Endemic Fungal Infective Endocarditis Caused by Coccidioides, Blastomyces and Histoplasma Species in the United States.

We describe a recent case of Coccidioides bioprosthetic aortic valve infective endocarditis successfully managed at our institution. This led us to perform a literature review of endemic fungal infective endocarditis in the United States caused by Coccidioides, Blastomyces, and Histoplasma. Symptoms preceded infective endocarditis diagnosis by several months. Patients with Coccidioides and Blastomyces infective endocarditis were younger with fewer comorbid conditions. Valvular involvement was relatively uncommon in Blastomyces infective endocarditis (27%). Fungemia was noted in patients with infective endocarditis due to Histoplasma (30%) and Coccidioides (18%). Mortality rates for infective endocarditis were high (Histoplasma, 46%; Coccidioides, 58%; Blastomyces, 80%); infective endocarditis was commonly diagnosed post-mortem (Coccidioides, 58%; Blastomyces, 89%). Most surviving patients with infective endocarditis (Histoplasma, 79%; Coccidioides, 80%) underwent valve surgery along with prolonged antifungal therapy. The two surviving patients with Blastomyces infective endocarditis received antifungal therapy without surgery.

Whole-Blood PCR Preferred for Timely Diagnosis of Neuroinvasive West Nile Virus Infections: Lessons From the 2021 Arizona Outbreak.

Background: In 2021, the state of Arizona experienced the largest focal outbreak of West Nile virus (WNV) in US history. Timely and accurate diagnostic testing remains a challenge for WNV due to transient viremia and limited immunoassay specificity. Recent studies have identified whole blood (WB) and urine as more sensitive specimen types for the detection of WNV RNA. Methods: We evaluated ordering practices, test performance, and patient characteristics of probable and confirmed cases. In total, we identified 190 probable and proven cases, including 127 patients (66.8%) with neuroinvasive disease. Results: Among all cases, only 29.5% had WNV polymerase chain reaction (PCR) testing ordered on WB, of which 80.3% resulted as positive, including 7 cases in which WNV serologic testing was negative and 5 cases for which serologic testing was not ordered. In comparison, only 23.7% of cases that had cerebrospinal fluid (CSF) PCR ordered had a positive result, including 3 cases that were negative by PCR on WB. In contrast, WNV PCR on WB detected 12 neuroinvasive cases that were CSF PCR negative. WNV PCR testing in urine was only ordered on 2 patients, both of whom were positive. Crossing cycle threshold (Ct) values were not significantly different between WB and CSF specimen types, nor was there a correlation between Ct value and days from symptom onset at the time of sample collection; all specimen types and time points had Ct values, with 98% above 30. WB was positive by WNV PCR in several patients for >7 days (range, 7-25 days) after symptom onset, as was the CSF PCR. Conclusions: Taken together, these findings indicate that WNV PCR testing on WB may be the best initial test for timely diagnosis of WNV infection, irrespective of clinical manifestation; however, if negative in patients with suspected neuroinvasive disease, WNV PCR testing on CSF should be ordered.

Rhodococcus erythropolis septic arthritis.

A woman in her 50s presented with a 4-day history of left knee pain, erythema, swelling as well as malaise and rigours 1 month after undergoing a left knee meniscectomy. She was diagnosed with left native knee septic arthritis and underwent arthroscopic irrigation and debridement of the knee; cultures from synovial tissue grew Rhodococcus erythropolis. Rhodococcus spp are soil-dwelling and livestock-dwelling bacteria which occasionally cause disease in immunocompromised hosts. Infection in immunocompetent hosts is rare, and septic arthritis secondary to Rhodococcus erythropolis has not been reported previously.

Superimposed Neuroinvasive Coccidioidomycosis and West Nile Virus Infection.

A 58-year-old man with recently diagnosed coccidioidal meningitis presented to the ED with a five-day history of headache, photopsia, blurred vision, and worsening encephalopathy. His coccidioidal meningitis had responded well to fluconazole therapy, but three weeks later, he developed acute symptomatic worsening. Unfortunately, his clinical worsening coincided with Arizona's worst seasonal West Nile Virus (WNV) outbreak. He was ultimately found to have WNV neuroinvasive disease. Concurrent coccidioidal and WNV neuroinvasive diseases have not been described in the literature. Fortunately, he improved quickly to his normal baseline without neurologic deficits with supportive therapy for his WNV neuroinvasive disease and remains on lifelong antifungal therapy for coccidioidal meningitis.

Treatment of Recurrent Vulvovaginal Candidiasis With Ibrexafungerp.

Recurrent vulvovaginal candidiasis is a common disorder which causes significant morbidity among women worldwide, and treatment options are limited. Ibrexafungerp is a novel antifungal agent which was approved in 2021 for treatment of vulvovaginal candidiasis. We present a case of recurrent vulvovaginal candidiasis successfully treated with ibrexafungerp.

One man, three tick-borne illnesses.

A 70-year-old man presented to the emergency department with fevers, ankle edema and nausea following a presumed insect bite on his ankle 1 month prior. On examination, he was febrile and had left leg pain with passive range of motion. Laboratory studies revealed anemia, thrombocytopenia, acute kidney injury and elevated aminotransaminases. Due to his recent travel to the Northeastern United States, he was suspected of having a possible tick-borne illness. Serologies were positive for Borrelia burgdorferi, Anaplasma phagocytophilum and Babesia microti, and the patient was diagnosed with Lyme disease, babesiosis and anaplasmosis. He was treated with doxycyline, atovaquone and azithromycin, leading to resolution of symptoms. While co-infection with Lyme disease is common, infection with three tickborne illnesses at one time is relatively rare.

Erythroderma: A Rare Complication of Dyshidrotic Eczema.

A 47-year-old man with a history of dyshidrotic eczema presented to the emergency department with diffuse erythema, chills and pruritus of three weeks' duration. The patient had received two injections of methotrexate in the preceding two weeks, both of which had failed to improve his whole-body erythema and pruritus. In the emergency department, the patient was evaluated for infection and admitted for the dermatology consultation. After being seen on the general medical floor by the dermatology service the diagnosis of erythroderma was made and the patient was treated with intravenous (IV) cyclosporine therapy, with which his rash dramatically improved over three days. This case report summarizes the presentation and differential of erythroderma, and highlights the importance of having a high index of suspicion for this potentially fatal disease.

The epidemiology and survivorship of clear cell sarcoma: a National Cancer Database (NCDB) review.

PURPOSE: Clear cell sarcoma (CCS) is a rare soft tissue tumor thought to originate from tendons and aponeuroses. This is the largest and most comprehensive study of CCS to the best of our knowledge. In addition, this is the first study to determine the estimated 10-year overall survival, specific treatment modalities including neoadjuvant and adjuvant combinations, and sites of distant metastasis in CCS utilizing a national database. METHODS: The National Cancer Database (NCDB) was used to study 489 patients diagnosed with CCS from 2004 to 2014. Kaplan-Meier methods were used to estimate 5- and 10-year overall survival, and log-rank tests were used to compare survival amongst stage. RESULTS: Median age at diagnosis was 39 years. Males and females were equally affected. Race distribution was 78% Caucasian and 15% Black. Most common primary site was lower limb or hip (53%). Percentage of patients with distant organ metastases was 15%, with lung being the most common site (4%). Median overall survival was 57.2 months. Overall estimated 5- and 10-year survival was approximately 50 and 38%, respectively. Approximate 5-year survival for Stages I-IV was 75, 65, 35, and 15%, respectively. Stages at disease presentation were 34% at Stage I, 13% at Stage II, 16% at Stage III, and 38% at Stage IV. Surgery was the most common form of treatment (83%); 34% received radiation and 20% received chemotherapy. CONCLUSION: The 5-year overall survival for CCS in Stages III and IV was much worse than Stages I and II. Overall estimated 5- and 10-year survival was approximately 50 and 38%, respectively. Men and women were equally affected and had a median age at diagnosis of 39 years. The most common tumor location was lower limb and hip and the most common site of metastases was the lung.

Cold Pool-Land Surface Interactions in a Dry Continental Environment.

Cold pools influence convective initiation and organization, dust lofting, and boundary layer properties, but little is known about their interactions with the land surface, particularly in dry continental environments. In this study, two-way cold pool-land surface interactions are investigated using high-resolution idealized simulations of an isolated, transient cold pool evolving in a dry convective boundary layer. Results using a fully interactive land surface demonstrate that sensible heat fluxes are suppressed at the center of the cold pool but enhanced at the edge due to the spatial patterns of land surface cooling and the air temperature and wind speed perturbations. This leads to cold pool dissipation from the edge inward. Latent heat fluxes are primarily suppressed within the cold pool, and the magnitude of this suppression is controlled by competition between atmospheric and land surface effects. By comparing the fully interactive land surface simulation to a simulation with imposed surface fluxes, the land surface-cold pool feedbacks are shown to reduce the cold pool lifetime, extent, and intensity by up to 50% and influence the pattern of boundary layer turbulent kinetic energy recovery, which have significant implications for cold pool-induced convective initiation.

Olfactory dysfunction after head injury.

OBJECTIVE: To determine the incidence of olfactory dysfunction after head trauma using clinical and radiologic findings, quantitative assessment, and electro-physiologic methods. PARTICIPANTS: A total of 190 patients with head trauma of different severity (n = 32 with mild traumatic brain injury (TBI), n = 94 with signs of moderate TBI, and n = 64 with severe TBI) 6 to 32 months prior to the study. DESIGN: Patients were selected retrospectively, surveyed by telephone (n = 190), and screened for olfactory function with Brief Smell Identification Test (n = 82). Those with olfactory dysfunction were assessed as outpatients using the Sniffin' Sticks (n = 19) and olfactory-evoked potential recording (n = 16). RESULTS: Twenty-one participants (11%) reported a decreased sense of smell after trauma. The incidence of olfactory dysfunction after head injury was 12.8%. The results of the odor-evoked potentials were heterogeneous. A significant correlation was found between olfactory dysfunction and the appearance of skull base fractures and intracranial hemorrhage or hematoma. CONCLUSION: The site of trauma may be more relevant to prognosis than a simple probability (of olfactory loss) based on incidence. Odor-evoked potentials indicate that functional anosmia can occur even when there is some evidence of intact olfactory nerve function.

Australian norms for a quantitative olfactory function test.

Quantitative olfactory assessment is often neglected in clinical practice, although olfactory loss can assist diagnosis and leads to significant morbidity. The aim of this study was to develop normative data for the Australian population for the 'Sniffin' Sticks', an internationally established olfactory function test. As in other populations, Australian females performed better than males and both lost olfactory function with age. From the normative data, criterion test scores for males and females were established for clinical classifications ('normosmic', 'hyposmic', and 'nosmic'). These clinical classifications were assessed in Parkinson's patients: 81.1% were anosmic or severely hyposmic and only 7.7% were normosmic. A new term ('rebyosmia') is introduced to describe age-related loss of olfactory capacity of unknown aetiology. With these norms, the Sniffin' Sticks can be used in the Australian population to compare an individual's olfactory function against the population of others of similar age and sex and to identify olfactory dysfunction.