First reported Rhodotorula mucilaginosa brain abscess: Found as coinfection in woman with common variable immune deficiency.

Rhodotorula is a rare pathogen seen in the immunocompromised host; while cases of Rhodotorula meningitis have been reported, there are no published cases of Rhodotorula brain abscess. We describe the diagnosis and management of a woman with common variable immune deficiency presenting with concomitant Rhodotorula and Nocardia brain abscesses.

Diagnostic Algorithm for the Diagnosis of Pediatric Parasitic Gastroenteritis.

BACKGROUND: Current practices for ordering stool studies in patients with abdominal and gastrointestinal symptoms are not standardized. We hypothesized that an algorithm involving first-line use of a Cryptosporidium/Giardia combination antigen test and stricter use of ova and parasite (O&P) examinations would be clinically and cost effective. METHODS: In this study, stool O&P test results for pediatric patients in Dallas, Texas, were reviewed. All results obtained between 2009 and 2012 were included. Patient charts were reviewed to determine test results, symptoms, treatment, travel, and past medical history. Using these data, a retrospective modeling study was done to evaluate the utility of a diagnostic algorithm that limits O&P testing to those patients who are immunocompromised or have travelled outside the United States. RESULTS: Over the 3-year period of this study, we found that the prevalence of gastrointestinal parasitic disease in children was 1.9%. Analysis of the diagnostic algorithm for the judicious use of stool O&P showed that as much as 65% of testing may be unnecessary and could be eliminated. CONCLUSIONS: Our findings show that the prevalence of pediatric gastrointestinal parasitic disease in Texas may be lower than expected. In addition, these data show that a diagnostic algorithm limiting O&P testing may be both clinically and cost effective in low-prevalence settings. However, such an algorithm would miss a significant number of infections due to Dientamoeba fragilis and Blastocystis hominis.

Detection of intracellular parasites by use of the CellaVision DM96 analyzer during routine screening of peripheral blood smears.

Conventional microscopy is the gold standard for malaria diagnosis. The CellaVision DM96 is a digital hematology analyzer that utilizes neural networks to locate, digitize, and preclassify leukocytes and characterize red blood cell morphology. This study compared the detection rates of Plasmodium and Babesia species on peripheral blood smears utilizing the CellaVision DM96 with the rates for a routine red blood cell morphology scan. A total of 281 slides were analyzed, consisting of 130 slides positive for Plasmodium or Babesia species and 151 negative controls. Slides were blinded, randomized, and analyzed by CellaVision and microscopy for red cell morphology scans. The technologists were blinded to prior identification results. The parasite detection rate was 73% (95/130) for CellaVision and 81% (105/130) for microscopy for positive samples. The interobserver agreement between CellaVision and microscopy was fair, as Cohen's kappa coefficient equaled 0.36. Pathologist review of CellaVision images identified an additional 15 slides with parasites, bringing the total number of detectable positive slides to 110 of 130 (85%). Plasmodium ovale had the lowest rate of detection at 56% (5 of 9); Plasmodium malariae and Babesia spp. had the highest rate of detection at 100% (3/3 and 6/6, respectively). The detection rate by CellaVision was 100% (23/23) when the parasitemia was ≥2.5%. The detection rate for <0.1% parasitemia was 63% (15/24). Technologists appropriately classified all negative specimens. The percentage of positive specimens detectable by CellaVision (73%) approaches results for microscopy on routine scan of peripheral blood smears for red blood cell morphology.

Mycobacterium leprae and Mycobacterium haemophilum co-infection in an iatrogenically immunosuppressed patient.

We present the case of a native Texan who was diagnosed with tuberculoid leprosy and later developed a cutaneous infection with M. haemophilum following iatrogenic immunosuppression. To our knowledge, there are no such reports of M. haemophilum and M. leprae infection occurring simultaneously in the same host.

Evaluation of the nanosphere verigene gram-positive blood culture assay with the VersaTREK blood culture system and assessment of possible impact on selected patients.

The Verigene Gram-positive blood culture (BC-GP) assay (Nanosphere, Northbrook, IL) is a molecular method for the rapid identification of Gram-positive organisms and resistance markers directly from blood culture bottles. A total of 148 VersaTREK REDOX 1 40-ml aerobic bottles demonstrating Gram-positive bacteria were tested. Results were compared with those from conventional biochemical and matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) identifications. We obtained isolates of methicillin-resistant Staphylococcus aureus (MRSA) (24), methicillin-susceptible Staphylococcus aureus (MSSA) (14), methicillin-resistant Staphylococcus epidermidis (MRSE) (17), methicillin-susceptible Staphylococcus epidermidis (MSSE) (9), other coagulase-negative staphylococci (19), Streptococcus salivarius (5), Streptococcus parasanguinis (2), Streptococcus sanguinis (1), Streptococcus cristatus (1), the Streptococcus bovis group (5), Streptococcus agalactiae (9), the Streptococcus anginosus group (1), Streptococcus pneumoniae (6), vancomycin-resistant Enterococcus faecium (VRE FCM) (16), vancomycin-susceptible Enterococcus faecalis (3), Aerococcus viridans (2), Bacillus (6), Corynebacterium (8), Lactobacillus (2), Micrococcus (2), Neisseria mucosa (1), Escherichia coli (3), Candida tropicalis (1), Propionibacterium (1), and Rothia (1). Overall agreement with the culture results was 95%. A total of 137 of 138 (99%) monomicrobial cultures were concordant. We tested 9 polymicrobial samples and found 33% agreement. A chart review of 31 patients with MRSA, MSSA, or VRE demonstrated that the Nanosphere BC-GP assay might have led to more appropriate antibiotic selection for these patients an average of 42 h earlier. Additionally, contact isolation could have been initiated an average of 37 h earlier for patients with MRSA or VRE. The BC-GP assay may have a positive impact on patient care, health care costs, and antibiotic stewardship.

Pseudo-outbreak of vancomycin-resistant-enterococcus (VRE) Colonization in a neonatal intensive care unit using spectra VRE surveillance medium.

From November 2011 through March 2012, we surveyed 272 babies in our neonatal intensive care unit for rectal colonization with vancomycin-resistant enterococci (VRE). Using Spectra VRE medium (Remel Diagnostics, Lenexa, KS), we identified one neonate colonized with vancomycin-resistant Enterococcus faecium. In addition, 55 (13%) of the surveillance cultures yielded false-positive results with vancomycin-susceptible Enterococcus faecalis. During the same time period, 580 rectal swabs were collected from adult patients resulting in 20 (3%) false-positive cultures. The difference in false-positive rates between cultures from babies and adults was statistically significant (P < 0.001), prompting an investigation of factors that might influence the elevated false-positive rate in the neonates including patient demographics, nutrition, and topical ointments applied at the time of testing. Older neonates, with a median age of 6 weeks, were more likely to have false-positive cultures than younger neonates with a median age of 3 weeks (P < 0.001). The younger neonates receiving Similac Expert Care products were less likely to have false-positive surveillance cultures than those receiving other formulas (P < 0.001). Application of topical products was not associated with false-positive cultures. The false-positive E. faecalis strains were typed by Diversilab Rep-PCR (bioMérieux, Marcy l'Etoile, France) and found to represent eight different groups of isolates. The utility of the Spectra VRE media appeared to be significantly impacted by the age of the patients screened.

Impact of blood cultures drawn by phlebotomy on contamination rates and health care costs in a hospital emergency department.

We conducted a prospective comparison of blood culture contamination rates associated with dedicated phlebotomists and nonphlebotomy staff in the emergency department (ED) at Parkland Memorial Hospital in Dallas, TX. In addition, hospital charges and lengths of stay were determined for patients with negative, false-positive, and true-positive blood culture results. A total of 5,432 blood culture collections from two ED areas, the western wing of the ED (ED west) and the nonwestern wing of the ED (ED nonwest), were evaluated over a 13-month period. Phlebotomists drew 2,012 (55%) of the blood cultures in ED west while nonphlebotomy staff drew 1,650 (45%) in ED west and 1,770 (100%) in ED nonwest. The contamination rates of blood cultures collected by phlebotomists were significantly lower than those collected by nonphlebotomists in ED west (62/2,012 [3.1%] versus 122/1,650 [7.4%]; P < 0.001). Similar results were observed when rates between phlebotomists in ED west and nonphlebotomy staff in ED nonwest were compared (62/2,012 [3.1%] versus 100/1,770 [5.6%]; P < 0.001). Comparison of median patient charges between negative and false-positive episodes ($18,752 versus $27,472) showed $8,720 in additional charges per contamination event while the median length of stay increased marginally from 4 to 5 days. By utilizing phlebotomists to collect blood cultures in the ED, contamination rates were lowered to recommended levels, with projected reductions in patient charges of approximately $4.1 million per year.

Fascioliasis in pregnancy.

BACKGROUND: Fascioliasis is a common zoonotic infection worldwide, although cases in the United States are uncommon, sporadic, and predominantly found in the immigrant population. The small number of cases identified in the United States may reflect the unfamiliarity of physicians with this infection. CASE: A 28-year-old Hispanic woman who frequently visited northern Central Mexico presented at 36 weeks of gestation with nausea, vomiting, and right upper quadrant pain. She was diagnosed with cholelithiasis. Postpartum endoscopic retrograde cholangiopancreatography and sphincterotomy were performed, with discovery of the trematode Fasciola hepatica. The patient received triclabendazole, which led to clinical improvement. CONCLUSION: Fascioliasis often mimics another common problem in pregnancy, cholelithiasis; clinicians need to be aware of this disease in high-risk populations.

Case report: ophthalmomyiasis externa in Dallas County, Texas.

Ophthalmomyiasis externa is an uncommon condition in North America. If not recognized and managed accordingly, it can be complicated by the potentially fatal condition ophthalmomyiasis interna. Ophthalmomyiasis externa is mainly caused by the sheep bot fly Oestrus ovis; thus, it is more common in farming communities. We report a case of ophthalmomyiasis externa in a young woman from Dallas County, Texas, who had no known history of contact with farm animals.

Splenic abscess with Vibrio cholerae masking pancreatic cancer.

A 77-year-old man presented to our hospital with a clinical scenario suspicious for endocarditis with septic emboli to the lungs and splenic abscess. Vibrio cholerae was isolated from purulent material aspirated from the abscess. Medical therapy and percutaneous drainage of the abscess were unsuccessful. The patient underwent splenectomy and distal pancreatectomy revealing a pancreatic tail carcinoma involving the spleen and colon. The patient later expired secondary to metastatic disease. This case represents the first isolation of V. cholerae from a splenic abscess but also illustrates that although newer imaging technologies have made the diagnosis of splenic abscess easier, the true etiology of the abscess may remain elusive.