Escherichia coli Meningitis in a Patient With Urinary Tract Infection: A Case Report.

This article discusses a case of Escherichia coli (E. coli) meningitis resulting in altered mental status in a patient with multiple pre-existing comorbidities. The case highlights the underestimated risk of community-acquired gram-negative meningitis in adults, which can have a high mortality rate, particularly in elderly patients with sepsis and urinary tract infections. Diagnosis of E. coli meningitis was confirmed by analyzing cerebrospinal fluid obtained through the lumbar puncture and blood cultures. Treatment involved prompt administration of antibiotics and supportive care. However, the emergence of antibiotic resistance, such as extended-spectrum beta-lactamase production, in community-acquired E. coli meningitis is an increasing concern. Therefore, early recognition and appropriate management are crucial in the diagnosis and treatment of this life-threatening condition.

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.

A Challenging Diagnosis of Febrile Pancytopenia in a Patient With a History of Autoimmune Disease.

Pancytopenia is a hematologic condition characterized by a decrease in all three peripheral blood cell lines. There are many causes of pancytopenia, and the proper approach is required for accurate diagnosis. Brucellosis and systemic lupus erythematosus (SLE) are both diseases that can initially present as pancytopenia, both of which require a targeted workup to diagnose. Due to the immune system's complexity, many distinct diseases may have similar symptomatology. Furthermore, infections and rheumatological diseases can stimulate the same molecular pathways and trigger T and B cells. This creates a cross-reactivity between microbial peptides and self-peptides, allowing the spread of microbial-specific T cells that can also respond to self-peptides. Brucellosis has broad clinical manifestations, often mimicking many other diseases, such as rheumatoid arthritis, sarcoidosis, and SLE. In addition, brucellosis-induced autoantibody production has been described as a triggering factor for immunologic reactions, elevating rheumatological markers by a poorly understood mechanism. Finally, SLE is a well-known medical condition that can mimic several medical conditions, including brucellosis.  We present a case of a young patient who was admitted with febrile pancytopenia. The patient also had IgM antibodies positive for brucellosis and high immune markers for SLE. She was treated for both diseases, and afterward, in retrospect, it was confirmed that the patient did not have acute brucellosis.

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.

Septic shock caused by the under-recognized bacterium Eggerthella lenta in a 61-year-old male with a periurethral abscess: a case report.

Eggerthella lenta is a gram-positive anaerobic bacillus that has been associated with life-threatening infections. Bacteremia is always clinically significant and is mostly but not always associated with gastrointestinal disease. We present a unique case of abrupt deterioration and rapid development of septic shock secondary to periurethral abscess caused by E. lenta infection. This case highlights the atypical clinical presentation, risk factors, uncommon source of infection, challenges in therapy, and outcome of this infrequent infection. There is still a gap in the understanding of E. lenta pathogenicity, and more literature is needed to establish clear management recommendations.

Limited Added Value of Magnetic Resonance Imaging After Dynamic Transvaginal Ultrasound for Preoperative Staging of Endometriosis in Daily Practice: A Prospective Cohort Study.

OBJECTIVES: To assess the added value of magnetic resonance imaging (MRI) after dynamic transvaginal ultrasound (TVUS) in the diagnostic pathway for preoperative staging of pelvic endometriosis. METHODS: A prospective observational study was conducted between April 22, 2014, and May 1, 2015. During that period, 363 patients with a clinical suspicion of endometriosis were included. All patients underwent a history, clinical examination, and dynamic TVUS examination. Most of the patients (n = 274) underwent conservative treatment according to the European Society of Human Reproduction and Embryology guidelines. Eighty-nine patients were selected for surgery, of whom 72 patients underwent the complete diagnostic pathway: ie, history, clinical examination, dynamic TVUS, and MRI. All data were analyzed by the nonparametric McNemar test for comparing each step in the diagnostic algorithm. RESULTS: The sensitivity and specificity for the history, pelvic examination, and dynamic TVUS were 93.7% and 55.6% (P < .001), respectively; when MRI findings were included, the sensitivity and specificity were 85.9% and 62.5%. Adding MRI routinely to the diagnostic procedure of endometriosis did not significantly improve the sensitivity or specificity. CONCLUSIONS: There is no significant added value of routine MRI after dynamic TVUS for the preoperative staging of endometriosis.

Septic shock caused by the under-recognized bacterium Eggerthella lenta in a 61-year-old male with a periurethral abscess: a case report

Abstract Eggerthella lenta is a gram-positive anaerobic bacillus that has been associated with life-threatening infections. Bacteremia is always clinically significant and is mostly but not always associated with gastrointestinal disease. We present a unique case of abrupt deterioration and rapid development of septic shock secondary to periurethral abscess caused by E. lenta infection. This case highlights the atypical clinical presentation, risk factors, uncommon source of infection, challenges in therapy, and outcome of this infrequent infection. There is still a gap in the understanding of E. lenta pathogenicity, and more literature is needed to establish clear management recommendations.

MRI-Ultrasound Fusion Imaging for Diagnosis of Deep Infiltrating Endometriosis - A Critical Appraisal.

PURPOSE: It was the aim of our study to evaluate this procedure using pelvic anatomical landmarks in order to assess the accuracy of fusion imaging and to critically evaluate the applicability in daily practice. METHODS: In a prospective, single center study, 10 patients with clinical signs of deep infiltrating endometriosis (DIE) were selected. We measured the distance between the landmark organ and the target shown by the software system (measurement 1). Measurement 2 depicts the distance between the landmark and the nearest calibration point. The calibration inaccuracy was measured as a third type of measurement (measurement 3). RESULTS: Measurement 1: the average distance between the organ landmark to the target was 13.6 mm (range: 0-96 mm). Measurement 2: in 31 of the 40 attempts (77.5 %), we could measure the distance from the landmark organ to the nearest calibration point. The average distance was 34.4 mm (range: 0-69 mm).Measurement 3: A perfect match was seen in 6 of 20 attempts (30.0 %). There was a deviation in 14 of the 20 attempts (70.0 %). The mean distance was 11.1 mm (range: 6-23 mm). Conclusion Although very promising, MRI-ultrasound fusion imaging (MUFI) currently cannot be readily implemented into daily practice as a routine evaluation of DIE.

Surgical outcomes of laparoscopic hysterectomy with concomitant endometriosis without bowel or bladder dissection: a cohort analysis to define a case-mix variable.

BACKGROUND: Pelvic endometriosis is often mentioned as one of the variables influencing surgical outcomes of laparoscopic hysterectomy (LH). However, its additional surgical risks have not been well established. The aim of this study was to analyze to what extent concomitant endometriosis influences surgical outcomes of LH and to determine if it should be considered as case-mix variable. RESULTS: A total of 2655 LH's were analyzed, of which 397 (15.0%) with concomitant endometriosis. For blood loss and operative time, no measurable association was found for stages I (n = 106) and II (n = 103) endometriosis compared to LH without endometriosis. LH with stages III (n = 93) and IV (n = 95) endometriosis were associated with more intra-operative blood loss (p = < .001) and a prolonged operative time (p = < .001) compared to LH without endometriosis. No significant association was found between endometriosis (all stages) and complications (p = .62). CONCLUSIONS: The findings of our study have provided numeric support for the influence of concomitant endometriosis on surgical outcomes of LH, without bowel or bladder dissection. Only stages III and IV were associated with a longer operative time and more blood loss and should thus be considered as case-mix variables in future quality measurement tools.

Newly Diagnosed Idiopathic Liver Abscess: Colonoscopy Required!

Liver abscess is the most common type of visceral abscess reported in the United States. Biliary tract disease is the most common cause of the development of liver abscess. In the last decade, many cases of liver abscesses silently manifesting as colon cancer have been reported in East Asian countries. We herein describe a case of an immunocompetent man who immigrated from East Africa to Unites States and presented with a suspicion of colon mass with metastasis to the liver, and who was later diagnosed to have a colonic malignancy with a concomitant liver abscess. Our aim was to make clinicians aware of the importance of ruling out occult colonic malignancy in patients with idiopathic liver abscess.

MRSA Causing Infections in Hospitals in Greater Metropolitan New York: Major Shift in the Dominant Clonal Type between 1996 and 2014.

A surveillance study in 1996 identified the USA100 clone (ST5/SCCmecII)-also known as the "New York/Japan" clone-as the most prevalent MRSA causing infections in 12 New York City hospitals. Here we update the epidemiology of MRSA in seven of the same hospitals eighteen years later in 2013/14. Most of the current MRSA isolates (78 of 121) belonged to the MRSA clone USA300 (CC8/SCCmecIV) but the USA100 clone-dominant in the 1996 survey-still remained the second most frequent MRSA (25 of the 121 isolates) causing 32% of blood stream infections. The USA300 clone was most common in skin and soft tissue infections (SSTIs) and was associated with 84.5% of SSTIs compared to 5% caused by the USA100 clone. Our data indicate that by 2013/14, the USA300 clone replaced the New York/Japan clone as the most frequent cause of MRSA infections in hospitals in Metropolitan New York. In parallel with this shift in the clonal type of MRSA, there was also a striking change in the types of MRSA infections from 1996 to 2014.

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.

2D and 3D MALDI-imaging: conceptual strategies for visualization and data mining.

3D imaging has a significant impact on many challenges in life sciences, because biology is a 3-dimensional phenomenon. Current 3D imaging-technologies (various types MRI, PET, SPECT) are labeled, i.e. they trace the localization of a specific compound in the body. In contrast, 3D MALDI mass spectrometry-imaging (MALDI-MSI) is a label-free method imaging the spatial distribution of molecular compounds. It complements 3D imaging labeled methods, immunohistochemistry, and genetics-based methods. However, 3D MALDI-MSI cannot tap its full potential due to the lack of statistical methods for analysis and interpretation of large and complex 3D datasets. To overcome this, we established a complete and robust 3D MALDI-MSI pipeline combined with efficient computational data analysis methods for 3D edge preserving image denoising, 3D spatial segmentation as well as finding colocalized m/z values, which will be reviewed here in detail. Furthermore, we explain, why the integration and correlation of the MALDI imaging data with other imaging modalities allows to enhance the interpretation of the molecular data and provides visualization of molecular patterns that may otherwise not be apparent. Therefore, a 3D data acquisition workflow is described generating a set of 3 different dimensional images representing the same anatomies. First, an in-vitro MRI measurement is performed which results in a three-dimensional image modality representing the 3D structure of the measured object. After sectioning the 3D object into N consecutive slices, all N slices are scanned using an optical digital scanner, enabling for performing the MS measurements. Scanning the individual sections results into low-resolution images, which define the base coordinate system for the whole pipeline. The scanned images conclude the information from the spatial (MRI) and the mass spectrometric (MALDI-MSI) dimension and are used for the spatial three-dimensional reconstruction of the object performed by image registration techniques. Different strategies for automatic serial image registration applied to MS datasets are outlined in detail. The third image modality is histology driven, i.e. a digital scan of the histological stained slices in high-resolution. After fusion of reconstructed scan images and MRI the slice-related coordinates of the mass spectra can be propagated into 3D-space. After image registration of scan images and histological stained images, the anatomical information from histology is fused with the mass spectra from MALDI-MSI. As a result of the described pipeline we have a set of 3 dimensional images representing the same anatomies, i.e. the reconstructed slice scans, the spectral images as well as corresponding clustering results, and the acquired MRI. Great emphasis is put on the fact that the co-registered MRI providing anatomical details improves the interpretation of 3D MALDI images. The ability to relate mass spectrometry derived molecular information with in vivo and in vitro imaging has potentially important implications. This article is part of a Special Issue entitled: Computational Proteomics in the Post-Identification Era. Guest Editors: Martin Eisenacher and Christian Stephan.

MRI-compatible pipeline for three-dimensional MALDI imaging mass spectrometry using PAXgene fixation.

MALDI imaging mass spectrometry (MALDI-imaging) has emerged as a spatially-resolved label-free bioanalytical technique for direct analysis of biological samples and was recently introduced for analysis of 3D tissue specimens. We present a new experimental and computational pipeline for molecular analysis of tissue specimens which integrates 3D MALDI-imaging, magnetic resonance imaging (MRI), and histological staining and microscopy, and evaluate the pipeline by applying it to analysis of a mouse kidney. To ensure sample integrity and reproducible sectioning, we utilized the PAXgene fixation and paraffin embedding and proved its compatibility with MRI. Altogether, 122 serial sections of the kidney were analyzed using MALDI-imaging, resulting in a 3D dataset of 200GB comprised of 2million spectra. We show that elastic image registration better compensates for local distortions of tissue sections. The computational analysis of 3D MALDI-imaging data was performed using our spatial segmentation pipeline which determines regions of distinct molecular composition and finds m/z-values co-localized with these regions. For facilitated interpretation of 3D distribution of ions, we evaluated isosurfaces providing simplified visualization. We present the data in a multimodal fashion combining 3D MALDI-imaging with the MRI volume rendering and with light microscopic images of histologically stained sections. BIOLOGICAL SIGNIFICANCE: Our novel experimental and computational pipeline for 3D MALDI-imaging can be applied to address clinical questions such as proteomic analysis of the tumor morphologic heterogeneity. Examining the protein distribution as well as the drug distribution throughout an entire tumor using our pipeline will facilitate understanding of the molecular mechanisms of carcinogenesis.

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.

Vaginal flora changes on Pap smears after insertion of levonorgestrel-releasing intrauterine device.

BACKGROUND: The levonorgestrel intrauterine system (LNG-IUS) combines a uterine foreign body and the continuous release of low-dose levonorgestrel for contraception. Its influence on the rate of vulvovaginal infections and flora disturbance is insufficiently known, but important for contraceptive advice in women, especially those who develop recurrent vaginosis or Candida vulvovaginitis. STUDY DESIGN: Slides of 286 women who had a Pap smear taken before and 1 to 2 years after placement of a LNG-IUS were blindly reviewed for the presence of abnormal vaginal flora (AVF), bacterial vaginosis (BV), aerobic vaginitis (AV) and Candida vaginitis (CV). RESULTS: Prior to insertion, there were no differences in vaginal flora abnormalities between women using different kinds of contraception. LNG-IUS users did not have different rates of AVF, BV, AV or CV, but the general risk to develop any infection was increased. Uterine bleeding after insertion did not seem to predict a different flora type. CONCLUSION: We found that Pap smears suggested more vaginal infections after 1 year of LNG-IUS use than prior to insertion of the device.

[A woman with an obstetric curiosity]. / Een vrouw met een obstetrische bijzonderheid.

A primipara underwent a caesarean section for preeclampsia. It so happened that vasa praevia were seen during the operation. A healthy boy was born.

Feasibility of using audio computer-assisted self-interview (ACASI) screening in routine HIV care.

We evaluated the feasibility of implementing audio computer-assisted self-interviews (ACASI) as part of routine clinical care at two community hospital-based HIV clinics in New York City. Between June 2003 and August 2006, 215 patients completed 1001 ACASI sessions in English or Spanish prior to their scheduled clinical appointments. Topics covered included antiretroviral therapy adherence, depression symptoms, alcohol and drug use, and condom use. Patients and providers received feedback reports immediately after each session. Feasibility was evaluated by quantitative analysis of ACASI responses, medical chart reviews, a brief patient questionnaire administered at the conclusion of each computer session, patient focus groups, and semi-structured provider interviews. ACASI interviews frequently identified inadequate medication adherence and depression symptoms: at baseline, 31% of patients reported < or =95% adherence over the past three days and 52% had symptoms of depression (CES-D score > or =16). Substance abuse problems were identified less frequently. Patients were comfortable with the ACASI and appreciated it as an additional communication route with their providers; however, expectations about the level of communication achieved were sometimes higher than actual practice. Providers felt the summary feedback information was useful when received in a timely fashion and when they were familiar with the clinical indicators reported. Repeated ACASI sessions did not have a favorable impact on adherence, depression, or substance use outcomes. No improvements in HIV RNA suppression were observed in comparison to patients who did not participate in the study. We conclude that it is feasible to integrate an ACASI screening tool into routine HIV clinical care to identify patients with inadequate medication adherence and depression symptoms. Repeated screening was not associated with improved clinical outcomes. ACASI screening should be considered in HIV clinical care settings to assist providers in identifying patients with the greatest need for targeted psychosocial services including adherence support and depression care.

Impaction after partial expulsion of a neglected pessary.

BACKGROUND: Vaginal pessaries are effective for treating pelvic organ prolapse, and severe complications are rare. We describe an exceptional case of pessary impaction with partial expulsion. CASE: An elderly woman had mild discomfort from a pessary protruding through the perineal skin. The pessary was cut, removed, and the perineum healed uneventfully. CONCLUSION: Negligence of vaginal pessaries may result in migration to the bladder or to the rectum. This case of perineal expulsion was eventually easily treated. Although no evidence-based guidelines for pessary care exist, this rare manifestation suggests the need for follow-up on a regular basis.

Change in knowledge of women about cervix cancer, human papilloma virus (HPV) and HPV vaccination due to introduction of HPV vaccines.

OBJECTIVES: Test knowledge of HPV, cervix cancer awareness and acceptance of HPV vaccination of women now and a year ago. STUDY DESIGN: Questionnaires were filled out by 305 women visiting four gynaecologists of the Regional Hospital Heilig Hart, Tienen, Belgium during two subsequent weeks. Fisher T or Chi(2) were used as statistical methods to compare the data with the survey of 381 women exactly one year before. RESULTS: Knowledge about HPV as a cause of cervix cancer and the presence of a vaccine rose from roughly 50% in 2007 to over 80% in 2008 (p<0.0001). Level of education and having daughters, sons or no children no longer influenced the level of knowledge or willingness to accept the vaccine. Most parents favor the age group 12-16 years as an ideal time for vaccination. In contrast with the 2007 survey, women below 26 years had now acquired almost equivalent knowledge to older women about the virus, cervix cancer and the vaccine, but they were far less likely to accept the vaccine due to its cost, unless it would be reimbursed (OR 4.2 (1.6-11) p=0.0055). CONCLUSION: One year after introduction of the first two HPV vaccines, over 75% of women attending an ambulatory gynaecology clinic know HPV causes cervix cancer and that you can get vaccinated against it. Compared with a year earlier, young and lower educated women had dramatically improved their knowledge. However, women below 26 years are less prepared to pay the cost for vaccination if it is not reimbursed.