Introduction: Talaromyces marneffei causes a systemic fungal infection, referred to as talaromycosis, in immunocompromised individuals. Talaromycosis is an AIDS (acquired immunodeficiency syndrome) defining illness for patients living in the Southeast Asian region. Here we present two rarely reported cases of pulmonary talaromycosis in Southern California in patients with active cancer, negative HIV status, and no prior travel history to endemic regions. Case description: Case 1: A 76-year-old male with a past medical history of emphysema and latent tuberculosis status post rifampin treatment, presented with a necrotic lung mass. He was diagnosed with squamous cell lung carcinoma and bronchoalveolar lavage cultures grew Talaromyces marneffei. He had no animal exposure or prior travel history to Asia. Due to a transfusion reaction to liposomal amphotericin (the mainstay of treatment), he required a transition to posaconazole. He was HIV-negative and expired due to underlying cancer and infection complications.Case2: A 63-year-old male with a past medical history of tuberculosis, diabetes, and cavitary pneumonia with bronchoscopy positive for Talaromyces presented with worsening back pain and was found to have multiple sites of poorly differentiated adenocarcinoma likely originating from gastric adenocarcinoma. He was HIV-negative and expired due to complications from underlying cancer and infection. Conclusion: We demonstrate that patients with pulmonary Talaromyces are becoming more prominent outside of endemic areas even in the setting of no prior travel. In addition, since patients with this infection are severely immunosuppressed, they require extensive workup for other comorbidities such as possible underlying cancer or tuberculosis.
Background: Osteomyelitis of the diabetic foot remains a significant complication that may result in the need for amputation. Proximal surgical margin histopathology after limb-sparing amputation could be used to guide antimicrobial duration and prognostic management but remains debatable. Here we evaluate if negative proximal bone margins predict outcomes of diabetic foot osteomyelitis at 1 year. Methods: A retrospective study assessed adults with diabetes undergoing limb-sparing foot amputations from September 2016 to September 2019. Patients required histopathology confirmation of osteomyelitis, proximal margin histopathology report, and documented electronic medical record follow-up through 12 months. The primary outcome evaluated if no further amputation at the same site was required in the following 12 months. Results: Of 92 patients, 57 (61.9%) had pathology-confirmed negative margins for osteomyelitis. Patients with negative margins required less frequent subsequent amputations at the same site within 12 months compared to positive margins (86.0% vs 65.7%; P = .003). Antibiotic duration was shorter in patients with negative margins (mean, 18 vs 30 days; P = .001). Negative-margin patients also noted lower rates of readmission at 12 months (26.3% vs 51.4%; P = .015) for site-specific complications. Staphylococcus aureus was more predominant in patients with positive versus negative margins (57.1% vs 29.8%; P = .017). Conclusions: Negative proximal bone margin by histopathology was associated with lower frequency of further amputations at the index surgical site within 12 months. This group also received shorter courses of antibiotic therapy. It was also associated with lower rates of readmission at 12 months for surgical-site complications. Proximal margin histopathology results potentially can be integrated to guide antimicrobial duration and decrease the frequency of further amputation at the original site.
Staphylococcus hominis (S. hominis) is a Gram-positive, coagulase-negative bacteria that occurs as a normal commensal organism on the skin and may rarely cause native valve endocarditis (NVE). We present a 62-year-old male with type 2 diabetes mellitus, coronary artery disease, and hypertension presenting with fever and abdominal pain. CT (computerized tomography) of the abdomen revealed splenic and renal infarcts; further imaging with MRI (magnetic resonance imaging) revealed enhancements consistent with discitis in T5-6 and L1-2. Three sets of blood cultures were positive for S. hominis sensitive to methicillin on antimicrobial susceptibility tests, and echocardiogram showed posterior mitral valve vegetation. The patient was initially treated with 10 weeks of nafcillin IV (intravenous) 2 g q4 hours. He had recurrent bouts of S. hominis bacteremia that was treated with IV vancomycin. His clinical course was complicated by new-onset atrial fibrillation with rapid ventricular response and congestive heart failure. Once bacteremia was cleared, his infective endocarditis was successfully definitively treated with mitral valve replacement and tricuspid repair.
The emergence of the B.1.617.2 (Delta) variant of the severe acute syndrome coronavirus (SARS-CoV-2) that emerged in 2019 (COVID-19), resulted in a surge of cases in India and has expanded and been detected across the world, including in the United States. The B.1.617.2 (Delta) variant has been seen to be twice more transmissible coupled with potential increases in disease severity and immune escape. As a result, case numbers and hospitalisations are once again on the rise in the USA. On 16 July 2021, the Centers for Disease Control and Prevention (CDC) reported a 7-day average 69.3% increase in new cases and a 35% increase in hospitalisations. Although the gold standard for SARS-CoV-2 variants identification remains genomic sequencing, this approach is not accessible to many clinical laboratories. The main goal of this study was to validate and implement the detection of the B.1.617.2 (Delta) variant utilising an open reverse transcription polymerase chain reaction (RT-PCR) platform by explicitly detecting the S-gene target failure (SGTF) corresponding to the deletion of two amino acids (ΔE156/ΔF157) characteristic of B.1.617.2 (Delta) variant. This approach was conceived as a rapid screening of B.1.617.2 (Delta) variant in conjunction with CDC's recommended N1 (nucleocapsid gene), N2, and RP (human RNase P) genes, as a pre-screening tool prior to viral genomic sequencing. We assessed 4,937 samples from 5 July to 5 September 2021. We identified the B.1.617.2 (Delta) variant in 435 of 495 positive samples (87.8%); the additional positive samples (7 samples, 1.4%) were found to belong to the B.1.1.7 (Alpha, UK) lineage and the remaining 53 samples (10.7%) were reported as 'other' lineages. Whole genome sequencing of 46 randomly selected samples validated the strains identified as positive and negative for the B.1.617.2 (Delta) variant and confirmed the S gene deletion in addition to B.1.617.2 characteristic mutations including L452R, T478K, P681R and D950N located in the spike protein. This modality has been used as routine testing at the Riverside University System Health (RUHS) Medical Center as a method for detection of B.1.617.2 (Delta) to pre-screen samples before genome sequencing. The assay can be easily implemented in clinical laboratories, most notably those with limited economic resources and access to genomic platforms.
COVID-19 , SARS-CoV-2 , COVID-19/diagnosis , Genomics , Humans , Mutation , SARS-CoV-2/genetics
High pressure injection injuries to the hand should not be taken lightly as urgent surgical debridement is required to ensure favorable outcomes. Empiric antibiotic administration is recommended; however, few studies focus on the secondary infection risk associated with these high pressure injection injuries. We present a rare case of a patient presenting with carbapenem resistant Pseudomonas aeruginosa following a high pressure paint gun injury of the thumb. Urgent surgical debridement with administration of broad-spectrum antibiotic coverage for both gram-negative and gram-positive bacteria is recommended. The injection of foreign materials can cause extensive tissue damage and immunosuppression facilitating growth of opportunistic bacteria that are often rare in healthy adults. We advocate for obtaining cultures at initial debridement to optimize treatment in these unique and rare injection injuries. Concerns should be raised as carbapenem resistant bacteria become more prevalent in the community.
Bacterial spinal epidural abscess (SEA) is a rare suppurative infection that commonly presents with nonspecific symptoms along with the infrequent triad of fever, back pain, and neurological deficits. Risk factors include diabetes mellitus, intravenous drug use, degenerative disc disease, infection with human immunodeficiency virus, and recent trauma or surgery. Patients with SEA often experience poor outcomes such as permanent neurological deficits, residual motor weakness, and even death. Staphylococcus aureus is the most predominant organism known to cause SEA; however, gram-negative bacteria are isolated in a small percentage of cases. Here we report three cases of SEA caused by gram-negative organisms. Each patient had identifiable risk factors known to increase the risk for SEA, and upon presentation had symptoms of SEA. Upon work up, the patients had positive cultures for gram-negative organisms and MRI imaging confirmed the presence of SEA. One patient made a full recovery while the other two cases resulted in permanent paraplegia. These cases stress the importance of considering SEA even in the presence of gram-negative infections, despite them being a rare cause. Furthermore, these cases emphasize the importance of broad-spectrum antibiotics that cover gram-negative bacteria in patients found to have risk factors along with symptoms of SEA.
