Invasive Fungal Rhinosinusitis Caused by Curvularia in a Patient With Type 1 Diabetes Mellitus: A Case Report.

Invasive fungal rhinosinusitis (IFRS) is a serious illness requiring early diagnosis, surgical debridement, and administration of antifungals. We report a case of an acute IFRS caused by Curvularia in a patient with diabetes mellitus. An 18-year-old female presented to the emergency department with an acute onset of fever, headache, facial discomfort, and a blood glucose reading of 500 mg/dL. The patient was admitted for the management of hyperosmolar hyperglycemia. Her past medical history includes uncontrolled type 1 diabetes mellitus and a recent toothache. A computed tomography scan of the facial maxillary region revealed sinus disease with bony erosion. Empiric therapy with liposomal amphotericin B 400 mg i.v. every 24 hours, piperacillin/tazobactam 4.5 g i.v. every 6 hours and vancomycin 1 g i.v. every 12 hours was started. A functional endoscopic sinus surgery revealed invasive rhinosinusitis and cultures were positive for fungal elements. The patient was discharged on liposomal amphotericin B 400 mg i.v. daily and cefuroxime 500 mg orally twice daily. However, she was readmitted for the management of acute kidney injury and was discharged on itraconazole capsules 200 mg orally twice daily. Sinus cultures grew Curvularia and itraconazole was prescribed for 6 weeks, but the patient discontinued treatment after 3 weeks and had no signs or symptoms of rhinosinusitis when she was last seen in the clinic. The possibility of IFRS should be explored in patients with diabetes and signs and symptoms of rhinosinusitis.

Phase 3 Safety and Efficacy of AZD1222 (ChAdOx1 nCoV-19) Covid-19 Vaccine.

BACKGROUND: The safety and efficacy of the AZD1222 (ChAdOx1 nCoV-19) vaccine in a large, diverse population at increased risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the United States, Chile, and Peru has not been known. METHODS: In this ongoing, double-blind, randomized, placebo-controlled, phase 3 clinical trial, we investigated the safety, vaccine efficacy, and immunogenicity of two doses of AZD1222 as compared with placebo in preventing the onset of symptomatic and severe coronavirus disease 2019 (Covid-19) 15 days or more after the second dose in adults, including older adults, in the United States, Chile, and Peru. RESULTS: A total of 32,451 participants underwent randomization, in a 2:1 ratio, to receive AZD1222 (21,635 participants) or placebo (10,816 participants). AZD1222 was safe, with low incidences of serious and medically attended adverse events and adverse events of special interest; the incidences were similar to those observed in the placebo group. Solicited local and systemic reactions were generally mild or moderate in both groups. Overall estimated vaccine efficacy was 74.0% (95% confidence interval [CI], 65.3 to 80.5; P<0.001) and estimated vaccine efficacy was 83.5% (95% CI, 54.2 to 94.1) in participants 65 years of age or older. High vaccine efficacy was consistent across a range of demographic subgroups. In the fully vaccinated analysis subgroup, no severe or critical symptomatic Covid-19 cases were observed among the 17,662 participants in the AZD1222 group; 8 cases were noted among the 8550 participants in the placebo group (<0.1%). The estimated vaccine efficacy for preventing SARS-CoV-2 infection (nucleocapsid antibody seroconversion) was 64.3% (95% CI, 56.1 to 71.0; P<0.001). SARS-CoV-2 spike protein binding and neutralizing antibodies increased after the first dose and increased further when measured 28 days after the second dose. CONCLUSIONS: AZD1222 was safe and efficacious in preventing symptomatic and severe Covid-19 across diverse populations that included older adults. (Funded by AstraZeneca and others; ClinicalTrials.gov number, NCT04516746.).

Tick borne illness-Lyme disease.

Lyme disease is the most commonly reported tick-borneillness in the United States. Thecausative spirochete, Borrelia burgdorferi is transmitted by 4 species of Ixodes tick species. Over 90% of US cases occur in northeasternstates from Maine to Virginia, and in Wisconsin, Minnesota, and Michigan. Infection also takes place in northern California and Oregon. Lyme borreliosis is also diagnosed in parts of Europe, China, and Japan. The white-footed mouse is the primary animal reservoir for B. burgdorferi in the U.S. and the preferred host for nymphal and larval forms of the deer tick. Deer are hosts for the adult ticks but do not carry the spirochete. Signs and symptomsof infection occur in 3 stages; early localized, typified by erythema migrans; early disseminated with a flu-like syndrome, neurologic, and cardiac manifestations; and late, characteristically with arthritis. Although, the term 'Chronic Lyme Disease' has been assigned to many patients with a variety of unexplained symptoms, experts in the field question the validity of this diagnosis and warn against prolonged unproven antimicrobial therapies. Diagnosis relies upon clinical evaluation and is supported by serologic testing using a 2-step process which requires careful interpretation. Treatmentvaries with stage of disease, but normally includes doxycycline, amoxicillin,and ceftriaxone. Currently, no preventative vaccine is available. In some geographic areas, patients may be confected with Babesia, Ehrlichia, and Anaplasma since the same Ixodes ticks transmit these pathogens.

AIDS-Associated Cardiac Lymphoma-A Review: Apropos a Case Report.

Despite treatment with potent and effective combination antiretroviral medications, the incidence of non-Hodgkin lymphoma (NHL) in the population living with HIV/AIDS remains significantly higher than that in noninfected individuals. The majority of the HIV-infected patients with NHL present with advanced stage extranodal disease of the B-cell phenotype. Lymphomas are the second most common tumors involving the heart in HIV-infected patients. Although the heart may serve as the primary focus of the lymphoma, in most HIV-related cases, cardiac lymphomatous involvement is part of a metastatic process that originated elsewhere.

Iatrogenic Cushing syndrome and secondary adrenal insufficiency related to concomitant triamcinolone and ritonavir administration: a case report and review.

Triamcinolone is a long-acting glucocorticoid medication that can be responsible for transient suppression of the hypothalamic­pituitary­adrenal (HPA) axis. This physiologic alteration may persist for weeks after repeated or even single localized injection of this agent. However, when this glucocorticoid agent is given to patients receiving the HIV protease inhibitor (PI) ritonavir (RTV),inhibition of their shared cytochrome P450 3A4 degradation pathway leads to an increased bioavailability of triamcinolone, with subsequent heightening and prolongation of the glucocorticoid serum levels. In those instances, iatrogenic Cushing syndrome may ensue. The authors encountered such an event in an HIV-infected patient on chronic treatment with an antiretroviral regimen containing RTV. The patient's clinical presentation and laboratory investigations confirmed a diagnosis of Cushing syndrome and secondary adrenal insufficiency. This was believed to have occurred in close association following cervical vertebral column facet joint injections with triamcinolone acetonide for cephalagia deemed related to cervical spine disease. The discontinuation of the RTV-boosted PI therapy alone, promoting the clearance of the elevated triamcinolone serum levels and restoration of HPAhomeostasis, proved successful in this patient. For this case, the authors review the published English medical literature relating to this uncommon phenomenon.

Iatrogenic Cushing syndrome and secondary adrenal insufficiency related to concomitant triamcinolone and ritonavir administration: a case report and review.

Triamcinolone is a long-acting glucocorticoid medication that can be responsible for transient suppression of the hypothalamic­pituitary­adrenal (HPA) axis. This physiologic alteration may persist for weeks after repeated or even single localized injection of this agent. However, when this glucocorticoid agent is given to patients receiving the HIV protease inhibitor (PI) ritonavir (RTV),inhibition of their shared cytochrome P450 3A4 degradation pathway leads to an increased bioavailability of triamcinolone, with subsequent heightening and prolongation of the glucocorticoid serum levels. In those instances, iatrogenic Cushing syndrome may ensue. The authors encountered such an event in an HIV-infected patient on chronic treatment with an antiretroviral regimen containing RTV. The patient's clinical presentation and laboratory investigations confirmed a diagnosis of Cushing syndrome and secondary adrenal insufficiency. This was believed to have occurred in close association following cervical vertebral column facet joint injections with triamcinolone acetonide for cephalagia deemed related to cervical spine disease. The discontinuation of the RTV-boosted PI therapy alone, promoting the clearance of the elevated triamcinolone serum levels and restoration of HPAhomeostasis, proved successful in this patient. For this case, the authors review the published English medical literature relating to this uncommon phenomenon.

Liver abscess as a complication of laparoscopic gastric banding bariatric surgery.

BACKGROUND: The World Health Organization has identified the rapidly growing prevalence of obesity as one of today's serious health problems. Various surgical interventions categorized collectively as bariatric surgery now play an ever-increasing important role as the only known effective treatment for severe obesity. Laparoscopic gastric bypass is currently the most frequent bariatric surgical procedure performed. However, the laparoscopic adjustable gastric band (LAGB) is rapidly gaining in popularity as a minimally invasive surgical option with anticipated similarly efficacious outcomes. Gastric band erosion following LAGB is an uncommon yet potentially serious complication unique to this form of weight loss surgery. METHODS: Case report and literature review. RESULTS: We report a case of a pyogenic liver abscess related to a LAGB procedure. Apropos to this case, we review the presumed pathophysiologic mechanism of this particular infectious process, and discuss this and other complications associated with LAGB operations. CONCLUSIONS: As LAGB bariatric procedures become more popular, clinicians need to be aware of uncommon, but potentially serious complications unique to this form of weight loss surgery.

Acute sinusitis resulting in a craniotomy: an uncommon complication of a common infection.

Acute bacterial sinusitis is a common infectious condition. Patients may initially present with an uncomplicated infection and later, despite appropriate initial antibiotic therapy, develop a potentially life-threatening complication. Interventions aimed at alleviating such unexpected events need be prompt and adequate. We describe a case of a patient who initially presented with signs and symptoms of acute sinusitis later to be diagnosed with a frontal epidural abscess.

The anthrax attacks 10 years later.

Ten years ago, just weeks after the September 11 attacks, the United States experienced a deliberate act of bioterrorism. Through use of the postal service, anthrax spores were widely disseminated, including to homes, the Senate, and major newsrooms, resulting in morbidity and mortality and effectively disrupting our way of life and revealing our vulnerability. Even though such attacks had been the subject of much writing and had been planned for, detection of and the appropriate response to an attack with an agent from the so-called "Category 'A' List" had only been considered in theoretical terms. What transpired during the following difficult weeks, including how public health and federal government agencies performed, has been both praised and criticized. An intertwined epidemiologic and criminal investigation of such magnitude was unprecedented in U.S. history. To address the question of whether we as a nation are now better prepared for future threats involving biologic agents, it is important to learn from the lessons of the 2001 anthrax attacks, including the critical role of clinicians in surveillance. As physicians involved in diagnosing anthrax in the index case and alerting authorities, we offer our perspective on these events a decade after their occurrence.

Cumulative clinical experience from over a decade of use of levofloxacin in urinary tract infections: critical appraisal and role in therapy.

The treatment of urinary tract infections (UTIs) continues to evolve as common uropathogens increasingly become resistant to previously active antimicrobial agents. In addition, bacterial isolates, which were once considered to be either colonizers or contaminants, have emerged as true pathogens, likely related to the more complex array of settings where health care is now delivered. Even though the reliability of many antimicrobial agents has become less predictable, the fluoroquinolone group of agents has remained a frequent, if not the most often prescribed, antimicrobial therapy for almost all types of UTIs. Levofloxacin has taken its position at the top of the list as one of the most regularly administered fluoroquinolone agents given to patients with a suspected or proven UTI. The authors review the clinical experience of the use of levofloxacin over the past decade and suggest that the use of levofloxacin for the treatment of UTIs, although still fairly dependable, is perhaps not the best use of this important antimicrobial agent.