Ocular MPox: A report of two cases.

We report two cases of ocular MPox in men living with HIV, and review the clinical manifestations, diagnosis, and treatment of this rare syndrome. Our cases highlight the need for early recognition and prompt treatment for this potentially sight threatening infection.

Micromonas micros: A rare anaerobic cause of late implant failure following spinal surgery.

Context: Delayed, postoperative, spine infections are rare, most commonly occurring secondary to fastidious, less virulent pathogens. The etiology may involve a distant infectious focus, not related to the index operation. Patients may present months, or even years postoperatively with pain related to mechanical implant failure, often without additional signs of systemic infection.Findings: We present the case of a 59-year-old male who developed rapid disk degeneration and implant failure seven months following instrumented lumbar fusion surgery. The causal organism was found to be Micromonas micros, an anaerobic bacterium typically located in the oral cavity and associated with periodontal disease. The patient was found to have extensive oral caries, which were presumed to have occurred secondary to poor oral hygiene and his use of fentanyl lozenges for chronic back pain. The patient was treated with revision staged spinal surgery and long-term intravenous antibiotics.Conclusion/clinical relevance: This case highlights an unusual etiology of delayed postoperative spinal implant failure and provides evidence for periodontal disease as a source of hematogenous seeding in postoperative spinal infections. The orthopaedist should also be aware of the potential relationship between poor oral hygiene and the use of high sugar content fentanyl lozenges in treating chronic back pain in these patients.

Mycobacterium abscessus Periprosthetic Hip Infection Complicated by Superimposed Polymicrobial Infection: A Case Report.

CASE: A 79-year-old man developed Mycobacterium abscessus prosthetic joint infection (PJI) after hip hemiarthroplasty that was complicated by polymicrobial infection. He was ultimately treated with resection arthroplasty and chronic suppressive therapy. He has had no evidence of recurrent infection after 2 years of follow-up. CONCLUSION: As far as we know, this is the first reported case of M. abscessus hip PJI complicated by superimposed polymicrobial infection. This case demonstrates the challenge of treating M. abscessus infection, the need for a multidisciplinary approach with aggressive surgical intervention, and prolonged combination antimicrobial therapy for a successful outcome.

Brevibacteria tibial osteomyelitis.

Brevibacteria are Gram-positive rods found in human skin flora and dairy products. Although generally not considered human pathogens, case reports have implicated Brevibacterium species as rare causes of bacteremia, endocarditis, peritonitis, and osteomyelitis. We report a case of Brevibacterium tibial osteomyelitis in an immunocompetent individual with implanted hardware and highlight the challenge of identifying the organism and recognizing it as a potential pathogen.

Stratification of the risk factors of community-acquired methicillin-resistant Staphylococcus aureus hand infection.

PURPOSE: Several recent studies showed an increase in methicillin-resistant Staphylococcus aureus (MRSA) hand infections. The purpose of this study was to determine the prevalence of community-acquired MRSA hand infections in an urban setting and to determine independent risk factors for such infections. METHODS: A retrospective chart review of patients with hand infections was performed from 2002 to 2009. Those with community-acquired hand infections who had surgical irrigation and debridement and intraoperative culture were entered into the study. Patient demographics-including age and gender; mechanism of injury; infection risk factors (diabetes, chronic hepatitis, intravenous intravenousdrug use, and immune-compromised conditions); place of residence/housing status; history of hospitalization, prior antibiotics use and surgery; and culture results, erythrocyte sedimentation rate, C-reactive protein, and white blood cell count-were extracted from the medical records. Regression analyses were performed to identify significant risk factors for MRSA infection. RESULTS: A total of 102 patients met our inclusion criteria. The MRSA organism was identified in 32 patients. In the analysis of all the potential risk factors, only intravenous drug use showed significant correlation with MRSA infection. CONCLUSIONS: In our patients, only intravenous drug use correlated with community-acquired MRSA hand infections. Patient education about intravenous drug use and empiric treatment with MRSA-appropriate antibiotics for intravenous drug users presenting with hand infections are recommended. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Bezold's abscess: A rare complication of suppurative mastoiditis.

Bezold's abscess is a suppurative complication of mastoiditis rarely seen in the current era of antimicrobials. It can lead to seriously sequelae if not diagnosed and treated early. We describe a patient with recurrent bilateral otalgia who had received multiple courses of antimicrobials who presented with severe headache, neck pain and right sided hearing loss. Imaging studies showed chronic mastoiditis and formation of a Bezold's abscess. Drainage was performed but symptoms persisted. Our report highlights the need for further evaluation of patients presenting with complicated mastoiditis and the need for prolonged antimicrobial therapy.

Case Report: Mucocutaneous Leishmaniasis Masquerading as Idiopathic Midline Granulomatous Disease.

Mucocutaneous leishmaniasis (MCL) is a rare infection caused by several species within the genus Leishmania. We present a patient with multifocal MCL masquerading as idiopathic midline granulomatous disease, featuring the unusual complication of ocular leishmaniasis, as a result of prolonged immunosuppressive therapy. We review clinical features, diagnosis, and treatment of this syndrome.

Botulism-like symptoms in an immunocompetent patient with Clostridium subterminale bacteremia.

Clostridium subterminale is a low virulence species of Clostridium that is an infrequent cause of human infections. We report a case of C. subterminale bacteremia in an immunocompetent patient who developed botulism-like symptoms.

Oropharyngeal histoplasmosis: The diagnosis lies in the biopsy.

Histoplasma capsulatum, a dimorphic fungus found world-wide, is endemic to regions of the Mississippi and Ohio River valleys and portions of Central and South America. Initial infection can present with acute pulmonary symptoms or remain clinically asymptomatic, with disease course generally guided by degree of inoculum and underlying immunosuppression. A chronic, progressive course of weight loss, oral ulceration, and fatigue has been associated with elderly males. We present a 79-year-old man with a chronic, progressive course of oral lesions, odynophagia, and weight loss who was found to have histoplasmosis on oral biopsy performed for suspicions of oropharyngeal squamous cell carcinoma. Histoplasma urine antigen, serum complement fixation antibody titers, and fungal tissues were all negative despite validated sensitivities in the >90% range. Our case report highlights the critical role of tissue biopsy in establishing a diagnosis of oropharyngeal histoplasmosis.

An uncommon presentation of HIV-related lymphoma.

Although highly active antiretroviral therapy has improved the clinical course of patients with HIV, this population remains at a significantly increased risk for non-Hodgkin's lymphoma (NHL). Spinal cord compression is a rare presentation of NHL, regardless of the patient population. We encountered a patient with HIV-related NHL who presented with a thoracic spinal cord compression and had a complicated clinical course as a result of the atypical presentation.

Colistin- and Carbapenem-Resistant Escherichia coli Harboring mcr-1 and blaNDM-5, Causing a Complicated Urinary Tract Infection in a Patient from the United States.

UNLABELLED: Colistin is increasingly used as an antibiotic of last resort for the treatment of carbapenem-resistant Gram-negative infections. The plasmid-borne colistin resistance gene mcr-1 was initially identified in animal and clinical samples from China and subsequently reported worldwide, including in the United States. Of particular concern is the spread of mcr-1 into carbapenem-resistant bacteria, thereby creating strains that approach pan-resistance. While several reports of mcr-1 have involved carbapenem-resistant strains, no such isolates have been described in the United States. Here, we report the isolation and identification of an Escherichia coli strain harboring both mcr-1 and carbapenemase gene blaNDM-5 from a urine sample in a patient without recent travel outside the United States. The isolate exhibited resistance to both colistin and carbapenems, but was susceptible to amikacin, aztreonam, gentamicin, nitrofurantoin, tigecycline, and trimethoprim-sulfamethoxazole. The mcr-1- and blaNDM-5-harboring plasmids were completely sequenced and shown to be highly similar to plasmids previously reported from China. The strain in this report was first isolated in August 2014, highlighting an earlier presence of mcr-1 within the United States than previously recognized. IMPORTANCE: Colistin has become the last line of defense for the treatment of infections caused by Gram-negative bacteria resistant to multiple classes of antibiotics, in particular carbapenem-resistant Enterobacteriaceae (CRE). Resistance to colistin, encoded by the plasmid-borne gene mcr-1, was first identified in animal and clinical samples from China in November 2015 and has subsequently been reported from numerous other countries. In April 2016, mcr-1 was identified in a carbapenem-susceptible Escherichia coli strain from a clinical sample in the United States, followed by a second report from a carbapenem-susceptible E. coli strain originally isolated in May 2015. We report the isolation and identification of an E. coli strain harboring both colistin (mcr-1) and carbapenem (blaNDM-5) resistance genes, originally isolated in August 2014 from urine of a patient with recurrent urinary tract infections. To our knowledge, this is the first report in the United States of a clinical bacterial isolate with both colistin and carbapenem resistance, highlighting the importance of active surveillance efforts for colistin- and carbapenem-resistant organisms.

Benefits and harms of doxycycline treatment for Gulf War veterans' illnesses: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: It has been hypothesized that certain Mycoplasma species may cause Gulf War veterans' illnesses (GWVIs), chronic diseases characterized by pain, fatigue, and cognitive symptoms, and that affected patients may benefit from doxycycline treatment. OBJECTIVE: To determine whether a 12-month course of doxycycline improves functional status in Gulf War veterans with GWVIs. DESIGN: A randomized, double-blind, placebo-controlled clinical trial with 12 months of treatment and 6 additional months of follow-up. SETTING: 26 U.S. Department of Veterans Affairs and 2 U.S. Department of Defense medical centers. PARTICIPANTS: 491 deployed Gulf War veterans with GWVIs and detectable Mycoplasma DNA in the blood. INTERVENTION: Doxycycline, 200 mg, or matching placebo daily for 12 months. MEASUREMENTS: The primary outcome was the proportion of participants who improved more than 7 units on the Physical Component Summary score of the Veterans Short Form-36 General Health Survey 12 months after randomization. Secondary outcomes were measures of pain, fatigue, and cognitive function and change in positivity for Mycoplasma species at 6, 12, and 18 months after randomization. RESULTS: No statistically significant differences were found between the doxycycline and placebo groups for the primary outcome measure (43 of 238 participants [18.1%] vs. 42 of 243 participants [17.3%]; difference, 0.8 percentage point [95% CI, -6.5 to 8.0 percentage points]; P > 0.2) or for secondary outcome measures at 1 year. In addition, possible differences in outcomes at 3 and 6 months were not apparent at 9 or 18 months. Participants in the doxycycline group had a higher incidence of nausea and photosensitivity. LIMITATIONS: Adherence to treatment after 6 months was poor. CONCLUSION: Long-term treatment with doxycycline did not improve outcomes of GWVIs at 1 year.

Antibiotics in the treatment of acute exacerbations of chronic bronchitis.

The benefit of antimicrobial therapy for patients with an acute exacerbation of chronic bronchitis (AECB) remains controversial for two main reasons. First, the distal airways of patients with chronic bronchitis are persistently colonised, even during clinically stable periods, with the same bacteria that have been associated with AECB. Second, bacterial infection is only one of several causes of AECB. These factors have led to conflicting analyses on the role of bacterial agents and the response to antimicrobial therapy of patients with AECB. An episode of AECB is said to be present when a patient with chronic obstructive pulmonary disease (COPD) experiences some combination of increased dyspnoea, increased sputum volume, increased sputum purulence and worsening lung function. While the average COPD patient experiences 2 - 4 episodes of AECB per year, some patients, particularly those with more severe airway obstruction, are more susceptible to these attacks than others. Bacterial agents appear to be particularly associated with AECB in patients with low lung function and those with frequent episodes accompanied by purulent sputum. Non-typeable Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis account for up to 50% of episodes of AECB. Gram-negative bacilli are more likely to occur in patients with more severe lung disease. Antibiotics have been used to ameliorate AECB, to prevent AECB and to prevent the long-term loss of lung function that characterises COPD. Numerous prevention trials have been conducted with fairly consistent results; antibiotics do not lessen the number of episodes of AECB but do reduce the number of days lost from work. Most antibiotic trials have studied the impact of treatment on episodes of AECB and results have been inconsistent, largely due to patient selection and end point definition. In patients with severe airway obstruction, especially in the presence of purulent sputum, antibiotic therapy significantly shortens the duration of symptoms and can be cost-effective. Over the past 50 years, virtually all classes of antimicrobial agents have been studied in AECB. Important considerations include penetration into respiratory secretions, spectrum of activity and antimicrobial resistance. These factors limit the usefulness of drugs such as amoxicillin, erythromycin and trimethoprim-sulfamethoxazole. Extended-spectrum oral cephalosporins, newer macrolides and doxycycline have demonstrated efficacy in clinical trials. Amoxicillin-clavulanate and flouoroquinolones should generally be reserved for patients with more severe disease. A number of investigational agents, including ketolides and newer quinolones, hold promise for treatment of AECB.

Nosocomial pneumonia.

Nosocomial pneumonia, or terminal pneumonia as it was formerly called, results from the repetitive microaspiration of contaminated oropharyngeal secretions into the lungs in the presence of impaired host defenses. This pathophysiologic sequence was suggested by the observations of Osler but clarified by the seminal work of Rouby and colleagues. The enormous impact of antimicrobial agents on the organisms responsible for nosocomial pneumonias was first identified by Kneeland and Price who found that organisms of the normal pharyngeal flora virtually disappeared in terminal pneumonias following administration of these drugs, being replaced by gram-negative bacilli. The remarkable susceptibility of seriously ill patients to becoming colonized by exogenous organisms, even in the absence of antimicrobial therapy, was shown by Johanson et al. These factors, antibiotics and the change in bacterial binding receptors in the airways associated with illness, lead to infections caused by exogenous organisms that are frequently resistant to antimicrobial agents. Clinical findings that usually identify patients with respiratory infections are unreliable for the diagnosis of nosocomial pneumonias as shown by Andrews et al. Invasive techniques, especially the protected specimen brush (PSB) technique, avoid contamination of the specimen by proximal secretions and accurately reflect the bacterial burden of the lung, as first shown by Chastre et al. Quantitation of such specimens serves as an excellent proxy for direct cultures of the lung and are the current gold standard for diagnosis.

Role of continuous renal replacement therapy ultrafiltrate cultures in the microbial diagnosis of sepsis.

In a cohort of 23 critically ill patients receiving continuous renal replacement therapy, we investigated the role of ultrafiltrate fluid cultures as an adjunct to blood cultures in identifying the microbial etiology of sepsis. We found they provided no additional benefit and may yield false positives due to contamination.

Pulmonary Kaposi's sarcoma as the initial presentation of human immunodeficiency virus infection.

Kaposi's sarcoma (KS) usually presents in HIV-infected patients with cutaneous lesions that may advance to extensive visceral disease. There have been only a few documented cases in which the initial presentation of Kaposi's sarcoma involved the bronchopulmonary system. We describe a newly diagnosed patient who presented with pulmonary KS as his initial presentation of the disease. Our report is intended to increase clinicians' awareness that pulmonary Kaposi's sarcoma should be considered in HIV-infected patients who present with respiratory symptoms, even if they do not manifest the typical mucocutaneous manifestations of KS or have low CD4 counts. Early diagnosis and therapy are essential in improving outcomes as this condition carries a high mortality.

Molecular characterization of an early invasive Staphylococcus epidermidis prosthetic joint infection.

Historically regarded as a skin commensal, Staphylococcus epidermidis has been increasingly implicated in invasive foreign body infections such as catheter-related bloodstream infections, indwelling device infections, and prosthetic joint infections. We report a case of an aggressive, difficult-to-eradicate, invasive prosthetic hip infection occurring early after hardware implant and associated with a high-grade bacteremia and assess its salient molecular characteristics. The clinical and molecular characteristics of this isolate mirror the pathogenesis and persistence commonly seen with invasive methicillin-resistant S. aureus and may be attributed to the combination of resistance genes (SCCmec type IV), putative virulence factors (arcA and opp3a), cytolytic peptide production (α-type phenol-soluble modulins), and biofilm adhesion, interaction, and maturation (bhp, aap, and ß-type phenol-soluble modulins).

Daptomycin and rifampin for the treatment of methicillin-resistant Staphylococcus aureus septic pulmonary emboli in the absence of endocarditis.

Daptomycin has demonstrated clinical efficacy in the treatment of methicillin-resistant Staphylococcus aureus-associated bacteremia and right-sided infective endocarditis. Although daptomycin is not approved for treatment of gram-positive pneumonia, clinical evidence suggests that it may be effective therapy for S. aureus-associated septic pulmonary emboli (SPE). We present our clinical experience with the use of daptomycin in combination with rifampin in four patients with SPE in the absence of infective endocarditis. Three of the patients had a history of injection drug use; two of these patients also had soft-tissue infections. All patients had clinical resolution of their infections. Daptomycin and rifampin appear to have a role in the treatment of methicillin-resistant S. aureus bacteremia with SPE in the absence of infective endocarditis and should be considered in patients that have failed therapy with vancomycin.

Digital clubbing in HIV-infected patients: an observational study.

Digital clubbing is characterized by bulbous enlargement of the distal phalanges due to an increase in soft tissue. It has been associated with a variety of conditions including cyanotic heart disease, neoplasms and infections of the lungs, bronchiectasis, liver cirrhosis, and inflammatory bowel disease. We conducted an observational study at an urban Veterans Affairs Medical Center outpatient HIV clinic to confirm our clinical impression that clubbing is common in HIV-infected patients and to identify factors that might be associated with it. Clinical, laboratory, and physical examination data including measurement of the circumference of the nail bed and distal phalanx of each finger were obtained on 78 HIV-infected patients seen for their routine care over a 3-month period. A digital index (DI), the ratio of the nail bed:distal phalanx circumference was determined for each patient. Clubbing was found in 28 patients (36%). Clubbed patients did not differ from nonclubbed patients with respect to most patient characteristics; CD4 cell counts and quantitative HIV RNA were similar in both groups. Clubbed patients had a significantly higher DI than controls (1.03 versus 0.96, p < 0.001), were younger (45 versus 49 years, p = 0.04), and had longer duration of HIV disease (48 versus, 42 months, p = 0.03). HIV infection should be considered in the differential diagnosis of acquired digital clubbing.

Impact of adding maraviroc to antiretroviral regimens in patients with full viral suppression but impaired CD4 recovery.

We reviewed the effect of adding maraviroc on CD4 cell counts in nine patients on antiretroviral therapy with full viral suppression but impaired CD4 cell recovery. There were no significant differences in changes in CD4 cell count, percentage of CD4 cells, or in the ratio of CD4/CD8 cells at 30 days and 25 weeks of maraviroc therapy. Plasma endotoxin levels measured in four patients before and during maraviroc treatment also showed no significant differences.