Cryptococcosis and Cryptococcal Meningitis: A Narrative Review and the Up-to-Date Management Approach.

Cryptococcosis is a fungal infectious disease that enormously impacts human health worldwide. Cryptococcal meningitis is the most severe disease caused by the fungus Cryptococcus, and can lead to death, if left untreated. Many patients develop resistance and progress to death even after treatment. It requires a prolonged treatment course in people with AIDS. This narrative review provides an evidence-based summary of the current treatment modalities and future trial options, including newer ones, namely, 18B7, T-2307, VT-1598, AR12, manogepix, and miltefosine. This review also evaluated the management and empiric treatment of cryptococcus meningitis. The disease can easily evade diagnosis with subacute presentation. Despite the severity of the disease, treatment options for cryptococcosis remain limited, and more research is needed.

Hypermetabolic Pulmonary and Mediastinal Lesions With Elevated Cancer Antigen (CA) 15-3 and CA 27-29 in a Patient With a History of Ovarian and Breast Cancer.

Breast cancer affects around 13% of women. Breast cancer gene 1 (BRCA1) carriers are prone to lung and lymph node metastasis, while breast cancer gene 2 (BRCA2) carriers tend to have bone metastasis. Findings of pulmonary nodules, mediastinal lymphadenopathy, and elevated markers such as cancer antigen (CA) 15-3 and CA 27-29 suggest metastatic disease. Here, we present the case of a patient with BRCA1-positive breast cancer in remission and a history of ovarian cancer with mediastinal lymphadenopathy and pulmonary nodules, with avid fluorodeoxyglucose uptake on positron emission tomography (PET) scan and elevated CA 15-3 and CA 27-29. A 70-year-old female with a history of bilateral breast and ovarian cancer and a positive BRCA test presented with pulmonary nodules, mediastinal lymphadenopathy, and elevated CA 15-3 and CA 27-29. Imaging showed mediastinal and hilar lymphadenopathy. A PET scan revealed increased metabolic activity in the lymph nodes and pulmonary lesions. Fiberoptic bronchoscopy and endobronchial ultrasound lymph node sampling demonstrated granulomatous inflammation without malignant cells. The patient underwent a therapeutic trial of steroids with clinical improvement of symptoms and decreased hypermetabolic activity in chest lesions, as well as a decrease in tumor markers. The coexistence of sarcoidosis and breast cancer is rare; sarcoidosis can coexist, precede, or appear after breast cancer. In both conditions, tumor markers and PET avidity are seen, which makes diagnosis and management challenging. In case of ambiguity, biopsy is crucial. This case underscores the importance of integrating clinical, pathological, and imaging data to reach an accurate diagnosis and consider a therapeutic trial of steroids. Furthermore, the early PET response to treatment can be pivotal in differentiating between sarcoidosis and malignancy, especially in complex clinical scenarios. Proper differentiation is paramount to avoid therapeutic missteps and ensure appropriate patient management.

Glass in the Airways: A Bronchoscopic Challenge.

Foreign body aspiration (FBA) in adults is indeed a significant medical concern, albeit less common than in children. The increase in incidence with advancing age can be attributed to factors such as a decline in mental status and impairment of the swallowing reflex, which is more prevalent in the elderly population. The symptoms of FBA are highly variable, ranging from severe, acute asphyxiation, which may or may not involve complete airway obstruction, to more subtle signs like coughing, shortness of breath (dyspnea), choking, or fever. These varied presentations, coupled with the fact that many other medical conditions can mimic the respiratory symptoms seen in FBA, make diagnosis challenging. A high index of suspicion is often required, especially in cases where the patient's history does not clearly point toward aspiration. Immediate management focuses on supporting the airway, which is crucial given the potential for severe obstruction. Radiographic imaging plays a key role in localizing the foreign body, which is vital for planning its removal. Bronchoscopy, particularly flexible bronchoscopy, is the cornerstone of both diagnosis and treatment. This technique allows for direct visualization of the airways, localization of the foreign body, and its subsequent removal. This is crucial to avoid long-term complications, which can arise if the foreign body is not promptly and effectively removed. In this case report, we present a 64-year-old female patient who was found to have a foreign object positioned in the right lower lobe of the lungs that was removed via flexible bronchoscopy.

Unusual Aspergillus Pleural Effusion in a Patient With Immunodeficiency.

Pleural aspergillosis is a rare form of invasive bronchopulmonary aspergillosis that is most often seen in immunocompromised hosts. It appears because of the coagulative necrosis of lung tissue induced by the Aspergillus species, which promotes the formation of a fungal pleural effusion. We present the case of a 51-year-old liver transplant patient on chronic immunosuppression therapy who presented with respiratory failure and was found to have a large left-sided pleural effusion from invasive aspergillosis. After thoracentesis, he started antifungal therapy with isavuconazole. This newer, second-generation broad-spectrum triazole is non-inferior to voriconazole but with less hepatotoxicity and was noted to have an improvement in his symptoms. In the differential diagnosis of pulmonary effusions in immunocompromised patients, it is crucial to consider invasive aspergillosis, as demonstrated by our case. This case study highlights the importance of quick diagnosis and treatment to enhance outcomes in this vulnerable population.

Metastatic Prostate Cancer With Reticular Micronodular Opacities of Lung: A Case Report.

Prostate cancer, a common malignancy in males, can metastasize to various sites such as the bone, brain, liver, and less commonly, the lung. Detecting pulmonary metastases presents both diagnostic and therapeutic difficulties. Identifying patients with this condition is crucial for gaining a deeper comprehension of the disease's pathogenesis. In this report, we describe the case of a 64-year-old African American male who exhibited elevated prostate antigen levels and was found to have unique reticular Micronodular opacities in the lungs caused by prostate cancer.

An Atypical Presentation of Chronic Inflammatory Myelin Degeneration in Neuromyelitis Optica (NMO).

Neuromyelitis optica (NMO) is an autoimmune disorder characterized by aquaporin-4 (AQP4) IgG autoantibodies. These autoantibodies induce chronic neuroinflammatory damage to the spinal cord and optic nerve. NMO clinically manifests as relapsing and overlapping neurodegenerative episodes of optic neuritis (ON) and transverse myelitis (TM). Contrasting from other autoimmune neurodegenerative disorders, NMO has a poor prognostic profile often involving permanent neurological disability. We present a case of a 65-year-old male who presented with a progressive weakening in his left upper and lower extremities with reduced sensation and was found to have an acute flare of NMO. We explore the broad symptomatology involved in the disorder along with relevant crucial imaging findings pointing toward the diagnosis of NMO. Finally, we discuss treatment modalities in the context of our patient's clinical course and prognostic factors. Early intervention and suppression of relapse in this neuroinflammatory neurodegenerative disorder can help decrease the duration of acute flares and improve long-term outcomes for patients affected by NMO.

Comparison of patients admitted to an inner-city intensive care unit across 3 COVID-19 waves.

To expand our limited knowledge of COVID-19-related outcomes in patients admitted to inner-city intensive care unit (ICU across multiple infection waves. This retrospective study compared patients admitted to the ICU in Bronx, NY, during 3 COVID-19 waves (March 2020 to February 2022). Outcomes included in hospital mortality, length of stay (LOS), use of mechanical ventilation, and discharge disposition. The study included 716 patients (343, 276, and 97 in the first, second, and third COVID-19 waves, respectively). The number of days on mechanical ventilation and LOS were lower in the first wave. Of the 345 discharged patients, 37% went home directly, whereas 11% were discharged to a skill nursing facility. More patients went home during the second and third waves. Mortality decreased from the first to the third waves (57%-37%; P < .001). Predictors of mortality included age, male gender, COPD, shock, acute kidney injury (AKI), dialysis requirement, and mechanical ventilation. The decreased mortality and better discharge disposition of these inner-city patients during the second and third waves is encouraging, as this population historically had a high COVID-19-related mortality risk.

Chronic hepatitis-C infection in COVID-19 patients is associated with in-hospital mortality.

BACKGROUND: There is little evidence about the association of pre-existing hepatitis C infection (HCV) with outcomes in patients with coronavirus disease 2019 (COVID-19). AIM: To assess the prevalence of history of HCV among patients with COVID-19 and to study the relationship of in-hospital mortality in relation with other predictors of poor outcomes in the presence or absence of COVID-19 induced acute liver injury. METHODS: In a retrospective single-center study design, 1193 patients with COVID-19 infection were studied. Patients were then classified into those with and without a history of HCV, 50 (4.1%) and 1157 (95.9%) respectively. RESULTS: Multivariate cox-regression models showed that age, HCV, D-Dimer, and ferritin were the only predictors of in-hospital mortality. Acute liver injury and fibrosis score (Fib-4 score) were not different between both groups. Multivariate cox-regression model for liver profile revealed that aspartate aminotransferase/ alanine aminotransferase ratio, Fib-4 score, and HCV were predictors of in-hospital mortality. After propensity score matching HCV was the only predictor of mortality in the multivariate cox-regression model. A model including HCV was found to add predictive value to clinical and laboratory parameters. CONCLUSION: In patients with COVID-19, history of HCV infection leads to an accentuated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virulence, irrespective of baseline comorbidities, admission laboratory variables, or COVID-19-induced liver injury, which may be related to extrahepatic effects of HCV leading to enhanced ACE-2/TMPRSS mechanisms of SARS-CoV-2 viral entry, baseline cytokine-mediated pro-inflammation, and endothelial dysfunction.

Apixaban Causing Hepatic Cystic Bleeding: A Rare but a Life-Threatening Complication.

Cystic lesions of the liver are a heterogeneous group of disorders with varied etiology, prevalence, and clinical manifestations. Fibropolycystic liver disease encompasses a spectrum of related liver and biliary tract lesions caused by abnormal embryologic development of the ductal plates. These disorders include congenital hepatic fibrosis, biliary hamartomas, polycystic liver disease (PCLD), choledochal cysts, and Carolis disease. PCLD is arbitrarily defined as a liver that contains >20 cysts. Most liver cysts are incidentally found on imaging studies, and the majority of the patients with liver cysts are asymptomatic. Rarely, complications such as compression, infection, and bleeding within the cyst can occur. Under the effect of the increased pressure, the epithelial lining of the cyst undergoes necrosis and sloughing, causing injury of the fragile blood vessels, leading to intracystic bleeding. The bleeding within or from the cyst can be precipitated by anticoagulation. We present a patient with PCLD who developed intracystic bleeding after he was started on apixaban for the prevention of thromboembolism.

May-Thurner Syndrome: A Rare Case of Unilateral Deep Vein Thrombosis in an Elderly Woman.

BACKGROUND Deep vein thrombosis (DVT) is a critical disorder with a high incidence and a high disease burden. Multiple acquired and genetic factors leading to hypercoagulation, venous injury, and venous stasis account for its basic pathophysiology. One of the rarely considered underlying etiologies of DVT is May-Thurner Syndrome (MTS), also known as iliac vein compression syndrome. MTS is an anatomical variant in which the left common iliac vein is extrinsically compressed by the right common iliac artery against the lumbar spine, leading to the development of iliofemoral DVT. CASE REPORT We present the case of a 78-year-old woman who presented with chronic unilateral lower-extremity swelling and pain. Ultrasound was consistent with extensive DVT extending from the left common femoral vein to left popliteal vein. Further workup revealed left common iliac venous outflow obstruction due to the extrinsic compression by the overlying atherosclerotic calcified right common iliac artery crossing against the lumbosacral region. CONCLUSIONS MTS usually presents in the second to fourth decades of life, making it challenging to consider it as a differential diagnosis in older patients. The conventional treatment of DVT with anticoagulation alone is insufficient to address thrombotic MTS and can lead to recurrent DVT, post-thrombotic syndrome, and life-threatening complications. Our patient presented in the seventh decade of life, warranting a high index of clinical suspicion of MTS in patients presenting with unilateral leg DVT, regardless of patient age, for timely diagnosis and appropriate therapeutic management.

Abdominal Ascites of Unknown Origin: Diagnostic Accuracy of Adenosine Deaminase for Tuberculous Peritonitis.

The occurrence of tuberculosis (TB) is exceedingly rare in the United States (US), and incidence has steadily declined since 1993, but the pace of decline has slowed in recent years. The US TB rate during 2019 declined to 2.7 cases per 100,000 persons, the lowest level on record. The abdominal form is the sixth leading cause of extrapulmonary TB, after lymphatic, genitourinary, osteoarticular, miliary, and meningeal. Abdominal TB can infect any part of the gastrointestinal tract, including the peritoneum and the pancreaticobiliary system. We present a case of persistently elevated adenosine deaminase in peritoneal ascites of a young, healthy female with new-onset ascites. An extended diagnostic evaluation was performed to reach the diagnosis.

A Rare Case of Concomitant Septic Arthritis, Osteomyelitis, and Pyomyositis Caused by Salmonella.

A common causative organism in osteomyelitis in sickle cell disease is Salmonella. Septic arthritis and muscle infection due to Salmonella are much less common. We present a case of a 28-year-old woman with sickle cell disease who presented with left shoulder and elbow pain for two days. Physical examination revealed swelling of the left upper arm. The patient was initially treated for a sickle cell pain crisis. On hospital day 4, the patient developed a fever. She empirically started intravenous vancomycin and cefepime before her blood culture showed Salmonella. Subsequently, the antibiotic was changed to ceftriaxone. Synovial fluid analysis of the left shoulder revealed a white blood cell count of 53,250/mm3 with mostly neutrophils, and this led to a presumptive diagnosis of septic arthritis. She underwent a left shoulder arthroscopic irrigation and debridement. The synovial fluid culture was negative. Magnetic resonance imaging (MRI) revealed osteomyelitis in the left humerus, a 4.4 x 5 cm intramuscular abscess near the distal anterior humerus, and pyomyositis. Percutaneous abscess drainage was done. The patient was discharged home on ceftriaxone but returned 12 days later with worsening pain in her shoulder. Repeat MRI showed a complex glenohumeral joint effusion. She had an incision and drainage of her left shoulder. The patient was discharged on an eight-week course of ceftriaxone. Prompt diagnosis and early treatment are essential in reducing the mortality and morbidity associated with these joint, bone, and muscle infections.

Association of smoking status with outcomes in hospitalised patients with COVID-19.

INTRODUCTION: Smoking causes inflammation of the lung epithelium by releasing cytokines and impairing mucociliary clearance. Some studies have linked smoking with severity of illness of COVID-19 whereas others have found no such association. METHODS: This was a retrospective analysis of all adults hospitalised with COVID-19 from 9 March to 18 May 2020. RESULTS: 1173 patients met the study criteria. 837 patients never smoked whereas 336 patients were either current smokers or past smoker and were grouped together in smokers group. Patients in smokers group were more likely to be male and had higher incidence of underlying chronic obstructive pulmonary disease (19% vs 6%, p<0.001), HIV infection (11% vs 5%,p<0.001), cancer (11% vs 6%, p=0.005), congestive heart failure (15% vs 8%, p<0.001), coronary artery disease (15% vs 9%, p=0.3), chronic kidney disease (11% vs 8%, p=0.037) and end-stage renal disease (10% vs 6%, p=0.009) compared with non-smokers. Outcome analysis showed that smokers were more likely to develop critical illness requiring mechanical ventilation (47% vs 37% p=0.005). Univariate Cox model for survival analysis by smoking status showed that among smokers only current smokers had higher risk of death compared with never smokers (HR 1.61, 95% CI 1.22 to 2.12, p<0.001). In the multivariate approach, Cox model for the survival, female sex, young age, low serum lactate dehydrogenase and systemic steroid use were associated with overall improved survival. CONCLUSION: In our large single-centre retrospective database of patients hospitalised with COVID-19, smoking was associated with development of critical illness and higher likelihood of death.

COVID-19 in the Healthy Patient Population: Demographic and Clinical Phenotypic Characterization and Predictors of In-Hospital Outcomes.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) can infect patients in any age group including those with no comorbid conditions. Understanding the demographic, clinical, and laboratory characteristics of these patients is important toward developing successful treatment strategies. Approach and Results: In a retrospective study design, consecutive patients without baseline comorbidities hospitalized with confirmed COVID-19 were included. Patients were subdivided into ≤55 and >55 years of age. Predictors of in-hospital mortality or mechanical ventilation were analyzed in this patient population, as well as subgroups. Stable parameters in overall and subgroup models were used to construct a cluster model for phenotyping of patients. Of 1207 COVID-19-positive patients, 157 met the study criteria (80≤55 and 77>55 years of age). Most reliable predictors of outcomes overall and in subgroups were age, initial and follow-up d-dimer, and LDH (lactate dehydrogenase) levels. Their predictive cutoff values were used to construct a cluster model that produced 3 main clusters. Cluster 1 was a low-risk cluster and was characterized by younger patients who had low thrombotic and inflammatory features. Cluster 2 was intermediate risk that also consisted of younger population that had moderate level of thrombosis, higher inflammatory cells, and inflammatory markers. Cluster 3 was a high-risk cluster that had the most aggressive thrombotic and inflammatory feature. CONCLUSIONS: In healthy patient population, COVID-19 remains significantly associated with morbidity and mortality. While age remains the most important predictor of in-hospital outcomes, thromboinflammatory interactions are also associated with worse clinical outcomes regardless of age in healthy patients.

Pulmonary Embolism in COVID-19 Pneumonia: Random Association or Causality?

Coronavirus disease 2019 (COVID-19) is an ongoing pandemic. COVID-19 leads to a plethora of clinical syndromes, most commonly affecting the pulmonary system but also the cardiovascular, hematologic, and gastrointestinal systems. There is emerging evidence of an association between COVID-19 and venous thromboembolism (VTE). In this report, we have discussed three cases with a COVID-19 infection, whose clinical course was complicated by the presence of pulmonary embolism (PE) without evident risk factors for VTE. All three patients presented with hypoxia and were found to have elevated D-dimer levels. Subsequently, the patients underwent computed tomography (CT) angiography of the chest, which confirmed the presence of pulmonary embolism. Anticoagulation was initiated per guidelines. There is a need to have a low threshold for suspecting pulmonary embolism in patients with COVID-19 infection who present with a sudden onset of severe hypoxia. There is a dire need to increase awareness among health care providers regarding this manifestation of the virus.

A Rare Case of Parvovirus B19 Infection Manifesting as Chronic Aplastic Anemia and Neutropenia in a Human Immunodeficiency Virus-Infected Patient.

Parvovirus B19 (PVB19) is a deoxyribonucleic acid (DNA) virus, the only member of the Parvoviridae, which has a direct cytopathic effect on erythroid progenitor cells, resulting in an arrest of hematopoiesis and subsequent anemia. Less frequently, neutropenia and thrombocytopenia have been reported with the PVB19 infection. We report a rare case of chronic neutropenia due to PVB19 in a human immunodeficiency virus (HIV) patient. A 51-year-old male with a medical history of HIV presented to the Emergency Department (ED) with complaints of generalized weakness. His laboratory tests were significant for severe anemia and new neutropenia. PVB19 DNA by polymerase chain reaction (PCR) was positive. PVB19 immunoglobulin M (IgM) and IgG were reported negative. He was diagnosed with aplastic anemia from PVB19 and neutropenia. From June 2013 to January 2019, the patient was admitted 23 times with severe neutropenia and anemia, and on each occasion, PVB19 DNA by PCR was positive. During these multiple admissions, he was treated with antibiotics for neutropenic fever, methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and methicillin-sensitive Staphylococcus aureus (MSSA) skin abscesses. On each occasion, he required multiple blood transfusions, and he received intravenous immunoglobulin (IVIG) that resulted in significant improvement of absolute neutrophil count (ANC) count. He had bone biopsy twice, which showed normal maturation of the myeloid series and reduced erythroid progenitor cells consistent with PVB19 infection. PVB19 DNA by PCR remains positive to date. Immunocompromised individuals usually develop a chronic infection from PVB19, and rarely infection with PVB19 can cause severe neutropenia that can be long-lasting and life-threatening. Early recognition and treatment with IVIG are the key to improve the clinical outcome.

An Unusual Case of Polymicrobial Bacteremia From Methicillin-Resistant Staphylococcus Aureus and Shigella.

Bloodstream infections (BSIs) are a significant cause of morbidity and mortality worldwide. Patients with polymicrobial BSI have a two-fold risk of hospital mortality as compared with patients with monomicrobial BSI. We present a case of a 53-year-old African American male with a medical history significant for hyperlipidemia, coronary artery disease, hypertension, anxiety, depression, and human immunodeficiency virus non-adherent to antiretroviral therapy who presented to the hospital with complaints of shoulder pain and diarrhea. The physical exam was significant for multiple skin abscesses, the largest being 5x6 cm. Blood culture grew Shigella and methicillin-resistant Staphylococcus aureus (MRSA), stool culture grew Shigella, and wound culture after incision and drainage grew MRSA. Transthoracic echocardiogram showed no vegetations. He was treated with vancomycin and ceftriaxone. The patient's clinical condition improved, and diarrhea resolved. Patient repeat cultures showed no growth. As polymicrobial bacteremia is associated with higher morbidity and mortality, early initiation of antibiotics and appropriate antibiotic therapy are pivotal.