Gradenigo's Syndrome and Vernet Syndrome as Presenting Signs of Nasopharyngeal Carcinoma.

Both Gradenigo's syndrome and Vernet syndrome are rare pathologies of the intracranial space; both involve compression of a particular anatomic location in the skull, thus affecting structures nearby or within that space. A patient presenting with one or both of these syndromes should raise concern for malignancy, head trauma, or an intracranial infection. We present a case of a 39-year-old female with three weeks of left-sided ear, face, and neck pain along with difficulty swallowing and reduced vision in the left eye. Magnetic resonance imaging of the brain revealed fullness in the left nasopharyngeal region, raising concern for malignancy or infection. Biopsy of the mass ultimately revealed Epstein-Barr virus positive nasopharyngeal carcinoma, nonkeratinizing undifferentiated type, along with culture data revealing methicillin-resistant Staphylococcus aureus positive left otomastoiditis. She received chemoradiation therapy along with six weeks of antibiotic therapy. A patient presenting with symptoms reflective of a sinus infection unrelieved by antibiotics with concomitant cranial nerve deficits should raise clinical concern for an intracranial pathology rather than a simple case of sinusitis.

Drug-Induced Hidradenitis Suppurativa: A Case Report.

Hidradenitis suppurativa (HS) is a chronic, debilitating inflammatory disorder of the hair follicles that localizes to the intertriginous and anogenital regions of the body. Lesions are characterized by inflammatory nodules, subcutaneous abscesses, fibrosis, and sinus tracts. Crohn's disease (CD) is an idiopathic chronic inflammatory bowel disease that affects any part of the gastrointestinal tract. Multiple treatment options exist for CD, including monoclonal anti-tumor necrosis factor alpha (TNF-α) antibodies like adalimumab (Humira). Adalimumab is an anti-TNF agent that has been approved by the United States Food and Drug Administration (FDA) for the treatment of HS. A 35-year-old African American male with a history of fistulizing CD presented to the hospital for evaluation of severe pain and purulent drainage from open sores in his bilateral axillary regions, groin, buttocks, and face for four days. He was on adalimumab for two years, during which time he noted the development of Hurley stage III HS. The physical exam was remarkable for a cachectic, painful-appearing male, with multiple abscesses on his lower jaw extending to his upper neck draining thick serosanguinous fluid, with similar findings in his bilateral axillary regions, bilateral groin, and perianal regions. He was treated with intravenous antibiotics consisting of a fourth-generation cephalosporin and vancomycin. While the etiology of HS in this patient is inconclusive, the timing of its development closely aligns with the initiation of Humira and is not a manifestation of CD. Paradoxical adverse effects describe a phenomenon in which a medication can induce a condition that it classically can be used to treat. In this patient's case, it was HS.

Herpes Simplex Virus Causing Necrotizing Granulomatous Lymphadenitis.

Localized necrotizing granulomatous lymphadenitis (GLA) is a very rare presentation of herpes simplex virus (HSV) infection. We are reporting a case that required multidisciplinary expertise to confirm the diagnosis and effectively treat the patient. Our patient had a recent diagnosis of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and presented with hematuria and palpable inguinal lymph nodes. Affirmative diagnosis required a core biopsy of the lymph node with immunochemistry staining and polymerase chain reaction (PCR) testing. This case reviews the unusual presentation of an HSV infection and emphasizes the importance of maintaining a high index of suspicion for infection when treating an immunocompromised patient with persistent symptoms.

Thinking Beyond Bacterial Infection: A Case of Cutaneous Blastomycosis.

Blastomycosis is caused by Blastomyces dermatitidis, a dimorphic fungus that primarily causes pulmonary disease. Cutaneous blastomycosis is infrequent and tends to be misdiagnosed given its similar presentation to other cutaneous fungal infections and malignancies. A 51-year-old woman presented with a two-month history of disfiguring nasal lesions. The patient had a past medical history of cervical cancer which was currently in remission. Social history was significant for frequent travel throughout the United States as a truck driver, including the Midwest. The patient had a non-purulent verrucous plaque on her right nare, which was painless and mildly pruritic. Superficial cultures grew Enterococcus faecalis, prompting treatment with oral cephalexin and topical mupirocin. Given no relief, the patient was started on clindamycin followed by Augmentin. Both treatments were unsuccessful.  The lesion was then biopsied and fungal cultures were sent. The biopsy showed broad-based budding yeast surrounded by pseudoepitheliomatous hyperplasia, and cultures grew Blastomyces dermatitidis. The patient was initiated on 200 mg itraconazole thrice daily for the first three days, followed by 200 mg itraconazole twice daily for the next 12 months. She showed notable improvement within a month. This patient was initially misdiagnosed with bacterial infection due to superficial cultures, which were likely a contaminant. It was only after a biopsy that the patient was accurately diagnosed. Besides bacterial infection, cutaneous blastomycosis is often confused with coccidioidomycosis, mycobacterial infection, or squamous cell carcinoma. In patients such as ours who are presenting with persistent facial lesions in the setting of frequent travel history, fungal etiologies should be high on the differential. A biopsy and fungal cultures should be sent at the outset for accurate diagnosis and treatment.

A Rare Case of the Newly Recognized Kaposi Sarcoma Herpesvirus-Associated Disease.

Kaposi sarcoma herpesvirus (KSHV) is associated with Kaposi sarcoma (KS), primary effusion lymphoma, and multicentric Castleman disease (KSHV-MCD) in patients infected with human immunodeficiency virus (HIV). We present a case consistent with a newly recognized KSHV inflammatory cytokine syndrome (KICS), distinct from KSHV-MCD. Although both disorders exhibit signs of substantial inflammation, KICS has minimal lymphadenopathy/splenomegaly and negative pathologic nodal changes in the setting of low CD4 count. KICS is easily misdiagnosed as severe sepsis or other KS-related diseases in HIV/AIDS patients and carries a high mortality. ​Standard therapy is still under investigation due to its rarity, whereas the treatment regimen for KSHV-MCD may lead to clinical remission. Early recognition and prompt management are crucial to improve the survival of the under-recognized KICS.

Cutaneous Fusariosis in a Patient with Job's (Hyper-IgE) Syndrome.

Fusarium is a filamentous fungus that is ubiquitous in nature and can cause severe opportunistic infections in immunocompromised hosts. The association between Fusarium and hyper-IgE syndrome is exceedingly rare and has only been documented in a single report previously. A 44-year-old male, working as marijuana grower, with prior diagnosis of hyper-IgE syndrome and recurrent infections presented with enlarging right knee ulcer that did not respond to antimicrobial treatment. The patient was diagnosed with cutaneous fusariosis, confirmed with punch biopsy and positive wound cultures. The patient was managed with extended antifungal therapy (i.e., posaconazole) and surgical debridement resulting in remarkable improvement with wound healing leaving a pale scar. Fusarium should be considered in differential for cutaneous and invasive fungal infections in presence of cutaneous manifestations. Exposure to Cannabis plants is a noticeable risk factor. Multimodal approach involving systemic antifungals and wound debridement is essential for favorable outcome. Posaconazole was demonstrated to be a highly efficacious antifungal choice.

Artificial Differences in Clostridium difficile Infection Rates Associated with Disparity in Testing.

In 2015, Clostridium difficile testing rates among 30 US community, multispecialty, and cancer hospitals were 14.0, 16.3, and 33.9/1,000 patient-days, respectively. Pooled hospital onset rates were 0.56, 0.84, and 1.57/1,000 patient-days, respectively. Higher testing rates may artificially inflate reported rates of C. difficile infection. C. difficile surveillance should consider testing frequency.

Rare Case of Olmesartan Induced Enteropathy.

Olmesartan (brand name Benicar) is an antihypertensive drug clinicians commonly use to treat high blood pressure. Olmesartan induced enteropathy (OSE) is a rare entity that authors first identified in 2012. The etiological basis of OSE remains unclear, although authors have suggested that this condition could be due to alternations in cell mediated immune responses induced by the drug. The objective of the case report is to describe a patient who presented with diarrhea and was eventually diagnosed with OSE. A female patient in her later 60s presented to an emergency room after two recent hospitalizations with profound diarrhea, generalized weakness and weight loss. She underwent a diagnostic workup including endoscopy and colonoscopy. The patient's endoscopy with duodenal biopsy revealed villous atrophy with attenuated and blunted villi with intraepithelial CD3 positive T lymphocytes, suggestive of gluten-induced enteropathy. When the patient's symptoms did not improve after the authors placed her on a gluten free diet for a few days, they further investigated her for secretory diarrhea, including Gastrin, Somatostatin and Vasoactive Intestinal Peptide lab values that they found to be within normal limits. Due to the patient's lack of improvement with initial treatment, the authors suspected OSE and stopped her olmesartan and the patients' symptoms gradually improved in three weeks.

Bone and joint infections in injection drug users.

Skeletal infections in injection drug users have an insidious onset, present with indolent symptoms, and often occur in unusual locations. Unless physicians are familiar with the disease entities unique to the injection drug user, the diagnosis is frequently delayed. Systemic signs of infection are often lacking. The organisms causing the infection represent a wide spectrum; hence, empiric therapy is not generally recommended. Plain-film radiographs are of little help for early diagnosis. Imaging studies, especially radionucleotide studies and CT or MR imaging scans, can help localize the site of infection. For etiologic diagnosis of these infections, bone biopsy or needle aspiration of the involved bone or joint is required. The choice of antibiotic agent should be based on culture results and the antimicrobial susceptibility of the causative organism. Treatment may also involve surgical drainage or débridement of affected structures. Failure to manage acute bone and joint infection aggressively inevitably leads to chronic, often incurable, infection. Successful therapy requires a team approach including the internist and consultants from orthopedic surgery, infectious diseases, and substance abuse counselors.