Myelofibrosis: An unusual presentation of disseminated tuberculosis.

Disseminated tuberculosis (DTB) often presents with protean clinical manifestations that often leads to potential diagnostic dilemmas. The nonspecific features may include pyrexia of unknown origin, hepatosplenomegaly, lymphadenopathy, meningitis, and a variety of hematological abnormalities, namely anemia, pancytopenia, and leukemoid reaction. Tuberculosis is one of the nonhematopoietic diseases that has been reported in conjunction with myelofibrosis. We, hereby, report a case of DTB with massive splenomegaly, severe pancytopenia, and marrow fibrosis.

Septicemic melioidosis complicating undiagnosed chronic kidney disease and beta-thalassemia minor in a Bangladeshi farmer.

Melioidosis is an emerging infectious disease in many countries including Bangladesh. Patients with diabetes mellitus are at increased risk for infection by Burkholderia pseudomallei, the causative agent for melioidosis. Here, we report an autochthonous case of septicemic melioidosis occurring in a middle-aged non-diabetic Bangladeshi farmer who presented with prolonged pyrexia and splenomegaly. Diagnostic workup revealed splenic micro-abscesses, previously undetected chronic kidney disease (CKD) and beta-thalassemia minor. This case stresses the importance of searching for less common risk factors for melioidosis such as CKD and hemolytic anemia.

[Periodic fever and pancytopenia in a 35-year-old patient]. / Periodisches Fieber und Panzytopenie bei einem 35­jährigen Patienten.

MEDICAL HISTORY AND INITIAL PRESENTATION: A 35-year-old patient with a previous history of persistent episodic fever, sore throat, myalgia, and cephalgia presented for evaluation of pancytopenia. He had no recent travel history, except for a stay in Italy 1 year prior to admission and in Spain several years in the past. DIAGNOSTIC WORKUP: Laboratory evaluation confirmed pancytopenia, agranulocytosis, and elevated infection parameters without indicative serological results en par with lymphadenitis colli. Computed tomography scanning revealed cervical lymphadenopathy, hepatosplenomegaly, and colitis with occult perforation of the sigmoid colon. Bone marrow biopsy showed an infiltration of polyclonal plasma cells. Lymph node biopsy was compatible with necrotizing lymphadenitis. DIAGNOSIS: Polymerase chain reaction analysis of a lymph node specimen confirmed the presence of Leishmania species, thereby enabling the diagnosis of visceral Leishmania. THERAPY COURSE: Treatment with liposomal amphotericin B was initiated. Both fever and lymphadenopathy quickly resolved. CONCLUSION: VL is a clinically pleiotropic, severe disease with fatal outcome if left untreated. It often presents with distinct similarities to hematologic malignancies. Exacerbation can occasionally occur as fulminant macrophage activation syndrome. Disease incidence is globally increasing and has not peaked as yet. A complex interplay between pathogen and the immune system is the key pathophysiological mechanism.

Hepatosplenic brucella abscesses on computed tomography and magnetic resonance imaging: Case series.

INTRODUCTION: Because of its infrequent and the lack of clinical data and image finding, the management of acute infections with the hepatosplenic brucella abscesses is challenging. METHODS: There were 10 serologically diagnosed cases with this brucella infection. All patients had fever, 50% patients had upper abdominal pain. Ninety percent patients lived in an urban environment. The localization of lesions included: 30% hepatosplenic, 30% liver, and 40% spleen. RESULTS: Abdominal computed tomography (CT) scans and magnetic resonance imaging (MRI) demonstrated hepatosplenomegaly, with multiple small abscess lesions of various sizes in the acute stage of brucellosis, with the largest diameter of 1.5 cm in the liver. After contrast-enhanced CT and MRI findings, the arterial phase in which the enhancing area of lesions was thick, revealed multifocal hypodense or hypointense lesions of various sizes. These lesions manifested distinct boundary, which was intensified obviously in portal venous phase. CONCLUSION: Our results indicate that early CT or MRI dynamic contrast enhancement of suspected cases could improve rapid diagnosis. However, diagnostic criteria remain problematic and diagnosis is mostly based on a combination of clinical suspicion, serologic markers, and radiologic findings.

Brucellosis in pregnancy: results of multicenter ID-IRI study.

Brucellosis in pregnant women is reported to be associated with obstetric complications (OCs), and adequate data for human brucellosis during pregnancy are largely lacking. We performed this multicenter retrospective cross-sectional study to evaluate the epidemiology, clinical course, treatment responses, and outcomes of brucellosis among pregnant women. The study period comprised a 14-year period from January 2002 to December 2015. All consecutive pregnant women diagnosed with brucellosis in 23 participating hospitals were included. Epidemiological, clinical, laboratory, therapeutic, and outcome data along with the assessment data of the neonate were collected using a standardized questionnaire. Data of 242 patients were analyzed. The OC rate was 14.0% (34/242) in the cohort. Of the 242 women, 219 (90.5%) delivered at term, 3 (1.2%) had preterm delivery, 15 (6.2%) aborted, and 5 (2.1%) had intrauterine fetal demise. Seventeen (7.0%) of the newborns were considered as low birth weight. Spontaneous abortion (6.1%) was the commonest complication. There were no maternal or neonatal deaths and pertinent sequelae or complications were not detected in the newborns. Splenomegaly (p = 0.019), nausea and/or vomiting (p < 0.001), vaginal bleeding (p < 0.001), anemia (blood hemoglobin < 11 g/dL; p < 0.001), high level of serum aspartate aminotransferase (> 41 IU/L; p = 0.025), oligohydramnios on ultrasonography (p = 0.0002), history of taking medication other than Brucella treatment during pregnancy (p = 0.027), and Brucella bacteremia (p = 0.029) were the significant factors associated with OCs. We recommend that pregnant women with OC or with fever should be investigated for brucellosis if they live in or have traveled to an endemic area.

Case Report: Scrub Typhus and Q Fever Coinfection.

A 56-year-old female goat herder had scrub typhus that persisted after receiving doxycycline for 5 days. Her symptoms continued, prompting us to perform further examinations that revealed coinfection of Q fever and scrub typhus via molecular and serological testing. We also isolated Orientia tsutsugamushi using BALB/c mice and L929 cells.

Disseminated histoplasmosis mimicking relapsed chronic lymphocytic leukaemia.

Histoplasma microconidia when inhaled are presented in antigenic form to T cells, limiting the extent of infection; however, defects in cellular immunity results in disseminated disease. Chronic lymphocytic leukaemia (CLL) is a lymphoproliferative disorder resulting in functionally impaired lymphocytes, predisposing patients to various opportunistic infections. The author reports a recently treated patient with CLL presenting with constitutional symptoms accompanied by hepatosplenomegaly and diffuse adenopathy. Considering the recent diagnosis and treatment of CLL, initial suspicion was relapsed disease. However, considering the immune deficiency associated with CLL and its treatment, infectious aetiologies were strongly considered. Further investigation revealed a case of disseminated histoplasmosis mimicking CLL in this reported patient. Considering appropriate diagnosis and timely therapy, the reported patient had good prognosis despite being diagnosed with disseminated histoplasmosis. This case highlights consideration of disseminated histoplasmosis in patients presenting with diffuse adenopathy along with hepatomegaly and/or splenomegaly in the right clinical setting.

Septicemic listeriosis: An emerging food-borne illness in India?

Listeriosis is a food borne illness of significant public health concern, caused by consumption of food contaminated by gram negative bacilli, Listeria monocytogenes. Clinical listeriosis is relatively rare and it has varying spectrum of presentation, ranging from severe sepsis in immune-compromised individuals, febrile gastroenteritis and meningo-encephalitis in infants and adults. This disease is under reported in developing nations due to the lack of awareness and inadequate laboratory facilities to promptly isolate and identify the organism. We report a case of sporadic food-borne listeriosis, in an otherwise healthy individual presenting with meningo-encephalitis. Prompt identification and appropriate antibiotic therapy led to a favorable outcome.

Congenital jaundice in bovine aborted foetuses: an emerging syndrome in southern Belgium.

Southern Belgium faces an unusual recent increase of icteric bovine aborted foetuses. In the necropsy room, the majority of foetuses presented jaundice and splenomegaly. Despite a wide range of analyses, no definitive cause of abortion has yet been established but some analysis results support the leptospirosis hypothesis. This first description of cases will help veterinary practitioners to recognize more cases and to conduct those to the laboratory for future investigations.

Splenic abscess as a potential initial manifestation of quiescent infective endocarditis in a patient with bronchopneumonia.

A 78-year-old woman presented to the acute medical unit with a productive cough, dyspnoea and decreased appetite of 4 days duration. Initial assessment supported a diagnosis of right-sided community-acquired pneumonia and she was started on antibiotics. In view of the clinical finding of splenomegaly, she had an ultrasound and, subsequently, a CT of the abdomen, which revealed a large splenic abscess. Pending cultures from a sample obtained from percutaneous drainage of the abscess, she was started on intravenous meropenem. The initial echocardiogram did not suggest any evidence of endocarditis. The pus drained from the abscess on cultures was subsequently positive for Staphylococcus aureus. An MRI of the spine excluded discitis as a source of infection. Owing to a high index of clinical suspicion a repeat echocardiogram was undertaken after 1-week, which confirmed acute endocarditis. The patient was treated with intravenous antibiotics for 6 weeks with improvement in clinical, radiological and biochemical parameters.

Brucella cyclic ß-1,2-glucan plays a critical role in the induction of splenomegaly in mice.

Brucella, the etiological agent of animal and human brucellosis, is a bacterium with the capacity to modulate the inflammatory response. Cyclic ß-1,2-glucan (CßG) is a virulence factor key for the pathogenesis of Brucella as it is involved in the intracellular life cycle of the bacteria. Using comparative studies with different CßG mutants of Brucella, cgs (CßG synthase), cgt (CßG transporter) and cgm (CßG modifier), we have identified different roles for this polysaccharide in Brucella. While anionic CßG is required for bacterial growth in low osmolarity conditions, the sole requirement for a successful Brucella interaction with mammalian host is its transport to periplasmic space. Our results uncover a new role for CßG in promoting splenomegaly in mice. We showed that CßG-dependent spleen inflammation is the consequence of massive cell recruitment (monocytes, dendritics cells and neutrophils) due to the induction of pro-inflammatory cytokines such as IL-12 and TNF-α and also that the reduced splenomegaly response observed with the cgs mutant is not the consequence of changes in expression levels of the characterized Brucella PAMPs LPS, flagellin or OMP16/19. Complementation of cgs mutant with purified CßG increased significantly spleen inflammation response suggesting a direct role for this polysaccharide.

Ultrasound presentation of abdominal tuberculosis in a German tertiary care center.

OBJECTIVE: Abdominal tuberculosis (TB) is a relatively rare disease in most of Europe and the typical clinical and sonographic findings in this setting have not been studied. We aimed to define sonographic findings that should alert an examiner to the possibility of abdominal TB in a low endemic region. METHODS: Case records of 17 patients with proven (n = 11) or highly likely (n = 6) abdominal TB detected in the gastrointestinal ultrasound unit at a German tertiary care center in 2003-2013 were analyzed retrospectively. Findings were compared with reported series from high-prevalence regions. RESULTS: While 76% of patients had an immigrant background, only 35% had a condition associated with immunosuppression. Lymphadenopathy was present in all cases of abdominal TB, while it was absent in 28% of patients from a control group with proven abdominal sarcoidosis. Moreover, retroperitoneal lymphadenopathy was significantly more common in TB. Other findings in patients with abdominal TB in descending order of frequency were ascites, altered hepatic texture, splenomegaly, splenic lesions, peritoneal thickening, intestinal wall lesions, hepatic lesions and hepatomegaly. 76% of abdominal TB patients had 2 or more pathological findings. CONCLUSIONS: Multiple pathological intra-abdominal findings including lymphadenopathy should alert the examiner to the possibility of abdominal TB.

Ultrasonographic appearance of histoplasmosis identified in the spleen in 15 cats.

Histoplasmosis is the second most common fungal infection reported in the cat. The disseminated form involving lung, liver, lymph nodes, spleen, and bone marrow is a frequent manifestation of the disease. Limited information is available in the literature regarding the ultrasonographic appearance of the spleen in cats with disseminated or splenic histoplasmosis. A retrospective review of splenic ultrasound images from 15 cats confirmed to have histoplasmosis by splenic aspirates was performed. Size, echotexture, echogenicity, margin appearance, presence of nodules, and the overall shape of the spleen were reported in each case. Splenomegaly was documented in all cases (15/15) and a hypoechoic appearance of the spleen was documented in 14/15 of cases. The spleen was diffusely and uniformly affected in 14/15 (six homogenous and eight with a subtle mottled appearance) and had discrete nodules in 1/15 cats. Histoplasmosis should be included in the differential list for an enlarged and hypoechoic spleen in cats with consistent clinical findings. Additionally, ultrasound guided splenic aspirate may be a useful method to obtain a cytology sample for diagnosis.

Streptococcus anginosus group disseminated infection: case report and review of literature.

Streptococcus anginosus group is widely known for its ability to cause invasive pyogenic infections. There are very few reports of disseminated infections sustained by members of this streptococcal group. We report a case of a highly disseminated infection and analyse previous literature reports. Disseminated pyogenic infection has been defined as an infection affecting two or more of the following organs/systems: central nervous system, lung, liver and spleen. We performed a PubMed search using the terms: S. milleri, S. anginosus, brain abscess, pulmonary abscess, hepatic abscess, spleen abscess. We reviewed 12 case reports including the one presented in this paper. Underlying conditions such as dental infections, malignancy, gastrointestinal and respiratory tract disease accounted for 42% of cases. No definite endocarditis was encountered, even though positive blood cultures were found in 67% of patients. Concomitant brain-liver, brain-lung and brain-spleen involvement occurred in 50%, 42% and 8% of cases respectively. Ninety-one percent (91%) of patients were treated with ß-lactams, and surgical procedures were performed in 67% of patients. Infections caused by S. anginosus group members are satisfactorily treated with penicillin G and cephalosporins. It is very important to associate surgery to antimicrobial chemotherapy in order to achieve a full or nearly full clinical recovery.

Polyfunctional CD4+ T cell responses to immunodominant epitopes correlate with disease activity of virulent Salmonella.

Salmonella enterica serovars are intracellular bacteria capable of causing typhoid fever and gastroenteritis of significant morbidity and mortality worldwide. Current prophylactic and therapeutic treatment is hampered by the emergence of multidrug-resistant (MDR) strains of Salmonella, and vaccines provide only temporal and partial protection in vaccinees. To develop more effective Salmonella vaccines, it is important to understand the development of protective adaptive immunity to virulent Salmonella. Here we report the identification of novel CD4(+) T cell peptide epitopes, which are conserved among Salmonella serovars. Immunization of Salmonella-infected mice with these peptide epitopes reduces the burden of Salmonella disease. Furthermore, we show that distinct polyfunctional (interferon-γ(+), tumor necrosis factor(+), and interleukin-2(+)) Salmonella-specific CD4(+) T cell responses develop with respect to magnitude and kinetics. Moreover, we found that CD4(+) T cell responses against immunodominant epitopes are predictive for active Salmonella disease. Collectively, these data could contribute to improved diagnosis of Salmonella-related diseases and rational design of Salmonella vaccines.

Clinical and laboratory profile of enteric fever in children in northern India.

The diagnosis of enteric fever poses several problems due to the non-specific and wide array of clinical features. A five-year retrospective study enrolling 136 culture-proven cases of enteric fever was undertaken in order to estimate the clinical and laboratory characteristics, fever clearance time and outcome. The common symptoms and signs were: fever, vomiting, cough, anorexia, diarrhoea, abdominal pain, hepatomegaly, splenomegaly and coated tongue. Enteric fever should be considered in the differential diagnosis of febrile patients with abdominal symptoms.