Anaplasma phagocytophilum Encephalitis: A Case Report and Literature Review of Neurologic Manifestations of Anaplasmosis.

Anaplasma phagocytophilum is an obligate intracellular, Gram-negative pathogen, causative agent of Human Granulocytic Anaplasmosis (HGA). HGA usually manifests as a non-specific febrile illness, accompanied by evidence of leucopenia, thrombocytopenia, and an alteration in liver enzymes. Neurologic manifestations of anaplasmosis are rare and rarely reported. We describe a 62-year-old man who developed encephalitis due to an Anaplasma phagocytophilum infection. The patient favorably responded to intravenous doxycycline and recovered without neurological sequela. In the tick endemic area, clinicians should have a high index of suspicion for tick-borne diseases in patients presenting with neurological deficits. A prompt diagnosis and treatment lead to improvements in morbidity and mortality.

Trust the Process: Prolonged Babesia Parasitemia in an Elderly Man with Asplenia from the American Midwest.

BACKGROUND Babesia species are intraerythrocytic parasitic protozoa that are endemic to the Northeast and north Midwest of the United States. Babesia microti is the most common cause of babesiosis in North America and causes a malaria-like tick-borne parasitosis. Babesia is commonly transmitted through the bite of Ixodes species ticks, often concomitantly with other tick-borne organisms such as Borrelia burgdorferi, Ehrlichia, Rickettsia rickettsii, and Anaplasma phagocytophilum. In the Midwest, Lyme disease is the most common tick-borne illness, and other organisms can sometimes be overlooked. The risk of tick-borne parasitic or bacterial infection is increased in patients after splenectomy. CASE REPORT An 89-year-old man with asplenia and multiple other comorbidities presented to the Emergency Department after a fall at home preceded by 2 to 3 days of fever and loss of appetite and 1 week of generalized weakness. The patient had thrombocytopenia, leukocytosis with neutrophilia, transaminitis, hyperbilirubinemia, and elevated creatine kinase level consistent with tick-borne illness. Laboratory testing revealed Borrelia and Babesia co-infection and other culprits were ruled out via high sensitivity PCR. Owing to the patient's asplenic status, the babesiosis was slow to resolve with appropriate treatment. After an extended 8-week treatment with azithromycin and atovaquone, the patient demonstrated clinical resolution of babesiosis with a negative blood smear. CONCLUSIONS First-line treatment with azithromycin and atovaquone is effective in treating babesiosis even in complicated patients, such as this elderly, asplenic patient. However, in cases such as this, an extended course of a first-line treatment regimen is still appropriate.

Successful treatment of rapid growing mycobacterial infections with source control alone: Case series.

Rapid growing mycobacteria have been increasingly recognized as pathogens, both in immunocompromised and immunocompetent population, and their incidence has increased over the last decade significantly. Pulmonary infections are the most common, however, any organ can be affected. The treatment of these infections is costly, prolonged, and often antimicrobial resistance poses a significant challenge to a successful outcome. The source control together with antimicrobials is the cornerstone of treatment. We report a case series of 3 patients with extrapulmonary rapid growing mycobacterial infections in whom the successful treatment was achieved with source control alone.

Case of fatal eastern equine encephalitis.

Eastern Equine Encephalitis (EEE) is a rare and very serious arbovirus that is transmitted to humans through the bite of infected mosquitoes. When symptomatic, patients with this condition are typically seriously ill and the fatality rate is high. We present a fatal case of EEE that exhibited classic symptoms and findings. Included are high quality MRI images that show the classic radiographic findings of this infection. In addition to confirmatory laboratory findings, the case report includes pathologic specimens from brain tissue obtained at autopsy. Perhaps due to climate change and human encroachment on mosquito habitat, there is a westward spread of EEE in the United States.

A Framework for Outpatient Infusion of Antispike Monoclonal Antibodies to High-Risk Patients with Mild-to-Moderate Coronavirus Disease-19: The Mayo Clinic Model.

The administration of spike monoclonal antibody treatment to patients with mild to moderate COVID-19 is very challenging. This article summarizes essential components and processes in establishing an effective spike monoclonal antibody infusion program. Rapid identification of a dedicated physical infrastructure was essential to circumvent the logistical challenges of caring for infectious patients while maintaining compliance with regulations and ensuring the safety of our personnel and other patients. Our partnerships and collaborations among multiple different specialties and disciplines enabled contributions from personnel with specific expertise in medicine, nursing, pharmacy, infection prevention and control, electronic health record (EHR) informatics, compliance, legal, medical ethics, engineering, administration, and other critical areas. Clear communication and a culture in which all roles are welcomed at the planning and operational tables are critical to the rapid development and refinement needed to adapt and thrive in providing this time-sensitive beneficial therapy. Our partnerships with leaders and providers outside our institutions, including those who care for underserved populations, have promoted equity in the access of monoclonal antibodies in our regions. Strong support from institutional leadership facilitated expedited action when needed, from a physical, personnel, and system infrastructure standpoint. Our ongoing real-time assessment and monitoring of our clinical program allowed us to improve and optimize our processes to ensure that the needs of our patients with COVID-19 in the outpatient setting are met.

Possible Lyme Carditis with Sick Sinus Syndrome.

Borrelia burgdorferi (B. burgdorferi) is a spirochete bacterium that is transmitted via the Ixodes tick. Infection results in Lyme disease with possible cardiac manifestations, which is also known as Lyme carditis. Patients can present with bradycardia due to rapidly fluctuating atrioventricular block (AVB), which is the hallmark of Lyme carditis. However, we present a rare case of sick sinus syndrome (SSS) without AVB in a 47-year-old man with Lyme disease. He initially presented with a headache and subsequently developed new onset bradycardia and a right cranial nerve (CN) VI palsy with diplopia. B. burgdorferi enzyme-linked immunosorbent assay (ELISA) screen and IgM western blot were positive. He was admitted to the intensive care unit. Electrocardiography (EKG) indicated a heart rate in the high 30 s beats per minute (BPM) with several pauses, but no AVB was present. The patient responded well to therapy, and was discharged with an outpatient regimen of doxycycline. Lyme carditis should be considered in patients who develop new onset bradycardia and live in endemic areas.

Managing and preventing vascular catheter infections: A position paper of the international society for infectious diseases.

A panel of experts was convened by the International Society for Infectious Diseases (ISID) to overview recommendations on managing and preventing vascular catheter infections, specifically for the prevention and management of central line-associated bloodstream infections. These recommendations are intended to provide insight for healthcare professionals regarding the prevention of infection in the placement and maintenance of the catheter and diagnosis as well as treatment of catheter infection. Aspects of this area in pediatrics and in limited-resource situations and a discussion regarding the selection of empiric or targeted antimicrobial therapy are particular strengths of this position paper.

TB or not TB? Mycobacterium celatum mimicking Mycobacterium tuberculosis: A case of mistaken identity.

Mycobacterium celatum is a slow-growing, non-tuberculous mycobacterium (NTM) and a rare cause of infection in humans. Infection occurs primarily by inhalation or direct inoculation from environmental sources, and this pathogen has been reported to cause localized infections in the lungs and lymph nodes of both immunocompetent and immunocompromised patients, and disseminated disease in immunocompromised patients. Here, we present a case of pulmonary infection with M. celatum in an immunocompetent 68-year-old male with clinical features similar to tuberculosis. The patient initially developed palpitations, worsening fatigue, night sweats, dyspnea, productive cough, and weight loss. Computed tomography angiogram of the chest revealed a right upper lobe pulmonary artery embolus and extensive biapical fibronodular cavitary densities. Two separate sputum samples were positive for acid-fast bacilli (AFB) and sputum cultures were positive for M. celatum. The patient responded well to treatment with clarithromycin, ciprofloxacin, and ethambutol. We advise physicians to consider M. celatum infection in the differential diagnosis of patients with symptoms and radiographic and microbiologic evidence suggestive of NTM pulmonary infection.

HIV/AIDS: A Case-Based Learning Module for First-Year Medical Students.

In medical and healthcare-related education, case-based learning (CBL) is a teaching strategy that uses clinical cases to engage students in active learning using course concepts to solve important problems. Here we describe the design and implementation of a CBL module to teach first year medical students about the human immunodeficiency virus (HIV), acute retroviral syndrome, clinical progression to acquired immunodeficiency syndrome, HIV diagnostics, assays used to assess stage of disease and response to antiretroviral treatment, and highly active antiretroviral therapy. A team of basic science and clinical faculty in the disciplines of microbiology, immunology, infection prevention and control, clinical medicine, pharmacology, and medical ethics collaboratively designed the CBL module. The results of a questionnaire indicated that the students found the CBL case interesting, engaging, and a useful educational strategy for linking basic science concepts to important clinical problems. In our experience, the CBL promoted student synthesis of basic science concepts across disciplines and engaged learners in the application of basic science knowledge to address significant real-world clinical problems.

Benefits and harms of doxycycline treatment for Gulf War veterans' illnesses: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: It has been hypothesized that certain Mycoplasma species may cause Gulf War veterans' illnesses (GWVIs), chronic diseases characterized by pain, fatigue, and cognitive symptoms, and that affected patients may benefit from doxycycline treatment. OBJECTIVE: To determine whether a 12-month course of doxycycline improves functional status in Gulf War veterans with GWVIs. DESIGN: A randomized, double-blind, placebo-controlled clinical trial with 12 months of treatment and 6 additional months of follow-up. SETTING: 26 U.S. Department of Veterans Affairs and 2 U.S. Department of Defense medical centers. PARTICIPANTS: 491 deployed Gulf War veterans with GWVIs and detectable Mycoplasma DNA in the blood. INTERVENTION: Doxycycline, 200 mg, or matching placebo daily for 12 months. MEASUREMENTS: The primary outcome was the proportion of participants who improved more than 7 units on the Physical Component Summary score of the Veterans Short Form-36 General Health Survey 12 months after randomization. Secondary outcomes were measures of pain, fatigue, and cognitive function and change in positivity for Mycoplasma species at 6, 12, and 18 months after randomization. RESULTS: No statistically significant differences were found between the doxycycline and placebo groups for the primary outcome measure (43 of 238 participants [18.1%] vs. 42 of 243 participants [17.3%]; difference, 0.8 percentage point [95% CI, -6.5 to 8.0 percentage points]; P > 0.2) or for secondary outcome measures at 1 year. In addition, possible differences in outcomes at 3 and 6 months were not apparent at 9 or 18 months. Participants in the doxycycline group had a higher incidence of nausea and photosensitivity. LIMITATIONS: Adherence to treatment after 6 months was poor. CONCLUSION: Long-term treatment with doxycycline did not improve outcomes of GWVIs at 1 year.

Mycobacterium avium-intracellulare brain abscesses in an HIV-infected patient.

The Mycobacterium avium-intracellulare complex (MAC) is an uncommon cause of brain abscesses even in patients with acquired immunodeficiency syndrome (AIDS). We present a case of a multiple MAC brain abscesses, confirmed by brain biopsy and culture, in a patient with AIDS. The patient's initial symptoms were weakness, confusion and headaches. The patient was initially treated for toxoplasmosis and pyogenic bacterial brain abscesses with no resolution. Following treatment for MAC the patient's abscesses resolved.

Delayed diagnosis of Q fever endocarditis in a rheumatoid arthritis patient.

Chronic Q fever caused by Coxiella burnetii is uncommon in the United States and is most often associated with infective endocarditis. We present a 52-year-old woman with a history of aortic valve replacement and rheumatoid arthritis treated with Etanercept with chronic Q fever manifesting as prosthetic valve infective endocarditis. Explanted valve tissue showed organisms confirmed to be C. burnetii by PCR (polymerase chain reaction) sequencing. She subsequently reported consumption of unpasteurized cow milk which was the likely source of C. burnetii. She continues to do well 6 months after valve replacement on oral doxycycline and hydroxychloroquine.

Vaccines for Category A bioterrorism diseases.

Vaccination programmes are very successful as a preventive strategy against many infectious diseases which have had a major impact on human morbidity and mortality. One of these diseases, smallpox, has been eliminated as a natural infection. The recent concern about biological attacks has turned attention to the use of an immunisation programme to prevent infection with what are considered the most significant potentially harmful biowarfare pathogens. This review puts into perspective the available information on current immunisation and newer vaccine options for anthrax, smallpox, tularaemia, plague and botulism.

Active immunisation against human tick-borne diseases.

With the development and licensure of a recombinant vaccine for the tick-borne infection Lyme disease, more attention has been paid to other vaccines that have been used or are being developed for the prevention of other tick-borne infections. This review highlights vaccine information for Lyme borreliosis, tick-borne encephalitis (TBE), Rocky Mountain spotted fever, tularaemia, Query (Q) fever, Kyasanur Forest disease (KFD) and tick paralysis. Additionally, discussion on the use of immunisation against the tick itself is included which not only can decrease veterinary tick burdens but may also decrease the transmission of arthropod-transmitted diseases.

Community-acquired pneumonia in immunocompromised patients. Opportunistic infections to consider in differential diagnosis.

Immunocompromised persons are at increased risk for a large group of infections that are either uncommon or much less severe in the immunocompetent host. These opportunistic infections broaden the diagnostic considerations in differential diagnosis of community-acquired pneumonia in patients with immunodeficiencies. This article highlighted epidemiologic factors, clinical presentations, and treatment options for four selected opportunistic infections that represent varied classes of pathogens: nematodes (S stercoralis), mycoses (C neoformans), bacteria (P aeruginosa in patients with HIV infection), and viruses (measles virus).

Parotid gland abscess caused by Haemophilus paraphrophilus: a case report.

Human diseases caused by Haemophilus paraphrophilus (H.paraphrophilus) are unusual. The following case report describes a 67-year-old man who presented with pain and swelling of the right side of the face. Fine needle aspiration suggested a parotid gland abscess. Microbiological studies identified H.paraphrophilus. This is the first time a parotid abscess has been found to be caused by this organism.

C. glycolicum as the sole cause of bacteremia in a patient with acute cholecystitis.

Here we describe a case of Clostridia glycolicum (C. glycolicum) bacteremia in a bed-ridden elderly man with chronic illnesses. The bacterium was identified by the Remel RapID ANA II System. We believe that this is the fifth published report of human illness caused by this bacterium. In the four previously reported cases, C. glycolicum was found in cultures with other bacteria. This is the first reported case in which C. glycolicum was the sole causative agent of disease.