A Case of Disseminated Histoplasmosis Presenting in a 65-Year-Old Male Without Apparent Immunodeficiency Successfully Treated With Isavuconazole.

Histoplasma capsulatum causes symptoms in fewer than 5% of infected people, with most recovering without treatment two to three weeks after the onset of symptoms. Progressive disseminated histoplasmosis in adults occurs most often in persons with underlying immunodeficiency. We present a case of a 65-year-old caucasian male without any known immune defect from North Alabama, United States, presenting with chronic tongue ulcer and constitutional symptoms. CT and positron emission tomography scans showed disseminated infection with pulmonary nodule, oral/buccal lesions, and bilateral adrenal hyperplasia. The patient's left adrenal gland and tongue were biopsied and stains confirmed the presence of histoplasmosis in both samples. The patient was treated with isavuconazole off-label as per the United States FDA. The patient tolerated the therapy well and had symptomatic improvement. A follow-up CT scan showed improvement and resolution of adrenal masses.

Dosing and Administration Strategies of Tocilizumab in Patients With COVID-19: A Retrospective Cohort Analysis.

BACKGROUND: Tocilizumab may reduce the risk of death, length of stay, and time of mechanical ventilation in patients hospitalized with COVID-19. Limited data are available evaluating low-dose subcutaneous administration of tocilizumab in this setting. OBJECTIVE: To compare outcomes of 2 tocilizumab dosing and administration strategies in patients hospitalized with COVID-19. METHODS: A retrospective, observational cohort study was conducted to compare clinical outcomes in patients hospitalized with COVID-19 receiving tocilizumab 400 mg intravenously (400 mg IV) or 162 mg subcutaneously (162 mg SC). Hospitalized patients receiving a single dose of tocilizumab were eligible for inclusion and grouped by dosing and administration strategy. The primary endpoint was ventilator-free days at day 28. Secondary endpoints included length of stay (LOS), intensive care unit (ICU) LOS, mechanical ventilation required after dose, 28-day readmission, 28-day mortality, and change in inflammatory markers. RESULTS: A total of 303 patients were included, with 147 who received tocilizumab 400 mg IV and 156 who received 162 mg SC. There was no significant difference in average ventilator-free days at day 28 in patients receiving 400 mg IV compared with 162 mg SC (26.4 ± 5.3 vs 25.6 ± 6.8 days, respectively; P = 0.812). There was also no difference in LOS (10.4 ± 12.6 vs 10.5 ± 14.0 days; P = 0.637), ICU LOS (3.9 ± 9.0 vs 3.5 ± 8.3 days; P = 0.679), mechanical ventilation after dose (15.6% vs 19.2%; P = 0.412), 28-day readmission (6.1% vs 9.6%; P = 0.268), or 28-day mortality (23.1% vs 25.6%; P = 0.611). Finally, there was no difference regarding change in inflammatory markers at 48 hours (P > 0.05 for all interactions). CONCLUSION AND RELEVANCE: In this retrospective study involving hospitalized patients with COVID-19, there was no difference between tocilizumab 162 mg SC and 400 mg IV in terms of efficacy. The 162 mg SC dose may be a reasonable alternative to traditional doses.

A Rare Complication of Leptospirosis: Weil's Disease Diagnosed in the United States.

Leptospirosis is mostly found in tropical regions such as Latin America and Southeast Asia. Here we present a case of leptospirosis in the United States in a 43-year-old African American male who had complications such as sepsis, acute renal failure, hyperbilirubinemia, and transaminitis. Through this case report, we want to highlight the rare occurrence of this infection in the United States. It should be considered high in the list of differential diagnoses for patients traveling to underdeveloped countries and participating in adventure sports. Early recognition and treatment of leptospirosis are essential in decreasing life-threatening complications.

Myocarditis presentation following COVID-19 virus infection versus COVID-19 vaccination.

Coronavirus disease 2019 (COVID-19) vaccine-induced cardiac injury has recently emerged as a major public health concern around the globe. There are reported cases of COVID-19 vaccine-induced myocarditis, but they are generally extremely rare and mild. In contrast, COVID-19 infection can cause acute cardiac injury with poor prognosis and high mortality rates. Herein, we describe the difference in patients' presentation by comparing two cases of myocarditis. One after contracting COVID-19 virus infection with a severe clinical course, and the other patient developed myocarditis post-COVID-19 vaccine.

Evaluation of a Capped Dosing Telavancin Regimen Compared to Standard Dosing at a Large Community Teaching Hospital.

Telavancin, a lipoglycopeptide antibiotic, is traditionally dosed at 10 mg/kg based on total body weight but is associated with toxicities that limit its use. This study supports the use of a capped dosing regimen of 750 mg in obese patients, which is associated with equal efficacy and fewer adverse effects compared to traditional dosing.

Tuberculous mycotic aneurysm of aortic arch: a case report emphasising on multidisciplinary management approach.

Although tuberculosis (TB) is a well-known infection worldwide, the disease involvement in blood vessels, mainly aorta, is quite rare. The objective of this case report is to address the importance of a multidisciplinary approach aiming at successful treatment of tuberculosis, especially when presenting with mycotic aneurysm. We report a case of a 45-year-old woman with the history of sputum positive pulmonary TB, presenting with seizures and eventually found to have developed disseminated infection involving multiple organs, including the aorta. The patient was started on WHO-recommended anti-tubercular treatment but ended up requiring surgical intervention for the aneurysm. Although the main modality of treatment is the use of proper and adequate medical therapy, vascular dissemination in the form of mycotic aneurysm is difficult to be dealt singlehandedly due to their irreversible and multifactorial nature, with infection being the leading cause and their tendency to progress despite the primary infection being treated.

Utilization and impact of a rapid Candida panel on antifungal stewardship program within a large community hospital.

BACKGROUND: The T2 Candida Panel (T2CP) bodes high sensitivity and specificity to detect candidemia, enabling providers to make quick therapy decisions and possibly decrease mortality. However, utilization in practice and clinical application remains to be evaluated. OBJECTIVES: To evaluate the overall provider-utilization of the T2CP at a large community hospital. METHODS: This single center, retrospective, observational study compared antifungal management in all patients with positive or negative T2CP. Additional endpoints included patient-specific variables influencing antifungal management decisions. RESULTS: Six hundred twenty-eight T2CP results were evaluated. Antifungal optimization occurred in 54% of patients who had antifungal orders at the time of T2CP test. Antifungal therapy was avoided in 60.4% of negative cases. Patients with negative T2CP had significantly fewer days of therapy compared to positive tests. CONCLUSIONS: Although the T2CP led to fewer days of antifungal therapy with negative tests, many opportunities for improvement in antifungal stewardship were identified, specifically, with negative tests.

Can we reduce contact precautions days for methicillin-resistant Staphylococcus aureus and vancomycin resistant Enterococcus infected patients?

BACKGROUND: Patients with MRSA (methicillin-resistant Staphylococcus aureus) and VRE (vancomycin resistant Enterococcus) are placed under contact precautions according to the Center of Disease Control protocol. Contact precautions however increases patient isolation from Health Care Workers, increase overall hospital costs and may increase depression and anxiety. Our aim in this study was to observe the effects of shortening the number of days of contact precautions for patients infected with MRSA and VRE. METHOD: We observed patients as two cohorts (Pre-Pilot and Pilot) in one Medical Intensive Care Unit, one Surgical Intensive Care Unit & two medical floors during 2014-2015. In the Pre-pilot period contact precautions were kept throughout admission. In the Pilot period contact precautions were initially placed followed by universal gloving. Comparisons were made for MRSA and VRE infection rates. Total costs were estimated assuming the average cost of 1 gown was $26 per patient per day. RESULTS: Mean isolation days were reduced from 11.9 days to 6.8 days for MRSA and 12.8 days to 8.4 days for VRE. There were 86 MRSA infections in the Pre-Pilot period and 73 MRSA infections during the Pilot period (p=0.052). Incidence of hospital acquired MRSA in the wards decreased from 15 to 7 cases and 6 to 2 cases in the Intensive Care Unit in both the Pilot and Pre-Pilot periods respectively. Cost reduced by $2476 and $17,336 per month for VRE and MRSA patients. Number of readmissions also decreased by 39% for MRSA and 50% for VRE. CONCLUSIONS: A reduction in contact precautions has reduced patient costs without affecting the rate of MRSA and VRE infection within a one-year period.

Clinical Experience with Telavancin: Real-World Results from the Telavancin Observational Use Registry (TOUR™).

BACKGROUND: Telavancin-a lipoglycopeptide antibacterial agent active against Gram-positive pathogens including methicillin-sensitive and -resistant Staphylococcus aureus (MRSA)-is approved in the USA for once-daily intravenous use. This registry study captured patient characteristics, prescribing patterns, and treatment outcomes associated with telavancin use in real-world clinical practice. OBJECTIVE: This prospective, multicenter, observational study will characterize current real-world practice patterns for the use of telavancin in the USA by describing demographic and clinical conditions, examining the process of care and rationale for use, and describing the clinical effectiveness and selected safety outcomes among patients treated with telavancin. METHODS: The Telavancin Observational Use Registry (TOUR™) is an observational multicenter registry study. Clinical data-including patient demographics, pathogens, telavancin dosing and treatment duration, and adverse events-along with investigators' assessments of outcome, were collected through retrospective medical chart review. RESULTS: Data from 1063 patients were collected from 45 US sites. Of these patients, 29.4% were ≥ 65 years of age [mean age ± standard deviation, 55.2 ± 15.4 years; median age (interquartile range), 57.0 (46.0-66.0)], 53.4% were male, and 83.4% were White. The primary infections in these patients included complicated skin and skin-structure infection (48.7%), bone and joint infections (27.4%), bacteremia and endocarditis (14.2%), and lower respiratory tract infections (8.5%). The predominant pathogen identified was MRSA (37.7%). The mean telavancin dose and duration of treatment were 741.7 ± 194.3 mg and 17 ± 17 days, respectively. Of the 964 (90.7%) patients for whom an end-of-treatment assessment was available, 77.7% had a positive clinical response, 10.1% failed treatment, and 12.2% had indeterminate outcomes. CONCLUSIONS: Real-world data collected from the TOUR study show once-daily telavancin is being used for the treatment of a variety of Gram-positive infections with generally positive clinical outcomes.

Cryptosporidium infection in a case of appendicitis.

A 39-year-old Caucasian woman presented to the emergency department with worsening abdominal pain, localised to the right lower quadrant, and diarrhoea for a week. Stool tested negative for Clostridium difficile, Giardialamblia and Cryptosporidium Following an abdominal CT, she was diagnosed with appendicitis. The histological preparation, along with the acute inflammatory changes of the vermiform appendix, was notable for clusters of small, basophilic spherical bodies most consistent with Cryptosporidium parvum infection. Ultimately, the patient was diagnosed with appendicitis secondary to C. parvum infection. This is exceedingly rare and only one other case has been previously reported.

Real-world use of telavancin in the treatment of osteomyelitis.

This is a retrospective analysis of patients with osteomyelitis who received telavancin at some time during their treatment course. The primary outcome was the percent of patients cured or improved at the end of telavancin therapy (EOTT). The secondary outcome was the percent of patients cured or improved three months after discontinuation of telavancin therapy. There were 32 cases of osteomyelitis with methicillin-resistant Staphylococcus aureus identified in 17 (56.7%), methicillin-sensitive Staphylococcus aureus 2(6.6%), coagulase negative staphylococci 6 (20.0%) and other pathogens, 5 (16.7%). At EOTT, 87.5% of patients had their osteomyelitis cured and 94.6% had the infection cured at three months after telavancin was completed. The most common adverse events associated with telavancin were gastrointestinal in nature (nausea (25.8%), vomiting (9.7%) and diarrhea (3.2%)) followed by metallic taste (6.5%). A favorable outcome was achieved for many patients receiving the antimicrobial regimen that included telavancin for the treatment of osteomyelitis.

Solitary Brain Mass in a Patient with Seizures: An Unexpected Infectious Etiology.

Neurocysticercosis is a parasitosis caused by the larval stage of the pork tapeworm Taenia solium. The diagnosis is challenging as morphology on neuroimaging can be inconclusive and serology is frequently negative. We describe the case of a 24-year old Hispanic man who presented with seizures and loss of consciousness. Magnetic resonance imaging (MRI) showed a cystic mass in right frontal lobe. Work-up that included body computed tomography (CT) scan and Western blot serology for Echinococcus and cysticercosis was unrevealing. He underwent craniotomy with resection of the mass. Histopathology showed fragments of Taenia solium. He was treated with albendazole for 14 days. No further seizures were noted at 6-month follow-up.

Disseminated cryptococcosis in HIV negative patient.

A 52-year-old white diabetic male with 4-weeks history of persistent cough followed by headache, drenching night sweats, low-grade fever, worsening photophobia, nausea and vomiting was presented. Examination was significant for photophobia and diminution of vision. His spinal fluid and blood cultures were positive for Cryptococcus neoformans Intravenous fluconazole were given for 2 weeks followed by oral fluconazole. There was significant improvement in systemic and ocular symptoms. HIV serology was negative, but his CD4 counts were low with inverted CD4:CD8 ratio.

Incidence, prevalence, and management of MRSA bacteremia across patient populations-a review of recent developments in MRSA management and treatment.

Methicillin-resistant Staphylococcus aureus (MRSA) infection is still a major global healthcare problem. Of concern is S. aureus bacteremia, which exhibits high rates of morbidity and mortality and can cause metastatic or complicated infections such as infective endocarditis or sepsis. MRSA is responsible for most global S. aureus bacteremia cases, and compared with methicillin-sensitive S. aureus, MRSA infection is associated with poorer clinical outcomes. S. aureus virulence is affected by the unique combination of toxin and immune-modulatory gene products, which may differ by geographic location and healthcare- or community-associated acquisition. Management of S. aureus bacteremia involves timely identification of the infecting strain and source of infection, proper choice of antibiotic treatment, and robust prevention strategies. Resistance and nonsusceptibility to first-line antimicrobials combined with a lack of equally effective alternatives complicates MRSA bacteremia treatment. This review describes trends in epidemiology and factors that influence the incidence of MRSA bacteremia. Current and developing diagnostic tools, treatments, and prevention strategies are also discussed.