Comparing Polymerase Chain Reaction Testing of Nasopharyngeal Swab and Lower Respiratory Tract Specimens for the Diagnosis of Pneumocystis jirovecii Pneumonia.

Using nasopharyngeal (NP) swab samples instead of lower respiratory tract specimens for polymerase chain reaction (PCR) to diagnose Pneumocystis jirovecii pneumonia (PJP) may be better tolerated and improve diagnostic accessibility. In this 2-year Australian retrospective cohort study of patients with clinically suspected PJP, P jirovecii PCR on NP swab samples had perfect specificity but low sensitivity (0.66).

Acute Q fever in third trimester pregnancy.

A 29-year-old gravida 2 para 1 woman presented at 29 weeks gestation with fevers, back pain, thrombocytopenia and hepatitis. PCR testing of blood samples detected Coxiella burnetii and paired serology later confirmed the diagnosis of acute Q fever in pregnancy. The patient was treated empirically with oral clarithromycin and experienced a symptomatic and biochemical improvement. Therapy was changed to oral trimethoprim/sulphamethoxazole but was complicated by a delayed cutaneous reaction, prompting recommencement of clarithromycin. Therapy continued until delivery of a healthy girl at 39 weeks and 3 days. Q fever in pregnancy is likely under-reported and is associated with the development of chronic infection and obstetric complications. Treatment with clarithromycin is an alternative to trimethoprim/sulphamethoxazole in the setting of drug intolerance.

Burkholderia pseudomallei sepsis with osteoarticular melioidosis of the hip in a patient with diabetes mellitus.

Melioidosis is caused by the tropical soil pathogen Burkholderia pseudomallei Infection, usually in the form of pneumonia, disproportionately affects people with a risk factor for immune dysregulation and mortality remains high even with treatment. Climate change and increasing rates of diabetes render the populations of endemic areas increasingly vulnerable to the disease, which is emerging as a serious global health threat. We present here a case of a 68-year-old man from northern Australia with sepsis and osteoarticular melioidosis of the hip, and explore the links between diabetes mellitus and melioidosis, particularly with respect to musculoskeletal infection.

Epidemiology of fungal keratitis in Queensland, Australia.

IMPORTANCE: Fungal keratitis is a rare but sight-threatening ocular infection. The epidemiology varies with geography, in particular climate and demography. BACKGROUND: We present descriptive epidemiology of fungal keratitis in Queensland, a large, geographically heterogenous Australian state. DESIGN: Descriptive ecological study. PARTICIPANTS: Queensland residents in the period 1996 to January 2016. METHODS: We searched the state-wide pathology database for positive fungal cultures from corneal scrapings, aqueous humour, vitreous humour or contact lens specimens. Data were analysed by age, sex, climate and location. Cumulative incidence rates were estimated. MAIN OUTCOME MEASURES: Episodes of fungal keratitis, from which the abovementioned positive fungal cultures were assumed to originate. RESULTS: Two hundred and twenty-one episodes of fungal keratitis in 215 Queensland residents were identified (140 males and 75 females). The median age was 48 years and the modal age range was 25-50 years. Seasonal variation was seen in tropical Queensland. Fusarium (33%) and Aspergillus (13%) were the commonest pathogens. The cumulative incidence per 100 000 population was 4.7, but was significantly higher in rural/regional (5.4) and tropical Queensland (7.9). CONCLUSIONS AND RELEVANCE: In Queensland, fungal keratitis occurs most frequently in males under 50 with increased case identification associated with the hot dry season in tropical Queensland. The sex and age distribution may reflect increased environmental exposure to fungi related to occupation. The higher cumulative incidence in tropical Queensland is in keeping with the rates observed in other tropical regions of the world. Knowledge of the epidemiology of the condition is essential in formulating empirical antifungal regimens in suspected fungal keratitis.

Ethambutol Is Cleared by a Contemporary High-Flux Hemodialyzer, and Drug Monitoring Ensures Safety and Therapeutic Effect.

It is uncertain, given the lack of recent data and the inconclusive nature of previous data, whether ethambutol is cleared by hemodialysis using contemporary dialyzers. We measured serum ethambutol concentrations before, during, and 1 h after hemodialysis in a 75-year-old Caucasian man receiving ethambutol for disseminated Bacille Calmette-Guérin infection. There was a mean 41% decrease in serum ethambutol concentration during dialysis, confirming the hemodialyzability of ethambutol and the utility of drug monitoring in ensuring safety.

Cerebral cryptococcoma mimicking glioblastoma.

Cryptococcus neoformans and C. gattii cause invasive fungal disease, with meningitis being the most common manifestation of central nervous system (CNS) disease. Encapsulated cryptococcomas occur rarely, predominantly in immunocompetent hosts, usually related to C. gattii Our patient was an immunocompetent man who presented with headache and a large cystic CNS lesion thought to be glioblastoma. Biopsy of a concomitant lung lesion confirmed cryptococcoma and empiric antifungal therapy was started for presumed CNS cryptococcoma. Antifungal therapy failed to shrink the CNS lesion, and surgical excision confirmed C. gattii CNS cryptococcoma. Following surgery he had complete resolution of symptoms. This case highlights that cryptococcoma cannot be distinguished from tumour on clinical or imaging findings. A combined medical and surgical approach is optimal for the management of large or surgically accessible cryptococcomas, as antifungal therapy alone is unlikely to penetrate large lesions sufficiently to lead to a cure.

Sepsis and siderosis, Yersinia enterocolitica and hereditary haemochromatosis.

A 60-year-old woman was admitted with sepsis, relative bradycardia, CT evidence of numerous small liver abscesses and 'skin bronzing' consistent with hereditary haemochromatosis (HH). Yersinia enterocolitica O:9 infection was confirmed by serology specimens taken 10 days apart. Iron overload was detected, and homozygous C282Y gene mutation confirmed HH. Liver biopsy revealed grade IV siderosis with micronodular cirrhosis. Haemochromatosis is a common, inherited disorder leading to iron overload that can produce end-organ damage from excess iron deposition. Haemochromatosis diagnosis allowed aggressive medical management with phlebotomy achieving normalisation of iron stores. Screening for complications of cirrhosis was started that included hepatoma surveillance. Iron overload states are known to increase patient susceptibility to infections caused by lower virulence bacteria lacking sophisticated iron metabolism pathways, for example, Yersinia enterocolitica Although these serious disseminated infections are rare, they may serve as markers for occult iron overload and should prompt haemochromatosis screening.

Purpureocillium lilacinum keratitis: a case series and review of the literature.

OBJECTIVE: To describe the clinical features and risk factors of and optimal antifungal therapy for Purpureocillium lilacinum keratitis. DESIGN: Retrospective case series in a quaternary referral hospital setting. METHODS: Comprehensive chart review of patients diagnosed with P. lilacinum keratitis in the past 10 years. PARTICIPANTS: Four patients were identified. All were aged 60 years or greater, with none having prior ocular trauma. Two had significant potential environmental exposure risks, and 3 were using systemic immunosuppressants for scleritis. RESULTS: All cases received empirical treatment that included topical corticosteroids. Three were treated with combined oral, topical, and intracameral voriconazole, but developed endophthalmitis necessitating surgery with poor outcomes, including enucleation in 2. One case received combined oral and topical voriconazole with terbinafine, and maintained visual acuity without the need for surgery. All P. lilacinum isolates were susceptible to voriconazole. CONCLUSIONS: P. lilacinum keratitis is rare, with the major risk factor being immunosuppression. There may be no history of ocular trauma. Microbiological diagnosis and antifungal susceptibility testing is essential. Combination synergistic antifungal therapy with topical voriconazole and oral terbinafine, with addition of systemic voriconazole if needed, results in the best outcome.

Flucloxacillin does not achieve therapeutic cerebrospinal fluid levels against meticillin-sensitive Staphylococcus aureus in adults: A case report and review of the literature.

It is uncertain whether flucloxacillin achieves therapeutic concentrations against meticillin-sensitive Staphylococcus aureus (MSSA) in cerebrospinal fluid (CSF). In this study, plasma and CSF concentrations of flucloxacillin and vancomycin in an adult patient were compared. Unlike vancomycin, the flucloxacillin CSF level was not therapeutic. Flucloxacillin monotherapy should be used with caution for MSSA central nervous system infection in adults.

Decompressive Laminectomy Complicated by Postoperative Mycoplasma hominis Epidural Abscess and Meningitis in a Young Woman: A Case Report.

CASE: A twenty-eight-year-old woman underwent decompressive laminectomy and placement of an interlaminar stabilizer due to L4/L5 disc herniation. Thirteen days later she developed a fever unresponsive to meropenem and vancomycin, along with signs of meningitis. A Mycoplasma hominis epidural abscess was identified. She had no preoperative risk factors for extragenital M. hominis infection, but had had a urinary catheter inserted intraoperatively. CONCLUSION: M. hominis postoperative surgical site infection is a rarely identified complication of spinal surgery. Seeding from the genitourinary tract is the most likely source.

Non-rheumatic streptococcal myocarditis - warm hands, warm heart.

Acute myopericarditis in the developed world is ascribed predominantly to viral infections. Enteroviruses and adenoviruses are commonly implicated but are not routinely tested for, as the condition is self-limiting and has a good prognosis. However, we recently encountered two cases of acute myopericarditis associated with concomitant Streptococcus pyogenes [group A Streptococcus (GAS)] pharyngotonsillitis. A microbiological aetiology was pursued because of the severity of the upper respiratory tract infection and associated systemic illness rather than to explain the myopericarditis per se. We report these two cases and review the literature of this potentially under-recognized condition. In the absence of features of rheumatic fever, we hypothesize a toxin-mediated process as opposed to an immune-mediated one. We suggest that perhaps all patients with myopericarditis be assessed for GAS pharyngitis.

Cystic echinococcosis in a fox-hound hunt worker, UK.

A male resident in Vanuatu with prior history of employment as a hunt kennel-man in England (1980-2001) was surgically treated for the removal of a hydatid cyst subsequently confirmed as Echinococcus granulosus (G1 genotype). This is the first human molecularly identified CE case reported from the UK and a first in a fox-hound handler and indicates a general neglected occupational risk.

Chronic urticaria following acute hepatitis A.

Urticaria has a documented association with the prodromal phases of hepatitis A, B and, although still contentious, likely hepatitis C. Despite the documented association there are few actual reported cases of urticaria occurring with hepatitis A infection and in all of the cases reported so far the urticaria preceded the diagnosis of hepatitis A and was acute rather than chronic. We describe a case of urticaria occurring following acute infection with hepatitis A, which persisted beyond 6 weeks and therefore was by definition chronic. Although chronic urticaria has been reported to be associated with other forms of viral hepatitis, to the best of our knowledge this has not been reported previously with hepatitis A.

Histoplasmosis in Australia: report of 16 cases and literature review.

We describe 16 previously unreported patients with histoplasmosis from Queensland and northern New South Wales, Australia, and review all previous Australian reports, providing 63 cases in total to study (17 cases of acute pulmonary histoplasmosis, 2 cases of chronic pulmonary disease, and 44 cases of systemic disease, including 17 cases of single-organ infection and 27 instances of disseminated disease). All acute pulmonary disease was acquired in Australia, with 52% of systemic disease definitely autochthonous. Most cases of single-organ disease occurred in immunocompetent patients (76%), and were oropharyngeal (53%) in location. Forty-one percent of disseminated disease occurred in patients with human immunodeficiency virus (HIV). Patients with HIV had high rates of systemic symptoms, pancytopenia, fungemia, and hepatosplenomegaly. Oropharyngeal and adrenal involvement as well as systemic symptoms were prominent in immunocompetent patients with disseminated disease, with 6 of 7 cases of adrenal involvement leading to Addison disease. Most systemic disease was diagnosed by culture of Histoplasma capsulatum. Where serology was assessed in cases other than acute pulmonary disease, it was positive in only 32%.Prognosis for patients with single-organ disease was excellent. Disseminated disease was associated with recurrence in 30% and death in 37%. The results of this study confirm several previously known patterns of disease but also provide new insights into this rare but endemic condition in Australia.

Fungal infections of the central nervous system: A review of fungal pathogens and treatment.

Multiple factors influence the outcome of fungal infection of the central nervous system (CNS). The host and the pathogen in concert with drug delivery across the blood-brain barrier and drug activity are key factors in outcome. Drug costs can be prohibitively expensive. Drug toxicity with standard antifungal agents such as amphotericin B (infusion rate toxicity) can be reduced using simple techniques such as slower infusion and appropriate saline loading. Continuous infusion can allow relatively large doses of amphotericin B (up to 2 mg/kg/day, remaining below 0.08 mg/kg/hour) to be given with toxicity profiles comparable to expensive lipid formulations of amphotericin B. Dedicated peripherally inserted central catheters can remain in situ for weeks to months and are safe and relatively inexpensive. Correction of metabolic pathology in the case of mucormycosis and resolution of neutropenia are essential to effective treatment of filamentous fungal infections such as Mucor, Aspergillus and Scedosporium. The pharmacology and pharmacokinetics of the current major antifungal agents used to treat fungal infections of the CNS are reviewed. Tables that provide information about achievable CNS drug levels, antifungal susceptibilities and the likelihood of intrinsic drug resistance of significant fungal pathogens have been included to help the clinician with therapy. Treatment recommendations for Cryptococcal and Candida meningitis and for rhinocerebral infection with Mucor and Aspergillus have been included.

Epidemic syphilis exhibits diverse manifestations.

There are recent reports of a sustained increase in the incidence of syphilis around the world, including in the Australian cities of Sydney and Melbourne.