Approach to skin and soft tissue infections in non-HIV immunocompromised hosts.

PURPOSE OF REVIEW: Skin and soft tissue infections are frequent contributors to morbidity and mortality in the immunocompromised host. This article reviews the changing epidemiology and clinical manifestations of the most common cutaneous pathogens in non-HIV immunocompromised hosts, including patients with solid organ transplants, stem cell transplants, solid tumors, hematologic malignancies, and receiving chronic immunosuppressive therapy for inflammatory disorders. RECENT FINDINGS: Defects in the innate or adaptive immune response can predispose the immunocompromised host to certain cutaneous infections in a predictive fashion. Cutaneous lesions in patients with neutrophil defects are commonly due to bacteria, Candida, or invasive molds. Skin lesions in patients with cellular or humoral immunodeficiencies can be due to encapsulated bacteria, Nocardia, mycobacteria, endemic fungal infections, herpesviruses, or parasites. Skin lesions may reflect primary inoculation or, more commonly, disseminated infection. Tissue samples for microscopy, culture, and histopathology are critical to making an accurate diagnosis given the nonspecific and heterogeneous appearance of these skin lesions due to a blunted immune response. SUMMARY: As the population of non-HIV immunosuppressed hosts expands with advances in medical therapies, the frequency and variety of cutaneous diseases in these hosts will increase.

Clinical Case of the Month: A 57-Year-Old Man with an Axillary Mass.

A 57-year-old man presented to the surgical oncology clinic with a mildly tender mass under his right arm. Four years prior, the patient had a melanoma removed from his right shoulder along with an ipsilateral right axillary sentinel lymph sampling. Computed tomography (CT) scan was negative for metastatic disease at that time. The patient did not undergo completion axillary node dissection and was lost to follow-up. The patient was originally from Australia, did not tan but reported multiple sunburns before age 18. He was of Irish ancestry. He denied weight gain, fever, fatigue, anorexia, or night sweats. The patient had a medical history of atrial fibrillation, hypertension, gout, melanoma, and benign prostatic hypertrophy. His surgical history included an appendectomy and a facial laceration repair. His brother died at 16 years old from leukemia and his mother died from colon cancer. He consumed 3 alcoholic beverages per day and denied tobacco or illicit drug use. On physical exam, the patient's temperature was 98.8° Fahrenheit, heart rate of 73 beats / minute, blood pressure of 121 / 59 mm Hg, respiratory rate of 18 / min. He appeared to be healthy and in no apparent distress. Cardiovascular, respiratory, breast, gastrointestinal, musculoskeletal, and neurological exam were unremarkable. His right axillary lymph node exam revealed a firm mass roughly 2.5 cm tall by 1.5 cm wide. This mass was biopsied and findings were consistent with metastatic melanoma. CT scan revealed small volume mediastinal adenopathy and a 4.5 cm right axillary mass. There was a 4.7 cm lesion within the anterior left lower lobe of the liver and periportal node conglomerate measuring 3.9 cm consistent with metastatic disease (Figure 1). He was negative for the BRAF V600E mutation. The patient was consented for treatment with combination immune checkpoint inhibition with ipilimumab and nivolumab. After two cycles the patient showed good response, but temporarily stopped treatment after complications related to a ST segment elevation myocardial infarction. He developed mild pneumonitis felt to be related to nivolumab, and recovered after a short course of glucocorticosteroids. Restaging CT scans were ordered after two cycles of therapy (Figure 2), which showed decrease in the size of the axillary and hepatic metastases. At six months, CT scans showed continued durable response (Figure 3).

Clinical Case of the Month: A 56-Year-Old Man with Sudden Onset Abdominal Pain.

Acute abdominal pain is one of the most common presentations encountered in the emergency department (ED). The differential diagnosis of acute abdominal pain is extensive and identifying the underlying etiology can be challenging. Spontaneous renal artery thrombosis is a rare cause of acute abdominal pain. We review a case of acute presentation of renal artery thrombosis in a patient without risk factors for thromboembolism, and highlight the importance of considering this rare cause of abdominal pain.

Clinical Case of the Month: A 64 Year-Old Woman Presenting With Fever, Confusion, Ophthalmoplegia and Pneumonia.

Legionella pneumophila is a major cause of atypical community-acquired pneumonia, which is commonly severe enough to require hospitalization. Though primarily a respiratory infection, Legionellosis involves the central nervous system (CNS) in up to 50% of patients, and diagnosis can be obscured by the absence of obvious respiratory symptomatology. A reversible diffuse encephalopathy is the most common neurologic complication, but focal CNS involvement can sometimes be the initial presentation. We report a case of a woman infected with Legionella pneumophila presenting with vague symptomatology and focal neurologic findings. This report highlights the challenges of early recognition of Legionella infection when neurologic symptoms predominate.

Clinical Case of the Month:A 54 Year-Old Woman With Fever and Chills of Four-Days Duration.

CASE REPORT: A 54 year-old woman with diabetes mellitus type two and end-stage renal disease on hemodialysis presented to the emergency department with a four day history of generalized malaise, fever, and chills. Her symptoms were also associated with occasional dyspnea without a cough. She reported intermittent chronic diarrhea with hemodialysis which was currently unchanged. On the day of admission, she could not tolerate hemodialysis due to her symptoms. Over the past year she admitted to night sweats and a 40 pound weight loss. She denied having palpitations, chest pain, hemoptysis, lymph node swelling, sick contacts, or recent travel. The remainder of the review of systems was negative.

Clinical Case of the Month: PERSISTENT HYPERTENSION IN A YOUNG WOMAN: A CLASSIC PRESENTATION OF CONN'S SYNDROME.

Primary aldosteronism PA is a secondary cause of hypertension that is often missed due to inadequate clinical evaluation and the lack of classically described laboratory abnormalities. Based on guidelines from the Endocrine Society, primary aldosteronism should be suspected in young patients with moderate to severe hypertension, patients with hypertension and coexisting hypokalemia, any patient with hypertension and an incidental adrenal adenoma, and hypertension in the setting of a significant family history of early onset hypertension or cerebral vascular accident in a first degree relative less than 40 years of age.1 In previous years, primary aldosteronism was attributed to less than one percent of all causes of secondary hypertension. However, recent research and increased utilization of aldosterone plasma renin ratio ARR as a method for screening has led to the understanding that majority of patients with PA are not hypokalemic, and the current literature now places the incidence of PA between 5-13 percent. Additionally, a growing body of evidence has demonstrated inflammatory, fibrotic, and remodeling effects on the cardiovascular and renal tissue that appear to be independent of PA- induced hypertension. Therefore a high suspicion for PA must be incorporated into evaluation of hypertensive patients, as diagnosis and subsequent treatment not only improves blood pressure control, but also acts to diminish cardiovascular morbidity and mortality. Here we present a case of a young woman with a seven-year history of hypertension prior to receiving a diagnosis of Conn's Syndrome.

Clinical Case of the Month: A 48-Year-Old Man With Fever and Abdominal Pain of One Day Duration.

A 48-year-old man residing in a mental health department inpatient program with a history of schizoaffective disorder presented to the emergency department with a chief complaint of fever and intense abdominal pain for one day. The patient stated he initially fell in the shower and afterwards experienced back pain. He was transferred to an acute care unit within the facility for further evaluation. The facility physician noted that the patient had a mild temperature elevation and abdominal rigidity on exam. At that time, he was given two doses of benztropine intramuscularly, and transferred to our hospital for further evaluation. The patient exhibited fever, diffuse abdominal pain and a nonproductive cough, but denied chills, dysuria, urinary frequency, hematuria, weakness, diarrhea, melena or hematochezia. He did have a one-week history of constipation for which he was given sodium phosphate enemas, magnesium citrate and docusate sodium, eventually resulting in a bowel movement. He also complained of new onset dysphagia. There were no recent changes to his medications, which included clonazepam, divalproex sodium extended release, olanzapine and risperidone. He denied use of tobacco, alcohol or illicit drugs.

CLINICAL CASE OF THE MONTH: A Review of Situs Inversus and Dextrocardia.

A 21-year-old woman at 25 weeks gestation presented to the emergency department with chief complaints of decreased appetite for one week, fever, runny and stuffy nose, and generalized muscle pains.

Clinical Case of the Month: Hypereosinophilia in a Young Woman with a History of Childhood Asthma.

Hypereosinophillia is a rare clinical entity. It is associated with a wide differential diagnosis including neoplasm, infection, and allergic etiologies. Clinicians should have a well defined approach to hypereosinophilia in order to find treatable causes. We present a case of hypereosinophillia caused by parasitic infection with Toxocara canis. We also review epidemiology, transmission, microbiology, and management of Toxocara canis.

Clinical Case of the Month: A 49-Year-Old Man with Fever, Headache and Leg Weakness.

A 49-year-old man with an unremarkable past medical history presented to an outside hospital with a five-day history of fever, left leg weakness, myalgia and headache. The patient reported that the illness started as a fever and sore throat and he was originally diagnosed with streptococcal pharyngitis and prescribed antibiotics. The day after his initial diagnosis, his fever had progressed to include a headache, myalgia, a rash on his upper torso and right shoulder and sudden-onset left leg weakness with preserved sensation. With progressively worsening symptoms, he eventually presented to a local emergency department (ED), five days after his symptoms first started. He was experiencing continued left leg weakness, an inability to ambulate, persistent fevers to 103ºF, muscle aches, an intense band-like headache and confusion. The patient denied neck stiffness, photophobia, loss of sensation or any additional muscle weakness. He denied any recent travel aside from work, any sick contacts, recent tick/insect bites, history of sexually transmitted diseases or contact with animals. He reported no history of illicit drug use as well as no recent weight loss, trauma or radiation exposure. The patient had approximately a 10-pack-year tobacco smoking history. For the last ten years he drank about a six-pack of beer daily while onshore (roughly two weeks out of every month). He works on an offshore oil platform. He was not taking any home medications besides his recently prescribed antibiotics. He lived alone at home in a moderately rural area of South Louisiana. His family history was non-contributory.

CLINICAL CASE OF THE MONTH. A 63-Year-Old Woman With Rash and Proximal Muscle Weakness.

A 63-year-old woman with a history of infiltrating ductal breast cancer, status post-mastectomy and chemotherapy, was in remission for 18 months prior to being admitted to the hospital with complaints of a pruritic erythematous macular rash involving her head, chest, and bilateral upper and lower extremities. Along with the dermatologic manifestations, physical exam revealed proximal symmetrical muscle weakness and bilateral axillary lymphadenopathy. Initial workup for muscle weakness revealed a creatine kinase of 2,200 IU/L (normal 20-180 IU/L). After administration of intravenous fluids for renal protection, serum sodium dropped to 121 mEQ/L (normal 135-145 mEQ/L). Computed tomography of the chest showed axillary and supraclavicular lymphadenopathy. Biopsy of a supraclavicular node revealed infiltrating ductal cancer with histologic and morphologic characteristics similar to her previous breast cancer. Following an extensive laboratory workup, we concluded that our patient's myositis and hyponatremia were paraneoplastic syndromes secondary to her recurrent breast cancer.

Clinical case of the month: a 22-year-old man with AIDS presenting with shortness of breath and an oral lesion.

Since the development of combination antiretroviral therapy (cART), the incidence and mortality associated with Kaposi sarcoma (KS) have been reduced, although not eliminated. Clinical presentations of KS range from simple skin involvement to disseminated disease, including involvement of the oral cavity and viscera, which portends a more ominous prognosis. Multiple case reports and data from clinical trials indicate that administration of systemic corticosteroids may aggravate KS. We present a case of disseminated KS following administration of prednisone for presumed immune reconstitution inflammatory syndrome (IRIS) associated with fungal pneumonia in an HIV-infected individual. The discussion that follows outlines the pathophysiology and clinical presentations associated with KS and existing data for the role of corticosteroids in promoting KS progression.

Clinical Case of the Month. A 44-Year-Old HIV-Infected Man With Righ-Shoulder Swelling.

Immunocompromised patients are susceptible to various joint infections with less-common pathogens, such as mycobacterium. Physicians should have a low threshold to investigate the cause of an arthropathy further. An aspiration of the effusion is usually warranted to identify the possible pathogen and target treatment. We report an unusual presentation of a human immunodeficiency virus-infected patient with a chronic effusion arthropathy of his right shoulder due to Mycobacterium kansasii. We review the risk factors, transmission, clinical manifestations, and management of Mycobacterium kansasii.

Clinical case of the month. A 50-year-old man with a persistent rash.

In September 2006, the United States Centers for Disease Control and Prevention (CDC) published updated recommendations for routine opt-out human immunodeficiency virus (HIV) testing in all healthcare settings. As late diagnosis of infection increases individual and societal risks, a goal of the 2010 National HIV/AIDS Strategy is to increase the percentage of those aware of their infection. In 2008, two years following changes in the CDC testing recommendations, 44.6% of individuals 18-64 years of age reported a history of having a HIV test, resulting in close to 40,000 new HIV diagnoses. Emergency departments accommodate more than 120 million patient visits per year in the United States and can be the only point of contact individuals have with the healthcare system, particularly in uninsured and marginalized groups. Further implementation of opt-out testing can result in earlier diagnosis and improved health outcomes at the both the individual and public health levels.

Clinical case of the month. A 63-year-old woman with lumbago. Eikenella corrodens.

We present a case of facet joint infection (pyogenic facetitis) due to Eikenella corrodens, diagnosed by physical examination, radiography, positive blood cultures, and response to antibiotic therapy. E. corrodens is a very rare cause of spine infection. There are fewer than 20 such cases reported in the literature, only one of which was diagnosed by non-invasive means, and none of which were isolated to the facet joint. We briefly review the microbiology of E. corrodens in addition to the diagnosis and management of spine infection.

A case of disseminated cryptococcosis with skin manifestations in a patient with newly diagnosed HIV.

In this case report, we provide a concise review of the pathogenesis, clinical presentation, key diagnostic findings, and treatment options for Cryptococcus. Cryptococcus neoformans is a ubiquitous dimorphic fungus that can potentially be life threatening, especially in immunocompromised hosts. It commonly infects the respiratory tract or central nervous system. However, skin manifestations can be a marker of severe and disseminated disease, particularly in individuals at higher risk, including those patients with AIDS, cancer, long-term corticosteroid use, and organ transplant recipients. A timely diagnostic workup, including skin biopsy,blood cultures, and lumber puncture, is crucial since skin lesions may mimic other infectious processes. In addition, prompt, appropriate antifungal treatment should be initiatedto decrease morbidity and mortality.

Clostridium difficile infection in non-HIV-immunocompromised patients and in HIV-infected patients.

Clostridium difficile infection is a common cause of morbidity in patients with HIV infection and in patients with non-HIV immune deficiency. The frequency of C. difficile--associated diarrhea (CDAD) seen in these two patient populations has been attributed to immune deficiency, as well as to increased exposure to hospital environments and antibiotic therapy, both of which are major risk factors for CDAD. This article reviews recent data useful in the evaluation, treatment, and prevention of C. difficile infection in these patient groups. Recent publications relating to C. difficile infection in specific immunocompromised conditions are also discussed.

A 57-year-old man with diabetes and a toe infection.

Foot infections are common complications in the diabetic population resulting in significant associated morbidity. Several risk factors predispose these individuals to foot infections including, but not limited to, sensory neuropathy, autonomic neuropathy, motor neuropathy, atherosclerotic disease, hyperglycemia, and immune dysfunction.5 Medical work-up and treatment of diabetic foot infections depends on the extent and severity of the infection. An organized and practical approach based on an understanding of the pathophysiology and microbiology is helpful in the evaluation and treatment of these infections. 2

Clinical case of the month. A rare case of Budd Chiari syndrome.

Budd Chiari syndrome is a rare disorder resulting from hepatic venous outflow tract obstruction anywhere from the small hepatic veins to the suprahepatic inferior vena cava. This patient has a hypercoagulable state secondary to heterozygous mutation of factor V and the JAK2 mutation and is being anticoagulated. We hypothesize that the low protein C and low antithrombin III levels seen in this patient resulted from decreased synthetic function of the liver and were not indicative of actual deficiencies. Indeed, reports of coexisting protein C and antithrombin III deficiencies are not existent in the literature and likely are not compatible with life. All patients with BCS warrant a hypercoagulable work up and JAK2 mutation is increasingly recognized as a contributing factor, even in those patients without obvious signs of polycythemia vera.