Acute Presentation of Tuberculosis Empyema in a Healthy Adolescent.

BACKGROUND Tuberculosis (TB) was the leading cause of infectious death worldwide until the COVID-19 pandemic, which reduced case reporting and disrupted TB diagnosis and services. While Mycobacterium tuberculosis remains a leading cause of morbidity and mortality globally, the disease burden within developed nations remains relatively rare. Although the many complications of TB are well known, no current data exists on those infected with TB who subsequently developed recurrent TB empyema, as it is such a rare complication, especially in pediatric and adolescent populations. CASE REPORT A previously healthy 15-year-old male patient presented with 5-day duration of cough, congestion, intermittent fever, and post-tussive emesis. Although born in the United States, 3 months before presentation, he returned from Senegal, where he had lived for 4 years. Imaging demonstrated consolidation with loculated effusion. Patient underwent video-assisted thoracoscopy and chest tube placement, draining 750 mL of purulent fluid testing positive for rare acid-fast bacilli. Rifampin, isoniazid, pyrazinamide, and ethambutol were administered, with discharge medication compliance ensured by daily videos surveillance through the Department of Health. Although compliant with medications, patient presented to the Emergency Department 2 months later with a multi-loculated fluid recollection and fistula formation requiring chest tube placement. After this discharge, patient experienced resolution of disease following completion of therapy. CONCLUSIONS TB complication should be considered as a differential diagnosis for pleural effusion in the appropriate clinical setting. Providers should not only consider the diagnosis but pursue appropriate testing and management early, particularly in those with risk factors, including travel to an endemic location.

A Case of Kikuchi-Fujimoto Disease in a 7-Year-Old African American Patient: A Case Report and Review of Literature.

BACKGROUND Kikuchi-Fujimoto disease (KFD) is a rare self-limited necrotizing lymphadenitis which is likely under-diagnosed in pediatric patients who present with fever of unknown origin and lymphadenopathy. Definitive diagnosis is challenging as it requires an invasive open lymph node biopsy or lymph node needle aspiration cytology that shows pathologic findings of histiocytic necrotizing lymphadenitis. CASE REPORT We report the case of one of the youngest patients diagnosed with KFD in the United States, at the age of 7 years. KFD has a higher prevalence in patients of Asian descent, but this patient was an African American. This case report shows the often convoluted and complicated course these patients undergo with their presenting complaints of fever of unknown origin and lymphadenopathy and highlights particular clinical findings that suggest KFD. CONCLUSIONS This patient is one of the youngest persons diagnosed with KFD in the United States, with an atypical ethnic background. It is likely that KFD is under-recognized and under-diagnosed in this population. With a broad differential diagnosis for fever of unknown origin and lymphadenopathy, awareness of KFD as a potential diagnosis may reduce other unnecessary investigations. The increased risk of patients with KFD of developing systemic lupus erythematosus (SLE) accentuates the importance of an accurate diagnosis and appropriate referral for heightened surveillance after recovery.

Case Report: Invasive Non Type b Haemophilus influenzae in Immunocompromised Children.

BACKGROUND Implementation of the Haemophilus influenzae type b (Hib) conjugate vaccine brought about a reduction in the number of cases and morbidity from type B but increase in nontypeable strain infections. CASE REPORT We had 3 cases of invasive non type Hemophilus influenzae (NTBHI) in immunocompromised children. The first was a fully vaccinated 2-year-old male with a history of pseudomonas sepsis who presented with 1 day of lethargy, fever, vomiting, and diarrhea. Blood culture was positive for Haemophilus influenzae e and cerebrospinal fluid (CSF) confirmed meningitis. Immune deficiency and genetic testing revealed X-linked agammaglobulinemia. The second case was a 4-year-old male, status post liver transplantation, who presented with pneumonia, with positive blood culture for H. influenzae. The last case was of a 2-year-old male with H. influenzae biotype VI in both blood and CSF cultures, who on follow-up was confirmed to have hypogammaglobulinemia. CONCLUSIONS For children diagnosed with an invasive disease caused by NTBHI, a workup for immunodeficiency could be warranted. With the appearance of nontype b serotypes, more studies are needed to determine epidemiology and virulence of these types, and their clinical relevance - perhaps developing a new vaccine to cover nontype b stereotypes, especially for immunodeficient patients.

Colloidal Silver Ingestion Associated with Leukocytoclastic Vasculitis in an Adolescent Female.

BACKGROUND Leukocytoclastic vasculitis is a disease of the small vessels and is uncommon in children. In this case report, we present an adolescent case of leukocytoclastic vasculitis associated with the ingestion of colloidal silver, a naturopathic drug. This report highlights the rarity of the patient's presentation and inducing agent. CASE REPORT A 19-year-old female presented in the Emergency Department with severe rash on the face, and neck, and then continued to spread in a craniocaudal fashion during the day of presentation to involve trunk, back, upper and lower extremities. There was no recent travel, no pets and a negative family history for rheumatologic or autoimmune diseases. Her home medications included colloidal silver for "internal cleansing" for 4 weeks prior to Emergency Department presentation. Once the clinicians were aware of the continued ingestion of colloidal silver, the patient was advised to discontinue the drug. The patient was started on methylprednisolone with preliminary diagnosis of vasculitis, as well as concurrent therapy with colchicine. The rash was noted to be receding from the face within 24 hours. Over a hospital course of 5 days, the patient's rash and pruritus continued to slowly improve. CONCLUSIONS The ingestion of a naturopathic drug, colloidal silver, caused vast leukocytoclastic vasculitis in our patient warranting hospitalization due to the extent of the disease. The symptoms resolved after discontinuation of colloidal silver ingestion. Due to unknown safe ingestion concentrations and potential side effects, use of colloidal silver should be discouraged.

Diagnosis of Tuberculosis in an Asymptomatic Child, Sibling, and Symptomatic Pregnant Mother in New York City by Tuberculin Skin Testing and the Importance of Screening High-Risk Urban Populations for Tuberculosis.

BACKGROUND In 2017, in New York City (NYC), 86% of the cases of tuberculosis (TB) occurred in patients who were born outside the United States (US). This case report illustrates the importance of the use of the tuberculin skin test (TST), and other tests for TB infection (TTBI), in screening high-risk groups, the challenges of diagnosing TB in young children, and highlights the importance of preventing a delay in the diagnosis of TB in family members. CASE REPORT Following a routine TST in an asymptomatic 10-year-old girl, a diagnosis of TB was made, which was confirmed on chest X-ray (CXR) and by the presence of acid-fast bacilli (AFB) in the sputum. Her family had emigrated from China to NYC ten years previously. All the family was screened using the TST, which was positive in her 2-year-old sister and her 37-year-old pregnant mother, and pulmonary TB was confirmed on CXR and by AFBs in the sputum. All three family members and the newborn baby were treated according to current guidelines, with a good clinical outcome. CONCLUSIONS This case report raises awareness about the lack of symptoms in childhood TB and the importance of screening high-risk patients in an urban immigrant population. In children under 5 years of age, a diagnosis of TB can indicate a sentinel event, suggesting a potential undiagnosed or untreated source case, which is usually an adult family member. This report highlights the challenges of diagnosing TB in children, who may be asymptomatic with negative laboratory findings.

Effectiveness of Early Antiviral Therapy in Disseminated Neonatal Herpes Simplex Virus 2 (HSV-2) with Fulminant Hepatic Failure.

BACKGROUND Liver failure in the neonatal population is a life-threatening complication and has a wide array of etiologies, including infectious, immune-mediated, metabolic, or drug-induced. Although neonatal herpes simplex virus (HSV) hepatitis only accounts for 1% of all acute liver failures, it has an extremely aggressive clinical course that carries a mortality rate of 85%. CASE REPORT We report a rare case of disseminated neonatal HSV-2 with late presentation associated with fulminant liver failure. The patient recovered without obvious neurologic deficits or need for liver transplant. CONCLUSIONS This case study emphasizes and promotes awareness of early recognition and appropriate clinical management of neonatal HSV infection, and its positive outcome.

Acute Hematogenous Osteomyelitis in a Five-Month-Old Male with Rickets.

Osteomyelitis is defined as an infection of the bone, bone marrow, and the surrounding soft tissues. Most cases of acute hematogenous osteomyelitis in children are caused by Gram-positive bacteria, principally Staphylococcus aureus. We present a case where a 5-month-old male had an acute onset of decreased movement of his left leg and increased irritability and was subsequently diagnosed with rickets and hematogenous osteomyelitis with bacteremia. The case explores a possible association between hematogenous osteomyelitis and rickets.

Impact of surveillance stool culture guided selection of antibiotics in the management of pediatric small bowel transplant recipients.

Surveillance stool cultures (SSC) have been used in immunocompromised populations to predict the organisms associated with invasive infections and aid in the selection of empiric antibiotic regimens. To evaluate the utility of this approach in pediatric small bowel transplant (SBT) recipients, we conducted a retrospective review of 33 patients who underwent SBT, 16 of whom had SSC done. In no case was the same organism isolated from SSC and subsequent blood, peritoneal fluid or wound cultures. In the first month post-transplantation, blood cultures were positive in 44% and 35% of patients that had and did not have SSC done, respectively (p = 0.73); peritoneal fluid cultures in 44% and 65% (p = 0.30); and wound cultures in 44% and 24% (p = 0.28). There were no significant differences among both groups in time to first infection, duration of ICU stay following SBT, graft survival or long-term patient survival. We conclude that SSC-guided antibiotic selection does not have a significant impact on the incidence of invasive infections in the first month following SBT or on specific indicators of patient outcome. This suggests that empiric antibiotic regimens should be selected based on clinical presentation and hospital flora and susceptibility patterns.

PRO 2000 gel inhibits HIV and herpes simplex virus infection following vaginal application: a double-blind placebo-controlled trial.

BACKGROUND: Microbicides used to prevent the transmission of human immunodeficiency virus (HIV) are advancing to clinical trials on the basis of activity observed in vitro and in animal models. However, no data demonstrate activity of microbicides after application in humans. This study was designed to determine the antiviral activity in cervicovaginal lavage (CVL) samples collected after intravaginal application of 0.5% PRO 2000 gel (Indevus). METHODS: A randomized, double-blind study was conducted to assess the anti-HIV and anti-herpes simplex virus (HSV) activity of PRO 2000 in CVL samples obtained at screening (48 hours before) and 1 hour after application of study or placebo gel. HeLa cells or human macrophages were inoculated with CVL samples spiked with replication-defective HIV containing a luciferase indicator gene and pseudotyped with an R5 envelope. Human cervical epithelial cells were inoculated with CVL samples and challenged with HSV-2(G), and the virus titer was then determined. RESULTS: CVL samples obtained after application of PRO 2000 gel significantly inhibited HIV and HSV infection by at least 1000-fold, compared with CVL samples obtained at screening (P < .001). There were no differences in cytokine levels between the drug and placebo groups. CONCLUSIONS: PRO 2000 gel (0.5%) is sufficiently bioavailable and retains substantial antiviral activity after intravaginal application. This strategy provides a mechanism for testing the efficacy of a microbicide before embarking on large-scale clinical trials.

Cervicovaginal secretions contribute to innate resistance to herpes simplex virus infection.

Defining and preserving the innate antiviral activity found in cervicovaginal secretions is critical. Cervicovaginal lavage (CVL) samples were obtained from 20 healthy women and evaluated for anti-herpes simplex virus (HSV) activity. CVL samples reduced HSV-2 yields by 23-fold (median), and the anti-HSV activity of CVL samples correlated with the concentration of human neutrophil peptides (HNP)-1-3. Both CVL samples and HNP-1-3 interacted with virus and prevented entry after binding. Substantially less protective activity was observed in CVL samples obtained from 20 human immunodeficiency virus--infected subjects, but the addition of CVL samples from healthy subjects enhanced the antiviral activity. The significance of the innate activity was further demonstrated by showing that CVL samples prevented murine genital herpes. Fourteen of 15 mice were protected from genital herpes if they were challenged with HSV-2 pretreated with CVL samples from healthy subjects. In contrast, all 15 mice challenged with untreated HSV-2 died. These findings are evidence that cervicovaginal secretions contribute to innate resistance to HSV-2 and identify defensins as contributors to this activity.

Candidate topical microbicides bind herpes simplex virus glycoprotein B and prevent viral entry and cell-to-cell spread.

Topical microbicides designed to prevent acquisition of sexually transmitted infections are urgently needed. Nonoxynol-9, the only commercially available spermicide, damages epithelium and may enhance human immunodeficiency virus transmission. The observation that herpes simplex virus (HSV) and human immunodeficiency virus bind heparan sulfate provided the rationale for the development of sulfated or sulfonated polymers as topical agents. Although several of the polymers have advanced to clinical trials, the spectrum and mechanism of anti-HSV activity and the effects on soluble mediators of inflammation have not been evaluated. The present studies address these gaps. The results indicate that PRO 2000, polystyrene sulfonate, cellulose sulfate, and polymethylenehydroquinone sulfonate inhibit HSV infection 10,000-fold and are active against clinical isolates, including an acyclovir-resistant variant. The compounds formed stable complexes with glycoprotein B and inhibit viral binding, entry, and cell-to-cell spread. The effects may be long lasting due to the high affinity and stability of the sulfated compound-virus complex, as evidenced by surface plasmon resonance studies. The candidate microbicides retained their antiviral activities in the presence of cervical secretions and over a broad pH range. There was little reduction in cell viability following repeated exposure of human endocervical cells to these compounds, although a reduction in secretory leukocyte protease inhibitor levels was observed. These studies support further development and rigorous evaluation of these candidate microbicides.