Etiologies of Extreme Leukocytosis.

OBJECTIVE: The objective of this study was to determine the etiologies and co-morbidities associated with extreme leukocytosis, which is characterized by a white blood cell (WBC) count ≥ 35 × 109 leukocytes/L.  Method: Retrospective chart review was conducted for all patients, aged 18 years and older, admitted to the internal medicine department between 2015 and 2021 with an elevated WBC count ≥ 35 × 109 leukocytes/L within the first 24 hours of admission.  Results: Eighty patients were identified to have WBC count ≥ 35 × 109 leukocytes/L. The overall mortality was 16% and increased to 30% in those presenting with shock. Mortality increased from 2.8% in patients with WBC count in the range of 35-39.9 × 109 leukocytes/L to 33% in those with WBC count in the range of 40-50 × 109 leukocytes/L. There was no correlation with underlying co-morbidities or age. Pneumonia was the most common infection (38%), followed by UTI or pyelonephritis (28%) and abscesses (10%). There was no predominant organism responsible for these infections. The most common etiology for WBC count between 35-39.9 × 109 leukocytes/L and 40-50 × 109 leukocytes/L was infections, while malignancies (especially chronic lymphocytic leukemia) were more common with WBC count > 50 × 109 leukocytes/L.  Conclusion: For WBC counts in the range of 35-50 × 109 leukocytes/L, infections were the main reason for admission to the internal medicine department. Mortality increased from 2.8% to 33% as WBC counts increased from 35-39.9 × 109 leukocytes/L to 40-50 × 109 leukocytes/L. Overall, mortality for all WBC counts ≥ 35 × 109 leukocytes/L was 16%. The most common infections were pneumonia, followed by UTI or pyelonephritis and abscesses. The underlying risk factors did not correlate with WBC counts or mortality.

Perinephric Abscess Extending to the Psoas Muscle and Causing a Nephro-Cutaneous Fistula.

We present a case of a 76-year-old male with dementia transferred from a nursing home with a fever and an abscess on his back. Workup revealed an extensive perinephric abscess, which extended to his psoas muscle, with an additional fistula to his back where the abscess was noted. The extent and tracking of the perinephric abscess were unusual as well as the organisms isolated, Citrobacter koseri and Bacteroides species.

Adult-Onset Still's Disease in a 28-Year-Old Man From Ghana.

Adult-onset Still's disease is a rare, autoinflammatory disease characterized by spiking fevers, arthritis, salmon-colored skin rash, and leukocytosis. It has been compared to systemic juvenile idiopathic arthritis because of its similar features but is much rarer than its pediatric counterpart. It is usually treated with corticosteroids and disease-modifying anti-rheumatic drugs. However, those with refractory disease are candidates for one of many biological therapies. We present the case of a 28-year-old man who was successfully managed with first-line steroid therapy.

Severe Lower Extremity Cellulitis Caused by an Unusual Pathogen: Haemophilus Influenzae Type F.

We present a case of unusual cellulitis of the lower extremities caused by Haemophilus influenzae (HI). A 64-year-old female with human immunodeficiency virus (HIV) with a suppressed viral load on treatment, presented with severe, very painful cellulitis of her lower extremity. CT scan did not show any gas or collections; however, she was taken to the operating room for concern of necrotizing fasciitis but no evidence of deep tissue involvement was found. Blood culture and wound culture were positive forHI type F (HiF), a newly emergent pathogenic capsulatedHI that has emerged post-HI type B (HiB) vaccination.

Fever in trauma patients: evaluation of risk factors, including traumatic brain injury.

BACKGROUND: The role of fever in trauma patients remains unclear. Fever occurs as a response to release of cytokines and prostaglandins by white blood cells. Many factors, including trauma, can trigger release of these factors. OBJECTIVES: To determine whether (1) fever in the first 48 hours is related to a favorable outcome in trauma patients and (2) fever is more common in patients with head trauma. METHOD: Retrospective study of trauma patients admitted to the intensive care unit for at least 2 days. Data were analyzed by using multivariate analysis. RESULTS: Of 162 patients studied, 40% had fever during the first 48 hours. Febrile patients had higher mortality rates than did afebrile patients. When adjusted for severity of injuries, fever did not correlate with mortality. Neither the incidence of fever in the first 48 hours after admission to the intensive care unit nor the number of days febrile in the unit differed between patients with and patients without head trauma (traumatic brain injury). About 70% of febrile patients did not have a source found for their fever. Febrile patients without an identified source of infection had lower peak white blood cell counts, lower maximum body temperature, and higher minimum platelet counts than did febrile patients who had an infectious source identified. The most common infection was pneumonia. CONCLUSIONS: No relationship was found between the presence of fever during the first 48 hours and mortality. Patients with traumatic brain injury did not have a higher incidence of fever than did patients without traumatic brain injury. About 30% of febrile patients had an identifiable source of infection. Further studies are needed to understand the origin and role of fever in trauma patients.

Clostridium difficile at a community hospital in the Bronx, New York: incidence prevalence and risk factors from 2006 to 2008.

BACKGROUND: The rate of Clostridium difficile has increased over the last decade. This study was undertaken to determine the incidence, prevalence, and risk factors for infection at a 460-bed community hospital in the Bronx, New York. METHOD: Retrospective study reviewing all patients with a positive stool test for C difficile toxin A/B from 2006 to 2008. RESULTS: Three hundred fifty-two stools were positive for toxin. Average age was 58 years; 4% of patients with stools positive for C difficile were asymptomatic; 7% had community-acquired infection; 57% of C difficile acquisition occurred in the hospital; and 36% were in patients who acquired C difficile from a health care facility prior to admission. The incidence of C difficile was 7.8 cases/10,000 days in 2006, 10.3 in 2007, and 9.7 in 2008. The prevalence was 6.2 cases per 1,000 admissions in 2006, 7.6 in 2007, and 7.0 in 2008. The increased prevalence was not uniform throughout the hospital. CONCLUSION: At a community hospital in the Bronx, the incidence of C difficile increased but at a lower rate than previously reported. Prior health facility contact accounted for one third of these cases. Rooms with clusters of patients with C difficile suggest environmental propagation of infection.

Mycobacterium fortuitum and anaerobic breast abscess following nipple piercing: case presentation and review of the literature.

PURPOSE: Body piercing has become increasingly prevalent. We describe a case of breast infection with combined mycobacteria and anaerobe following nipple piercing, and review the literature. CASE: A 17-year-old female developed a breast abscess 4 months after nipple piercing. Cultures grew Prevotalla melangenica and Mycobacterium fortuitum. She required drainage and antibiotic treatment. Three months into her treatment she stopped her medications, relapsed, and required drainage. Two months later, on antimycobacteria therapy, her wound is healing. DISCUSSION: Review of the infectious complications of nipple piercing yielded 12 cases, 5 of which had a foreign body. The pathogens isolated (coagulase negative staphylococcus, mycobacteria, streptococcus, anaerobe, and gordonia) are not the usual organisms to be isolated from a breast abscess. This could result from reporting bias or the presence of a foreign body, the nipple ring. The three cases of mycobacteria, in addition to ours, are reviewed. The average age is 22 years. Three to 9 months elapsed between piercing and infection. All cases required drainage. Antimycobacteria therapy was used in three of the four cases for 10 days to 6 months. CONCLUSION: With the increasing prevalence of body piercing, it is important to document and report infections. We describe a breast abscess following nipple piercing with combined anaerobic and a mycobacterial pathogens. This underscores the need for obtaining cultures including anaerobes and mycobacteria.

Characterization of intersubtype recombinant HIV type 1 genomes using a nonradioactive heteroduplex tracking assay.

The HIV-1 epidemic is characterized by the dominance of distinct viral subtypes in different regions of the world, and intersubtype recombinants are common. Traditional subtyping methods analyze only a small fragment of the HIV-1 genome, so the true extent of diversity and recombination has been difficult to examine. We developed a heteroduplex tracking assay (HTA) to identify viral subtypes and rapidly detect recombinant HIV-1 genomes. By using probes that target seven regions across the HIV-1 genome, HTAs can identify intersubtype recombinants on the basis of the heteroduplex mobility pattern. We used this method to analyze HIV-1 strains from 12 patients from the United States and Kenya, comparing the results with those obtained by sequencing. HTA analysis correctly identified the subtype of each region of the genome, revealing that several isolates were recombinants. This method is suitable for studies of HIV-1 diversity and recombination in areas of the world where multiple subtypes are found.