Ureaplasma septic arthritis in an immunosuppressed patient with juvenile idiopathic arthritis.

Mycoplasmas, including Ureaplasma and Mycoplasma species, are uncommon but important causes of septic arthritis, especially affecting immunosuppressed patients. Many of the reported cases have been associated with congenital immunodeficiency disorders, especially hypogammaglobulinemia. Mycoplasmas are difficult to grow in the laboratory, and these infections may be underdiagnosed using culture techniques. We report a case of a 21-year-old woman with juvenile idiopathic arthritis and hip arthroplasties treated with rituximab and adalimumab who developed urogenital infections and soft tissue abscesses followed by knee arthritis with negative routine cultures. Ureaplasma species was identified from synovial fluid on 2 separate occasions using a broad-range 16S ribosomal RNA gene polymerase chain reaction. Azithromycin led to rapid improvement in symptoms, but after completion of therapy, involvement of the hip prosthesis became apparent, and again, 16S rRNA gene polymerase chain reaction was positive for Ureaplasma species. The literature is reviewed with a discussion of risk factors for Mycoplasma septic arthritis, clinical presentation, methods of diagnosis, and treatment.

Case report: false negative serum cryptococcal latex agglutination test in a patient with disseminated cryptococcal disease.

A case of false-negative serum latex agglutination cryptococcal antigen (CRAG) test in a 45-year-old HIV-positive male with Cryptococcus-positive culture is described. The patient was presented to a hospital in Botswana, with breathlessness and a diffuse papular rash. His CD4 count was 25 cells/µL. Despite the suspicion for disseminated cryptococcal disease, an initial serum CRAG latex test was negative. Results of subsequent Indian ink staining, culture of cerebrospinal fluid and skin scrapings, and serum lateral flow immunoassay (LFA) were all positive for Cryptococcus neoformans. There are several possible explanations for the false-negative CRAG latex test. Given the positive LFA result, we speculate that disease may have been caused by Cryptococcus gattii, which is estimated to be responsible for between 15% and 30% of all cryptococcal diseases in Botswana. Reduced sensitivity of CRAG latex assays for detecting C gattii may lead to underdiagnosis of cryptococcal infection.

From the Medical Board of the National Psoriasis Foundation: Vaccination in adult patients on systemic therapy for psoriasis.

Patients with moderate to severe psoriasis often require systemic immunomodulatory medications that place them at risk for infection. Vaccination is a proven strategy to reduce infections. However, vaccination rates among patients with inflammatory autoimmune conditions, including psoriasis, remain low. We review the literature regarding vaccine-preventable illness and vaccinations commonly used in the United States in patients older than 18 years on immunosuppressive therapies that are used in the treatment of psoriasis. The medical board of the National Psoriasis Foundation recommends that dermatologists counsel patients on updating vaccinations in accordance with recommendations of the Advisory Committee for Immunization Practices as any measures taken to prevent infection can increase the safety of immunomodulatory therapies.

Acute respiratory infections in a recently arrived traveler to your part of the world.

Many acute infectious pulmonary diseases have incubation periods that are long enough for travelers to have symptoms after returning home to a health-care system that is not familiar with "foreign" infections. Respiratory infections have a relatively limited repertoire of clinical manifestations, so that there is often nothing characteristic enough about a specific infection to make the diagnosis obvious. Thus, the pathway to the diagnosis of infections that are not endemic in a region relies heavily on taking a thorough history of both itinerary and of specific exposures. One important caveat is that on occasion, the history of a recent trip creates an element of "tunnel vision" in the evaluating health-care provider. It is tempting to relate a person's problem to that recent trip; however, when evaluating recent returnees, it is always important to remember that the travel may have nothing to do with the patient's presentation. Recent travel may add diagnostic considerations to the list of possibilities, but an astute clinician must not disregard the possibility that the patient's illness has nothing to do with the recent trip.

Travel immunizations.

Advising travelers on vaccine-preventable illnesses is increasingly becoming the responsibility of primary care physicians. The approach to vaccine recommendations should be based on a thorough assessment of the risks for travel-related diseases, the time available before trip departure, and current knowledge of the epidemiology of vaccine-preventable diseases. Routine childhood vaccinations should be reviewed in all travelers and updated as necessary. Yellow fever vaccination may be required for entry by countries that lie within a yellow fever zone or for travelers coming from an endemic area to prevent introduction of the disease. Immunization against hepatitis B virus should be considered in travelers who expect to have close contact with local populations that have high rates of hepatitis B transmission. Japanese encephalitis vaccine should be offered to travelers who plan prolonged trips to rural areas in southeast Asia or the Indian subcontinent during the transmission season. Typhoid fever immunization is recommended for travelers who may be exposed to potentially contaminated food and drink. Preexposure rabies vaccination should be considered in travelers who plan a prolonged duration of stay in a remote area or who engage in activities that might involve working near animals or that could attract animals. Physicians should be aware of the adverse events and contraindications associated with each travel vaccine.

Fever in the returned traveler.

With the rising popularity of international travel to exotic locations, family physicians are encountering more febrile patients who recently have visited tropical countries. In the majority of cases, the fever is caused by a common illness such as tracheobronchitis, pneumonia, or urinary tract infection. However, fever in returned travelers always should raise suspicion for a severe or potentially life-threatening tropical infection. In addition to the usual medical history, physicians should obtain a careful travel history, a description of accommodations, information about pretravel immunizations or chemoprophylaxis during travel, a sexual history, and a list of exposures and risk factors. The extent and type of lymphadenopathy are important diagnostic clues. Altered mental status with fever is an alarm symptom and requires urgent evaluation and treatment. Malaria must be considered in patients who traveled even briefly within an endemic area. Enteric fever is treated with fluoroquinolones, dengue fever with supportive measures only, leptospirosis with penicillin or doxycycline, and rickettsial infections with doxycycline.

Prevention of malaria in travelers.

Malaria is a major international public health problem, responsible for considerable morbidity and mortality around the world each year. As travel to tropical locations increases, U.S. physicians are being asked more frequently to provide recommendations for malaria prevention. An organized approach to reducing the risk of acquiring this disease is necessary. Physicians must review the itineraries of their patients in detail, paying particularly close attention to travel within malaria-endemic areas and drug-resistant zones. Appropriate chemoprophylaxis must be chosen to reduce the risk of acquiring malaria. It also is important to provide advice on the use of protective measures that reduce the risk of mosquito bites. Finally, travelers should be instructed to seek medical attention immediately if symptoms of the disease develop during or after the trip.

Eosinophilic meningitis.

Eosinophilic meningitis is a rare clinical entity that can be useful in narrowing the differential diagnosis of central nervous system disease. It is defined by the presence of 10 or more eosinophils/microL in the cerebrospinal fluid (CSF) or a CSF eosinophilia of at least 10%. The most common cause is invasion of the central nervous system by helminthic parasites, particularly Angiostrongylus cantonensis, but other infections as well as noninfectious conditions may also be associated. This review describes the etiologies of eosinophilic meningitis, focusing primarily on the helminths that cause CSF eosinophilia.