Southern California neuroinvasive West Nile virus case series.

Approximately 80% of individuals infected with West Nile virus (WNV) are asymptomatic, and less than 1% suffer from neuroinvasion that can result in permanent neurological deficits or mortality. Our institution's location in southern California predisposes it to a sizable case volume of neuroinvasive WNV. A 2-year retrospective study was performed at the Olive View-UCLA Medical Center to identify patients with confirmed WNV infection with neuroinvasion. Patient demographics, neurological exam findings, and laboratory diagnostics were reviewed. Data were tabulated and are presented as percentage, mean ± standard deviation, or median [range]. Twenty-two patients (36.4% female, age 50.2 ± 10.6 years) were identified between 20 August 2012 and 24 September 2013. The most common positive findings on review of symptoms included fever (81.8%), nausea/vomiting (81.8%), and headache (68.2%). Thirteen patients (59.1%) presented with fever defined as ≥ 37.8 °C. Motor strength was reduced in nine patients (40.9%) and eight patients (36.4%) were hyporeflexive. Lumbar puncture was performed in all but three patients (cerebrospinal fluid [CSF] protein 76.8 ± 29.6 mg/dL and glucose 71.0 ± 18.8 mg/dL). Elevated CSF anti-WNV IgM and IgG antibody was detected in 93.8% and 62.5% of the 16 tested cases, respectively. Elevated serum anti-WNV IgM and IgG antibody was detected in 100% and 72.2% of the 18 tested cases, respectively. Encephalitic presentations, with or without focal neurological deficits (e.g., motor weakness, hypotonia), dominated this series. In endemic areas, seasonal presentation of such symptoms should raise suspicion for WNV with neuroinvasion.

HIV DNA Is Frequently Present within Pathologic Tissues Evaluated at Autopsy from Combined Antiretroviral Therapy-Treated Patients with Undetectable Viral Loads.

UNLABELLED: HIV infection treatment strategies have historically defined effectiveness through measuring patient plasma HIV RNA. While combined antiretroviral therapy (cART) can reduce plasma viral load (pVL) to undetectable levels, the degree that HIV is eliminated from other anatomical sites remains unclear. We investigated the HIV DNA levels in 229 varied autopsy tissues from 20 HIV-positive (HIV(+)) cART-treated study participants with low or undetectable plasma VL and cerebrospinal fluid (CSF) VL prior to death who were enrolled in the National Neurological AIDS Bank (NNAB) longitudinal study and autopsy cohort. Extensive medical histories were obtained for each participant. Autopsy specimens, including at least six brain and nonbrain tissues per participant, were reviewed by study pathologists. HIV DNA, measured in tissues by quantitative and droplet digital PCR, was identified in 48/87 brain tissues and 82/142 nonbrain tissues at levels >200 HIV copies/million cell equivalents. No participant was found to be completely free of tissue HIV. Parallel sequencing studies from some tissues recovered intact HIV DNA and RNA. Abnormal histological findings were identified in all participants, especially in brain, spleen, lung, lymph node, liver, aorta, and kidney. All brain tissues demonstrated some degree of pathology. Ninety-five percent of participants had some degree of atherosclerosis, and 75% of participants died with cancer. This study assists in characterizing the anatomical locations of HIV, in particular, macrophage-rich tissues, such as the central nervous system (CNS) and testis. Additional studies are needed to determine if the HIV recovered from tissues promotes the pathogenesis of inflammatory diseases, such as HIV-associated neurocognitive disorders, cancer, and atherosclerosis. IMPORTANCE: It is well-known that combined antiretroviral therapy (cART) can reduce plasma HIV to undetectable levels; however, cART cannot completely clear HIV infection. An ongoing question is, "Where is HIV hiding?" A well-studied HIV reservoir is "resting" T cells, which can be isolated from blood products and succumb to cART once activated. Less-studied reservoirs are anatomical tissue samples, which have unknown cART penetration, contain a comparably diverse spectrum of potentially HIV-infected immune cells, and are important since <2% of body lymphocytes actually reside in blood. We examined 229 varied autopsy specimens from 20 HIV(+) participants who died while on cART and identified that >50% of tissues were HIV infected. Additionally, we identified considerable pathology in participants' tissues, especially in brain, spleen, lung, lymph node, liver, aorta, and kidney. This study substantiates that tissue-associated HIV is present despite cART and can inform future studies into HIV persistence.

HIV and COVID-19: two pandemics with significant (but different) central nervous system complications.

Human immunodeficiency virus (HIV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cause significant neurologic disease. Central nervous system (CNS) involvement of HIV has been extensively studied, with well-documented invasion of HIV into the brain in the initial stage of infection, while the acute effects of SARS-CoV-2 in the brain are unclear. Neuropathologic features of active HIV infection in the brain are well characterized whereas neuropathologic findings in acute COVID-19 are largely non-specific. On the other hand, neuropathologic substrates of chronic dysfunction in both infections, as HIV-associated neurocognitive disorders (HAND) and post-COVID conditions (PCC)/long COVID are unknown. Thus far, neuropathologic studies on patients with HAND in the era of combined antiretroviral therapy have been inconclusive, and autopsy studies on patients diagnosed with PCC have yet to be published. Further longitudinal, multidisciplinary studies on patients with HAND and PCC and neuropathologic studies in comparison to controls are warranted to help elucidate the mechanisms of CNS dysfunction in both conditions.

Vertebral osteomyelitis secondary to Streptococcus cristatus infection.

A 66-year-old male with a history of low back pain was found to have discitis and osteomyelitis. Biopsy and PCR testing revealed Streptococcus cristatus infection. This bacteria does not typically cause disease, and only a few cases in the literature have reported it to cause infection in the bones or joints. This case illustrates that vertebral osteomyelitis with a rare causative agent, S. cristatus, is possible and can be identified with PCR. Treatment typically requires long-term antibiotics tailored to the causative agent for a minimum of 6 weeks and can sometimes include surgical management.

Serum ivermectin levels after enteral and subcutaneous administration for Strongyloides hyperinfection: a case report.

An AIDS patient was diagnosed with Strongyloides stercoralis hyperinfection complicated by ileus. Serum ivermectin concentrations were very low after rectal administration, but increased after subcutaneous doses. Absorption of rectal ivermectin appears poor, and subcutaneous administration can increase serum levels quickly, which may improve treatment in critically ill patients.

Safety and outcomes of open-label deferasirox iron chelation therapy for mucormycosis.

We sought to describe the safety profile of open-label, adjunctive deferasirox iron chelation therapy in eight patients with biopsy-proven mucormycosis. Deferasirox was administered for an average of 14 days (range, 7 to 21) at 5 to 20 mg/kg of body weight/day. The only adverse effects attributable to deferasirox were rashes in two patients. Deferasirox treatment was not associated with changes in renal or liver function, complete blood count, or transplant immunosuppressive levels. Thus, deferasirox appears safe as an adjunctive therapy for mucormycosis.

Acquiring tetanus after hemorrhoid banding and other gastrointestinal procedures.

Tetanus after hemorrhoidal banding is an extremely rare but serious complication of the procedure. We describe the second reported case of this complication and review the literature concerning tetanus after different gastrointestinal procedures. Although a rare complication, practicing physicians need to be aware of the clinical presentation of this deadly disease when encountered in at-risk patient populations. Such cases also reemphasize the importance of primary tetanus immunization and follow-up boosters for all vulnerable patients.

Rethinking smallpox.

The potential consequences of a competently executed smallpox attack have not been adequately considered by policy makers. The possibility of release of an aerosolized and/or bioengineered virus must be anticipated and planned for. The transmission and infectivity of variola virus are examined. Arguments for and against pre-event vaccination are offered. The likely morbidity and mortality that would ensue from implementation of a mass pre-event vaccination program, within reasonable boundaries, are known. The extent of contagion that could result from an aerosolized release of virus is unknown and may have been underestimated. Pre-event vaccination of first responders is urged, and voluntary vaccination programs should be offered to the public. Two defenses against a vaccine-resistant, engineered variola virus are proposed for consideration. Methisazone, an overlooked drug, is reported to be effective for prophylaxis only. The extent of reduction in the incidence of smallpox with use of this agent is uncertain. It is useless for treatment of clinical smallpox. N-100 respirators (face masks) worn by uninfected members of the public may prevent transmission of the virus.

Severe cases of pandemic H1N1 pneumonia and respiratory failure requiring intensive care.

BACKGROUND: The objective of our study is to analyze the clinical data of patients with pandemic H1N1 2009 infection admitted to the intensive care unit (ICU) and to report key features observed among these patients. METHODS: A total of 18 patients were admitted to our ICU between July and November 2009, with a primary diagnosis of influenza. Clinical data were analyzed to identify potential risk factors and characteristics thought to affect outcomes. RESULTS: Our patients were between ages 23 and 62 (mean 41). In all, 10 were obese. Two had no other comorbid conditions and 6 had obesity as their only comorbid condition. The most common symptoms were fever, shortness of breath, and cough. Laboratory data were notable for elevated creatine kinase levels, transaminitis, and lack of leukocytosis. The rapid influenza detection test (RIDT) had a 76% false negative result. Patients with a negative RIDT had their infection confirmed with real-time reverse transcriptase polymerase chain reaction (rRT-PCR). A total of 12 patients required invasive mechanical ventilation, with over half of whom responded only to nonconventional modes of ventilation. Most patients received high-dose (150 mg twice daily) oseltamivir. In all, 3 patients died and 11 were discharged without any long-term sequalae. CONCLUSIONS: Unlike seasonal influenza, our patients were not in the extremes of age. Most were obese and presented with severe respiratory distress and hypoxia in the summer months. A negative RIDT did not exclude pandemic H1N1 2009. Using a higher dose of oseltamivir and nonconventional modes of ventilation may have improved the outcome in our subset of patients. Hence, patients with a high clinical suspicion of severe influenza infection should be treated early and aggressively, even before confirmatory results are available.

A comparison of screening batteries in the detection of neurocognitive impairment in HIV-infected Spanish speakers.

BACKGROUND: A substantial number of Spanish-speaking individuals from Mexico and Central America are now living in the United States. These individuals are at heightened risk for HIV infection and, due to late diagnosis and limited resources, for HIV-associated neurocognitive disorders (HAND). Early detection is key, yet adequate methods for detecting HAND in Spanish speakers, especially in resource-poor areas, remains problematic. Therefore, it is necessary to identify accurate yet efficient neurocognitive screening tools that are appropriate for use in resource-limited AIDS clinics serving Spanish-speaking patients. METHODS: Twenty-one Spanish-speaking, HIV-positive adults who migrated from Mexico or Central America underwent neuromedical and neurocognitive evaluation in Spanish. The concordance of three neurocognitive screening measures (the HIV Dementia Scale [HDS], the Mini-Mental State Examination [MMSE], and the NEUROPSI) with a comprehensive neuropsychological battery was examined. In addition, accuracy in detecting neurocognitive impairment using standard and alternative cutoff scores was examined. RESULTS: The HDS and the NEUROPSI showed high correlation with the comprehensive neuropsychological battery. The HDS and the NEUROPSI also had the highest sensitivity (67% and 75%, respectively) and specificity (50% and 38%, respectively). Both measures also showed greater sensitivity than the MMSE to very mild forms of HAND. CONCLUSION: In this small sample of HIV-positive Spanish speakers from Mexico and Central America living in the United States, the HDS and the NEUROPSI demonstrated reasonable accuracy in detecting neurocognitive impairment, while the MMSE demonstrated very poor accuracy. The HDS and the NEUROPSI were equally sensitive in detecting mild HAND. Continued test development is required to capture this disorder, especially in resource-limited settings.

Coccidioidal meningitis: clinical presentation and management in the fluconazole era.

Despite the advent of new antifungal agents, coccidioidal meningitis (CM) remains a difficult-to-treat condition with significant morbidity and mortality. In this study we directly compare the clinical presentation and management of patients with Coccidioides immitis meningitis in the azole era (after 1980) to that of a cohort of patients from the pre-azole era. We reviewed 30 CM cases seen at 3 Los Angeles hospitals between the years 1993 to 2008 ("2008 cohort") and compared them to 31 patients ("1980 cohort") described by Bouza et al in a previous study. The demographics and clinical presentation of patients in the 2008 cohort were similar to those of the 1980 cohort except for a higher incidence of Hispanic patients (2008: 53% vs. 1980: 6%) and a greater percentage of patients with underlying, predisposing clinical conditions (2008: 66% vs. 1980: 32%). Ten patients in the 2008 cohort had human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), a condition not reported in the earlier study. Laboratory findings were similar between the 2 groups except for a lower incidence of peripheral leukocytosis and eosinophilia in the 2008 group.There were marked differences in drug treatment between the 2 eras. In the 2008 cohort, 29 patients received fluconazole therapy: 13 were treated with fluconazole monotherapy, and 16 received a combination of fluconazole and intravenous amphotericin B. Although almost all patients (29/31) in the 1980 cohort received intrathecal amphotericin B, only 3 patients in the 2008 study received amphotericin B via this route. With respect to complications of CM, a similar percentage of patients in each cohort developed complications such as stroke and hydrocephalus. The 2008 cohort (40%) had similar mortality compared to patients in the 1980 study (39%); survivors in both groups experienced significant impairment of activities of daily living. Although recommended as first-line therapy for CM, azole-based therapies are not curative and do not necessarily prevent complications associated with the disease.CM remains a serious illness with a high rate of morbidity and mortality. Immunocompromised individuals, especially those with HIV/AIDS, are at special risk for CM and represent a greater share of the overall population with this condition. Despite the clear advantages of azole treatment in CM, new therapeutic approaches are needed to provide definitive cure and to reduce the need for long-term suppressive therapy.

30-year-old HIV-positive female with diffuse alveolar hemorrhage.

We present a case of Strongyloides stercoralis hyperinfection in a 30-year-old HIV positive female who presents with diffuse alveolar hemorrhage. We discuss the relevant differential diagnoses and characteristic imaging findings.

Head and neck manifestations of lymphogranuloma venereum.

Lymphogranuloma venereum (LGV)--caused by Chlamydia trachomatis serovars L1, L2, or L3--rarely occurs in the United States. The disease clinically manifests in three stages: primary, secondary, and tertiary. The primary manifestation, a self-limited genital ulcer at the site of inoculation, often is absent by the time the patient seeks medical attention. The most common clinical manifestation of LGV is evident in its secondary stage: unilateral tender inguinal and/or femoral lymphadenopathy. However, proctocolitis or inflammatory involvement of perirectal or perianal lymphatic tissues resulting in fistulas and strictures may also occur. The diagnosis of LGV is usually made serologically and by exclusion of other causes of inguinal lymphadenopathy or genital ulcers. Doxycycline is the preferred treatment; it cures the infection and prevents ongoing tissue damage. This case highlights an unusual manifestation of LGV infection--cervical lymphadenopathy following suspected oropharyngeal infection with C trachomatis. Head and neck manifestations of LGV may become an increasing problem in the future if sexual practices such as orogenital contact become more widespread.

Clostridium tertium isolated from gas gangrene wound; misidentified as Lactobacillus spp initially due to aerotolerant feature.

Clostridium tertium has been increasingly reported as a human pathogen. This organism is an aerotolerant Gram-positive rod that is often mistaken for other organisms, such as Lactobacillus or Bacillus species. We describe a case of a patient with a history of intravenous drug use presenting to UCLA-Olive View Medical Center with gas gangrene of both upper extremities. The organism was initially misidentified as a Lactobacillus species on aerobic culture plates. However, terminal spore formation was detected in this isolate on a sub-cultured anaerobic culture plate and this isolate was confirmed as C. tertium biochemically and genetically by 16S rDNA sequencing. Additional DNA cloning libraries made from the formalin-fixed specimen revealed Peptoniphilus species and an uncultured Clostridium clone, but not C. tertium. C. tertium might be a causative organism of gas-producing myonecrosis but such an association has never been described. Clinicians should be aware of the phenomenon of aerotolerance of some anaerobes and need to clarify the identification of organisms if the clinical picture does not fit the isolated organism.