A Case of Lassa Fever Diagnosed at a Community Hospital-Minnesota 2014.

BACKGROUND: In April 2014, a 46-year-old returning traveler from Liberia was transported by emergency medical services to a community hospital in Minnesota with fever and altered mental status. Twenty-four hours later, he developed gingival bleeding. Blood samples tested positive for Lassa fever RNA by reverse transcriptase polymerase chain reaction. METHODS: Blood and urine samples were obtained from the patient and tested for evidence of Lassa fever virus infection. Hospital infection control personnel and health department personnel reviewed infection control practices with health care personnel. In addition to standard precautions, infection control measures were upgraded to include contact, droplet, and airborne precautions. State and federal public health officials conducted contract tracing activities among family contacts, health care personnel, and fellow airline travelers. RESULTS: The patient was discharged from the hospital after 14 days. However, his recovery was complicated by the development of near complete bilateral sensorineural hearing loss. Lassa virus RNA continued to be detected in his urine for several weeks after hospital discharge. State and federal public health authorities identified and monitored individuals who had contact with the patient while he was ill. No secondary cases of Lassa fever were identified among 75 contacts. CONCLUSIONS: Given the nonspecific presentation of viral hemorrhagic fevers, isolation of ill travelers and consistent implementation of basic infection control measures are key to preventing secondary transmission. When consistently applied, these measures can prevent secondary transmission even if travel history information is not obtained, not immediately available, or the diagnosis of a viral hemorrhagic fever is delayed.

Development and validation of a Clostridium difficile risk assessment tool.

The incidence of Clostridium difficile infection has increased rapidly during the past decade, increasing lengths of stays in the hospital, costs, and mortality rates. To address this increased incidence, we performed a retrospective case-control study using known risk factors to develop a tool to determine which patients are at risk for infection. Multivariate analysis generated a combination of risk factors associated with development of infection including prior admission, endoscopy within 30 days, cephalosporin/fluoroquinolone use, length of stay 7 days or longer, age 65 years or older, body mass index less than 25, and albumin level less than 2.7 g/dL. A weighted scoring tool was created that predicted disease with a sensitivity of 86% and a specificity of 44% in the derivation sample, and 92% sensitivity and a specificity of 39% when applied to the validation sample. Application of this 8-item tool by nurses in multiple settings could aid in the determination of patients who are at risk, allowing prophylactic treatment, prompt isolation of patients, restricted antibiotic use, and decreased testing of low-risk patients.

Histoplasmomas of uncommon size.

Histoplasma capsulatum infection demonstrates a broad spectrum of acute and chronic clinical manifestations. Unlike the acute reaction to proliferating organisms, the chronic complications are often the result of excessive or prolonged host response with a paucity of organisms. Lung nodules (histoplasmomas) may be noted decades after initial infection and present a challenging clinical problem, as they can be difficult to distinguish from malignancy or tuberculomas. Typically, histoplasmomas are small (<1 cm), asymptomatic, and may be stable in size or slowly enlarge over time. Here we report three patients with unusually large, or giant, histoplasmomas (>3 cm) and describe their extreme phenotype. Importantly, two of the patients presented with subacute symptomatic disease, a presentation that is very atypical for histoplasmoma. The term "buckshot" calcification has been used to describe dozens of small (2-4 mm) calcified nodules, so it may be appropriate to label masses that exceed 3 cm as "cannonball" histoplasmoma.

Milkers' nodules complicated by erythema multiforme and graft-versus-host disease after allogeneic hematopoietic stem cell transplantation for multiple myeloma.

We describe a case of cow-transmitted parapoxvirus infection--also known as milkers' nodules--after a hematopoietic stem cell transplantation for multiple myeloma. The infection was complicated by erythema multiforme and acute exacerbation of graft-versus-host disease. Parapoxvirus was confirmed by electron microscopy. The natural history of milker's nodules in immunocompetent hosts is described and compared to that in our immunocompromised patient.