Ehrlichiosis mimicking acute leukemia.

Human monocytic ehrlichiosis is a tickborne disease with a spectrum of presentations ranging from asymptomatic, mild to fatal. Ehrlichiosis can transiently cause white blood cells abnormalities that mimic leukemia/lymphoma and cases have been, on rare occasions, initially mistaken for hematological malignancies. We report a case of Ehrlichia chaffeensis infection suspected to be acute promyelocytic leukemia at presentation, prompting therapy with all-trans-retinoic acid. Physicians should keep tickborne transmitted illnesses on the differential in patients presenting with pancytopenia, especially in endemic areas.

Culture Yield in the Diagnosis of Native Vertebral Osteomyelitis: A Single Tertiary Center Retrospective Case Series With Literature Review.

BACKGROUND: Vertebral osteomyelitis is a serious condition that requires prompt diagnosis to avoid delays in proper management. There is no well-defined gold standard for diagnosis. We describe the current diagnostic approach at our institution, with a focus on the yield of image-guided vertebral biopsy. METHODS: We performed a single-centre 10-year retrospective case series, including adults with imaging suggestive of vertebral osteomyelitis/discitis, with either positive blood cultures, and/or a vertebral biopsy. We defined positive histopathology as our gold standard for test characteristic evaluation of biopsy cultures. RESULTS: Out of 694 patients identified, 221 met our inclusion criteria, and 173/221 (78.2%) patients underwent a spinal biopsy. Of those patients with biopsies, 113 (65%) had received antibiotics within 2 weeks preceding their evaluation. Six of 43 (13.9%) bone specimens were positive by culture, while 66/152 (43.4%) of disc specimens were culture positive. Forty-seven of 84 (55.9%) histopathology (bone or disc) specimens were diagnostic for osteomyelitis/discitis. The sensitivity of bone and disk culture were 30.0% and 56.0%, respectively, with specificities of 92.8% and 75.0%, respectively. Twenty-three (13.4%) patients had repeat biopsies, including 10 bone specimens and 14 disc specimens, and 11 (47.8%) specimens had histopathology performed which diagnosed an additional 3/23 patients (13% additional diagnostic yield). CONCLUSIONS: Culture of percutaneous biopsy of disc resulted in the highest diagnostic yield. Histopathology added to the diagnostic yield in culture-negative specimens. Histopathologic evaluation of bone had better yield than bone culture. A repeat biopsy can add to the diagnostic yield.

Clostridioides difficile Infection and Risk of Acute Graft-versus-Host Disease among Allogeneic Hematopoietic Stem Cell Transplantation Recipients.

Clostridioides difficile infection (CDI) is a major cause of infectious diarrhea among allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. The relationship between CDI and acute graft-versus-host disease (aGVHD) has been a topic of interest, as these 2 conditions may influence each other. We studied the temporal relationship of CDI to aGVHD in the first 100 days post-transplantation in a large cohort of allo-HSCT recipients. We performed a retrospective cohort study of adult patients undergoing their first allo-HSCT at our tertiary care medical center between January 1, 2010, and December 31, 2016. Patients were followed for CDI diagnosis, development of aGVHD, and vital status up to day +100 post-transplantation. Descriptive statistics and multivariate Cox models with CDI as a time-varying covariate and aGVHD and high-grade aGVHD as outcomes were used for data analyses. A total of 656 allo-HSCT recipients were included in the analysis. Of these, 419 (64%) developed aGVHD, and 111 (17%) were diagnosed with CDI within the first 100 days post-transplantation. CDI developed before the onset of aGVHD in 72 of the 84 allo-HSCT recipients (85%) with both CDI and aGVHD. Fidaxomicin was used in the treatment of 57 of the 111 CDI cases (50%), whereas vancomycin was used in 52 (47%). Most of the CDI cases (88%) were diagnosed in the peritransplantation period (between day -10 and day +10). The median time to the development of CDI and aGVHD was 3.5 days (range, -7 to 95 days) and 33 days (range, 9 to 98 days) post-transplantation, respectively. Using multivariate Cox model, the following predictors were significantly associated with the development of aGVHD: CDI (adjusted hazard ratio [aHR], 1.52; 95% confidence interval [CI], 1.17 to 1.97; P = .0018), transplantation from a matched related donor (MRD) compared with a matched unrelated donor (aHR, 0.68; 95% CI, 0.54 to 0.85; P = .0003), and myeloablative versus nonmyeloablative conditioning (aHR, 2.45; 95% CI, 1.80 to 3.34; P < .0001), adjusting for age, sex, race, underlying disease, cytomegalovirus CMV serostatus, transplant source, and receipt of antithymocyte globulin (ATG). There was no association between CDI and high-grade aGVHD after adjustment for age, underlying disease, transplant type, intensity of conditioning, and receipt of ATG (aHR, 1.59; 95% CI, 0.95 to 2.66; P = .0755). CDI after allo-HSCT is associated with increased risk of GVHD when no CDI prophylaxis was used. Further studies examining CDI preventive measures, including prophylaxis, as well as the preservation or reconstitution of the gastrointestinal microbiome in the setting of HSCT are warranted.

De Novo Acute Myeloid Leukemia with Combined CBFB-MYH11 and BCR-ABL1 Gene Rearrangements: A Case Report and Review of Literature.

Acute myeloid leukemia (AML) with inv(16)(p13.1q22) resulting in CBFB-MYH11 fusion is associated with a favorable prognosis. The presence of a KIT mutation modifies it to an intermediate prognosis. Additionally, inv(16) can cooperate with other genetic aberrations to further increase cell proliferation. Coexistence of inv(16) and t(9;22) is extremely rare (20 cases). We present a case of a 55-year-old male with elevated white blood cell count. Bone marrow evaluation and flow cytometry analysis were compatible with AML with monocytic features. Cytogenetic studies revealed two-related clones, a minor clone with inv(16) and a major clone with concurrent inv(16) and t(9;22) rearrangements. Fluorescent in situ hybridization studies confirmed these rearrangements. Molecular analysis detected a p190 BCR-ABL1 transcript protein. KIT mutations were negative. The patient was initially treated with standard induction regimen; 7 daily doses of cytarabine from day 1-day 7, 3 daily doses of daunorubicin from day 1-day 3, and 1 dose of Mylotarg (gemtuzumab ozogamicin) on day 1. The detection of t(9;22) led to the addition of daily doses of dasatinib (tyrosine kinase inhibitor) from day 7 onwards. The patient achieved complete remission on day 45. During his treatment course, he acquired disseminated Fusarium infection. Day 180 bone marrow evaluation revealed florid relapse with 64% blasts. Cytogenetic study showed clonal evolution of the inv(16) clone with no evidence of the t(9;22) subclone. Eventually, bone marrow transplantation was contraindicated, and the patient was transferred to palliative care. Literature review revealed that AML with co-occurrence of CBFB-MYH11 and BCR-ABL1 gene rearrangements was involved by only a small number of cases with de novo and therapy-related AML. Most cases were in myeloid blast crisis of chronic myeloid leukemia (CML). Treatment and prognosis among the de novo AML cases varied and majority of them achieved clinical remission. In contrast, these cytogenetic abnormalities in the blast phase of CML had a poor prognosis. As the prognosis and management of AML is dependent upon the underlying genetic characteristics of the neoplasm, it is imperative to include clinical outcome with such rare combinations of genetic alterations.

Isolated Sporothrix schenckii Monoarthritis.

Sporothrix schenkii sensu lato is a rare cause of arthritis. Its course is indolent with lack of constitutional symptoms resulting in delayed presentation and diagnosis. It is a dimorphic fungus found ubiquitously in sphagnum moss, decaying vegetation, soil, and hay. Inoculation of dirt into the skin and soft tissues and, in rare instances, inhalation of aerosolized conidia from soil and plants can lead to infection. Subacute and chronic involvement of skin and subcutaneous tissues is the most common manifestation of sporotrichosis in immunocompetent hosts. In patients with underlying risk factors (HIV, alcoholism, diabetes mellitus, organ transplant patients, immunosuppressive medications, steroids, and malignancies), it can often have disseminated visceral, osteoarticular, meningeal, and pulmonary involvement. Sporothrical arthritis most commonly infects knee joint followed by hand and wrist joints. A culture of Sporothrix schenkii sensu lato is the gold standard for the diagnosis of sporotrichosis. Itraconazole is the drug of choice for osteoarticular sporotrichosis. We present a case of sporotrichal arthritis in a patient without skin or lymph node involvement who underwent treatment with itraconazole resulting in resolution of his symptoms.

Bilateral inflammatory myofibroblastic tumor mastoiditis.

BACKGROUND: Inflammatory myoblastic tumors (IMTs) are rare, mesenchymal neoplasms most commonly located in areas of previous inflammation. In the temporal bone, these tumors typically present as solitary, space-occupying lesions that clinically resemble chronic otitis media. METHODS: We present a case of bilateral IMTs with facial nerve involvement, sigmoid sinus thrombosis, leptomeningeal enhancement, and seizures. RESULTS/CONCLUSION: This case demonstrates the need for a high index of suspicion of IMT when imaging reveals bilateral mastoid opacification. These tumors are more aggressive than their orbital counterparts and require multimodality therapy to prevent recurrence and alleviate severe neurotologic symptoms.

Ribosomal RNA sequence analysis of Brucella infection misidentified as Ochrobactrum anthropi infection.

A Brucella isolate was identified from purulent material collected during a hip surgery. Two previous blood cultures from the same patient yielded Ochrobactrum anthropi. After rRNA sequencing, all the isolates were identified as Brucella species and subsequently serotyped as Brucella suis. Misidentification of Brucella species remains a problem with bacterial identification systems.