Lost in the Clinics and Found in the Morgue: A Case of Peripheral T-cell Lymphoma Masquerading as Pneumonia.

In modern medicine, there is an increasing dependence on noninvasive imaging modalities, for diagnosis and management of diseases. Though there are definite advantages to this, they are at times offset by diagnostic pitfalls especially in entities with elusive clinical presentation.Peripheral T-cell lymphoma-not otherwise specified (PTCL-NOS) is an aggressive subtype of T-cell lymphomas that does not meet criteria for a specific subtype. Peripheral T-cell lymphoma usually has varied clinical presentations depending on the site of involvement. Vast majority of PTCL patients present with systemic disease, generalized lymphadenopathy and constitutional symptoms. Pulmonary involvement is relatively rare and is seen in approximately 10% of patients.Here in we highlight a rare case of PTCL, masquerading as pneumonia due to extensive pulmonary involvement that went undiagnosed and was discovered at autopsy. This case of malignant lymphoma of T-cell origin involving the lung, which is very rare, highlights the continued importance of medical autopsies not only as a teaching tool but also as an important adjunct to investigative medicine in uncovering lapses that can subsequently be avoided to improve patient care and decrease mortality.

Monkeypox Proctitis: A Case of Targeted Treatment With Tecovirimat.

Monkeypox (MPX) is an exanthematous disease first identified in the 1950s, associated with animals in Central and Western Africa, and has since been found sporadically worldwide. In May 2022, a returning family from Nigeria tested positive for MPX, which marked the onset of the current outbreak. It has now become a disease of concern in most parts of the world. The current standings are nearing 90,000 cases, with numbers increasing daily. The United States reported 29,711 cases so far. The characteristic exanthem of MPX is known to be present ubiquitously on the human habitus, with recent reports describing anogenital and mucosal lesions. Here, we present a rare case of a 43-year-old male presenting with excruciating perianal pain and purulent discharge, found to have proctitis secondary to MPX, and subsequently treated with Tecovirimat, a targeted antiviral therapy.

AngioVac system for infective endocarditis: A new treatment for an old disease.

Three different patients presented to our institution with right-sided infective endocarditis (IE). All three were found to have vegetation on the tricuspid valve. These patients were started on appropriate antimicrobial therapy according to their blood cultures sensitivities. Despite this management, the patients' clinical status did not improve solely on antimicrobials. Surgery was, therefore, indicated to remove the vegetations. Traditionally, the appropriate management would have been invasive surgery. However, these patients were subjected to a novel treatment in our institution for right-sided IE: percutaneous mechanical vegetation debulking with an AngioVac system. After this procedure, all three patients' clinical status improved drastically. This new less invasive approach seems to offer the same results as the traditional invasive surgery, with faster recovery time. More comparative studies are needed to confirm this idea.

Balamuthia mandrillaris and Acanthamoeba amebic encephalitis with neurotoxoplasmosis coinfection in a patient with advanced HIV infection.

We describe a patient with advanced HIV infection and Balamuthia mandrillaris and Acanthamoeba amebic encephalitis with Toxoplasma gondii coinfection. A multidisciplinary effort and state-of-the-art diagnostic techniques were required for diagnosis. Our patient is the first reported case of an HIV-infected person with dual Balamuthia mandrillaris and Acanthamoeba amebic encephalitis with neurotoxoplasmosis coinfection.

Pulmonary Granulomas and Mycobacterial Infection: Concordance between the Results of Special Stains Performed on Lung Tissue Sections and Tissue Cultures.

Background: The most common cause of infectious pulmonary granulomas worldwide is Mycobacterium tuberculosis. The diagnosis is based on clinical presentation, histopathologic findings, detection of acid-fast bacilli (AFB) in tissue or sputum using special stains, and/or isolation of mycobacteria in cultures or via PCR-based methods. Different studies have shown that high levels of discrepancy exist between these diagnostic approaches in lung tissue specimens. Objective: To assess the degree of concordance between the results of special stains and cultures on lung tissue specimens in the diagnosis of mycobacterial infections. Methodology: Eighty-seven patients with a diagnosis of granulomas (necrotizing and non-necrotizing) on lung tissue specimens were identified. Cohen's kappa was used to measure the general concordance between the results of the histopathological examination (special stains) and bacteriological tissue cultures. Results: With Kinyoun acid-fast stains, 8/48 (16.7%) cases were positive for AFB. With FITE stains, 10/57 (17.5%) cases were positive for AFB. There was strong agreement between Kinyoun acid-fast and FITE stains (Kappa = 0.806; p-value < 0.001). Tissue cultures were performed on 38/87 cases (43.7%), and 10/38 (26.3%) of the cultures were positive for mycobacteria. There was no concordance between Kinyoun acid-fast stains or FITE stains and tissue cultures results. Conclusion: Our observations represent an initial step in the process of reviewing the two methods used at our institution to diagnose mycobacterial infections on lung tissue specimens and highlight the need of incorporating more advanced diagnostic methods such as PCR to confirm mycobacterial infections and improve patient management. Importantly, species-level identification of mycobacteria is necessary to guide treatment.

Cutibacterium acnes: An emerging pathogen in culture negative bacterial prosthetic valve infective endocarditis (IE).

Cutibacterium acnes (previously known as Propionibacterium) infections are reportedly increasing in patients with implanted foreign material. Though it is a rare cause of bacterial endocarditis, patients with implanted prosthetic valves and devices have potential increased risk. Cutibacterium species are an ubiquitous environmental surface contaminant and typically difficult to culture, in case of high suspicion for infective endocarditis extended duration incubation of blood or any tissue sample and 16S RNA sequencing of any tissue sample is helpful for a microbiological identification. We report a case of a 50 year old male with culture negative prosthetic valve endocarditis in which the pathogen was identified by molecular testing 16S RNA gene sequencing.

Mycobacterium marinum Infection and Interferon-Gamma Release Assays Cross-Reactivity: A Case Report.

Mycobacterium marinum (M. marinum) is a pathogen that causes skin and soft tissue infections in people who work with contaminated water, such as fish handlers. M. marinum infection is mostly limited to patients with compromised immune systems. As per current guidelines, susceptibility testing is not routinely recommended, although sporadic cases have been reported with resistance to routinely prescribed anti-tuberculous drugs. We report a case of a 61-year-old male taking adalimumab with ulcerative skin and soft tissue infection with positive interferon-gamma release assays (IGRA) identified as M. marinum and the treatment challenges involved in this case.

Sporadic leptospirosis case in Florida presenting as Weil`s disease.

Leptospirosis has been rarely reported in the United States and has been historically related to occupational exposure to infected animals, and contaminated environments. Over the past decade, there are indications that at-risk populations may be changing in the United States, to also include participants in freshwater sports and occasionally individuals living in economically disadvantaged urban inner- city environments. We present a case of Weil`s disease in a 39-year-old homeless man who had been released from prison two weeks prior and denied direct contact with infected animals or contaminated fresh water. Prison inmates and homeless patients are potentially at high risk of rat exposure and infection with Leptospira. A high index of suspicion is needed for diagnosis of leptospirosis in the absence of traditional risk factors. To our knowledge, this is the first case of leptospirosis associated with homelessness and incarceration in the United States. A literature review on leptospirosis cases in Florida over the past 60 years was performed.

Fluoroquinolone resistant tuberculosis: A case report and literature review.

Despite the advancements made in medicine and treatment of tuberculosis over the last century, it remains a significant healthcare challenge. It remains the leading cause of death from a single infectious agent and the ninth leading cause of death worldwide. A 23-year-old male with a history of tuberculosis treated in Nepal seven years prior, presented to the emergency department with one week of hemoptysis, fever, chills, night sweats and weight loss. A CT scan of the chest showed multiple cavitary lesions at the superior segment of the left lower lobe. He had persistent massive hemoptysis and required blood transfusions. He underwent bronchial artery embolization followed by lobectomy. He was ultimately diagnosed with fluoroquinolone-resistant tuberculosis, and required a prolonged intensive care unit with transfer to a regional tuberculosis center to successfully complete treatment.

Thyroid Abscess: Challenges in Diagnosis and Management.

Thyroid abscess is an uncommon infectious pathology. The thyroid is highly resistant to infection due to high iodine content, capsular encasement, and rich vascularity. Acute suppurative thyroiditis represents <1% of thyroid diseases that could potentially become a life-threatening endocrine emergency. A 48-year-old woman with AIDS presented with 3 days of fever, tender neck swelling, and methicillin-resistant Staphylococcus aureus bacteremia. Apart from leukocytosis, initial laboratory values including thyroid function tests were normal. The initial plain computed tomography scan of the neck and ultrasound scan of the neck were inconclusive as well. By day 4, she worsened, and on repeat computed tomography scan of the neck with contrast, multiloculated abscesses in the thyroid and retro pharynx were seen, which needed emergent drainage. Acute suppurative thyroiditis, a rare disease, occurs in patients with either preexisting disorders of the thyroid or in the immunocompromised. The most common pathogen is Staphylococcus aureus. In our case, we highlight the fact that initial imaging may be negative in the early stages of acute suppurative thyroiditis and lead to an erroneous diagnosis of subacute thyroiditis. There are less than 5 cases of methicillin-resistant Staphylococcus aureus suppurative thyroiditis reported.

A rare case of prototheca algaemia in a patient with systemic lupus erythematosus and recent belimumab infusion.

Novel agents for the treatment of immune-mediated diseases such as systemic lupus erythematosus (SLE) have been increasingly used as an alternative to or in combination with conventional therapies. Belimumab, a human monoclonal antibody that inhibits B-cell activating factor (BAFF), has demonstrated efficacy in moderate-to-severe SLE with similar adverse effects when compared to other biologic agents and conventional SLE therapies. Here, we describe a woman with SLE and diabetes mellitus (DM) on immunosuppressive therapy for five years who was admitted to the hospital for pneumonia but had a complicated hospital course with multiple infections and, most notably, a nosocomial algaemia due to Prototheca wickerhamii, which was treated successfully with amphotericin B. She had recently received three belimumab infusions as an outpatient prior to admission to the hospital. To the best of our knowledge no cases of human protothecosis in patients receiving belimumab have been described in the English literature; however, unusual infections have to be considered in all patients undergoing immunosuppressive therapies who persist with fever despite conventional antimicrobials.

Challenging cases discussed by experts: retinal vasculitis following coinfection with HIV and syphilis.

A patient with HIV and syphilis presents with bilateral retinal vasculitis and recurrent vitreous hemorrhage. Diagnostic and treatment strategies are discussed.