Disseminated Enteric Salmonella Infection Associated With Empyema and Septic Arthritis in an Immunocompromised Patient.

Thoracic empyema is a collection of infectious material (pus) in the pleural cavity. Salmonella enterica species rarely cause pleuropulmonary infections. This condition poses a significant challenge in diagnosis and management due to its atypical presentation and potential for severe complications. This is a case of an immunocompromised host with glioblastoma who presented with a large loculated fluid collection in the left pleural space. The patient received broad-spectrum antibiotics and underwent urgent chest tube placement and drainage of pus, which grew Salmonella enterica subspecies enterica. He was also found to be bacteremic with the same organism. Subsequently, he underwent video-assisted thoracoscopic surgery (VATS) with decortication and evacuation of the empyema. Even though the prognosis for empyema is generally unfavorable, with increased morbidity and mortality, due to timely intervention, a successful outcome was achieved in this patient with an atypical presentation of salmonella infection.

A Rare Case of Septic Ovarian Thrombophlebitis Caused by Tissierella praeacuta.

We report a case of Tissierella praeacuta bacteremia and septic thrombophlebitis of the ovarian vein as a rare puerperal complication in a young patient. She was successfully managed with subcutaneous low molecular weight heparin (LMWH) and intravenous (IV) antibiotics before transitioning to a prolonged course of oral antibiotics at discharge.

The use of Vaccinia Immune Globulin in the Treatment of Severe Mpox. Virus Infection in Human Immunodeficiency Virus/AIDS.

We report a case of progressive, severe mpox virus (MPXV) infection in a patient with AIDS despite a standard course of tecovirimat. He significantly improved after administration of vaccinia immune globulin intravenous (VIGIV) highlighting its use as an adjunct for severe disease in immunocompromised hosts.

Outcomes of Monoclonal Antibody Infusion Treatment During Delta (B.1.617.2) and Omicron (B.1.1.529) COVID 19 Variant Surges among Vaccinated and Unvaccinated Patients.

Background: Coronavirus infection of 2019 (COVID-19) is associated with significant morbidity and mortality. Vaccines supplement public health and social measures in preventing severe illness and mortality from COVID-19; however, vaccination rates remain inadequate in many regions. It is important to continuously explore the effective treatment due to the insufficient vaccination rate and increasing number of patients infected with virus. The emergence of new variants has led to multiple surges throughout the world requiring changes to treatment protocols. Method: We conducted a single-center observational study on all adult patients who received monoclonal antibody (mAb) infusion as a treatment for COVID-19 infection. Based on the predominant variant, patients were either offered Casirivimab (600 mg)/imdevimab (600 mg) or Sotrovimab (500 mg). Forty-six patients were given mAbs; 24 were vaccinated, and the remaining unvaccinated. Result: The mean age was 56 years, and the majority (63.04%) of the patients were female. Clinical symptoms of COVID-19 improved within 3 days of infusion in the majority of the patients (70%). None of the patients who received mAb showed progression of disease or required hospitalization at 30 days follow-up. There were no deaths at 30 days follow-up. Monoclonal antibodies are highly effective in reducing hospitalizations and mortality when given within 7 days of symptoms onset in patients with high-risk factors for progression to severe COVID-19 infection. The mean number of days after the onset at which the mAbs were administered to the patient was 4. Conclusion: Monoclonal antibodies should be considered in both vaccinated and unvaccinated patients with COVID-19 infection if newer antiviral agents are contraindicated. Our study highlights the effectiveness of monoclonal antibody infusions when given early in the course of COVID-19 infection regardless of vaccination status.

The Impact of a Standardized Discharge Process on 30-Day Readmissions for Patients on Outpatient Parenteral Antibiotic Treatment.

Introduction: Outpatient parenteral antibiotic treatment (OPAT) is associated with shorter length of hospital stay and reduced cost. Yet, patients discharged home on OPAT are at risk of hospital readmissions due to adverse events and complications. Although the impact of a multidisciplinary approach to readmission has been assessed by previous studies, addition of an innovative technology has not been evaluated for OPAT. This study examines the impact of a multidisciplinary approach including automated voice calls on 30-day readmissions of OPAT patients. Methods: A post-discharge transitional care process (PDTCP) targeting OPAT patients was implemented in fall 2016. This process included an automated telephone patient engagement service and coordination among pharmacy, nursing, medicine, and social work personnel. The patients on OPAT received automated telephone calls at 2, 9, 16, 28, and 40 days post-discharge to ensure medication availability and adherence and to circumvent issues that would otherwise result in an emergency room visit or readmission to the hospital. Results: A total 429 voice calls were made to 148 patients from November 8, 2016 to February 28, 2019. Overall, 61% (n = 90/148) of the patients were successfully reached by the automated voice system. The patients who were reached by the automated voice system were less likely to be readmitted than those not reached (18.9% vs 41.4%; relative risk (RR) 0.46, 95% CI 0.27-0.77, P = .003). Conclusion: Our study demonstrated that a multidisciplinary approach involving the use of automated telephone calls was associated with decreased hospital readmissions.

A Case of Synthetic Cannabinoid (K2)-Induced Posterior Reversible Encephalopathy Syndrome (PRES).

BACKGROUND K2 is an artificially synthesized cannabinoid (SCB), manufactured as a non-consumption herbal incense but increasingly misused as a recreational drug. Posterior reversible encephalopathy syndrome (PRES) is a rare clinical and radiological entity characterized by brain edema, often in the setting of acute hypertension. Cases of PRES caused by recreational drug use have been reported in the literature. CASE REPORT We report an unusual case of PRES after consumption of K2 in a 24-year-old healthy woman who presented with episodic agitation and altered mental status. Magnetic resonance imaging showed nonspecific subtle high T2/FLAIR (fluid-attenuated inversion recovery) signal intensities in the region of the posterior parietal and occipital cortices. Her extensive drug screen report was positive for K2. Her mental status improved over the course of 3 weeks and she had returned to her baseline at 3-month follow-up. CONCLUSIONS Our case highlights the importance of having a high clinical suspicion in patients presenting with altered mental status and a history of recreational drug use. K2 is not detected by routine urine drug testing, so a high level of clinical suspicion is required to request an extensive drug screen. It is important for the physician to counsel active synthetic cannabinoid users regarding these rare complications.

Penile Necrosis Associated with Local Intravenous Injection of Cocaine.

BACKGROUND Cocaine is a highly addictive drug and its use has increased in recent years. It is the second most popular illicit drug in the United States and is the second most trafficked illicit drug in the world. Intravenous (i.v.) drug use leads to severe injury to the veins, including erythema, thrombophlebitis, vasoconstriction, necrosis, development of venous ulceration, and vein occlusion. CASE REPORT A 35-year-old man presented to our Emergency Department with a 3-day history of excruciating and progressive penile and scrotal pain after having injected cocaine in the dorsal vein of the penis. A genital examination revealed ulcerations and swelling on the ventral proximal penis and scrotum junction, with foul-smelling serous discharge. There was no crepitus. He also had stellate purpura with necrosis of the dorsum of the penis and tender bilateral inguinal lymphadenopathy. Computed tomography of the pelvis, with contrast, showed subcutaneous edema of the penis with ulceration of the penile tip on the right. It also revealed left inguinal adenopathy. Vasculitis and concomitant sexually transmitted disease were ruled out as well as Fournier gangrene, and he was started on i.v. broad-spectrum antibiotics. The patient's clinical condition improved with antibiotics and local wound care. CONCLUSIONS Our case highlights the importance of taking a thorough history from i.v. drug users, as they are at risk of injecting drugs into unusual sites, such as the dorsal penile vein. It is important for the physician to counsel active i.v. drug users regarding possible complications of injecting drug into unusual sites.

SARS-CoV-2 Seroprevalence Among Healthcare Workers by Job Function and Work Location in a New York Inner-City Hospital.

OBJECTIVE: To describe the seroprevalence and risk for SARS-CoV-2 among healthcare workers (HCWs) by job function and work location following the pandemic's first wave in New York City (NYC). METHODS: A cross-sectional study conducted between May 18 and June 26, 2020, during which HCWs at a large inner-city teaching hospital in NYC received voluntary antibody testing. The main outcome was presence of SARS-CoV-2 antibodies indicating previous infection. Seroprevalence and adjusted odds ratios (aORs) for seropositivity by type and location of work were calculated using logistic regression analyses. RESULTS: Of 2,749 HCWs tested, 831 tested positive, yielding a crude seroprevalence of 30.2% (95% CI, 29%-32%). Seroprevalence ranged from 11.1% for pharmacy staff to 44.0% for nonclinical HCWs comprised of patient transporters and housekeeping and security staff, with 37.5% for nurses and 20.9% for administrative staff. Compared to administrative staff, aORs (95% CIs) for seropositivity were 2.54 (1.64-3.94) for nurses; 2.51 (1.42-4.43) for nonclinical HCWs; between 1.70 and 1.83 for allied HCWs such as patient care technicians, social workers, registration clerks and therapists; and 0.80 (0.50-1.29) for physicians. Compared to office locations, aORs for the emergency department and inpatient units were 2.27 (1.53-3.37) and 1.48 (1.14-1.92), respectively. CONCLUSION: One-third of hospital-based HCWs were seropositive for SARS-CoV-2 by the end of the first wave in NYC. Seroprevalence differed by job function and work location, with the highest estimated risk for nurses and the emergency department, respectively. These findings support current nationwide policy prioritizing HCWs for receipt of newly authorized COVID-19 vaccines.

Association between fluoroquinolone utilization rates and susceptibilities of gram-negative bacilli: Results from an 8-year intervention by an antibiotic stewardship program in an inner-city United States hospital.

This study evaluated an antibiotic stewardship program (ASP) intervention aimed at reducing inpatient fluoroquinolone (FQ) use and examined its impact on ciprofloxacin susceptibilities of gram-negative bacteria in a large 611-bed community hospital. A two-step ASP intervention was implemented: an electronic medical record algorithm that prompted physicians to re-evaluate FQ use shortly after admission and changed institutional UTI/pneumonia guidelines that recommended options alternate to FQs for first-line empiric antibiotic therapy in 2010 and 2011 respectively. Between 2007 and 2017 FQ use and ciprofloxacin susceptibilities of all non-duplicate cultured isolates of Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa obtained ≥72 h after admission were reviewed. Ambulatory care isolates served as a comparison group. FQ utilization rates and relationships to ciprofloxacin susceptibility were evaluated using interrupted time series models. Over the 11-year period, FQ use decreased from 110.0 (2007) to 26.2 (2017) days of therapy/1000 days at risk (p < 0.001). Compared to pre-intervention, the estimated (post-intervention) reduction in FQ utilization was 28.4 (95% CI: 10.9-46) days of therapy/1000 days at risk. Reduced FQ utilization was correlated with increase susceptibilities to ciprofloxacin of hospital onset isolates of Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis (p < 0.02), and Pseudomonas aeruginosa (p = 0.07). No significant susceptibility change was observed in the ambulatory care isolates. Persuasive interventions by an ASP successfully modified physicians' inpatient empiric antibiotic use, produced a sustained reduction in FQ utilization rates and increased ciprofloxacin susceptibility to four commonly encountered gram-negative bacteria in a community hospital.

Effect of vitamin D3 and calcium carbonate supplementation on muscle strength in postmenopausal women living with HIV.

BACKGROUND: Both falls and fractures are increased in older persons living with HIV (PLWH). Low serum total 25-hydroxyvitamin D (25-OHD) levels have been associated with falls, fractures and poor muscle strength. We hypothesized that vitamin D (VitD) supplementation would improve muscle strength in postmenopausal PLWH. METHODS: In a 12-month prospective, randomized, double-blind, study of 69 African American and Hispanic postmenopausal PLWH on antiretroviral therapy with 25-OHD ≥10 ng/ml and ≤32 ng/ml, we investigated the effects of daily low (1,000 IU; n=31) and moderate (3,000 IU; n=38) cholecalciferol doses on lean mass and strength. Change in lean body mass was assessed by dual-energy X-ray absorptiometry (DXA), and isometric and isokinetic muscle strength in the dominant lower extremity was assessed using the Biodex System 4 Pro. RESULTS: Mean age was 56 ±5 years, median CD4+ T-cell count 722 cells/mm3 and 74% had HIV RNA≤50 copies/ml. Serum 25-OHD did not differ at baseline, but was higher in the moderate than low VitD group at 6 and 12 months. In both groups, there were significant increases in lower extremity isokinetic torque, work and power at 12 months, with no change in lean mass. CONCLUSIONS: VitD supplementation was associated with a modest increase in lower extremity strength in postmenopausal PLWH, without a concomitant increase in muscle mass. Magnitude of increase in strength were similar with 3,000 IU and 1,000 IU daily. Future larger studies will be required to determine the optimal dose of VitD to improve muscle strength and to determine whether supplementation reduces the risk of falls and fractures in PLWH.

A Rare Case of Parvovirus B19 Infection Manifesting as Chronic Aplastic Anemia and Neutropenia in a Human Immunodeficiency Virus-Infected Patient.

Parvovirus B19 (PVB19) is a deoxyribonucleic acid (DNA) virus, the only member of the Parvoviridae, which has a direct cytopathic effect on erythroid progenitor cells, resulting in an arrest of hematopoiesis and subsequent anemia. Less frequently, neutropenia and thrombocytopenia have been reported with the PVB19 infection. We report a rare case of chronic neutropenia due to PVB19 in a human immunodeficiency virus (HIV) patient. A 51-year-old male with a medical history of HIV presented to the Emergency Department (ED) with complaints of generalized weakness. His laboratory tests were significant for severe anemia and new neutropenia. PVB19 DNA by polymerase chain reaction (PCR) was positive. PVB19 immunoglobulin M (IgM) and IgG were reported negative. He was diagnosed with aplastic anemia from PVB19 and neutropenia. From June 2013 to January 2019, the patient was admitted 23 times with severe neutropenia and anemia, and on each occasion, PVB19 DNA by PCR was positive. During these multiple admissions, he was treated with antibiotics for neutropenic fever, methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, and methicillin-sensitive Staphylococcus aureus (MSSA) skin abscesses. On each occasion, he required multiple blood transfusions, and he received intravenous immunoglobulin (IVIG) that resulted in significant improvement of absolute neutrophil count (ANC) count. He had bone biopsy twice, which showed normal maturation of the myeloid series and reduced erythroid progenitor cells consistent with PVB19 infection. PVB19 DNA by PCR remains positive to date. Immunocompromised individuals usually develop a chronic infection from PVB19, and rarely infection with PVB19 can cause severe neutropenia that can be long-lasting and life-threatening. Early recognition and treatment with IVIG are the key to improve the clinical outcome.

A Randomized Placebo-Controlled Trial of Low- Versus Moderate-Dose Vitamin D3 Supplementation on Bone Mineral Density in Postmenopausal Women With HIV.

BACKGROUND: Prevalence of osteoporosis and fracture is increased among older people with HIV. We compared the effects of low (1000 IU) vs moderate (3000 IU) vitamin D3 (VitD) supplementation on areal bone mineral density (aBMD) and volumetric bone mineral density (vBMD) in African American and Hispanic postmenopausal women with HIV on antiretroviral therapy. METHODS: We performed a 12-month prospective, randomized, double-blind, placebo-controlled study with primary outcomes of change in aBMD by dual-energy X-ray absorptiometry (DXA) and secondary outcomes of change in vBMD by quantitative computed tomography and bone turnover markers. An intent-to-treat analysis was performed on 85 randomized subjects (43 low and 42 moderate) for primary DXA outcomes, and complete case analysis was performed for secondary outcomes. RESULTS: Mean age was 56 ± 5 years, median CD4 count was 722 cells/mm, and 74% had HIV RNA ≤ 50 copies/mL. Serum 25-OHD was higher in the moderate than low VitD group at 6 months (33.1 ± 10.3 vs 27.8 ± 8.1 ng/mL, P = 0.03) and 12 months, but parathyroid hormone levels remained similar. Percent change in aBMD, vBMD, and bone turnover markers did not differ between low and moderate VitD groups before or after adjustment for baseline aBMD. CONCLUSIONS: VitD supplementation at 3000 IU daily increased mean total 25-OHD levels in postmenopausal women with HIV, but we did not find evidence of an effect on BMD beyond those observed with 1000 IU daily. Future studies are necessary to determine whether VitD supplementation is beneficial in this patient population, and if so, what dose is optimal for skeletal health.

An Unusual Case of Ototoxicity with Use of Oral Vancomycin.

INTRODUCTION: Systemic absorption of oral vancomycin is poor due to the size of the molecule and its pharmacokinetics. It has an elimination half life of 5-11 hours in patients with normal renal function. We present a rare case of ototoxicity after oral vancomycin administration and detectable serum vancomycin levels 24 hours after cessation of vancomycin. CASE PRESENTATION: A 42-year-old woman with a history of hypertension, diabetes mellitus, and previously treated Clostridium difficile colitis presented with abdominal pain and diarrhea for two weeks. Clostridium difficile infection was confirmed by PCR, and at the time of diagnosis and initiation of therapy, the patient had normal renal function. Vancomycin was initiated at a dose of 125 mg po q6h. After the third dose of oral vancomycin, the patient reported new symptoms of lightheadedness, sensations of "buzzing" and whistling of bilateral ears, and decreased perception of hearing described as "clogged ears." The patient reported to the emergency department the next day due to worsening of these symptoms, and vancomycin dosing was reduced to every 8 hours; however, the patient reported the auditory symptoms persisted. On day three, vancomycin was discontinued with gradual resolution of symptoms over the next 12 hours. On day four, a serum random vancomycin level obtained 24 hours after the last dose was detectable at 2 mcg/dl. Temporal association of the patient's symptoms and improvement with cessation of therapy along with a detectable vancomycin level indicates systemic absorption of oral vancomycin with subsequent ototoxicity. DISCUSSION: The potential for absorption of oral vancomycin is not well described and is attributed to compromised intestinal epithelium allowing for increased drug absorption. Few studies suggested that oral vancomycin may result in therapeutic or even potentially toxic levels of serum vancomycin in patients with impaired renal function. Ototoxicity may be a transient or permanent side effect of vancomycin therapy and is related to high serum levels. Symptoms usually resolve after decreasing the dose or cessation of vancomycin. No detectable serum vancomycin levels were found in 98% of the patients treated with oral vancomycin in a prospective study. The described case is unusual because despite normal renal function, the patient still developed ototoxicity, and systemic absorption of the drug was confirmed with a measurable vancomycin level approximately 24 hours after the drug was stopped. Additionally, the only other medication prescribed to the patient at the time of vancomycin administration was metformin at a dose of 500 mg po bid which has no known idiosyncratic interactions potentiating adverse side effects to vancomycin. This case reflects that some patients may be more susceptible to increased systemic absorption via the oral route, and the possibility for ototoxicity should be considered and discussed with patients while prescribing oral vancomycin.

Native Valve Endocarditis due to Veillonella Species: A Case Report and Review of the Literature.

Veillonella species are fastidious bacteria that have been isolated from skin, dental, and respiratory tract infections and rarely have been implicated in serious infections like meningitis, endocarditis, and osteomyelitis. A 76-year-old woman presented to our hospital with fever, vomiting, and generalized weakness for 3 days. A transthoracic echocardiogram showed a mobile structure on anterior mitral valve leaflet measuring 0.9 cm suggestive of vegetation. Empiric therapy with vancomycin and piperacillin-tazobactam was started with clinical resolution of her symptoms. On day 6, the blood culture drawn at admission grew Veillonella species. A transesophageal echocardiogram confirmed a 1.2 × 0.4 cm echo dense structure attached to the left ventricular side of the anterior mitral leaflet. The patient was discharged home after 10 days of inpatient antibiotic therapy and completed 4 weeks of IV ceftriaxone at home without any adverse events. She was reevaluated in the clinic after completion of treatment and repeat blood cultures remained negative. We report the first case of successful treatment of endocarditis due to Veillonella species with once daily ceftriaxone.

Cardiovascular Risk in HIV-Infected and Uninfected Postmenopausal Minority Women: Use of the Framingham Risk Score.

OBJECTIVE: To characterize and compare cardiovascular disease (CVD) risk in HIV-infected and uninfected postmenopausal minority women using the Framingham Risk Score (FRS) as an assessment measure. METHODS: A cross-sectional analysis was performed in 152 (109 HIV+, 43 HIV-) subjects from an existing study cohort of postmenopausal Hispanic and African American women. Data necessary to calculate FRS and menopause features were retrieved by retrospective chart review. Bivariate statistics was used to compare CVD risk factors. Multivariable linear regression was used to determine factors associated with FRS in HIV-infected women. RESULTS: The HIV-infected group was younger, less obese, and with lower rates of diabetes versus controls. In a subset of age-matched participants, median FRS did not differ between groups (14.6 [IQR = 9.1, 21.6] vs. 15.5 [IQR = 12.3, 22.1]; p = 0.73). Fourteen percent of HIV-infected women meeting criteria for the low-risk FRS category (<10%) had a history of CVD, a similar rate as controls. HIV-infected women at intermediate/high CVD risk had higher rates of surgical menopause. According to 2013 clinical guidelines, more than half of HIV-infected women not prescribed statin therapy (52%) were eligible for treatment; however, statin therapy was similarly under-prescribed in uninfected women. CONCLUSIONS: In this study, CVD risk as assessed by the FRS was not significantly different by HIV status. Performance of the FRS may be compromised in postmenopausal HIV-infected minority women. HIV-infected and uninfected women may be undertreated with statin therapy. Large longitudinal cohorts and inclusion of subclinical measures of CVD are necessary to better characterize risk.

Anemia, intractable vomiting, chronic diarrhea, and syndrome of inappropriate antidiuretic secretion: a diagnostic dilemma: Disseminated strongyloidosis in a patient with newly diagnosed HTLV infection-case report and review of literature.

RATIONALE: Strongyloidiasis hyperinfection and disseminated disease have high mortality rates due to several complications and early detection of Strongyloides infection is therefore prudent. PATIENT CONCERNS: A 37-year-old male patient came with chronic diarrhea, intractable vomiting and was found to have hyponatremia, and anemia on the initial laboratory tests. DIAGNOSES: Further work up revealed syndrome of inappropriate antidiuretic secretion to be the cause of the hyponatremia in addition to gastrointestinal loses. His hospital course was complicated by persistent hyponatremia and later development of partial small bowel obstruction. INTERVENTIONS: Considering his symptoms we had a suspicion of small bowel pathology for which he underwent an esophagogastroduodenoscopywith biopsies that revealed strongyloidosis as the cause of his symptoms. He was also found to have human T-cell lymphotropic virus infection, likely contributing to the disseminated disease. OUTCOMES: He was started on ivermectin with complete resolution of symptoms and improvement of hyponatremia. LESSONS: It is very important to suspect Strongyloides infection in a patient presenting with syndrome ofinappropriate antidiuretic secretion as hyperinfection and disseminated disease can be life threatening without antihelmintic therapy.

Post-chikungunya rheumatic disorders in travelers after return from the Caribbean.

BACKGROUND: Due to increasing concerns about post-chikungunya (pCHIK) rheumatic disorders in Latin America we aimed to evaluate its occurrence in travelers returning to NYC from the Caribbean. METHOD: Patients diagnosed with chikungunya (CHIK) during 2014 at the Bronx-Lebanon Hospital Center (Bronx, NewYork) were identified by reviewing laboratory and electronic medical records. Patients and caregivers of pediatric patients were interviewed by phone ≥9 months after the CHIK diagnosis to survey for chronic symptomatology and current health care needs. Reported chronic musculoskeletal complaints were categorized according to validated criteria. RESULTS: A total of 28 patients (54% females, median age [range] of 51.5 [0, 88] years) diagnosed with CHIK at our center were identified. Most (82%) had returned from the Dominican Republic. Nineteen (68%) patients were successfully contacted at a median (range) of 13 (9, 16) months since the acute diagnosis. A third (37%) reported ongoing complaints related to CHIK including joint pain (32%), muscle pain (32%), and joint swelling (26%). A presumptive diagnosis of pCHIK chronic inflammatory arthritis (n = 4) and pCHIK musculoskeletal disorder (n = 3) was established. CONCLUSIONS: A third of travelers with CHIK acquired in the Caribbean may be at risk for developing persistent symptoms suggestive of pCHIK rheumatic disorder.

Empedobacter brevis Bacteremia in a Patient Infected with HIV: Case Report and Review of Literature.

Clinical disease caused by Empedobacter brevis (E. brevis) is very rare. We report the first case of E. brevis bacteremia in a patient with HIV and review the current literature. A 69-year-old man with human immunodeficiency virus (HIV) and CD4 count of 319 presented with chief complaints of black tarry stools, nausea and vomiting for 2 days. Physical exam was significant for abdominal pain on palpation with no rebound or guarding. His total leukocyte count was 32,000 cells/µL with 82% neutrophils and 9% bands. Emergent colonoscopy and endoscopic esophagogastroduodenoscopy showed esophageal candidiasis, a nonbleeding gastric ulcer, and diverticulosis. Blood cultures drawn on days 1, 2, and 3 of hospitalization grew E. brevis. Patient improved with intravenous antibiotics. This case is unusual, raising the possibility of gastrointestinal colonization as a source of the patient's bacteremia. In conclusion, E. brevis is an emerging pathogen that can cause serious health care associated infections.

Nontuberculous mycobacterium disease with pleural empyema in a patient with advanced AIDS.

Pleural involvement in nontuberculous mycobacterium infection has rarely been reported. We present a case of a patient with advanced AIDS, not on antiretroviral therapy, who presented with massive pleural empyema and splenic and liver abscess secondary to Mycobacterium avium-intracellulare complex. She was a 42-year-old female who was admitted with fever, chills, weight loss, and productive cough of 3 weeks duration. Her pleural fluid cultures were positive for Mycobacterium avium-intracellulare complex, and no other organism was identified. Our patient had good outcome after treatment with antitubercular agents (isoniazid, rifabutin, and clarithromycin).

Cluster of bloodstream infections caused by KPC-2 carbapenemase-producing Klebsiella pneumoniae in Manhattan.

BACKGROUND: Carbapenems are considered the agents of choice for treatment of serious infections caused by resistant gram-negative organisms. A new group of class A beta-lactamases, known as KPC-type carbapenemases, has recently been described and poses a serious clinical challenge. METHODS: Seven patients with bloodstream infections caused by Klebsiella pneumoniae isolates with decreased susceptibility to carbapenems were identified between January and April 2005 in the intensive care units of a hospital in Manhattan. Isolate identification and susceptibility testing were performed according to National Committee for Clinical Laboratory Standards methodology. All isolates were ribotyped and screened for (bla)KPC by polymerase chain reaction. The polymerase chain reaction product underwent nucleotide sequencing for one of the isolates. Medical records were reviewed retrospectively. RESULTS: Six isolates were carbapenem-resistant with minimum inhibitory concentrations for imipenem of >8microg/mL. Ribotyping showed that all isolates belonged to a single clone. All isolates possessed (bla)KPC and nucleotide sequencing identified the allelic type KPC-2. Patients' median age was 68 years. The median duration of hospitalization was 25.5 days before the first positive blood culture. Five of 6 patients received previous broad-spectrum beta-lactam antibiotics but none received prior carbapenems. Five of 6 isolates were susceptible to polymyxin B. Three of the 5 patients were treated with polymyxin B and 1 survived. Overall, only 2 of the 6 patients survived. CONCLUSION: This report describes the first outbreak of KPC-2 carbapenemase-producing K pneumoniae bloodstream infections in a hospital in Manhattan.