Colubrid snake envenomation: Erythrolamprus bizona "false coral" snakebite - clinical aspects and importance of identifying mimics.

Colubrids represent a diverse group of snakes historically regarded as harmless. With over 300 genera, the Colubridae family is the largest, encompassing approximately two-thirds of extant snake species. We describe a case of an 18-year-old male who suffered a colubrid snakebite from Erythrolamprus bizona, commonly known as the double-stranded coral snake mimic or false coral snake, which he misidentified as Lampropeltis sp., a fangless colubrid snake. Patient experienced localized erythema and edema, which later spread to the entire left hand along with moderate pain. Laboratory tests revealed leukocytosis and elevated creatine kinase. Symptoms resolved one week later. This case highlights the public health significance of ophidian accidents due to apparently "non-venomous snakes" or low-risk snakes such as the opisthoglyphous colubrid E. bizona. It also underscores the need to correctly identify and differentiate these snakes from other harmless colubrids, particularly double-stranded coral snake mimics in areas of geographic overlap and avoid their manipulation if uncertain of their taxonomic status.

Detection of Leishmania RNA Virus 1 in Leishmania (Viannia) panamensis Isolates, Panama.

We detected Leishmania RNA virus 1 (LRV1) in 11 isolates of Leishmania (Viannia) panamensis collected during 2014-2019 from patients from different geographic areas in Panama. The distribution suggested a spread of LRV1 in L. (V.) panamensis parasites. We found no association between LRV1 and an increase in clinical pathology.

Clinical manifestations of Rickettsia rickettsii in a familial outbreak in Panama.

We report an isolated outbreak of Rickettsia rickettsii in the Ngäbe-Buglé indigenous region, located 750 m (tropical wet) above sea level, in a jungle and mountainous area of Western Panama. Seven members of a family were infected simultaneously, resulting in four deaths. Family outbreaks have been previously described and are responsible for 4-8% of the cases described [1-4]. The simultaneous onset of symptoms in the affected population group is extremely unusual [1,5], but it should not dissuade the clinician from considering the possibility of Rickettsia rickettsii infection.

Hot Tub Lung: Case Report and Review of the Literature.

INTRODUCTION: Nontuberculous mycobacteria-related hypersensitivity pneumonitits (NTM-HP), otherwise known as hot tub lung, is an uncommon disease produced by exposure to aerosolized hot tub water containing nontuberculous mycobacteria. Patients usually present with nonspecific, prolonged respiratory symptoms and require a thorough respiratory workup, including radiography and even pulmonary biopsies. CASE PRESENTATION: We present the case of a 58-year-old patient with chronic respiratory symptoms and history of exposure to a hot tub. DISCUSSION: There is little data on why certain patients develop NTM-HP; however, it seems to be an immunologic response to the nontuberculous mycobacteria, not a primary infection. The treatment, as in this case, is typically just hot tub avoidance. CONCLUSION: To our knowledge, this is the first case of NTM-HP reported from Wisconsin. NTM-HP can mimic nontuberculous mycobacterial disease and should be on the differential diagnosis for patients with unclear chronic respiratory problems.

Understanding the relationship between patient characteristics and complication in veterans discharged on parenteral antibiotic therapy.

BACKGROUND: Many facilities utilize outpatient parenteral intravenous (IV) antimicrobial therapy (OPAT) to reduce cost, length of stay, and risk of nosocomial infections. OBJECTIVE: The objective of this study was to analyze patient demographics, substance use, mental and physical health diagnoses, and social determinants of health to seek relationships with complications for veterans discharged from the Zablocki Veterans Affairs Medical Center (ZVAMC) on OPAT. METHODS: This study was a retrospective chart review of veterans who completed OPAT between the years of 2013 and 2017 at the ZVAMC in Milwaukee, Wisconsin. Prior to discharge, patients were screened by the OPAT team for eligibility; patients were followed after discharge by pharmacy, home care, and providers. OPAT complication was defined as antibiotic change/dose adjustment, IV catheter complication, or an additional hospital visit secondary to current infection or therapy. RESULTS: 294 veterans' charts were reviewed. Of these patients, 106 (36.05%) had a complication. Tobacco use was the only factor significantly associated with OPAT complication. CONCLUSIONS: Cohabitation, employment status, mental health diagnosis and alcohol use were not associated with OPAT failure; however, tobacco use merits further review for use in OPAT screening protocols.

Implementation of Veterans Affairs Primary Care Antimicrobial Stewardship Interventions For Asymptomatic Bacteriuria And Acute Respiratory Infections.

BACKGROUND: Outpatient antimicrobial prescribing is an important target for antimicrobial stewardship (AMS) interventions to decrease antimicrobial resistance. The objective of this study was to design, implement, and evaluate the impact of AMS interventions focused on asymptomatic bacteriuria (ASB) and acute respiratory infections (ARIs) in the primary care setting. METHODS: This stepped-wedge trial evaluated the impact of multifaceted educational interventions to providers on adult patients presenting to primary care clinics for ARIs and ASB. The primary outcome was percentage of overall antibiotic prescriptions as a composite of prescriptions for ASB, acute bronchitis, upper respiratory infection not otherwise specified, uncomplicated sinusitis, and uncomplicated pharyngitis. Secondary outcomes were the individual components of the primary outcome; a composite safety endpoint of related hospital, emergency department, or primary care visits within 4 weeks; antibiotic selection appropriateness; and patient satisfaction surveys. RESULTS: A total of 887 patients were included (405 preintervention and 482 postintervention). After controlling for type I error using Bonferroni correction, the primary outcome was not significantly different between groups (56% vs 49%). There was a statistically significant decrease in prescriptions for acute bronchitis (20.99% vs 12.66%; P = .0003). Appropriateness of antibiotic prescriptions for uncomplicated sinusitis (odds ratio [OR], 4.96 [95% confidence interval {CI}, 1.79-13.75]; P = .0021) and pharyngitis (OR, 5.36 [95% CI, 1.93-14.90]; P = .0013) was improved in the postintervention vs the preintervention group. The composite safety outcome and patient satisfaction surveys did not differ between groups. CONCLUSIONS: Multifaceted educational interventions targeting providers can improve antibiotic prescribing for indications rarely requiring antimicrobials without increasing re-visits or patient satisfaction surveys.

Reactivation of Coccidioides immitis in a Prosthetic Knee after Initiation of Chemotherapy.

Coccidioides is an endemic fungus in the Southwestern United States and Central and South America. Coccidioidomycosis primary infections are typically of the lung with an asymptomatic or self-limiting course. Some infections disseminate to other parts of the body and a few can remain latent for many years. Reactivation of latent fungal disease can occur following an insult to the host immune system. Here, we describe a case of a 76-year-old Caucasian male patient who moved from California to Wisconsin with a history of coccidioidomycosis infection of the left knee that reactivated decades later in his prosthetic knee shortly after being initiated on ibrutinib (Imbruvica), a Bruton tyrosine kinase (BTK) inhibitor, for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). There have been some case reports regarding coccidioidomycosis infections after initiating ibrutinib therapy but none with a 50 year latency period before reactivation. Readers will learn the immunological effects of ibrutinib on the hosts' innate and adaptive immunity and its role in putting the host at risk for invasive fungal infections. We also review the literature and data on treatment regimens and recommendations based on current guidelines.

Factores relacionados con histoplasmosis diseminada en los pacientes admitidos con VIH-SIDA y fiebre, CHDrAAM, 2017 - 2019

Introducción: el diagnóstico de histoplasmosis diseminada (HD) es un desafío debido a la similitud del cuadro clínico con otras enfermedades infecciosas y no infecciosas. Confirmar un caso de HD requiere realizar procedimientos poco sensibles como hemocultivos, mielocultivos y biopsias de tejidos, o costosos como el antígeno urinario de Histoplasma capsulatum. Conocer los factores clínicos y de laboratorios relacionados con el diagnóstico de HD es de vital importancia en especial en sitios con recursos limitados. Metodología: se realizó un estudio de cohorte retrospectivo donde los expedientes clínicos de los pacientes con fiebre y VIH-SIDA, admitidos con sospecha de histoplasmosis diseminada del 1 de enero de 2017 al 31 de diciembre de 2019 en el Complejo Hospitalario Dr. Arnulfo Arias Madrid (CHDrAAM) de Panamá, fueron evaluados por características demográficas, clínicas y de laboratorio relacionadas con el diagnóstico de HD. Resultados: 63 pacientes cumplieron los criterios de inclusión, 14 con diagnóstico confirmado de HD y 49 con diagnóstico no confirmado de HD. Los niveles de lactato deshidrogenasa (LDH) y aspartato transaminasa (AST) se relacionaron con el diagnóstico de HD en el análisis univariado. Luego de realizar regresión logística ni AST ni LDH fueron estadísticamente significativas. (p= 0.22 y P = 0.92). Conclusión: Ninguna característica clínica ni de laboratorio se relacionó de forma independiente con el diagnóstico de HD, en pacientes con VIH-SIDA admitidos con sospecha de histoplasmosis diseminada. (provisto por Infomedic International)

Introduction: The diagnosis of disseminated histoplasmosis (HD) is a challenge due to the similarity of the clinical picture with other infectious and non-infectious diseases. Confirming a case of HD requires performing insensitive procedures such as blood cultures, myelocultures and tissue biopsies, or expensive procedures such as urinary Histoplasma capsulatum antigen. Knowing the clinical and laboratory factors related to the diagnosis of HD is of vital importance, especially in places with limited resources. Methodology: a retrospective cohort study was conducted where clinical records of patients with fever and HIV-AIDS, admitted with suspected disseminated histoplasmosis from January 1, 2017, to December 31, 2019, at the Complejo Hospitalario Dr. Arnulfo Arias Madrid (CHDrAAM) in Panama, were evaluated for demographic, clinical and laboratory characteristics related to the diagnosis of HD. Results: 63 patients met the inclusion criteria, 14 with confirmed diagnosis of HD and 49 with unconfirmed diagnosis of HD. Lactate dehydrogenase (LDH) and aspartate transaminase (AST) levels were related to HD diagnosis in univariate analysis. After logistic regression neither AST nor LDH were statistically significant. (p= 0.22 and P = 0.92). Conclusion: No clinical or laboratory characteristics were independently related to the diagnosis of HD in HIV-AIDS patients admitted with suspected disseminated histoplasmosis. (provided by Infomedic International)

Ischemic Stroke in a Child after a Probable Scorpion Sting.

Scorpion stings are common emergencies in the tropics. Species-specific antivenom therapies are available. However, fatalities resulting from scorpion stings remain a public health concern in many settings. Children residing in rural towns and peri-urban areas represent the most vulnerable populations. Delays in the diagnosis of scorpion stings often occur as a result of the non-specific clinical presentations, which then lead to life-threatening complications. We report a 2-year-old Venezuelan boy presenting with acute pancreatitis and pulmonary edema without an identifiable cause 48 hours after his initial symptoms. We administered antivenom therapy when an undetected scorpion sting was suspected. Despite some initial clinical improvement with respect to his acute pancreatitis, pulmonary edema, and coagulation abnormalities, our patient experienced an ischemic stroke. Fortunately, our patient did demonstrate some neurological improvement. Although acute pancreatitis and pulmonary edema are known end-organ damage manifestations of the sting of Tityus in the Americas, our particular case illustrates the risk of ischemic stroke.