Actinomyces-induced Osteomyelitis of the Mandible - A Rare Disease.

BACKGROUND: Actinomyces species are commensal oral cavity flora that can cause jaw osteomyelitis. Osteomyelitis of the jaw by Actinomyces is rare, and its presentation can be confused with many different pathologies. CASE PRESENTATION: This is the case of a 61-year-old female with breast cancer and on chemotherapy as well as non-invasive carcinoma of the tongue who initially presented to the dentist with white spots in the right mandible near the incisors associated with right mandible pain and swelling. Actinomyces-induced osteomyelitis of the mandible was diagnosed. The patient was treated with penicillin V for 6 weeks along with a course of hyperbaric oxygen therapy, which resulted in the complete resolution of the infection. CONCLUSION: In summary, jaw osteomyelitis caused by Actinomyces should always be part of the differential diagnosis; as these organisms are commensal flora, the symptoms manifested are nonspecific, and such a diagnosis could be easily missed, resulting in delay of care and disease progression.

Mycobacterium flavescens Infection - An Unusual Case of Prosthetic Joint Infection.

INTRODUCTION: The onset of prosthetic joint infections (PJIs) is characterized by early on-set defined as within 90 days of the procedure, delayed onset defined as within 3 to 12 months, and late onset defined as over 12 months. In only a scant number of case reports, Mycobacterium flavescens-associated infections are typically found in sputum cultures and associated with various forms of penetrating joint traumas, particularly post-surgical interventions. Due to its rarity in presentation among cases of PJIs, we have presented a case of PJI caused by Mycobacterium fla-vescens. CASE PRESENTATION: We have, herein, reported a case of a 70-year-old male presenting with stab-bing left knee pain over the past several months along with accompanying erythema and swelling with the presence of purulent discharge. Outpatient cultures have shown the growth of Mycobacte-rium flavescent; subsequently, the patient underwent a 2-stage revision arthroplasty and was treat-ed with a three-drug regimen and implant 5 months later. Although being an atypical cause of PJIs, we emphasize the importance of considering NTM as a differential for immunocompromised patients, especially those with prior surgical intervention. DISCUSSION: Mycobacterium spp. related PJIs manifest clinical features similar to other bacteria-causing PJIs, such as warm, indurated edema at the surgical site resulting in wound dehiscence and joint effusion. Diagnosis of Mycobacterium spp. related PJIs includes history and physical exami-nation findings, serum inflammatory markers, synovial fluid analysis, and culture. Concurrently with surgical interventions, utilization of antimicrobial agents provides additional control in My-cobacterium-related PJI. Mycobacterium flavescens should be included among other NTMs as a possible cause of PJIs.

Fusobacterium/Peptostreptococcus - A Case Report of Communityacquired Empyema Resulting in Surgical Decortication with Prolonged Antibiotic Therapy: A Case Series and Review of the Literature.

BACKGROUND: Infections caused by anaerobic bacteria occur frequently and can be serious and life-threatening. Anaerobes are a rare cause of community-acquired pneumonia with Streptococcus pneumonia and respiratory viruses being the most frequently detected pathogens. We, herein, report a case of Fusobacterium/Peptostreptococcus parapneumonic effusion with empyema in a patient without risk factors for aspiration pneumonia. This case presents an opportunity to discuss an unusual case of community-acquired empyema secondary to anaerobic infection in a patient without the common risk factors for aspiration. CASE PRESENTATION: A 59-year-old male patient without significant past medical history apart from a twenty-five-year history of smoking presented due to left flank pain and shortness of breath. Findings of a complicated parapneumonic effusion were found on imaging, resulting in surgical decortication and prolonged antibiotic therapy. DISCUSSION: Parapneumonic effusions and empyema are relatively common complications of pneumonia. It is important to note that the incidence of anaerobic empyema has been on the rise due to more modern culturing techniques. CONCLUSION: This case highlights an unusual presentation of community-acquired empyema secondary to anaerobes without any risk factors for aspiration pneumonia. Therefore, clinicians should consider the possibility of anaerobic coverage in the treatment of community-acquired empyema in the appropriate setting.

Structural, optical, and thermoluminescence characterizations of 1 mol% Dy3+ion-activated Fluro Boro-phosphate glass for photonic devices.

A novel Fluro boro-phosphate host matrix doped with the 1 mol% of Dy3+ ions (50B2O3 + 20P2O5 + 10TiO2 + 10SrCO3 + 4BaF2 + 5BaCO3 + 1Dy2O3) was prepared using a conventional melt-quenching mechanism, and its structural characteristics were explored through the Powder-XRD, FT-IR, FT-Raman, EDAX and SEM spectroscopic analysis. The XRD spectrum of the glass confirmed its non-crystalline or amorphous structure. FT-IR and FT-Raman spectrum studies revealed that various borate and phosphate groups present with a variety of stretching and bending vibrations. Scanning Electron Microscope (SEM) and Energy Dispersive X-ray analysis (EDAX) analysis have been used to examine the surface morphology and the presence of elements, respectively in the prepared glass. The optical absorption spectrum was used to explore the electronic band structure through the measurements of optical band-gap energy and Urbach energy. The luminescence spectrum reveals the emission characteristics of Dy3+ ions due to the electric-dipole and magnetic-dipole transitions. It is found that the decay time of the 4F9/2 excited level at a concentration of 1 mol% Dy3+ in the glass matrix is tri-fit non-exponential. The CIE chromaticity coordinates and the concentration influence on Y/B intensity ratios were computed for the creation of white light from the luminescence spectrum. The present work also discusses the findings after figuring out the correlated color temperature associated (CCT) with the color purity (Pe). The Thermoluminescence (TL) characteristics and the kinetic parameters of the glass were studied after the γ-irradiation with a dose of 2 kGy. EPR investigation revealed the paramagnetic characteristics through the hyperfine structure of Dy3+ ions and the electron-hole pair formation upon irradiation in the glass matrix.

Leptotrichia trevisanii: Case Report and Review of the Literature on Patients with Leptotrichia trevisanii Bacteremia in Acute Myeloid Leukemia.

BACKGROUND: Leptotrichia spp. are fastidious facultative anaerobic, pencil-shaped, gramnegative rods that reside in the mouths, intestines, and female genital tracts of humans. Bacteremia and septic shock have been rarely reported in the immunocompromised host. We report a case of L. trevisanii bacteremia in a patient recently diagnosed with acute myeloid leukemia (AML) on chemotherapy. CASE PRESENTATION: A 75-year-old male with a history of diabetes, chronic kidney disease, and coronary artery disease status post-CABG presented with neutropenic fevers and signs of sepsis after the initiation of chemotherapy. Blood cultures were ordered and extensive gene sequencing helped identify Leptotrichia trevisanii as the causative pathogen. Subsequently, the patient was successfully treated with empiric cefepime. DISCUSSION: Opportunistic pathogens are involved in a variety of diseases and have been isolated from immunocompromised patients undergoing transplantation or in patients with comorbidities, like leukemia, lymphoma, or neutropenia. L. trevisanii has been reported as a cause of bloodstream infections in patients with hematologic malignancies receiving chemotherapy. CONCLUSION: This case highlights the key role that Leptotrichia trevisanii plays in the introduction of sepsis among immunocompromised patients, particularly with hematologic malignancies, like AML, on chemotherapy.

Acute Colonic Perforation with Septic Shock Secondary to Disseminated Histoplasmosis in an Autologous Bone Marrow Transplant Recipient.

Histoplasma capsulatum is an opportunistic pathogen which can lead to a wide variety of clinical presentations in the immunocompromised host. Post-transplant histoplasmosis in hematopoietic cell transplant recipients is exceedingly rare, with an incidence of <1%. We present a case of acute caecal perforation resulting from disseminated histoplasmosis in a patient who had undergone autologous bone marrow transplant for plasma cell dyscrasia. This is a 71-year-old patient who initially presented due to progressive weakness associated with shortness of breath.

A Case of Primary Osteomyelitis of the Rib With Involvement of the Chest Wall, Presenting as a Non-Healing Abscess.

Coccidioidomycosis of the chest wall is a rare finding and diagnosis is often delayed. We report a case of chest wall abscess with underlying osteomyelitis and an expansile lytic lesion of the left fourth rib in a young and immunocompetent African American male. Initially, the diagnostic assumption gravitated towards bone malignancy, but the diagnosis of coccidioidomycosis was made when the culture results from the bone biopsy specimen confirmed Coccidioides immitis as the causative agent. The aim of this unique case is to demonstrate that as an emerging infectious agent, Coccidioides immitis is a known cause of chest wall abscess and should be considered among the differential diagnosis by clinicians.

Efficacy of VERIGENE® Blood Culture Assays in Accurately and Rapidly Detecting Gram-Negative and Gram-Positive Pathogens.

BACKGROUND: Rapid administration of appropriately indicated antibiotics is crucial in septic patients. Sepsis data supports that there is a higher risk of mortality for each hour delay from triage to antibiotic therapy, as well as for inappropriate antibiotic selection. There are a variety of rapid microbial detection systems, such as VERIGENE®, used in acute care facilities to rapidly detect bacteremia and identify resistance markers. Our study investigates the usefulness of VERIGENE® assays in accurately detecting Gram-positive and Gram-negative pathogens when compared to traditional blood culture analysis systems, such as VITEK®. METHODS: 819 Gram-positive and 373 Gram-negative blood samples were collected and tested using both VERIGENE® and VITEK®. Statistical tests were two-tailed and observations were defined as statistically significant if P ≤ 0.05. RESULTS: VERIGENE® detected a pathogen in 816/819 (99.6%) samples of the Gram-positive blood cultures and 367/373 (98.3%) samples of the Gram-negatives compared to 805/819 (98.3%) and 367/373 (98.4%), respectively, using VITEK®. Gram-positive cultures had a sensitivity of 99.5% and a specificity of 27.3% (PPV 99.0%, NPV 42.9%, 98.7% accuracy) with VERIGENE analysis. Gramnegatives had a sensitivity of 99.2% and a specificity of 20.0% (PPV 98.9%, NPV 25.0%, 98.4% accuracy). CONCLUSION: Although statistically insignificant (P = 0.25), VERIGENE® was 1.3% more likely to identify Gram-positive bacteria when compared to conventional methods. Overall, we concluded that VERIGENE® assays are valuable in their ability to rapidly detect microorganisms and resistance markers, given their high sensitivities. This allows for select targeted therapy in patients with sepsis and can ultimately reduce mortality rates.

Coccidioidomycosis Resulting in a Prosthetic Joint Infection in an Immunocompetent Patient after a Total Hip Arthroplasty: A Case Report and Review of the Literature.

INTRODUCTION/BACKGROUND: Coccidioidomycosis is a fungal infection that is a rare cause of prosthetic joint infection (PJI) in patients. CASE PRESENTATION: This case report describes an immunocompetent patient who had a right total hip arthroplasty (THA) complicated with Coccidioidomycosis. This patient is the 9th reported case of Coccidioidomycosis, causing a PJI and only the second case to be reported in a THA. Once progressed, it can be difficult to treat, often reoccurring and requiring repeat surgical and prolonged therapy. CONCLUSION: This study discusses the clinical presentation in this patient and reviews the literature on the currently published cases.

The Use of Single Therapy With Tocilizumab Versus Combination Therapy With Remdesivir and Tocilizumab in SARS-CoV-2 Patients in El Paso, Texas.

BACKGROUND: Currently, the management of SARS-CoV-2 varies with no definitive clinical guidelines, as scientific evidence across the globe differs in therapeutic options. This study intended to provide some clarity to the insufficient data based on the role of monotherapy with tocilizumab (TCZ) and combination therapy with remdesivir (RDV) and TCZ among patients with SARS-CoV-2 infection in El Paso, Texas. We evaluated the use of each therapy in the presence of steroids as the standard of care. METHODS:  One hundred and fifty-four SARS-CoV-2-infected patients from four different medical centers in El Paso, Texas, were screened, with 113 eligible for this longitudinal comparative observational study (February 1, 2020 to October 31, 2020). Group 1 (80 patients) received TCZ in the first 24 hours following admission, then methylprednisolone for the next 72 hours and group 2 (33 patients) were given TCZ as detailed in the single therapy group, plus RDV within the first 24 hours. Mann Whitney U test assessed median differences in laboratory biomarkers and Bivariate Logistic Regression assessed the odds of risk. An observation is considered statistically significant when P-value is ≤0.05. RESULTS: Patients in group 1 had a statistically significant lower odds for ventilation use than group 2 (OR=0.34, 95%CI=0.12-0.95, p=0.034), although no statistically significant difference in mortality outcomes was observed across groups (OR=0.43, 95%CI:0.13-1.39, p=0.269). CONCLUSIONS: We concluded that the use of TCZ in SARS-CoV-2-infected patients in El Paso, with or without RDV, reported no mortality benefit. However, some minimal/non-use of ventilation benefit was observed in group 1. Nonetheless, a randomized controlled trial study is recommended to ultimately determine the combination role of TCZ and RDV among this highly vulnerable group of patients.

Risk factors for mortality among patients with SARS-CoV-2 infection: A longitudinal observational study.

Recent literature suggests that approximately 5%-18% of patients diagnosed with severe acute respiratory syndrome coronavirus 2 may progress rapidly to a severe form of the illness and subsequent death. We examined the relationship between sociodemographic, clinical, and laboratory findings with mortality among patients. In this study, 112 patients were evaluated from February to May 2020 and 80 patients met the inclusion criteria. Tocilizumab was administered, followed by methylprednisolone to patients with pneumonia severity index score ≤130 and computerized tomography scan changes. Demographic data and clinical outcomes were collected. Laboratory biomarkers were monitored during hospitalization. Statistical analyses were performed with significance p ≤ .05. A total of 80 patients: 45 males (56.25%) and 35 females (43.75%) met the study inclusion criteria. A total of 7 patients (8.75%) were deceased. An increase in mortality outcome was statistically significantly associated with higher average levels of interleukin-6 (IL-6) with p value (.050), and d-dimer with p value (.024). Bivariate logistics regression demonstrated a significant increased odds for mortality for patients with bacterial lung infections (odds ratio [OR]: 10.83; 95% confidence interval [CI]: 2.05-57.40; p = .005) and multiorgan damage (OR: 103.50; 95% CI: 9.92-1079.55; p = .001). Multivariate logistics regression showed a statistically significant association for multiorgan damage (adjusted odds ratio [AOR]: 94.17; 95% CI: 7.39-1200.78; p = .001). We identified three main predictors for high mortality. These include IL-6, d-dimer, and multiorgan damage. The latter was the highest potential risk for in-hospital deaths. This warrants aggressive health measures for early recognition of the problem and initiation of treatment to reverse injuries.

Early use of tocilizumab in the prevention of adult respiratory failure in SARS-CoV-2 infections and the utilization of interleukin-6 levels in the management.

Respiratory failure in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection appears related to cytokine release syndrome that often results in mechanical ventilation (MV). We investigated the role of tocilizumab (TCZ) on interleukin-6 (IL-6) trends and MV in patients with SARS-CoV-2. In this longitudinal observational study, 112 patients were evaluated from 1 February to 31 May 2020. TCZ was administered followed by methylprednisolone to patients with >3L oxygen requirement and pneumonia severity index score ≤130 with computed tomography scan changes. IL-6, C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), D-dimer, and procalcitonin were monitored on days 0, 3, and 6 of therapy. Statistical analyses were performed with significance ≤0.05. Eighty out of 112 SARS-CoV-2-positive patients (45 males, 56.96%; 34 females, 43.04%) were included in this study. Seven patients expired (8.75%) and nine patients required MV (11.25%). Median IL-6 levels pre-administration of TCZ was 342.50 (78.25-666.25) pg/mL compared with post-administration on day 3 (563; 162-783) pg/mL (P < .00001). On day 6, the median dropped to 545 (333.50-678.50) pg/mL compared with day 3 (P = .709). CRP, ferritin, LDH, and D-dimer levels were reduced after TCZ therapy. Early use of TCZ may reduce the need for MV and decrease CRP, ferritin, LDH, and D-dimer levels. The sequential use of methylprednisolone for 72 hours seems to potentiate the effect and prolong the suppression of the cytokine storm. IL-6 levels may be helpful as a prognostic tool.

T9-T10 Osteomyelitis, Epidural Abscess and Cord Compression Secondary to Mycobacterium abscessus: A Case Report.

BACKGROUND: We report a case of spinal abscess/osteomyelitis at the T9-T10 levels in a non-immunocompromised patient who presented with lower extremity weakness secondary to a Mycobacterium abscessus infection. This patient was successfully treated with surgical debridement with amikacin-tigecycline-imipenem triple therapy before and after her debridement. Outcomes and treatment with this rare cause of epidural abscess/osteomyelitis are not well defined at this time. CASE REPORT: Clinical Presentations with this species of mycobacterium are usually systemic with patients presenting with pulmonary and soft tissue infections. The primary presentation of spinal epidural abscess/osteomyelitis is unusual, especially when there is no primary focus such as a lung infection or concurrent bacteremia. CONCLUSION: This paper presents a new case of spinal osteomyelitis without a primary source in addition to 10 previously reported M. abscessus cases. The treatment plans and outcomes suggest that surgical debridement along with a macrolide-based combination therapy should be considered a definitive treatment against Mycobacterium abscesses.

Early use of tocilizumab in respiratory failure associated with acute COVID -19 pneumonia in recipients with solid organ transplantation.

As of May 14, 2020, the World Health Organization has reported approximately 4.3 million cases of the novel Coronavirus Disease (COVID-19) with approximately 294,046 deaths worldwide [1]. Solid organ transplant recipients who are on chronic immunosuppressants fall within a special population of COVID-19 patients since they are more susceptible to complications secondary to COVID-19. Currently, we do not have data on treating COVID-19 patients with solid organ transplants with tocilizumab, an interleukin-6 (IL-6) inhibitor. We report a case of COVID-19 in a patient with a kidney and liver transplant and discuss the early use of tocilizumab to prevent the cytokine storm and attempt to reduce the likelihood of progression to Acute Respiratory Distress Syndrome (ARDS). In addition, we present other COVID-19 related transplant cases reported in the literature outlining the presenting clinical signs and outcomes.

Are coinfections with COVID-19 and influenza low or underreported? An observational study examining current published literature including three new unpublished cases.

As the coronavirus disease-2019 (COVID-19) pandemic continues, one major point of uncertainty is the impact this novel pathogen will have during the upcoming 2020 to 2021 flu season. While the influenza virus is a known contributor to human morbidity and mortality, the question of how a coinfection between COVID-19 and influenza might manifest is of utmost concern. The aim of this study was to review the limited cases of COVID-19/influenza coinfection currently available in the literature, along with cases in the community of El Paso, TX, to determine whether any patterns of clinical presentation and morbidity emerged. An international review of the literature was conducted. Six published articles describing COVID-19/influenza coinfection were identified, with a total of 13 patients described therein. Three additional patients were identified from the El Paso, TX data. The most common presenting symptoms were fever and cough. The most common laboratory findings were elevated C-reactive protein and lymphocytopenia. Thirteen patients presented with viral pneumonia findings on CT, and nine had findings of ground-glass opacity. Finally, complications were reported in six patients, with most common complication being acute respiratory distress syndrome. The results of the review indicate that, due to the similarity in presentation between COVID-19 and influenza, further analysis will be required to understand the effects of coinfection on morbidity and mortality. However, the limited number of coinfection cases in the literature indicates that the implementation of COVID-19 control measures may continue to play a role in limiting the spread of these human respiratory pathogens.

Prosthetic joint infection due to Mycobacterium moriokaense in an immunocompetent patient after a total knee replacement.

Nontuberculous mycobacteria (NTM) are a rare cause of prosthetic joint infection (PJI) that is documented to affect immunocompromised patients primarily. In this case report, we describe an immunocompetent patient with a rare case of PJI caused by Mycobacterium moriokaense after a total knee replacement. This patient is the eighth reported case of PJI caused by NTM and the first reported case in an immunocompetent individual. Because PJI caused by NTM is rare and difficult to treat, it is essential to include it in the differentials during initial workup of suspected PJI, especially in the context of negative preliminary bacterial cultures.

Proposed Guidelines for the Management of ESBL in Prosthetic Joint Infections.

The aim of this paper is to establish guidelines for the management of extendedspectrum beta-lactamases (ESBL) associated prosthetic joint infections (PJI). This study reviewed 21 patients in the literature documented with ESBL associated PJI. Literature suggests that patients with ESBL PJI are stratified into either early infections (<3 weeks) or late infections (>3 weeks), for which, appropriate laboratory and imaging studies need to be completed. Favorable outcomes require a two-stage revision with an antibiotic-impregnated spacer and a prolonged course of intravenous carbapenem antibiotic.

Cytomegalovirus Retinitis Diagnosis and Treatment in a Kidney Transplant Recipient.

Cytomegalovirus retinitis is a rare complication in kidney transplant patients with only one other reported incidence. A 70-year-old female with a previous history of kidney transplant began experiencing a decreased vision of her right eye and was diagnosed with CMV retinitis and started on ganciclovir treatment. After completing the treatment, the patient has had no signs of recurrence or any other complaints. There is only one other published case report of CMV retinitis in a kidney transplant patient, therefore appropriate treatment and predictability of recurrence are unknown.

Legionella pneumophila Pneumonia in Pregnancy: A Case Report and Review of the Literature.

L. pneumophila is an unusual cause of pneumonia with a prevalence of 2.7%, and it is even more uncommon in pregnancy. To date, only 11 cases of Legionnaire's Disease in pregnancy have been reported, though this small number could possibly be attributed to underdiagnoses and under documentation. Case Presentation: In this paper, we present a 31-year-old Hispanic female, gravida 4, para 1 from the southwest United States who presented with a 3-week history of fever, worsening cough, dyspnea on exertion, and hypoxemia. Chest x-ray showed bibasilar infiltrates, with positive serology for Legionella IgM and IgG (1:250 and 1:640 respectively), as well as positive urinary antigen. Despite appropriate treatment with azithromycin 500 mg, she continued to have dyspnea and mild respiratory distress. Conclusion: Upon follow up, mother and fetus initially remained stable without any signs of sequelae from Legionnaire's disease, but the patient miscarried 5 weeks after the second admission to the hospital. The chest x-ray eventually cleared up after almost 21 days of azithromycin.

Spontaneous Chest Abscess Caused by Salmonella Enterica subsp. Arizonae in the Desert Southwest; A Case Report and Review of the Current Literature.

Salmonella enterica subspecies arizonae is a rare pathogen but has been reported in the literature in immunosuppressed and rarely immunocompetent patients. Most disease states have been reported in animals and reptiles. Human exposure has resulted in a range of complications from skin and soft tissue infections to bacteremia and periprosthetic joint infections. Predisposing factors such as age, comorbidities, and use of Mexican folk healing practices increase the risk of developing an infection. S. arizonae has been associated with gastrointestinal infections in several parts of the country and on rare occasions have been isolated from skin and soft tissues, prosthetic joints, and empyema. Case: This is a unique case of a large de novo chest abscess that developed in a 59-year-old diabetic male from the Southwest region with cultures growing Salmonella enterica subspecies arizonae. This patient presented without predisposing factors and did not appear to be ill at the time of admission. He was treated successfully by aspirating the abscess along with a 2-week course of ceftriaxone intravenously.