Hemophagocytic lymphohistiocytosis induced by Toxoplasma gondii infection diagnosed by a bone marrow biopsy and DNA next-generation sequencing in an allogeneic hematopoietic stem cell transplant recipient.

In the United States, toxoplasmosis following allogeneic hematopoietic stem transplant (allo-HCT) is very rare with a rate only between 0.5% and 2%. The reported rates of hemophagocytic lymphohistiocytosis (HLH) following allo-HCT range between 0.3% and 17%. Secondary HLH due to toxoplasmosis infection is extremely rare. Herein, we report a case of secondary HLH due to toxoplasmosis following allo-HCT. The diagnosis was reached by a bone marrow biopsy and confirmed by DNA next generation sequencing and immunohistochemical (IHC) staining. The IHC staining included CD1a, a stain previously known to react with cells infected by Leishmania, here we show CD1a staining of macrophages infected with Toxoplasma gondii. Our report highlights the utility of bone marrow biopsy in diagnosing parasitic infection underlying HLH in post-transplant settings. The pre-transplant evaluation of patients from low endemic countries, is a great opportunity to obtain a travel history to determine the risks and the preventative measures against opportunistic infections including toxoplasmosis.

Disseminated Hormographiella aspergillata Infection with Lung and Brain Involvement after Allogenic Hematopoietic Stem-Cell Transplantation in a 54-Year-Old Man.

Hormographiella is a rare fungal pathogen in humans; however, case reports have described disseminated infection in immunocompromised hosts. This pathogen has been described to yield poor prognosis in patients who harbor it. Herein, we present a case report of autopsy-proven disseminated Hormographiella aspergillata infection, confirmed by DNA sequencing, in a patient experiencing a relapse of leukemia. This 54-year-old Caucasian man with chronic myelogenous leukemia (CML) that had been diagnosed in 1989, after having received a hematopoietic cell allotransplant from a compatible sibling donor, had B-cell lymphoid-blast phase of CML in April of 2013, with multiple relapses. His most recent relapse was in September of 2016, when bone marrow biopsy showed 90% blasts. The results of bronchoalveolar lavage (BAL) cultures were positive for filamentous fungus infection. The patient developed encephalopathy and worsening respiratory statusand tachycardia with flutter and hypotension, which resulted in his death. At autopsy, bilateral pleural effusions, multiple right pleural nodules, and subarachnoid hemorrhage were noted. Angioinvasive hyphal fungi were found in the right frontal lobe of the brain and the right upper lobe of the lung. Morphologically, the fungi had multiseptate, branching hyphae. The bronchoalveolar lavage specimen grew a fungus for which the colony morphologic characteristics and microscopic features were compatible with a Hormographiella species. H. aspergillata from the bronchoalveolar lavage was further identified by sequencing the D2 hypervariable region of the large-subunit (LSU) ribosomal DNA gene and the full internal transcribed spacer (ITS) regions.

Urinary tract blastomycosis diagnosed by urine cytology.

Urinary tract blastomycosis is an uncommon manifestation of disseminated Blastomyces infection. Here, we report a 50-year-old male with common variable immunodeficiency who presented with urinary symptoms and a renal mass concerning for a kidney neoplasm. Urine cytology revealed typical broad-based budding yeasts with thick-walled refractile capsules, leading to diagnosis of urinary tract blastomycosis. In this case, urine cultures were negative, and urine cytology was the main method of diagnosis of blastomycosis. Thus, urine cytology represents a rapid and reliable method of diagnosing blastomycosis, which in the current case led to prompt treatment of this potentially life threatening infection.

A Noninvasive Rhizopus Infection With a Bladder Fungal Ball in a Patient With Poorly Controlled Diabetes Mellitus.

Here we present the first reported case of a noninvasive Rhizopus fungal ball confined to the bladder of a patient with poorly controlled diabetes and right flank pain. The patient developed bilateral hydronephrosis after several hospital admissions for urinary tract infections with multiple failed courses of antibiotics. During cystoscopy to replace a ureteral stent, he was found to harbor a fungal ball in the bladder that was removed and grew Rhizopus in culture. Patient received treatment with amphotericin B and transitioned to long-term posaconazole therapy. This case highlights the importance of considering fungal agents in urinary tract infections, especially in persistent or refractory cases, and the role of the clinical microbiology laboratory in correct identification of the infectious source.

Strongyloides hyperinfection following hematopoietic stem cell transplant in a patient with HTLV-1-associated T-cell leukemia.

Strongyloides stercoralis has the potential to cause accelerated autoinfection in immunocompromised hosts. Screening tests for strongyloidiasis may be falsely negative in the setting of immunosuppression. We report a case of Strongyloides hyperinfection syndrome in a patient with human T-lymphotropic virus type 1-associated T-cell leukemia early after hematopoietic stem cell transplant. The diagnosis was made by stool ova and parasite examination, despite a negative screening enzyme-linked immunosorbent assay. Because of anticipated prolonged neutropenia, an extended course of treatment was utilized.

Trichosporon loubieri Fungemia in a 39-Year-Old Caucasian Woman With B-Cell Lymphoblastic Leukemia.

We report a case of Trichosporon loubieri (T. loubieri) fungemia with likely liver involvement in a 39-year-old Caucasian patient with relapsed B-cell acute lymphoblastic leukemia after an allogeneic hematopoietic cell transplant. This is the fifth published case of T. loubieri infection and only the third case of T. loubieri fungemia, to our knowledge. All 3 cases of T. loubieri infection with fungemia had liver involvement.

Comparison of rates of positivity for Bordetella pertussis by real-time PCR between specimens collected with rayon swabs on aluminum wire shaft in Amies gel with charcoal and specimens collected with flocked swabs in universal viral transport medium during an epidemic.

A comparison of real-time PCR positivity rates for Bordetella pertussis between specimens collected with rayon swabs on an aluminum wire shaft in Amies gel with charcoal and those collected with flocked swabs in universal viral transport medium during an epidemic revealed that their performances were comparable.

The changing epidemiology of healthcare-associated candidemia over three decades.

We describe the epidemiology of healthcare-associated candidemia (HAC) in our tertiary care hospital, in comparison with both the pre-fluconazole (pre-FLU) and pre-echinocandin (pre-EC) eras. We identified all patients with HAC using microbiology records from 1/2004 to 12/2007, reviewed medical records, and pulled isolates for testing. We compared mortality, underlying illness, Candida species distribution, and antifungal susceptibility with 2 prior University of Iowa cohorts (88 patients from 1983 to 1986 [pre-FLU], and 108 from 1997 to 2001 [pre-EC]). Of 108 patients with HAC from 2004 to 2007, species distribution was 47% C. albicans, 29% C. glabrata, 12% C. parapsilosis, 6% C. tropicalis, and no C. krusei. Compared with pre-FLU and pre-EC eras, there was a reduction in % C. albicans (from 61% and 60%, respectively), an increase in % C. glabrata (from 0% and 16%), and no change in % C. parapsilosis over time (12% and 12%). In-hospital mortality was lower in 2004-2007 than both pre-FLU and pre-EC (31% versus 57-61%), and 30-day mortality was also lower (33% versus 48% in pre-EC). Mean Charlson index was lower for the 2004-2007 cohort than pre-EC (3.0 versus 3.4)-fewer patients had leukemia or lymphoma (8% versus 16%) or other malignancies (18% versus 24%), while more were surgical patients (58% versus 48%). Using the new Clinical and Laboratory Standards Institute breakpoints for FLU and caspofungin, we found no caspofungin resistance, and FLU resistance only among C. glabrata (15% had FLU MICs >32 µg/mL). The epidemiology of HAC is changing at our hospital, with continued emergence of C. glabrata, fewer cases among oncology patients, and lower in-hospital and 30-day mortality.

Evaluation of the Bruker Biotyper and Vitek MS matrix-assisted laser desorption ionization-time of flight mass spectrometry systems for identification of nonfermenting gram-negative bacilli isolated from cultures from cystic fibrosis patients.

The Bruker Biotyper and Vitek MS matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry (MS) instruments were evaluated for the identification of nonfermenting gram-negative bacilli (NFGNB) by a blinded comparison to conventional biochemical or molecular methods. Two hundred NFGNB that were recovered from cultures from cystic fibrosis patients in the University of Iowa Health Care (UIHC) Microbiology Laboratory between 1 January 2006 and 31 October 2010 were sent to Mayo Clinic for analysis with the Bruker Biotyper (software version 3.0) and to bioMérieux for testing with Vitek MS (SARAMIS database version 3.62). If two attempts at direct colony testing failed to provide an acceptable MALDI-TOF identification, an extraction procedure was performed. The MS identifications from both of these systems were provided to UIHC for comparison to the biochemical or molecular identification that had been reported in the patient record. Isolates with discordant results were analyzed by 16S rRNA gene sequencing at UIHC. After discrepancy testing, the Bruker Biotyper result agreed with the biochemical or molecular method, with 72.5% of isolates to the species level, 5.5% to the complex level, and 19% to the genus level (3% not identified). The level of agreement for Vitek MS was 80% species, 3.5% complex, 6% genus, and 3.5% family (7% not identified). Both MS systems provided rapid (≤3 min per isolate) and reliable identifications. The agreement of combined species/complex/genus-level identification with the reference method was higher for the Bruker Biotyper (97% versus 89.5%, P = 0.004) but required an extraction step more often. Species-level agreement with the reference method was similar for both MS systems (72.5% and 80%, P = 0.099).