Tuberculous Hypertrophic Pachymeningitis.

Tuberculous pachymeningitis is a rare disease that should be suspected in patients with chronic headaches, focal neurological signs, and magnetic resonance imaging (MRI) findings of dural thickening. We report the case of a 62-year-old male who presented with chronic headaches for over a year, progressive right-sided vision and hearing loss for six months, and progressive dysphagia for a month. On investigation, MRI showed dural thickening, cerebrospinal fluid showed lymphocytic pleocytosis with high protein and normal glucose levels, and biopsy of the dural matter showed necrotizing granulomas with Langhans giant cells. The patient responded well to antitubercular treatment and steroids. Follow-up MRI 24 months later showed almost complete resolution of meningeal enhancement. Though tuberculosis is an uncommon cause of pachymeningitis, it should be considered, as it responds well to treatment.

A Fatal Case of Rhizopus azygosporus Pneumonia Following COVID-19.

We report a fatal case of Rhizopus azygosporus pneumonia in a 56-year-old man hospitalized for COVID-19 who had received methylprednisolone and tocilizumab. Although COVID-associated pulmonary aspergillosis has been widely documented, mucormycosis has been rarely reported. In this patient, receipt of two commonly used immunosuppressants likely contributed to mucormycosis risk, suggesting the need for vigilance in hospitalized patients with COVID-19.

A Survey of COVID-19 Preparedness Among Hospitals in Idaho.

BACKGROUND: SARS-CoV-2 has been implicated in the largest recorded coronavirus outbreak to date. Initially, most COVID-19 cases were in China, but the virus has spread to more than 184 countries worldwide, and the United States currently has more cases than any other country. OBJECTIVE: With person-to-person spread expanding in the United States, we describe hospital preparedness for managing suspected and confirmed COVID-19 patients. DESIGN: Cross-sectional survey focused on various elements of respiratory disease preparedness. SETTING: Critical access hospitals (CAHs) and acute-care hospitals (ACHs) in Idaho. METHODS: The electronic survey was sent to infection preventionists (IPs) and nurse administrators in 44 hospitals in Idaho. RESULTS: Overall, 32 (73%) hospitals responded to the survey. Participating facilities reported their preparedness with respect to existing, formalized structures for managing infectious disease incidents-specifically COVID-19-as well as availability of resources, such as isolation rooms and personal protective equipment, for safely managing suspected and confirmed COVID-19 cases. CONCLUSIONS: Hospitals covered by the survey had varying levels of preparedness for managing COVID-19 cases, with differences across the various categories of interest in this study. Although the study reveals strengths, including in application of emergency management and infection control frameworks, it also suggests that other areas, such as consistent implementation of federal guidelines and requirements for infection prevention, are potential areas for strengthening preparedness for SARS-CoV-2 and other respiratory pathogens with pandemic potential.

A cross-sectional survey of measles preparedness in critical-access hospitals of Idaho.

BACKGROUND: Patients with measles can precipitate outbreaks in health care facilities where they seek care. Rural critical-access hospitals (CAHs) may be at higher risk of outbreaks given their size and potentially limited infection prevention resources. METHODS: We surveyed CAHs in Idaho to ascertain their levels of preparedness for managing measles cases. A 25-item questionnaire was sent to infection preventionists at all 27 Idaho CAHs. The questionnaire covered organizational structure, resources for managing measles cases, and hospital policies for ensuring immunity among health care workers. RESULTS: A total of 22 (82%) CAHs responded, reporting varying availability of facilities and resources for managing measles cases and disparate procedures for testing clinical samples and providing vaccines to nonimmune, exposed staff. DISCUSSION: With measles incidence on the rise in the United States, our survey found that most of the responding hospitals had the basic organizational structure for facility-wide prevention and management efforts in case a patient with suspected or confirmed measles presented to that facility. Most of the hospitals also had at least some available resources to manage measles cases, as well as policies for ensuring immunity to measles among at least some groups of health care workers. CONCLUSIONS: This study provides initial perspectives on measles preparedness among Idaho CAHs, despite limited generalizability. Future studies should explore whether self-reported preparedness measures reflect the ability of the CAHs to control measles spread when cases present for care.

Clothing and shoes of personnel as potential vectors for transfer of health care-associated pathogens to the community.

In an acute care hospital, we demonstrated that the clothing and shoes that physicians and nurses wear home from health care facilities can be contaminated with health care-associated pathogens, particularly methicillin-resistant Staphylococcus aureus. These findings suggest that the clothing and shoes of personnel have the potential to serve as vectors for the transfer of health care-associated pathogens to the community.

Emergence of Resistance to Colistin During the Treatment of Bloodstream Infection Caused by Klebsiella pneumoniae Carbapenemase-Producing Klebsiella pneumoniae.

We report the emergence of colistin resistance in Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae after 8 days of colistin-based therapy, resulting in relapse of bloodstream infection and death. Disruption of the mgrB gene by insertion of a mobile genetic element was found to be the mechanism, which was replicated in vitro after exposure to subinhibitory concentrations of colistin and meropenem.

Impact of Antibiotic Treatment on the Burden of Nasal Staphylococcus aureus among Hospitalized Patients.

We examined the impact of systemic antibiotics on the burden of nasal Staphylococcus aureus in hospitalized patients. Of 1,482 patients, 237 (16%) had nasal methicillin-susceptible S. aureus (MSSA) and 92 (6%) had nasal methicillin-resistant S. aureus (MRSA) on admission. Treatment regimens that included agents with inhibitory activity against MRSA or MSSA significantly reduced the burden of carriage, whereas regimens lacking anti-MRSA activity, including fluoroquinolones, promoted MRSA overgrowth.

Contaminated clothing of methicillin-resistant Staphylococcus aureus (MRSA) carriers is a potential source of transmission.

We examined the burden of methicillin-resistant Staphylococcus aureus (MRSA) on the clothing of MRSA carriers in a hospital and long-term care facility and assessed the potential for clothing to be a source of transmission. Of 50 MRSA carriers studied, 37 (74%) had MRSA recovered from clothing. For a subset of carriers with clothing contamination, transfer of MRSA from clothing to gloved hands and to a wheelchair occurred in 8 of 13 (62%) and 5 of 10 (50%) carriers, respectively. These findings suggest that measures to reduce clothing contamination should be investigated as a potential means to reduce MRSA transmission in healthcare settings.

Hiding in Plain Sight: Contaminated Ice Machines Are a Potential Source for Dissemination of Gram-Negative Bacteria and Candida Species in Healthcare Facilities.

BACKGROUND Contaminated ice machines have been linked to transmission of pathogens in healthcare facilities. OBJECTIVE To determine the frequency and sites of contamination of ice machines in multiple healthcare facilities and to investigate potential mechanisms of microorganism dispersal from contaminated ice machines to patients. DESIGN Multicenter culture survey and simulation study. SETTING The study took place in 5 hospitals and 2 nursing homes in northeastern Ohio. METHODS We cultured multiple sites on ice machines from patient care areas. To investigate potential mechanisms of microbial dispersal from contaminated ice machines, we observed the use of ice machines and conducted simulations using a fluorescent tracer and cultures. RESULTS Samples from 64 ice machines in the 5 hospitals and 2 nursing homes (range, 3-16 per facility) were cultured. Gram-negative bacilli and/or Candida spp were recovered from 100% of drain pans, 52% of ice and/or water chutes, and 72% of drain-pan grilles. During the operation of ice machines, ice often fell through the grille, resulting in splattering, with dispersal of contaminated water from the drain pan to the drain-pan grille, cups, and the hands of those using the ice machine. Contamination of the inner surface of the ice chute resulted in contamination of ice cubes exiting the chute. CONCLUSIONS Our findings demonstrate that ice machines in healthcare facilities are often contaminated with gram-negative bacilli and Candida species, and provide a potential mechanism by which these organisms may be dispersed. Effective interventions are needed to reduce the risk of dissemination of pathogenic organisms from ice machines. Infect Control Hosp Epidemiol 2018;39:253-258.

Myocardial Amyloid Quantification with Look-Locker Magnetic Resonance Sequence in Cardiac Amyloidosis. Diagnostic Accuracy in Clinical Practice and Histological Validation.

BACKGROUND: Cardiac magnetic resonance (CMR) has demonstrated its utility in the noninvasive diagnosis of cardiac amyloidosis (CA). Our aim was to evaluate the ability of standard Look-Locker sequences to quantify amyloid deposition in CA. METHODS AND RESULTS: Consecutive patients referred for CMR for possible CA were retrospectively evaluated. Positive cardiac biopsy and/or typical pattern of late gadolinium enhancement were required for the diagnosis of CA. Postcontrast T1 values were obtained from Look-Locker sequences and correlated with markers of severity of disease and major events. When cardiac biopsies were available, histological validation was determined. A total of 174 patients were included. A final diagnosis of CA was reached in 37.4%. Myocardial and endocardial T1 times, as well as the respective ratios with blood and skeletal muscle, were lower among patients with CA and demonstrated good diagnostic performance. The best parameters were myocardial/blood (area under the curve 0.83; P < .001) and endocardial/blood (area under the curve 0.84; P < .001) T1 ratios. Among patients with CA, no associations were found between T1 ratios either with markers of amyloid burden or with prognostic variables. However, all T1 indexes showed significant correlations with histological quantification of amyloid deposition. CONCLUSIONS: Look-Looker derived postcontrast T1 shows good diagnostic accuracy to detect CA and correlation with histological amyloid burden.

Human Coronavirus-HKU1 Infection Among Adults in Cleveland, Ohio.

BACKGROUND: Human coronaviruses (CoV) have been long recognized as a common cause of respiratory tract disease including severe respiratory tract illness. Coronavirus-HKU1 has been described predominantly among children less than 5 years of age in the United States with few studies characterizing the disease spectrum among adults. METHODS: Nasopharyngeal specimens of patients with respiratory symptoms were analyzed for CoV-HKU1 by NxTAG Respiratory Pathogen Panel multiplex assay from February 7, 2016 to April 30, 2016. Epidemiologic, clinical, and laboratory data were collected on adults (patients >18 years) whose samples screened positive. RESULTS: Of 832 adult respiratory specimens screened, 13 (1.6%) cases of CoV-HKU1 were identified. Adults age ranged between 23 and 75 years and 6 (46%) were males. All of whom had 1 or more respiratory symptoms, and 5 (38%) also reported 1 or more gastrointestinal symptoms. Eleven (85%) reported history of smoking and 5 (38%) used inhaled steroids. Seven (54%) required hospitalization, 5 (71%) of these needed supplemental oxygen, and 2 (29%) were admitted to intensive care. Median length of hospitalization was 5 days. Eight (62%) received antibiotics despite identification of CoV-HKU1. Infectious work-up in 1 patient who died did not reveal any other pathogen. In 2 (15%) CoV-HKU1-positive adults, the only viral coinfection detected was influenza A. CONCLUSIONS: Coronavirus-HKU1 accounted for 1.6% of adult respiratory infections and should be considered in differential diagnosis of severe respiratory illnesses among adults.

A cold hard menace: A contaminated ice machine as a potential source for transmission of carbapenem-resistant Acinetobacter baumannii.

During an investigation of potential sources of transmission of multidrug-resistant gram-negative bacilli on a spinal cord injury unit, we recovered genetically related carbapenem-resistant Acinetobacter baumannii isolates from the stool of 3 patients, the hands of a nurse, and an ice machine water outlet spout and drain. Our findings suggest that contaminated ice machines could serve as a potential reservoir for dissemination of multidrug-resistant gram-negative bacilli.

How well does transfer of bacterial pathogens by culture swabs correlate with transfer by hands?

In laboratory testing and in isolation rooms, pickup and transfer of health care-associated pathogens by premoistened rayon swabs correlated well with pickup and transfer by bare hands or moistened gloves. These results suggest that swab cultures provide a useful surrogate indicator of the risk for pathogen pickup and transfer by hands.

Cardiac magnetic resonance evaluation of left ventricular remodelling distribution in cardiac amyloidosis.

BACKGROUND: Cardiac amyloidosis (CA) is associated with typical morphological features on echocardiography, including concentric LV hypertrophy (LVH). Cardiac magnetic resonance (CMR) can accurately depict anatomy in different cardiomyopathies. Our aim was to describe the morphological features and remodelling patterns of CA with CMR, and establish their diagnostic accuracy, as well as the value of traditional diagnostic criteria derived from echocardiography and electrocardiography. METHODS: Consecutive patients referred for CMR for possible CA were retrospectively evaluated. The diagnosis of CA was established in the presence of a positive cardiac biopsy and/or a typical pattern of myocardial late gadolinium enhancement. Morphological parameters were obtained from standard cine sequences. The presence and distribution of LVH, relative wall thickness (RWT) and LV remodelling patterns were determined. RESULTS: 130 patients (92 males (70.8%), age 64±13 years) were included. CA was diagnosed in 51 (39.2%). Patients with CA had increased LV wall thickness and LV mass index. An LV remodelling pattern different from concentric LVH was found in 42% of patients with CA, and asymmetric LVH was noted in 68.6%. A model including RWT, asymmetric LVH, and LVMI showed diagnostic accuracy of 88%, sensitivity of 67% and specificity of 86% for CA detection. Traditional diagnostic criteria for CA showed high specificity but poor sensitivity. CONCLUSIONS: Asymmetric LVH and remodelling patterns different from concentric LVH are common in CA. Increased LV mass index, increased RWT, and asymmetric LVH are independently associated with the diagnosis. Traditional diagnostic criteria show poor sensitivity.

Epidemiological trends of RF/RHD in school children of Shimla in north India.

BACKGROUND & OBJECTIVES: There are no active surveillance studies reported from South East Asian Region to document the impact of change in socio-economic state on the prevalence of rheumatic fever/rheumatic heart disease (RF/RHD) in children. Therefore, we conducted a study to determine the epidemiological trends of RF/RHD in school children of Shimla city and adjoining suburbs in north India and its association with change in socio-economic status. METHODS: Active surveillance studies were conducted in 2007-2008 in urban and rural areas of Shimla, and 15145 school children, aged 5-15 yr were included and identical screening methodology as used in earlier similar survey conducted in 1992-1993 was used. The study samples were selected from schools of Shimla city and adjoining rural areas by multistage stratified cluster sampling method in both survey studies. After a relevant history and clinical examination by trained doctor, echocardiographic evaluation of suspected cases was done. An updated Jones (1992) criterion was used to diagnose cases of acute rheumatic fever (ARF) and identical 2D-morphological and Doppler criteria were used to diagnose RHD in both the survey studies. The socio-economic and healthcare transitions of study area were assessed during the study interval period. RESULTS: Time trends of prevalence of RF/RHD revealed about five-fold decline from 2.98/1000 (95% C.I. 2.24-3.72/1000) in 1992-1993 to 0.59/1000 (95% C.I. 0.22-0.96/1000) in 2007-2008. (P<0.0001). While the prevalence of ARF and RHD with recurrence of activity was 0.176/1000 and 0.53/1000, respectively in 1992-1993, no case of RF was recorded in 2007-2008 study. Prevalence of RF/RHD was about two- fold higher in rural school children than urban school children in both the survey studies (4.42/1000 vs. 2.12/1000) and (0.88/1000 vs. 0.41/1000), respectively. The indices of socio-economic development revealed substantial improvement during this interim period. INTERPRETATION & CONCLUSIONS: The prevalence of RF/RHD has declined by five-fold over last 15 yr and appears to be largely contributed by improvement in socio-economic status and healthcare delivery systems. However, the role of change in the rheumatogenic characteristics of the streptococcal stains in the study area over a period of time in decline of RF/RHD cannot be ruled out. Policy interventions to improve living standards, existing healthcare facilities and awareness can go a long way in reducing the morbidity and mortality burden of RF/RHD in developing countries.

Imaging a boa constrictor--the incomplete double aortic arch syndrome.

Incomplete double aortic arch is a rare anomaly resulting from atresia rather than complete involution in the distal left arch resulting in a non-patent fibrous cord between the left arch and descending thoracic aorta. This anatomic anomaly may cause symptomatic vascular rings, leading to stridor, wheezing, or dysphagia, requiring surgical transection of the fibrous cord. Herein, we describe an asymptomatic 59 year-old man presenting for contrast-enhanced CT angiography to assess cardiac anatomy prior to radiofrequency ablation, who was incidentally found to have an incomplete double aortic arch with hypoplasia of the left arch segment and an aortic diverticulum. Recognition of this abnormality by imaging is important to inform both corrective surgery in symptomatic patients, as well as assist in the planning of percutaneous coronary and vascular interventions.

Epidemiological study of hypertension in natives of Spiti Valley in Himalayas and impact of hypobaric hypoxemia; a cross-sectional study.

Hypertension is the result of interaction between genetic vulnerability and exposure to unhealthy lifestyle. However, studies investigating the impact of cardiovascular adaptive response to hypobaric hypoxia and extreme cold in natives of high altitude on the development of hypertension have yielded conflicting results. A community based cross-sectional study was carried out in an unique population of Spiti valley of Greater Himalayas residing at an altitude of 3100-3500 m (group 1) and 3500 m and above (group 2) to evaluate the impact of altitude of residence on prevalence of hypertension. 413 subjects, age 20 years and above were selected by stratified cluster random sampling technique and screened for recording socio-demographic profile, anthropometrics, fasting blood sugar and blood pressure. There was no significant difference in the mean age (40.1 vs.38.0 years) and gender distribution (65.7% vs. 61.4% females) between the two groups. The overall prevalence of hypertension was 22.5% and achieved higher significance in group 1 (27.5%) compared to group 2 (19%); p < 0.041. The socioeconomic profile and lifestyle of group from higher altitude was significantly different with people being less educated, agriculture as main occupation compared to the group at lower altitude. On comparison, the same group had a lower prevalence of obesity 17.4% vs. 35.9% (p < 0.000), Diabetes 0.4% vs. 4.1% (p < 0.03) and impaired fasting glucose 5% vs. 11.1% (p < 0.06). Obesity, age and altitude of residence were significantly associated as independent predictors of prevalence of hypertension in this study. Hypobaric hypoxia thus appears to have a protective effect from developing hypertension. The prevalence of hypertension in natives of Spiti valley is thus influenced by lifestyle related risk factors, age and possibly altitude of residence.