Polymicrobial anaerobic infection with a deep abscess in the supraspinous fossa following a subacromial corticosteroid injection.

In September 2015, a male aged 61 years with poorly controlled diabetes (his only medical problem) had left shoulder surgery that included an arthroscopic acromioplasty with debridement of suture material from a rotator cuff repair done 10 years prior. A subacromial corticosteroid injection was given 7 months later for pain and reduced motion. Three weeks later a fulminate infection was evident. Cultures grew Propionibacterium acnes Treatment included two arthroscopic debridement surgeries and 8 weeks of intravenous antibiotics (primarily daptomycin). Eight weeks after the cessation of the antibiotics, purulence recurred and tissue cultures then grew Staphylococcus epidermidis Several additional surgeries were needed to control the infection. We failed to recognise that an abscess that extended from the subacromial space across the entire supraspinous fossa. We report this case to alert clinicians that a seemingly innocuous subacromial corticosteroid injection can lead to an atypical infection and also extend into the supraspinous fossa.

Upper Extremity Compartment Syndrome in a Patient with Acute Gout Attack but without Trauma or Other Typical Causes.

We report the case of a 30-year-old Polynesian male with a severe gout flare of multiple joints and simultaneous acute compartment syndrome (ACS) of his right forearm and hand without trauma or other typical causes. He had a long history of gout flares, but none were known to be associated with compartment syndrome. He also had concurrent infections in his right elbow joint and olecranon bursa. A few days prior to this episode of ACS, high pain and swelling occurred in his right upper extremity after a minimal workout with light weights. A similar episode occurred seven months prior and was attributed to a gout flare. Unlike past flares that resolved with colchicine and/or anti-inflammatory medications, his current upper extremity pain/swelling worsened and became severe. Hand and forearm fasciotomies were performed. Workup included general medicine, rheumatology and infectious disease consultations, myriad blood tests, and imaging studies including Doppler ultrasound and CT angiography. Additional clinical history suggested that he had previously unrecognized recurrent exertional compartment syndrome that led to the episode of ACS reported here. Chronic exertional compartment syndrome (CECS) presents a difficult diagnosis when presented with multiple symptoms concurrently. This case provides an example of one such diagnosis.

Transmission of Balamuthia mandrillaris by Organ Transplantation.

BACKGROUND: During 2009 and 2010, 2 clusters of organ transplant-transmitted Balamuthia mandrillaris, a free-living ameba, were detected by recognition of severe unexpected illness in multiple recipients from the same donor. METHODS: We investigated all recipients and the 2 donors through interview, medical record review, and testing of available specimens retrospectively. Surviving recipients were tested and treated prospectively. RESULTS: In the 2009 cluster of illness, 2 kidney recipients were infected and 1 died. The donor had Balamuthia encephalitis confirmed on autopsy. In the 2010 cluster, the liver and kidney-pancreas recipients developed Balamuthia encephalitis and died. The donor had a clinical syndrome consistent with Balamuthia infection and serologic evidence of infection. In both clusters, the 2 asymptomatic recipients were treated expectantly and survived; 1 asymptomatic recipient in each cluster had serologic evidence of exposure that decreased over time. Both donors had been presumptively diagnosed with other neurologic diseases prior to organ procurement. CONCLUSIONS: Balamuthia can be transmitted through organ transplantation with an observed incubation time of 17-24 days. Clinicians should be aware of Balamuthia as a cause of encephalitis with high rate of fatality, and should notify public health departments and evaluate transplant recipients from donors with signs of possible encephalitis to facilitate early diagnosis and targeted treatment. Organ procurement organizations and transplant centers should be aware of the potential for Balamuthia infection in donors with possible encephalitis and also assess donors carefully for signs of neurologic infection that may have been misdiagnosed as stroke or as noninfectious forms of encephalitis.

Candida glabrata olecranon bursitis treated with bursectomy and intravenous caspofungin.

Orthopedic surgeons are becoming more involved in the care of patients with septic arthritis and bursitis caused by yeast species. This case report involves a middle-aged immunocompromised female who developed a Candida glabrata septic olecranon bursitis that developed after she received a corticosteroid injection in the olecranon bursa for presumed aseptic bursitis. Candida (Torulopsis) glabrata is the second most frequently isolated Candida species from the bloodstream in the United States. Increased use of fluconazole and other azole antifungal agents as a prophylactic treatment for recurrent Candida albicans infections in immunocompromised individuals is one reason why there appears to be increased resistance of C. glabrata and other nonalbicans Candida (NAC) species to fluconazole. In this patient, this infection was treated with surgery (bursectomy) and intravenous caspofungin, an echinocandin. This rare infectious etiology coupled with this intravenous antifungal treatment makes this case novel among cases of olecranon bursitis caused by yeasts.

The medical management of central nervous system infections in Uganda and the potential impact of an algorithm-based approach to improve outcomes.

BACKGROUND: In sub-Saharan Africa, HIV has increased the spectrum of central nervous system (CNS) infections. The etiological diagnosis is often difficult. Mortality from CNS infections is higher in sub-Saharan Africa compared to Western countries. This study examines the medical management of CNS infections in Uganda. We also propose a clinical algorithm to manage CNS infections in an effective, systematic, and resource-efficient manner. METHODS: We prospectively followed 100 consecutive adult patients who were admitted to Mulago Hospital with a suspected diagnosis of a CNS infection without any active participation in their management. From the clinical and outcome data, we created an algorithm to manage CNS infections, which was appropriate for this resource-limited, high HIV prevalence setting. RESULTS: Only 32 patients had a laboratory confirmed diagnosis and 23 of these were diagnosed with cryptococcal meningitis. Overall mortality was 39%, and mortality trended upward when the diagnosis was delayed past 3 days. The initial diagnoses were made clinically without significant laboratory data in 92 of the 100 patients. Because HIV positive patients have a unique spectrum of CNS infections, we created an algorithm that identified HIV-positive patients and diagnosed those with cryptococcal meningitis. After cryptococcal infection was ruled out, previously published algorithms were used to assist in the early diagnosis and treatment of bacterial meningitis, tuberculous meningitis, and other common central nervous system infections. In retrospective comparison with current management, the CNS algorithm reduced overall time to diagnosis and initiate treatment of cryptococcal meningitis from 3.5 days to less than 1 day. CONCLUSIONS: CNS infections are complex and difficult to diagnose and treat in Uganda, and are associated with high in-hospital mortality. A clinical algorithm may significantly decrease the time to diagnose and treat CNS infections in a resource-limited setting.

Invasive fungal sinusitis caused by Scytalidium dimidiatum in a lung transplant recipient.

We describe a case of invasive fungal sinusitis caused by Scytalidium dimidiatum in a lung transplant recipient. Treatment was complicated by renal failure with amphotericin B therapies. Following 6 months of voriconazole treatment, the patient remained radiographically and clinically stable for a short time before dying of respiratory failure precipitated by graft rejection.

Schistosomiasis in expatriates in the Arusha region of Tanzania.

BACKGROUND: In 1996 the seroprevalence of schistosomiasis in expatriates and travelers who had contact with Lake Malawi, a fresh water source thought to be schistosomiasis-free, was measured at 32%. Clinicians in Arusha, Tanzania, questioned the prevalence of Schistosoma infection in expatriates living in the Arusha region, and how schistosomiasis might relate to symptoms of chronic fatigue in Arusha expatriates. METHOD: We performed a cross-sectional survey of 80 expatriates living in the Arusha region of Tanzania to determine the seroprevalence of schistosome infection. Whole blood was analyzed by the Falcon assay screening test-enzyme-linked immunosorbent assay (FAST-ELISA) for the presence of species-specific Schistosoma mansoni and Schistosoma haematobium antibodies to microsomal antigens of adult Schistosoma worms, followed by confirmatory enzyme-linked immunoelectrotransfer blot (Western blot). Volunteers answered a questionnaire which included length of residence in Arusha, risk factors, symptoms, and previous diagnosis of schistosomiasis. RESULTS: Of the 80 expatriates sampled, 8 (10%) were positive for schistosomiasis (6 to S. mansoni only, 1 to S. haematobium, 1 to both species). Significant risk factors, elicited by questionnaire, included longer residence in the Arusha region (p =.020), history of fatigue (p =.010) and myalgias (p =.047), and previous diagnosis of schistosomiasis by stool or urine ova (p =.0007). CONCLUSION: The lower seroprevalence of schistosomiasis in Arusha expatriates, compared with expatriates and travelers to Lake Malawi, suggests a regional variation of rate of schistosomiasis infection. Although a history of fatigue and myalgias was related to seropositivity, there is no strong evidence that schistosomiasis infection is the cause of chronic fatigue in Arusha expatriates.