Clostridium perfringens Empyema: Anaerobic Invasion in an Uncommon Location.

Clostridium perfringens bacteremia arises due to skin inoculation from the external environment or translocation from the gastrointestinal tract. In the event of bacteremia, it tends to colonize in anaerobic environments due to its obligatory anaerobic nature. Its inoculation in the lung, albeit rare, can occur if an anaerobic nidus is created. In the presented case, the patient developed C. perfringens bacteremia andempyema in the area of lung necrosis caused by acute pulmonary embolism. He did not have any history of chest trauma, and the source of bacteremia was deemed to be via gut translocation. The patient was noted to have multiple gastric ulcers on endoscopy and jejunal wall thickening, which likely led to the bacterial translocation into the bloodstream. He underwent video-assisted thoracoscopic surgery-assisted decortication and intravenous antibiotics, eventually leading to clinical improvement. To identify the source of Clostridium in the absence of penetrating trauma, a thorough gastrointestinal evaluation, including a colonoscopy, is warranted to identify the pathology leading to the gastrointestinal translocation.

Sporadic Creutzfeldt-Jakob Disease With COVID-19 Infection: A Case Report.

Creutzfeldt-Jakob disease (CJD) is a rare and rapidly fatal neurological disease. Diagnosis is made through clinical features, imaging, electroencephalography, and cerebrospinal fluid analysis. Sporadic CJD accounts for the majority of cases and occurs due to somatic mutation in the gene or random structural change in the prion protein. Coronavirus disease 2019 (COVID-19) is known to cause neurodegeneration, and CJD acceleration is hypothesized due to systemic inflammatory response and prion misfolding. We present a 70-year-old lady with rapidly progressing dementia diagnosed as CJD, with the onset coinciding with COVID-19 infection.

Gradenigo's Syndrome and Vernet Syndrome as Presenting Signs of Nasopharyngeal Carcinoma.

Both Gradenigo's syndrome and Vernet syndrome are rare pathologies of the intracranial space; both involve compression of a particular anatomic location in the skull, thus affecting structures nearby or within that space. A patient presenting with one or both of these syndromes should raise concern for malignancy, head trauma, or an intracranial infection. We present a case of a 39-year-old female with three weeks of left-sided ear, face, and neck pain along with difficulty swallowing and reduced vision in the left eye. Magnetic resonance imaging of the brain revealed fullness in the left nasopharyngeal region, raising concern for malignancy or infection. Biopsy of the mass ultimately revealed Epstein-Barr virus positive nasopharyngeal carcinoma, nonkeratinizing undifferentiated type, along with culture data revealing methicillin-resistant Staphylococcus aureus positive left otomastoiditis. She received chemoradiation therapy along with six weeks of antibiotic therapy. A patient presenting with symptoms reflective of a sinus infection unrelieved by antibiotics with concomitant cranial nerve deficits should raise clinical concern for an intracranial pathology rather than a simple case of sinusitis.

Pancreatitis, panniculitis and polyarthralgia syndrome: A rare complication of pancreatic pathology.

Pancreatitis, panniculitis, and polyarthralgia (PPP) syndrome is a rare complication of chronic pancreatitis and occurs due to leakage of pancreatic enzymes in the systemic vasculature. This enzyme leakage leads to multiple manifestations such as polyarthralgia, panniculitis, and bone necrosis due to tissue autodigestion.The inciting pancreatic pathology may be masked, and the presentation may be due to one of the systemic consequences of enzyme leakage, which can present as a diagnostic challenge for clinicians. Here we present a patient who presented with nodular lesions and bone necrosis, and was found to have PPP syndrome. Therefore, a proper understanding of pathophysiology and radiology findings can help with prompt diagnosis and early exploration of management options.

Drug-Induced Hidradenitis Suppurativa: A Case Report.

Hidradenitis suppurativa (HS) is a chronic, debilitating inflammatory disorder of the hair follicles that localizes to the intertriginous and anogenital regions of the body. Lesions are characterized by inflammatory nodules, subcutaneous abscesses, fibrosis, and sinus tracts. Crohn's disease (CD) is an idiopathic chronic inflammatory bowel disease that affects any part of the gastrointestinal tract. Multiple treatment options exist for CD, including monoclonal anti-tumor necrosis factor alpha (TNF-α) antibodies like adalimumab (Humira). Adalimumab is an anti-TNF agent that has been approved by the United States Food and Drug Administration (FDA) for the treatment of HS. A 35-year-old African American male with a history of fistulizing CD presented to the hospital for evaluation of severe pain and purulent drainage from open sores in his bilateral axillary regions, groin, buttocks, and face for four days. He was on adalimumab for two years, during which time he noted the development of Hurley stage III HS. The physical exam was remarkable for a cachectic, painful-appearing male, with multiple abscesses on his lower jaw extending to his upper neck draining thick serosanguinous fluid, with similar findings in his bilateral axillary regions, bilateral groin, and perianal regions. He was treated with intravenous antibiotics consisting of a fourth-generation cephalosporin and vancomycin. While the etiology of HS in this patient is inconclusive, the timing of its development closely aligns with the initiation of Humira and is not a manifestation of CD. Paradoxical adverse effects describe a phenomenon in which a medication can induce a condition that it classically can be used to treat. In this patient's case, it was HS.

Herpes Simplex Virus Causing Necrotizing Granulomatous Lymphadenitis.

Localized necrotizing granulomatous lymphadenitis (GLA) is a very rare presentation of herpes simplex virus (HSV) infection. We are reporting a case that required multidisciplinary expertise to confirm the diagnosis and effectively treat the patient. Our patient had a recent diagnosis of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and presented with hematuria and palpable inguinal lymph nodes. Affirmative diagnosis required a core biopsy of the lymph node with immunochemistry staining and polymerase chain reaction (PCR) testing. This case reviews the unusual presentation of an HSV infection and emphasizes the importance of maintaining a high index of suspicion for infection when treating an immunocompromised patient with persistent symptoms.

A Retrospective Review of the Natural Progression of Cardiac Vegetation.

INTRODUCTION: Infective endocarditis (IE) is a life-threatening condition with an annual mortality of up to 40%. Vegetations are the hallmark of IE, however, factors that affect the initial size and changes in size remain unclear. Our study aims to investigate the natural history of cardiac vegetation, including changes in size and/or resolution with adequate treatment, and to analyze factors that influence size and potential for persistence. MATERIAL AND METHODS: We conducted a retrospective review of 102 patients admitted with native-valve endocarditis at Henry Ford Health System from September 1, 2017, to June 30, 2019. We included patients treated with six weeks of intravenous antibiotics who had both a diagnostic and a follow-up echocardiogram after antibiotic completion. The primary outcome was the change in vegetation size. Secondary measures included pathogen identification, valve involvement, number of complications, associated IV drug use, and co-infection with hepatitis B/C. RESULTS: Of the 102 patients reviewed, 30 patients matched the inclusion criteria. There was a significant decrease in vegetation size after adequate antibiotic treatment. However, complete resolution was not often seen. A statistically significant relationship was seen between vegetation size, IV drug use, and Staphylococcal species (including both methicillin-susceptible Staphylococcus aureus [MSSA] and methicillin-resistant S. aureus [MRSA]), whereas a history of hepatitis B or C was not significantly related to vegetation size. CONCLUSION: Large vegetation may predict a higher risk of embolic complications and can be reduced with IV antibiotics, although complete resolution is not likely. IV drug use and Staphylococcal endocarditis influence vegetation size and embolic complications. We argue that these subgroups should be prioritized for early surgical intervention.

Thinking Beyond Bacterial Infection: A Case of Cutaneous Blastomycosis.

Blastomycosis is caused by Blastomyces dermatitidis, a dimorphic fungus that primarily causes pulmonary disease. Cutaneous blastomycosis is infrequent and tends to be misdiagnosed given its similar presentation to other cutaneous fungal infections and malignancies. A 51-year-old woman presented with a two-month history of disfiguring nasal lesions. The patient had a past medical history of cervical cancer which was currently in remission. Social history was significant for frequent travel throughout the United States as a truck driver, including the Midwest. The patient had a non-purulent verrucous plaque on her right nare, which was painless and mildly pruritic. Superficial cultures grew Enterococcus faecalis, prompting treatment with oral cephalexin and topical mupirocin. Given no relief, the patient was started on clindamycin followed by Augmentin. Both treatments were unsuccessful.  The lesion was then biopsied and fungal cultures were sent. The biopsy showed broad-based budding yeast surrounded by pseudoepitheliomatous hyperplasia, and cultures grew Blastomyces dermatitidis. The patient was initiated on 200 mg itraconazole thrice daily for the first three days, followed by 200 mg itraconazole twice daily for the next 12 months. She showed notable improvement within a month. This patient was initially misdiagnosed with bacterial infection due to superficial cultures, which were likely a contaminant. It was only after a biopsy that the patient was accurately diagnosed. Besides bacterial infection, cutaneous blastomycosis is often confused with coccidioidomycosis, mycobacterial infection, or squamous cell carcinoma. In patients such as ours who are presenting with persistent facial lesions in the setting of frequent travel history, fungal etiologies should be high on the differential. A biopsy and fungal cultures should be sent at the outset for accurate diagnosis and treatment.

The role of tocilizumab therapy in critically ill patients with severe acute respiratory syndrome coronavirus 2.

CONTEXT: Tocilizumab (TCZ), an interleukin-6 (IL-6) receptor antagonist, has been approved for use in rheumatoid arthritis and cytokine storm syndrome (CSS) associated with chimeric antigen receptor T cells treatment. Although TCZ is currently utilized in the treatment of critically ill coronavirus 2019 (COVID-19) patients, data on survival impact is minimal. OBJECTIVES: To assess the mortality rate of patients presenting with COVID-19 who received TCZ for suspected CSS. METHODS: This retrospective cohort study was conducted at Henry Ford Health System between March 10, 2020 and May 18, 2020. Data collection began in May 2020 and was completed in June 2020. Patients included in the study required hospital admission and had positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction on nasopharyngeal swab. Eligibility criteria to receive TCZ, per hospital protocol, included any of the following: persistent fever, defined as 38.0 °C for at least 6 hours; a diagnosis of the acute respiratory distress syndrome (ARDS); serum ferritin ≥1,000 (ng/mL) or doubling within 24 hours; D-Dimer ≥ 5 (mg/L); serum lactate dehydrogenase ≥500 (IU/L); or interlukin-6 level ≥5 times the upper limit of normal. Dosing was initially determined by weight, then changed to a fixed 400 mg per hospital protocol. A comparator cohort was created from patients with COVID-19 and ARDS who did not receive TCZ. Patient survival was analyzed using the Kaplan-Meier method and compared by log rank test. A multivariable cox regression was applied to evaluate the association between TCZ and mortality. RESULTS: One hundred and thirty patients were evaluated in the study, 54 (41.5%) of whom received TCZ. Patients who received TCZ were younger (mean age, 63.8 vs. 69.4 years; p=0.0083) and had higher body mass indices (mean, 33.9 vs. 30.4; p=0.005). Of the comorbid conditions evaluated, heart disease was more common in the comparator group than the TCZ group (27 patients [35.5%] vs. 10 patients [18.5%]; p=0.034). A Kaplan-Meier survival curve demonstrated no difference in survival between TCZ and comparator patients (log rank p=0.495). In the multivariable Cox regression model for mortality at 30 days, treatment with TCZ was not associated with decreased mortality (hazard ratio, 1.1; 95% confidence interval, 0.53-2.3; p=0.77). Lower mean C-reactive protein (CRP) levels were demonstrated within 48 hours of disposition in the TCZ group (mean TCZ, 4.9 vs. mean comparator, 13.0; p=<0.0001). CONCLUSIONS: In this cohort study, no difference in survival was observed in critically ill patients treated with TCZ.

Characteristics and comparative clinical outcomes of prisoner versus non-prisoner populations hospitalized with COVID-19.

Prisons in the United States have become a hotbed for spreading COVID-19 among incarcerated individuals. COVID-19 cases among prisoners are on the rise, with more than 143,000 confirmed cases to date. However, there is paucity of data addressing clinical outcomes and mortality in prisoners hospitalized with COVID-19. An observational study of all patients hospitalized with COVID-19 between March 10 and May 10, 2020 at two Henry Ford Health System hospitals in Michigan. Clinical outcomes were compared amongst hospitalized prisoners and non-prisoner patients. The primary outcomes were intubation rates, in-hospital mortality, and 30-day mortality. Multivariable logistic regression and Cox-regression models were used to investigate primary outcomes. Of the 706 hospitalized COVID-19 patients (mean age 66.7 ± 16.1 years, 57% males, and 44% black), 108 were prisoners and 598 were non-prisoners. Compared to non-prisoners, prisoners were more likely to present with fever, tachypnea, hypoxemia, and markedly elevated inflammatory markers. Prisoners were more commonly admitted to the intensive care unit (ICU) (26.9% vs. 18.7%), required vasopressors (24.1% vs. 9.9%), and intubated (25.0% vs. 15.2%). Prisoners had higher unadjusted inpatient mortality (29.6% vs. 20.1%) and 30-day mortality (34.3% vs. 24.6%). In the adjusted models, prisoner status was associated with higher in-hospital death (odds ratio, 2.32; 95% confidence interval (CI), 1.33 to 4.05) and 30-day mortality (hazard ratio, 2.00; 95% CI, 1.33 to 3.00). In this cohort of hospitalized COVID-19 patients, prisoner status was associated with more severe clinical presentation, higher rates of ICU admissions, vasopressors requirement, intubation, in-hospital mortality, and 30-day mortality.

A Rare Case of the Newly Recognized Kaposi Sarcoma Herpesvirus-Associated Disease.

Kaposi sarcoma herpesvirus (KSHV) is associated with Kaposi sarcoma (KS), primary effusion lymphoma, and multicentric Castleman disease (KSHV-MCD) in patients infected with human immunodeficiency virus (HIV). We present a case consistent with a newly recognized KSHV inflammatory cytokine syndrome (KICS), distinct from KSHV-MCD. Although both disorders exhibit signs of substantial inflammation, KICS has minimal lymphadenopathy/splenomegaly and negative pathologic nodal changes in the setting of low CD4 count. KICS is easily misdiagnosed as severe sepsis or other KS-related diseases in HIV/AIDS patients and carries a high mortality. ​Standard therapy is still under investigation due to its rarity, whereas the treatment regimen for KSHV-MCD may lead to clinical remission. Early recognition and prompt management are crucial to improve the survival of the under-recognized KICS.

Cutaneous Fusariosis in a Patient with Job's (Hyper-IgE) Syndrome.

Fusarium is a filamentous fungus that is ubiquitous in nature and can cause severe opportunistic infections in immunocompromised hosts. The association between Fusarium and hyper-IgE syndrome is exceedingly rare and has only been documented in a single report previously. A 44-year-old male, working as marijuana grower, with prior diagnosis of hyper-IgE syndrome and recurrent infections presented with enlarging right knee ulcer that did not respond to antimicrobial treatment. The patient was diagnosed with cutaneous fusariosis, confirmed with punch biopsy and positive wound cultures. The patient was managed with extended antifungal therapy (i.e., posaconazole) and surgical debridement resulting in remarkable improvement with wound healing leaving a pale scar. Fusarium should be considered in differential for cutaneous and invasive fungal infections in presence of cutaneous manifestations. Exposure to Cannabis plants is a noticeable risk factor. Multimodal approach involving systemic antifungals and wound debridement is essential for favorable outcome. Posaconazole was demonstrated to be a highly efficacious antifungal choice.

Pulmonary oxalosis in pulmonary aspergillosis syndrome.

The presence of pulmonary oxalosis in bronchoalveolar lavage (BAL) or biopsied tissue samples is considered pathognomonic for Aspergillus disease etiology. The finding of calcium oxalate crystals in the tissue samples infected with aspergillosis can serve as a vital diagnostic clue. Detection of calcium oxalate crystals is achievable within 24 hours by most hospital microbiology laboratories. It is much quicker than the time it takes to receive results of other tests like histopathology, sputum cultures, and aspergillus antigen assays. We present this case to emphasize the importance of pulmonary oxalosis as a crucial early diagnostic factor in pulmonary aspergillosis syndromes.

Native valve endocarditis caused by E rysipelothrix Rh usiopathiae: presenting with refractory heart failure and requiring surgical valve replacement-report on a rare zoonosis.

Erysipelothrix Rhusiopathiae is a Gram-positive bacillus that is ubiquitous in nature. The bacterium is a zoonotic pathogen known to infect wild and domestic animals. Human infections, however, are uncommon and typically present with localised or generalised cutaneous lesions. Systemic infection in the form of bacteraemia with seeding to various organs is the least common form of the disease. Infections in humans tend to be associated with occupational exposure and close contact with animals. Clinical data of a 61-year-old male patient with Gram-positive bacilli bacteraemia and E. Rh usiopathiae-induced endocarditis are presented here. The patient presented with refractory congestive heart failure secondary to severe acute aortic regurgitation mandating surgical valve replacement. The described case has special clinical merit given the lack of fever and leukocytosis, absence of erysipeloid cutaneous manifestations and refractoriness to medical management. E. Rhusiopathiae should be considered in the differential diagnosis for Gram-positive bacilli bacteraemia and endocarditis. In the proper clinical setting, occupational exposure and animal contacts are helpful clues to raise suspicion for this bacillus. The high mortality associated with the pathogen should urge for early identification and initiation of antimicrobial treatment.

Complex encephalopathy arising from the combination of opioids and gabapentin.

The interactions between opioids and gabapentin are more clinically relevant than ever. Prescriptions dispensed for gabapentin increased from 39 million in 2012 to 64 million in 2018 in the USA and are ever increasing. Authors present a challenging case of these interactions. A 58-year-old man presented to the emergency department with acute respiratory failure and altered mental status. He was on high dose opioids and gabapentin as prescription medications. Despite full intensive care support and resolution of his respiratory failure with non-invasive positive pressure ventilation, the patient did not regain consciousness. After ruling out other causes, the diagnosis of gabapentin withdrawal was considered. Gabapentin was administered by a nasogastric tube that quickly resulted in a reversal of his symptoms. We concluded that severe gabapentin withdrawal should be considered in patients on higher doses of gabapentin when it is stopped abruptly. In such patients, gabapentin should be replaced. As most patients are unable to swallow in this situation and intravenous formulation is not available, nasogastric tube can be used for replacement.

Complex encephalopathy arising from the combination of opioids and gabapentin.

The interactions between opioids and gabapentin are more clinically relevant than ever. Prescriptions dispensed for gabapentin increased from 39 million in 2012 to 64 million in 2018 in the USA and are ever increasing. Authors present a challenging case of these interactions. A 58-year-old man presented to the emergency department with acute respiratory failure and altered mental status. He was on high dose opioids and gabapentin as prescription medications. Despite full intensive care support and resolution of his respiratory failure with non-invasive positive pressure ventilation, the patient did not regained consciousness. After ruling out other causes, the diagnosis of gabapentin withdrawal was considered. Gabapentin was administered by a nasogastric tube that quickly resulted in a reversal of his symptoms. We concluded that severe gabapentin withdrawal should be considered in patients on higher doses of gabapentin when it is stopped abruptly. In such patients, gabapentin should be replaced. As most patients are unable to swallow in this situation and intravenous formulation is not available, nasogastric tube can be used for replacement.

Artificial Differences in Clostridium difficile Infection Rates Associated with Disparity in Testing.

In 2015, Clostridium difficile testing rates among 30 US community, multispecialty, and cancer hospitals were 14.0, 16.3, and 33.9/1,000 patient-days, respectively. Pooled hospital onset rates were 0.56, 0.84, and 1.57/1,000 patient-days, respectively. Higher testing rates may artificially inflate reported rates of C. difficile infection. C. difficile surveillance should consider testing frequency.

Rare Case of Olmesartan Induced Enteropathy.

Olmesartan (brand name Benicar) is an antihypertensive drug clinicians commonly use to treat high blood pressure. Olmesartan induced enteropathy (OSE) is a rare entity that authors first identified in 2012. The etiological basis of OSE remains unclear, although authors have suggested that this condition could be due to alternations in cell mediated immune responses induced by the drug. The objective of the case report is to describe a patient who presented with diarrhea and was eventually diagnosed with OSE. A female patient in her later 60s presented to an emergency room after two recent hospitalizations with profound diarrhea, generalized weakness and weight loss. She underwent a diagnostic workup including endoscopy and colonoscopy. The patient's endoscopy with duodenal biopsy revealed villous atrophy with attenuated and blunted villi with intraepithelial CD3 positive T lymphocytes, suggestive of gluten-induced enteropathy. When the patient's symptoms did not improve after the authors placed her on a gluten free diet for a few days, they further investigated her for secretory diarrhea, including Gastrin, Somatostatin and Vasoactive Intestinal Peptide lab values that they found to be within normal limits. Due to the patient's lack of improvement with initial treatment, the authors suspected OSE and stopped her olmesartan and the patients' symptoms gradually improved in three weeks.

Infections on Cruise Ships.

The modern cruise ship is a small city on the seas, with populations as large as 5,000 seen on large ships. The growth of the cruise ship industry has continued in the twenty-first century, and it was estimated that nearly 21.3 million passengers traveled on cruise ships in 2013, with the majority of these sailing from North America. The presence of large numbers of individuals in close proximity to each other facilitates transmission of infectious diseases, often through person-to-person spread or via contaminated food or water. An infectious agent introduced into the environment of a cruise ship has the potential to be distributed widely across the ship and to cause significant morbidity. The median cruise ship passenger is over 45 years old and often has chronic medical problems, so it is important that, to have a safe cruise ship experience, any potential for the introduction of an infecting agent as well as its transmission be minimized. The majority of cruise ship infections involve respiratory and gastrointestinal infections. This article discusses infectious outbreaks on cruise ships and suggests preventative measures for passengers who plan to travel on cruise ships.