Upper extremity Histoplasma capsulatum treatment with isavuconazole.

Extrapulmonary Histoplasma capsulatum infections in the immunocompetent population are rare and pose a diagnostic challenge. Upper extremity histoplasmosis without a primary lung infection is uncommon. It is possible to acquire it by inadvertent trauma with direct inoculation. Our case describes an immunocompetent patient with progressive swelling with minimal pain in the wrist associated with a small puncture wound on the left dorsal forearm. The initial workup failed to identify a specific etiology. For the following six weeks, the patient experienced progressive worsening of symptoms, warranting a referral to an orthopedic hand surgeon. Left lower extremity magnetic resonance imaging (MRI) findings were non-specific. The surgeon performed a surgical exploration and debridement with the excision of hypertrophic tissue. Initial stains showed a granulomatous tissue but did not reveal an organism; however, a month later, mold was identified on the growth medium. The patient was initiated in isavuconazole empiric therapy. Four weeks later, a matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) confirmed the diagnosis as Histoplasma capsulatum. The patient had clinical remission with isavuconazole used as the United States Food and Drug Administration (FDA) off label use.

A multi-mechanism approach reduces length of stay in the ICU for severe COVID-19 patients.

PURPOSE: COVID-19 pandemic has multifaceted presentations with rising evidence of immune-mediated mechanisms underplay. We sought to explore the outcomes of severe COVID-19 patients treated with a multi-mechanism approach (MMA) in addition to standard-of-care (SC) versus patients who only received SC treatment. MATERIALS AND METHODS: Data were collected retrospectively for patients admitted to the intensive care unit (ICU). This observational cohort study was performed at five institutions, 3 in the United States and 2 in Honduras. Patients were stratified for MMA vs. SC treatment during ICU stay. MMA treatment consists of widely available medications started immediately upon hospitalization. These interventions target immunomodulation, anticoagulation, viral suppression, and oxygenation. Primary outcomes included in-hospital mortality and length of stay (LOS) for the index hospitalization and were measured using logistic regression. RESULTS: Of 86 patients admitted, 65 (76%) who had severe COVID-19 were included in the study; 30 (46%) patients were in SC group, compared with 35 (54%) patients treated with MMA group. Twelve (40%) patients in the SC group died, compared with 5 (14%) in the MMA group (p-value = 0.01, Chi squared test). After adjustment for gender, age, treatment group, Q-SOFA score, the MMA group had a mean length of stay 8.15 days, when compared with SC group with 13.55 days. ICU length of stay was reduced by a mean of 5.4 days (adjusted for a mean age of 54 years, p-value 0.03) and up to 9 days (unadjusted for mean age), with no significant reduction in overall adjusted mortality rate, where the strongest predictor of mortality was the use of mechanical ventilation. CONCLUSION: The finding that MMA decreases the average ICU length of stay by 5.4 days and up to 9 days in older patients suggests that implementation of this treatment protocol could allow a healthcare system to manage 60% more COVID-19 patients with the same number of ICU beds.

Successful treatment of a prosthetic hip infection due to Enterococcus faecalis with sequential dosing of oritavancin and prosthesis preservation without prosthetic joint surgical manipulation.

A patient with a prosthetic joint infection (PJI) complicated with deep surgical site infection due to vancomycin-susceptible Enterococcus faecalis. The initial treatment consisted of 10 days with daptomycin plus ampicillin. The hip prosthesis was retained and salvaged with six outpatient sequential doses of oritavancin 1200 mg every seven days without intra-articular irrigation or other surgical interventions. The patient was ambulating independently without symptoms after ten months of the last treatment of oritavancin.

Thymoma Causing Bilateral Upper Extremity Deep Vein Thrombosis.

A 38-year-old African American male presented with progressive pain, swelling, numbness, and warmth of the left upper extremity ten days before admission. A chest computerized tomography scan showed a large 8.3 cm × 6.1 cm x 9.9 cm anterior mediastinal mass with compression of the left brachiocephalic vein and superior vena cava. A venous doppler showed multiple occlusive venous thrombi in bilateral upper extremities, including the bilateral internal jugular and subclavian veins, as well as the left subclavian, axillary, cephalic, brachial and median cubital veins. Further laboratory workup came positive for acetylcholine receptor binding antibody suggesting myasthenia gravis, but the patient was asymptomatic for myasthenia gravis. A percutaneous core CT guided biopsy pathology resulted in a predominant T-cell population CD5 positive with few B cells; the immunophenotypic features suggested Type B2 thymoma. To the best of our knowledge, this case is the only reported thymoma presenting with bilateral deep vein thrombosis of the upper extremities. The deep vein thrombosis therapy was enoxaparin 1mg/kg subcutaneously every 12 hours and dexamethasone 4mg intravenously every 4 hours as an anti-inflammatory drug for thymoma related compression of the mediastinum. The patient was referred to a tertiary oncological medical center for a total thymectomy, chemotherapy, and adjuvant radiotherapy.

Cryptococcus laurentii meningitis in a non-HIV patient.

Cryptococcus species (other than Cryptococcus neoformans) have been labeled as saprophytic and nonpathogenic in immunocompetent individuals in the past. In recent years, infections caused by non-neoformans Cryptococcus species have been recognized. Cryptococcus laurentii is known to be a rare human pathogen. In this case report, we present a 59-year-old man who did not have HIV infection with meningoencephalitis caused by Cryptococcus laurentii. No significant underlying immunosuppressive disorder was found. The only identifiable risk factors were that the patient was a farmer with previous exposure to pigeon droppings. Here, we describe what we believe to be the fifth reported case of meningitis caused by Cryptococcus laurentii.

Nontyphoidal Salmonella purulent pericarditis presenting with pericardial tamponade in a patient on infliximab therapy.

Infection with nontyphoidal Salmonella is traditionally characterized by intestinal manifestations. However, extra-intestinal infections are known to occur, with purulent pericarditis associated with cardiac tamponade being rare. This case report is of a 57-year-old male with Crohn's disease initiated on infliximab therapy two months prior to presentation. He presented with recurrent chest pain and a single occurrence of fever. A Computed Tomography (CT) scan of the chest revealed a pericardial effusion. An echocardiogram confirmed the presence of the fluid with tamponade physiology, requiring immediate surgical decompression. The pericardial fluid culture grew Salmonella enterica, despite the patient having only a single episode of fever, disproportionate to the severity of the infection. Conceivably, the lack of systemic symptoms may be attributed to recent infliximab therapy. Upon conducting a literature review, immunosuppressive factors seem to play a significant role in nontyphoid Salmonella enterica pericardial effusion presenting with cardiac tamponade.