Rare Case of Disseminated Histoplasmosis Mitral Valve Endocarditis in Florida.

BACKGROUND Histoplasma capsulatum is prevalent in the mid-eastern United States and is an environmental fungus that causes human infection by the inhalation of its spores. It is commonly associated with areas containing large amounts of bird excrement and can survive for years in the soil. Only 1% of infected individuals develop disseminated histoplasmosis or Histoplasma endocarditis. CASE REPORT A 61-year-old man with atrial fibrillation had 8 months of fatigue, low-grade fevers, night sweats, and unexplained weight loss presented to the Emergency Department. He worked and lived in Central Florida and although he raised cattle, he denied exposure to birds or bats with regularity. A transesophageal echocardiogram confirmed a sessile echo density on the atrial surface of the mitral valve. His microbial Karius cell-free DNA test from his blood sample was positive for Histoplasma capsulatum, and he was immediately given intravenous liposomal amphotericin for 2 weeks. A tissue valve was used to successfully replace his mitral valve along with a coronary artery bypass and a maze procedure for his persistent atrial fibrillation and atrial flutter. The diagnosis of mitral valve endocarditis from disseminated histoplasmosis was confirmed by pathological analysis, and he was sent home on long-term itraconazole maintenance treatment. CONCLUSIONS Surgical intervention in combination with anti-fungal medication can be a lifesaving intervention for disseminated histoplasmosis. A thorough history is particularly important when evaluating a patient with an unknown infectious source, especially assessing for risk factors, including exposure to environmental factors, workplace, and animals.

Neurocysticercosis Presenting as Migraine in the United States.

BACKGROUND Cysticercosis is a condition caused by infection with the larval form of Taenia solium, a pork tapeworm that uses pigs as an intermediate host. Humans become infected when they ingest water or food contaminated with tapeworm cysts. Cysticercosis is increasing in frequency in developed countries due to increased access to travel. Neurocysticercosis occurs when Taenia solium cysts embed within the nervous system. The clinical presentation of neurocysticercosis ranges from asymptomatic to life-threatening, largely depending on the brain parenchymal involvement. The diagnosis is typically made with a combination of clinical evaluation, serology, and neuroimaging. Treatment for parenchymal neurocysticercosis may involve anthelmintic agents, symptomatic agents, surgery, or a combination of methods. CASE REPORT A 52-year-old man with a medical history of migraine headaches, complicated type 2 diabetes mellitus, and obesity presented with a 4-month change in his migraines becoming severe, worse over his occiput bilaterally, and unresponsive to abortive therapy. His exposure history was unremarkable except for a habit of eating undercooked bacon, by which he would have developed neurocysticercosis via autoinfection. Neuroimaging and serology confirmed a diagnosis of neurocysticercosis and he was treated accordingly with antiparasitic and anti-inflammatory medications. CONCLUSIONS This presentation is nonspecific and can easily be overlooked, especially if there is an underlying known neurological condition such as migraine. This case illustrates that neurocysticercosis should be considered when an existing neuropathological condition displays a change in presentation or requires a change in therapeutic management, even without obvious risk factors.

Epithelioid Hemangioendothelioma: A Rare Case of an Aggressive Vascular Malignancy.

BACKGROUND Epithelioid hemangioendothelioma (EHE) is a rare vascular malignancy that occurs in multiple organs and tissues with a predilection for the extremities, bone, liver, and lung. It is often characterized by a clinically indolent course, delayed diagnosis, and unestablished standardized treatment options. CASE REPORT A 46-year-old female presented with a 2-month history of right shoulder and arm pain. Imaging revealed involvement of the humerus, lung, liver; and brain and biopsies of both the lung and humerus were performed. A diagnosis of epithelioid hemangioendothelioma was confirmed and the patient received radiation therapy to the right humerus and brain stereotactic radiosurgery. She was scheduled to begin palliative chemotherapy with doxorubicin but developed complications and never received chemotherapeutic agents. She died 5.5 months from her first admission with widespread metastasis. CONCLUSIONS Epithelioid hemangioendothelioma (EHE) is typically a low-to-intermediate grade vascular malignancy, but, as seen in this case, can be aggressive. In the future, diagnosis, prognosis, and treatment may improve using genetic or immune therapy considering a structural chromosomal translocation has been identified.

Robot-Assisted Laparoscopic Myomectomy Versus Abdominal Myomectomy A Retrospective Comparison of Short-Term Surgical Outcomes.

OBJECTIVE: To compare intraoperative and postopera- tive surgical outcomes of robotic versus abdominal myo- mectomy. STUDY DESIGN: A retrospective chart review was performed using electronic medical records from Janu- ary 1, 2008-December 31, 2011, with 2008 being the first year that robotic- assisted myomectomy was performed at our institution. Intraoperative outcome data and postoperative complica- tions were reviewed as well as length of hospital stay. RESULTS: A total of 214 abdominal myomectomy cases and 165 robotic-assisted laparoscopic cases were available for review. Total operating time in minutes.was significantly longer for the robotic-assisted cases (236 ± 96) versus the abdom- inal cases (110 ± 46). Total myoma weight in grams removed was significantly greater in the abdominal myo- mectomy cases (391 ± 518) versus the robot-assisted- cases (229 ± 253). Length of stay in days was longer for abdominal cases as compared to robotic (3.3 ±1.2 vs. 1.6 ± 1). Estimated blood loss in milliliters was similar between abdominal and robotic cases (258 ± 335' vs. 241± 370). CONCLUSION: Robotic-assisted and abdominal myo- mectomies have similar surgical outcomes. However, the longer total operating time for robotic-assisted myomec- tomies is a drawback which may not be completely offset by the benefit of a shorter hospital stay.

Video assisted thoracic surgery in a second trimester pregnant woman with thoracic empyema: a case report.

BACKGROUND: An empyema is an infection of the pleural space that occurs most frequently secondary to the progression of pneumonia. The stages of empyema are based on pleural characteristics and reflect the risks of the condition for morbidity and mortality. Pregnancy is a risk factor for major complications of pneumonia, including empyema. CASE: A pregnant woman at 25 weeks' gestation with a community-acquired Streptococcus pneumoniae pneumonia underwent video-assisted thoracotomy decortication and debridement of a large loculated, gelatinous empyema after conservative medical therapy failed. CONCLUSION: Conservative medical therapy with antibiotics alone may not be adequate for advanced bacterial empyema in pregnancy.

Biliary cyst in pregnancy managed by percutaneous drainage: a case report.

BACKGROUND: A maternal biliary cyst diagnosed in pregnancy is extremely rare. The condition can be asymptomatic or can present with chronic and intermittent abdominal pain, rupture of the cyst, and liver function test abnormalities. Management depends on the gestational age and the patient's condition when it is diagnosed. CASE: We present a case of a symptomatic type IV biliary cyst with abnormal liver function tests diagnosed in the second trimester of pregnancy and treated with a percutaneous drainage. The patient delivered vaginally at term and developed obstruction of the percutaneous drain with superimposed bacterial infection postpartum. She was lost to follow-up intermittently throughout her treatment. CONCLUSION: Symptomatic biliary cyst in pregnancy may require palliative invasive intervention until delivery.

Effect of fundal pressure on maternal to fetal microtransfusion at the time of cesarean delivery.

AIM: To determine if fundal pressure at the time of cesarean delivery increases the amount of transplacental microtransfusion from mother to infant. METHODS: Pregnant women undergoing cesarean delivery were randomized to the standard uterine fundal pressure at the time of hysterotomy versus no fundal pressure. Babies of patients randomized to no fundal pressure were delivered with either vacuum or forceps. The proportion of placental alkaline phosphatase between maternal and cord blood was then determined and compared between the groups. RESULTS: Eighty-four women were randomized into two groups (44 in the pressure and 40 in the no pressure groups). There was no difference between the groups in demographic variables, or indications for cesarean. There was no difference in percentage of umbilical cord blood placental alkaline phosphatase between the pressure and no pressure groups (0.06 +/- 0.2 vs 10 +/- 0.29 IU, P = 0.43). CONCLUSIONS: Fundal pressure at the time of cesarean delivery does not increase the amount of transplacental microtransfusion, suggesting that modifying the method of cesarean would not decrease the chances of vertical transmission in HIV positive pregnant women.