Pulmonary Embolism in a Patient with Rheumatoid Arthritis on Etanercept Therapy.

Pulmonary embolism (PE) represents mechanical obstruction of one or more branches of pulmonary vasculature due to thromboembolism from a deep vein thrombosis. Hormonal contraceptives, hormonal replacement therapy, antipsychotics and fibrates are medications that are associated with increased risk of venous thromboembolism(VTE). Etanercept is a TNF alpha and beta receptor blocker. Rarely this medication has been identified as a risk factor for VTE. There is a possible correlation between rheumatoid arthritis(RA) and risk of VTE in patients with RA. Use of medication that can increase risk of VTE in a patient with systemic inflammatory condition that in itself may be a risk factor for VTE requires shared decision and risk versus benefit discussion with the patient. We present a case of unprovoked PE in a patient on Etanercept treatment for RA. Though in this case, a causal relationship between the drug use and the event could not be proved, the patient preferred to discontinue the medication. In newer classes of medications, when the mechanism of side effects is unclear, we strongly recommend extensive discussion with patients about available scientific literature and encourage shared decision making with the patient.

Subcutaneous pythiosis in human treated successfully with antimicrobial treatment, debridement and immunotherapy.

Pythiosis is caused due to a filamentous eukaryotic micro-organism called Pythium insidiosum and the disease occurs commonly in horses and cattle. Subcutaneous pythiosis infection in humans is rare with no clear clinical guidelines for treatment. We present a case of a man in his 20s with non-resolving ulcers noted over lower extremity after exposure to swamp water draining animal remains. The patient received several courses of oral antibiotics with no improvement in symptoms before getting admitted to our institution. A diagnosis of subcutaneous pythiosis was made after deep wound culture following debridement detected P. insidiosum by use of PCR. Due to the rare incidence of such infection in humans and no clear guidelines available for treatment, the case was discussed with infectious disease specialists outside our institution and with veterinary physicians. An emergent approval for use of immunotherapy in conjunction with surgical debridement and antimicrobials was obtained from Food and Drug administration. The patient underwent successful treatment of infection and skin graft following treatment.

Finding of Anaerococcus hydrogenalis in blood using cell-free DNA technique in a patient with infective endocarditis.

Introduction: The annual incidence of infective endocarditis (IE) is 3-9 cases per 100000 in developed countries and most cases are due to staphylococci and streptococci. IE due to Gram-positive anaerobic cocci (GPAC) is very rare. Case report: We present a case of a 38-year-old female with Anaerococcus hydrogenalis bacteremia and infective endocarditis of the native mitral valve. She presented with fever, chills, and abdominal pain. A computed tomographic scan of the abdomen showed splenic abscesses. Blood cultures and broad-range PCR from the splenic abscess sample were negative. Transthoracic echocardiography showed a mobile filamentous structure on the atrial side of the anterior mitral leaflet which was suggestive for infective endocarditis. Karius test (cell-free microbial DNA testing) showed Gram-positive anaerobic cocci Anaerococcus hydrogenalis. She was successfully treated with antibiotics. Conclusions: In cases of infection with fastidious organisms like GPACs, the use of next-generation sequencing (NGS) can allow the correct identification of culprit pathogens and streamlined treatment.

Treatment of Extra-Intestinal Clostridioides difficile Abscess following Acute Appendicitis.

Clostridioides difficile infection (CDI) commonly presents with diarrhoea, colitis, and in more severe cases, toxic megacolon. Extraintestinal Clostridioides difficile infection (EI CDI) is rarely reported. Intraabdominal abscesses are the most commonly reported EI CDI presentation. EI CDI-associated bacteraemia, as well as bone, lung, and even intracranial infections have been reported in the literature. EI CDI is usually seen in patients with multiple comorbidities. Due to the rarity of cases, no clear treatment guidelines exist, but metronidazole and vancomycin have been primarily used to treat EI CDI and additional antibiotics have been used for treatment when the isolates are polymicrobial. We report a case of a patient with significant comorbidities who developed EI CDI following acute ruptured appendicitis. She was successfully treated with drainage of abscess and intravenous metronidazole followed by oral metronidazole. LEARNING POINTS: Clostridioides difficile commonly causes colitis and extraintestinal Clostridioides difficile infection is a rare finding.Extraintestinal Clostridioides difficile infection occurs due to translocation of flora in the setting of acute inflammation.Extraintestinal Clostridioides difficile abscesses are commonly polymicrobial and associated with high mortality.

Pembrolizumab for the treatment of Progressive Multifocal Leukoencephalopathy (PML) in a patient with AIDS: A case report and literature review.

Progressive multifocal leukoencephalopathy (PML) is an opportunistic central nervous system (CNS) infection caused by the reactivation of John Cunningham polyomavirus (JCV) from suppression of the host immune system due to conditions such as human immunodeficiency virus causing acquired immunodeficiency syndrome (HIV/AIDS), hematological malignancies, multiple sclerosis, and use of immunosuppressant medications. Pembrolizumab is an immune checkpoint inhibitor targeting programmed cell death protein-1 (PD-1) receptors on lymphocytes. In recent years its use is expanding to treat several malignancies and it is a drug of interest for the treatment of PML. In this case report, we present a case of an HIV/AIDS patient who was given a trial of pembrolizumab for treatment of PML. We also provide a literature review of the reported cases of use of this medication in other immunocompromised states.

Listeria Meningitis in a Patient With Plaque Psoriasis on Ustekinumab Therapy.

Listeria monocytogenes is a foodborne infection and is a leading cause of meningitis. The at-risk population includes patients over age 65, neonates, pregnant females, and patients with impaired cell immunity. Ustekinumab is a human monoclonal antibody that binds to and interferes with the proinflammatory cytokines, interleukin-12 (IL-12) and interleukin-23(IL-23). The drug is used for the treatment of Crohn's disease, ulcerative colitis, psoriatic arthritis, and plaque psoriasis. We present a case of listeria meningitis in a patient on ustekinumab therapy for plaque psoriasis.

Bullous Pemphigoid Associated With Pembrolizumab Therapy for Non-Small-Cell Lung Cancer: A Case Report.

Pembrolizumab is an immune checkpoint inhibitor being increasingly used as immunotherapy for a multitude of cancers. With the increasing use of these agents, various immune-related adverse events are being recognized. Lichenoid reaction, pruritus, and eczema are well-established cutaneous side effects of pembrolizumab, but bullous pemphigoid (BP) is a rare side effect of the drug. It is difficult to establish this diagnosis because it needs a detailed history of the timeline of the evolution of symptoms and careful ruling out of other etiologies, especially other drugs. Here, we present the case of a 66-year-old male who developed BP after receiving pembrolizumab therapy for non-small-cell lung cancer. Discontinuation of pembrolizumab and the use of topical and systemic steroids led to the complete resolution of symptoms. Physicians should be aware of this potential complication and keep it on their differential diagnosis when treating patients on immune checkpoint inhibitors.

Case of coexisting Nocardia cyriacigeorgica and Aspergillus fumigatus lung infection with metastatic disease of the central nervous system.

Nocardiosis is a rare opportunistic gram-positive bacterial infection. The genus Nocardia consists of non-motile, aerobic, non-spore-forming, catalase-positive, filamentous-branching bacteria with fragmentation into coccoid or bacillary forms. Opportunistic infections due to Nocardia are reported in immunocompromised patients. Aspergillus fumigatus is a conidia forming fungus that can be found in soil, plant matter and dust, causing invasive pulmonary and disseminated infection in immunocompromised patients. Both Nocardia cyriacigeorgica and A. fumigatus are known to cause pulmonary infection with metastatic dissemination to the central nervous system. We present a case of Nocardia and Aspergillus co-infection in a patient who presented within a few days of initiation of immunosuppressants for suspected systemic lupus erythematosus.

A Case Report and Literature Review of New-Onset Myasthenia Gravis After COVID-19 Infection.

Myasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction caused by a B-cell-mediated, T-cell-dependent immunologic attack at the end plate of the postsynaptic membrane. Attack on muscle acetylcholine receptors (AChR) of the postsynaptic membrane due to the AChR, muscle-specific tyrosine kinase, or lipoprotein receptor-related peptide 4 antibodies lead to symptoms of painless, fluctuating weakness of muscle groups and often begins with ocular signs and symptoms. Coronavirus disease 2019 (COVID-19) is an acute respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus closely related to SARS-CoV. Serious neurologic complications are infrequent and diverse with reported cases of stroke, encephalitis/meningitis, Guillain-Barré syndrome, acute disseminated encephalomyelitis, ataxia, and unspecified limb weakness. MG is a rarely reported sequela of COVID-19 infection. To date, there are 15 reported cases of post-COVID-19 MG. In this article, we present a case of post-COVID-19 MG and a concise review of other reported cases. An 83-year-old Caucasian male with a medical history of atrial fibrillation status post-ablation and non-ischemic cardiomyopathy was initially admitted for COVID-19 pneumonia. He was treated with remdesivir, convalescent plasma, and supplemental oxygen therapy but did not require invasive mechanical intubation. One month after discharge, he started experiencing fatigue with muscle weakness and progressive dyspnea. He progressed to develop dysphonia, especially at the end of the day. After extensive workup, he was diagnosed with MG with a positive antibody against the AChR. The chronological events of developing slowly worsening muscular weakness after recovering from COVID-19 infection and positive AChR antibody led to the diagnosis of post-COVID-19 new-onset MG. Post-COVID-19 fatigue, long-term use of steroids, and intensive care unit-related physical deconditioning can be confounders in the clinical presentation of post-COVID-19 new-onset MG. Careful history-taking and meticulous assessment of chronological events are needed to diagnose this rare entity.

More than Valley Fever: Pulmonary Actinomycosis and Coccidioidomycosis Co-infection in a Patient.

Pulmonary coccidioidomycosis and pulmonary actinomycosis are unheard of as co-pathogens. Infection with these organisms on their own can mimic lung cancer, thus presenting a diagnostic challenge. We present the case of a 75-year-old woman presenting with haemoptysis with a chest CT chest finding of a lung mass suggestive of lung cancer. A diagnosis of concomitant infection by Coccidioides posadasii/immitis and Actinomyces odontolyticus was made based on culture and histopathology results. The patient was successfully treated with a combination of antifungal and antibacterial therapy. This is the first reported case of co-infection by these two microorganisms. LEARNING POINTS: Pulmonary coccidioidomycosis and pulmonary actinomycosis can mimic lung cancer.The diagnosis of infection by Coccidioides posadasii/immitis and Actinomyces odontolyticus is best obtained by histopathology and tissue culture.Treatment comprises a combination of oral azoles and a beta-lactam antibiotic for a total of 12 months.

Strongyloides Hyper-Infection Syndrome and Ciliocytophthoria Mimicking Balantidium coli.

Ciliocytophthoria is a phenomenon where degenerated cells in infections or malignancy can present as ciliated cells on microscopy and so may be confused with ciliated parasitic infection. We present an interesting case of recurrent shortness of breath, misdiagnosed as chronic obstructive pulmonary disease exacerbations leading to unnecessary exposure to antimicrobials and steroids. The case was diagnosed as Strongyloides hyper-infection syndrome. Another finding worth mentioning was that ciliated cells noted on broncho-alveolar lavage were thought to be a co-infection with Balantidium coli but were later confirmed as ciliocytophthoria. LEARNING POINTS: Strongyloides hyper-infection syndrome should be considered in the differential diagnosis of a patient from an endemic area presenting with non-resolving respiratory symptoms.Ciliocytophthoria is a type of degenerative process where degenerated cells can appear ciliated on microscopy.Balantidium coli appears to be similar but is much larger and has cilia circumferentially compared with ciliocytophthoria which has a polar distribution of cilia.

Deaths due to delayed presentation to the hospital from fear of contracting COVID-19 during lockdown period: a tertiary care center experience.

Background: Sudden rise in COVID-19 cases in March 2020 due to spread of pandemic led to immediate lockdown order in many states and cities across the USA. Everyone had to stay home to stop the spread of the virus. We investigated all deaths in our hospital during lockdown period and assessed how many presented and died from non-COVID-19-related illness. Among those deaths, we assessed how many presented late due to excessive fear of catching coronavirus in the hospital and succumbed to the same illness due to very late presentation. Methods: We retrospectively reviewed charts of every patient who expired in the hospital in a 45-day period, March-April 2020. Results: Three of 107 (2.8%) deaths during lockdown period in this hospital were clearly attributable to delayed presentation arising specifically from fear of coming to the hospital. All three died from non-COVID-19-related illnesses. Conclusions: Authors hereby propose enhanced efforts in the direction to alleviate unnecessary fear among public even during lockdown. People should be encouraged to continue to access health care for serious/fatal medical conditions regardless of the pandemic.

Paecilomyces Pneumonia Despite Voriconazole Prophylaxis: A Case Report and Literature Review.

Paecilomyces species are a rare cause of fungal pulmonary infections in immunocompromised hosts. Paecilomyces variotii and Paecilomyces lilacinus are the two most common species of clinical significance. Both species differ in their susceptibility to antifungal agents. We present a rare case of a 47-year-old immunocompromised woman who developed Paecilomyces pneumonia despite being on voriconazole prophylaxis. We also present a review of the literature on other reported cases. LEARNING POINTS: Paecilomyces species differ in their susceptibility to antifungal agents.Breakthrough invasive mould infections are increasingly being documented in immunocompromised patients on voriconazole prophylaxis.Posaconazole has been shown to be effective against both Paecilomyces species.

Capnocytophaga canimorsus meningitis diagnosed using next- generation sequencing of microbial cell-free DNA.

Capnocytophaga canimorsus meningitis is frequently caused by exposure to dog or cat bites and occurs more commonly in immunocompromised individuals. CSF analysis is the first step in diagnosis; however, in situations where CSF cultures turn negative, molecular techniques such as 16S rRNA gene amplification followed by polymerase chain reaction (PCR) product sequencing have shown promise. Next generation sequencing of cell free DNA (NGS cfDNA) can assist in identifying the causative agent in a quick and accurate manner. We present a rare case of C. canimorsus meningitis in an immunocompetent host that highlights the utility of NGS cfDNA in timely diagnosis after exhausting all other available diagnostic techniques.

Fulminant Pancreatitis Due to Disseminated Histoplasmosis: Case Report and Literature Review.

Acute pancreatitis (AP), an inflammatory disease of the pancreas, is clinically classified into mild AP, moderately severe, and severe based on local complications and presence of organ failure. Histoplasmosis, caused by the dimorphic fungus Histoplasma capsulatum, typically presents with pulmonary disease. Extrapulmonary disease/disseminated histoplasmosis can affect the gastrointestinal tract, with only a few reported cases of pancreatitis secondary to the above. We describe a rare case of a young woman who presented with necrotizing pancreatitis secondary to histoplasmosis. The etiology of pancreatitis remained unclear throughout her hospital stay despite extensive workup performed. Diagnosis of disseminated histoplasmosis was based on autopsy findings.

Rare Presentation of Toxoplasma Pneumonitis in the Absence of Neurological Symptoms in an AIDS Patient and Use of Next-Generation Sequencing for Diagnosis.

Toxoplasma gondii is a known cause of encephalitis in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients. Toxoplasma pneumonitis is a manifestation of extracerebral toxoplasmosis and can be clinically indistinguishable from other opportunistic infections including Pneumocystis jirovecii pneumonia (PJP) and miliary tuberculosis. In this case report, Toxoplasma pneumonitis and disseminated toxoplasmosis was diagnosed using next-generation sequencing (NGS) and polymerase chain reaction (PCR) assessment. NGS can detect microbial cell-free DNA (cfDNA) circulating in the plasma of over 1,000 pathogens. This case is a rare presentation of Toxoplasma pneumonitis in the absence of neurological symptoms and we discuss the use of NGS of microbial cfDNA and PCR tests that may be utilized for the timely diagnosis of such challenging cases. LEARNING POINTS: Next-generation sequencing can help make a correct diagnosis and detect culture-negative opportunistic infections.Recognition of Toxoplasma pneumonitis as a rare presentation of disseminated toxoplasmosis.In cases of Toxoplasma pneumonitis, brain imaging should be conducted to rule out CNS involvement even in the absence of neurological symptoms.

Disseminated Nocardia beijingensis Infection in an Immunocompetent Patient.

Nocardia is a genus of aerobic, non-motile and non-spore-forming filamentous branching bacteria with fragmentation into bacillary or coccoid forms. Infections caused by Nocardia often occur in immunocompromised hosts and are potentially life-threatening. Nocardia beijingensis has rarely been reported to cause infection in immunocompetent hosts. We present a case of disseminated infection due to Nocardia beijingensis in a patient with no known medical comorbidities, who presented with new-onset seizure. Another interesting finding in our case is that our patient did not have any pulmonary symptoms despite chest CT showing the pulmonary system as the likely primary site of infection. As per our literature review, this is the seventh reported case of infection due to Nocardia beijingensis in an immunocompetent host. LEARNING POINTS: To recognize Nocardia beijingensis, a slow-growing weakly acid-fast filamentous bacteria commonly causing opportunistic infections in immunocompromised hosts, as an emerging pathogen in immunocompetent patients.Tissue biopsy with Gram staining showing variable filamentous bacteria and confirmation of species using restriction enzyme analysis and 16S rRNA analysis is needed to establish a diagnosis of infection.Trimethoprim/sulfamethoxazole has been successfully used to treat infection due to Nocardia beijingensis.

Rapid Diagnosis of Invasive Aspergillosis and Active Hepatitis-B Virus Co-Infection in a HIV-1 Infected Patient Using Cell Free DNA Sequencing.

Multiple simultaneous opportunistic infections in Human Immunodeficiency virus-1/Acquired immunodeficiency syndrome (HIV-1/AIDS) is a known and dreaded occurrence that often leads to poor outcomes. We present a case of disseminated aspergillosis and active Hepatitis-B virus (HBV) infection in such a host, where cell free DNA (cfDNA) next generation sequencing (NGS) of plasma was used to expedite diagnosis. Bronchoscopy was avoided and treatment was started expeditiously. In this case report we discuss the interpretation of the cfDNA NGS, and its potential role for early diagnosis and avoidance of invasive testing.

Isolated Non-Resolving Vulvar Lesion as a Presentation of Disseminated Histoplasmosis in a Woman with HIV.

Disseminated histoplasmosis is most commonly caused by Histoplasma capsulatum and is a known opportunistic infection in immunocompromised patients. The clinical presentation of histoplasmosis varies from asymptomatic to a progressive disseminated form. Pulmonary and CNS involvement is common in disseminated histoplasmosis. Rarely, disseminated disease can present as vulvar lesion in the absence of pulmonary symptoms, causing a delay in diagnosis. As per our PubMed literature search, there have only been two reported cases where vulvar lesion was the only presenting symptom of disseminated disease. In our patient, a histopathological diagnosis was made with staining showing budding yeast forms of histoplasma. LEARNING POINTS: Histoplasmosis can be a cause of isolated non-resolving vulvar lesion in immunocompromised patients.In patients at risk, we recommend work-up for disseminated histoplasmosis with urine histoplasma antigen and further imaging to rule out disseminated infection when histoplasma is identified on local biopsy samples.In patients from endemic regions and in non-resolving vulvar lesions, fungal infection should be considered.

Segmental Arterial Mediolysis: An Under-Recognized Cause of Chronic Abdominal Pain.

Segmental arterial mediolysis (SAM) is a non-inflammatory, non-atherosclerotic vasculopathy mostly involving the abdominal arteries. SAM was recently recognized as a more prevalent aetiology of abdominal pain than initially thought by healthcare providers. It is still a commonly missed diagnosis in patients with recurrent emergency room (ER) visits for abdominal pain. Most published case reports in the past have highlighted catastrophic sequelae such as intra-abdominal haemorrhage requiring surgical intervention. We report a case of SAM where the diagnosis was initially missed. After diagnosis, conservative medical management was offered which led to clinical improvement. LEARNING POINTS: To recognize segmental arterial mediolysis (SAM) as a cause of chronic abdominal pain in the middle-aged and elderly population.To differentiate SAM from inflammatory vasculitis and atherosclerotic conditions.For cases with mild symptoms and haemodynamic stability, conservative management such as early lifestyle modifications, hypertension and hyperlipidaemia control and regular imaging follow-up should be offered.