncope induced by swallowing. Swallow syncope may occur in all age groups and, when diagnosed, is treatable. A woman, aged 60 years, presented with an episode of a syncopal attack associated with swallowing a sandwich. She had a 6-month history of recurrent episodes of lightheadedness while eating solid foods. Telemetry monitoring demonstrated several episodes of severe bradycardia and complete atrioventricular block with up to a 7.0 second pause associated with meals. Computed tomography of the head and neck revealed no significant findings, and barium esophagram was normal. Echocardiogram was within normal limits. Her symptoms resolved after permanent pacemaker placement. Herein, we review the diagnosis, mechanism, and management of swallow syncope.

Ignatzschineria spp. bacteremia from maggot infestation.

Ignatzschineria spp. bacteremia associated with maggot infestation is extremely rare in humans. There are only a few cases worldwide ever reported in the literature. We described a clinical case with a male patient who presented with maggot manifestation at his lower extremity, was found with bacteremia, and subsequently identified as Ignatzschineria spp by 16S rRNA sequencing.

Long-Acting Lipoglycopeptides for the Treatment of Bone and Joint Infections.

Background: The long-acting lipoglycopeptides dalbavancin and oritavancin possess excellent microbiologic activity against gram-positive bacteria and provide prolonged tissue exposure at sites of infection. Moreover, these antibiotics are well tolerated and do not require therapeutic drug monitoring. Methods: Pharmacokinetic/pharmacodynamic experiments ascertained that one to two doses of these long-acting agents can provide an extended period (≥6 weeks) of antimicrobial therapy. Results: Clinical studies subsequently found that microbiologic and clinical response rates with these agents were comparable to standard antibiotic agents used in the treatment of bone and joint infections. In addition, pharmacoeconomic analyses have discovered cost savings with the use of these antimicrobial agents in the treatment of serious deep-seated bacterial infections. Conclusions: Thus, these long-acting lipoglycopeptides offer potential for cost-effective outpatient parenteral antibiotic therapy of difficult to treat infections, such as osteomyelitis.

Extranodal histiocytic sarcoma mimicking colorectal lymphoma: Case report and review of literature.

Histiocytic sarcoma is a rare malignant neoplasm that demonstrates mature histiocytic traits as characterized by immunohistochemistry. We report a case of extranodal histiocytic sarcoma (ENHS) of colon in a 56-year-old man presenting with gastrointestinal symptoms. Radiological findings were indicative of lymphoma or diffuse metastatic disease in colon. Histopathology of colectomy specimen was suggestive of ENHS, and immunohistochemical studies confirmed the uncommon diagnosis. The patient refused further therapy and succumbed to systemic complications of metastatic disease within a month of diagnosis. There have only been seven previous reports in world literature of ENHS involving large intestine.

Pharmacokinetic and Pharmacodynamic Analysis of Ceftazidime/Avibactam in Critically Ill Patients.

BACKGROUND: The pharmacokinetics, especially the volume of distribution (Vd), of ß-lactam antibiotics can be altered in critically ill patients. This can lead to decreased serum concentrations and a reduction in clinical cures. Ceftazidime/avibactam (CZA) is a new antimicrobial agent utilized in critically ill patients although its pharmacokinetics has not been well defined in these patients. PATIENTS AND METHODS: In this study, the serum concentrations of CZA from adult patients treated in an intensive care unit (ICU) with standard dosing regimens were measured and both pharmacokinetic and pharmacodynamic parameters were computed. The pharmacodynamic analyses included Monte Carlo simulations to determine the probability of target attainment (PTA: free ceftazidime concentrations exceed the minimum inhibitory concentration [MIC] for 50% of the dosing interval; free avibactam concentrations exceed 1 mg/L over the dosing interval) and serum time-kill curves against multi-drug-resistant Enterobacteriaceae susceptible to CZA. Serum concentrations were measured in 10 critically ill patients at two, four, six, and eight hours after multiple doses (infused over two hours) of CZA. RESULTS: A significant linear relation between creatinine clearance and total body clearance was identified for both ceftazidime (R = 0.91) and avibactam (R = 0.88). The mean clearance, volume of distribution, and half-life for ceftazidime were 6.1 ± 3.8 L/h, 35 ± 10.5 L, and 4.8 ± 2.15 h, respectively. For avibactam, these values were 11.1 ± 6.8 L/h, 50.8 ± 14.3 L, and 4.1 ± 2.1 h, respectively. Ceftazidime/avibactam achieved optimal PTA for bacteria with MICs of 16 mg/L or less. Furthermore, time-kill experiments revealed that serum concentrations of CZA, at each collection time, exhibited bactericidal (≥ 3 log10 CFU/mL reduction) activity against each of the study isolates. CONCLUSION: In conclusion, our study results suggest that the current dosing regimens of CZA can provide effective antimicrobial activity in ICU patients against CZA-susceptible (MIC ≤8 mg/L) isolates.

Cytomegalovirus infection in immunocompetent adults: Is observation still the best strategy?

Cytomegalovirus (CMV) infection in immunocompetent patients generally resolves with few sequelae. However, it can cause severe and relapsing symptoms that can last for several weeks. Due to the self-limiting nature of CMV disease in immunocompetent individuals, criteria for specific antiviral therapy in this cohort are not well established. Additionally the adverse effect profile of currently available anti-CMV therapy limits its use in specific patient populations .We describe 3 immunocompetent adults who developed symptomatic CMV infection and were ill for several weeks. All patients had positive CMV viral assays and ultimately received anti-CMV therapy with significant improvement in symptoms within a few days of starting therapy. Choosing appropriate candidates for anti-CMV therapy, among mmunocompetent individuals, requires further research.

Intratumoral granulomatous reaction in recurrent pituitary adenoma: A unique presentation.

Pituitary adenoma is one of the most common intracranial neoplasms, usually presenting with endocrinopathies or visual field defects. Granulomatous hypophysitis, one of the subtypes of primary hypophysitis, is a rare neurological entity presenting as a sellar lesion with mass effect symptoms and endocrinological dysfunction. Majority of cases of primary hypophysitis are misdiagnosed as pituitary adenomas preoperatively, and histopathology is required for a definitive diagnosis. Granulomatous hypophysitis can be primary/idiopathic or secondary to a variety of causes such as infection, foreign body reactions, and systemic inflammatory conditions. The presence of tumoral microgranulomas in pituitary adenoma is exceedingly rare, having been documented only twice previously. We present a unique case of recurrent pituitary macroadenoma in a 59-year-old woman with histopathological features of idiopathic intratumoral noncaseating granulomatous inflammation. The presence of a granulomatous response in the absence of a systemic infectious or inflammatory disorder is suggestive of a local tumoral response to an as-yet unidentified antigen.

Bilateral ovarian metastases as the presenting manifestation of lung carcinoid in a 50-year-old woman: Case study and review of literature.

Neuroendocrine tumors (NETs) are neoplasms arising from dispersed neuroendocrine cells, localized to the gastrointestinal tract (GIT), lungs, adrenal medulla, and other sites. The term "carcinoid tumor" is usually limited to NETs of the lung and GIT. Ovarian carcinoids are uncommon, accounting for 0.1% of ovarian malignancies and 5% of all NETs. Primary ovarian tumors arise in pure form or as a component of teratomas, while ovarian NET metastases are predominantly from gastrointestinal primaries. To the best of our knowledge, there are only two previous reports of bronchopulmonary carcinoids (PCs) metastasizing to the ovaries. We describe a case of PC in a 50-year-old woman, with bilateral ovarian tumors as the presenting manifestation of the disease, and discuss the clinical and pathobiologic significance of this presentation.

Isolated ileal ganglioneuromatosis in an 11-year-old boy: Case report and review of literature.

Ganglioneuromatous proliferation in the gastrointestinal tract is a rare occurrence and is usually associated with specific syndrome complexes such as multiple endocrine neoplasia Type 2B or von Recklinghausen's disease. We report here a case of diffuse intestinal ganglioneuromatosis, presenting as intestinal obstruction and chronic constipation in an 11-year-old boy. Sporadic cases of intestinal ganglioneuromatosis in the absence of any systemic manifestations are a very rare cause of enteric motility disorders in childhood, and we discuss the pathological and clinical significance of this finding. Histopathological identification of this uncommon cause of a common pediatric problem is important since the condition is amenable to surgical treatment.

Immunogenicity of 13-Valent Conjugate Pneumococcal Vaccine in Patients 50 Years and Older with End-Stage Renal Disease and on Dialysis.

Patients with end-stage renal disease (ESRD) and on dialysis are at increased risk of pneumococcal disease. We evaluated the immunogenicity of the 13-valent pneumococcal conjugate vaccine (PCV13) in this population. Eligible patients with ESRD and on dialysis were given a single dose of PCV13. The concentrations of serum antibodies against 13 pneumococcal capsular polysaccharides were measured at the baseline and at 2 and 12 months postvaccination. A response to the vaccine was defined as a ≥2-fold increase in antibody concentration from that at the baseline and an absolute postvaccination value of at least 1 µg/ml. Seventeen patients completed the study. Increases in the concentrations of antibodies to the vaccine serotype were demonstrated 2 months after vaccination. The geometric mean antibody concentrations at 12 months postvaccination declined by 38% to 72% compared to those measured at 2 months postvaccination. A response to at least 1 serotype in the vaccine was seen in all patients at both 2 and 12 months postvaccination. The overall rate of the response to each individual vaccine serotype varied between 23.5% and 94.1% at 2 months postvaccination and 23.5% and 65% at 12 months postvaccination. Pain at the injection site was the most common local reaction. Vaccination with PCV13 induces antibody responses to vaccine serotypes in patients with ESRD and on dialysis at 2 months postvaccination. However, the decline in antibody concentrations at 12 months postvaccination with a conjugate pneumococcal vaccine requires further study. (This study has been registered at ClinicalTrials.gov under registration no. NCT01974817.).

IgG Lambda Myeloma Presenting as Plasmacytic Ascites: Case Report and Review of Literature.

Multiple myeloma is a neoplastic disease of plasma cells accounting for 13 % of haematological malignancies and 2 % of all malignancies worldwide. Ascites may develop very rarely during the course of disease in multiple myeloma. We report the case of a 78 years old male with IgG lambda multiple myeloma who initially presented with plasmacytic ascites. An exhaustive review of world literature reveals 65 cases of ascites to have been reported in myeloma over a span of 62 years (1952 till date), usually developing in the course of treatment. This is the 7th case of plasmacytic ascites to have been diagnosed at initial presentation. We review the clinical features, diagnosis, prognostic significance and treatment of such cases.

Profile of oritavancin and its potential in the treatment of acute bacterial skin structure infections.

Oritavancin, a semisynthetic derivative of the glycopeptide antibiotic chloroeremomycin, received the US Food and Drug Administration approval for the treatment of acute bacterial skin and skin structure infections caused by susceptible Gram-positive bacteria in adults in August 2014. This novel second-generation semisynthetic lipoglycopeptide antibiotic has activity against a broad spectrum of Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-intermediate S. aureus (VISA), and vancomycin-resistant Enterococcus. Oritavancin inhibits bacterial cell wall synthesis and is rapidly bactericidal against many Gram-positive pathogens. The long half-life of this drug enables a single-dose administration. Oritavancin is not metabolized in the body, and the unchanged drug is slowly excreted by the kidneys. In two large Phase III randomized, double-blind, clinical trials, oritavancin was found to be non-inferior to vancomycin in achieving the primary composite end point in the treatment of acute Gram-positive skin and skin structure infections. Adverse effects noted were mostly mild with nausea, headache, and vomiting being the most common reported side effects. Oritavancin has emerged as another useful antimicrobial agent for treatment of acute Gram-positive skin and skin structure infections, including those caused by MRSA and VISA.