Single Center Experience with Isolated Spinal Cord Neurosarcoidosis.

INTRODUCTION: Isolated spinal cord neurosarcoidosis is extremely rare. The potential implications of long-term immunosuppressant therapy make correct diagnosis imperative. However, there are challenges inherent in isolated spinal cord involvement that require a multidisciplinary approach. Here we present the largest series of definite and possible isolated spinal neurosarcoidosis and discuss our institutional experience in managing this rare but morbid condition. METHODS: A retrospective review was performed to identify all neurosarcoidosis cases starting from 2002 to 2020 at our institution. Patients were screened for cases of isolated spinal neurosarcoidosis. A descriptive analysis was performed for each case. RESULTS: A total of 64 cases of neurosarcoidosis were identified. The spine was involved in 26 (40.6%) patients. Only 4 (6.3%) cases had isolated spinal cord involvement. A full medical and imaging workup was performed in determining isolated spinal cord involvement. Three patients subsequently underwent surgical biopsy, and 1 did not undergo biopsy because of patient preference. One of the patients who underwent biopsy had an initial nondiagnostic biopsy and had a repeat biopsy. Corticosteroids were employed in all cases with additional immunosuppressive agents for maintenance therapy and refractory cases. All showed radiographic improvement and were clinically stable to improved. CONCLUSION: Isolated spinal cord involvement of neurosarcoidosis is rare and can present challenges in diagnosis. A biopsy can be performed when necessary. However, a biopsy of the spinal cord carries inherent risks and may not always be possible or result in a nondiagnostic sample. In the setting of high clinical suspicion, maximal medical therapy is still employed.

Case Report: Severe COVID-19 in a Kidney Transplant Recipient Without Humoral Response to SARS-CoV-2 mRNA Vaccine Series.

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Non-infectious thoracic discitis: A diagnostic and management dilemma. A report of two cases with review of the literature.

Discitis/ Osteomyelitis is an inflammatory process involving an intervertebral disc and the adjacent vertebral bodies. Infection is the most common cause of discitis, which is often spontaneous and hematogenous in origin. However, many noninfectious processes affecting the spine such as pseudarthrosis in ankylosing spondylitis, amyloidosis, destructive spondyloarthropathy of hemodialysis, Modic changes type 1, neuropathic arthropathy, calcium pyrophosphate dehydrate (CPPD) spondyloarthropathy and gout can mimic infectious discitis/ osteomyelitis. To determine whether a particular patient's spinal process is due to an infectious versus non-infectious cause can be challenging. Although clinical findings and laboratory studies including erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) can be helpful in the diagnosis of bacterial discitis/osteomyelitis due to their high sensitivity; however, their specificity is low. Moreover, both the infectious and non-infectious discitis can appear quite similar on the imaging studies. We present two cases of thoracic discitis with adjacent vertebral osteomyelitis of probable non-infectious etiology. Both were managed with instrumented fusion for stabilization. We also discuss a range of noninfectious causes of discitis/spondylitis and their radiological features which can help differentiate from infectious processes.

Urinary tract infection and drug-resistant urinary tract infection after intradetrusor onabotulinumtoxinA injection versus sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: Intradetrusor onabotulinumtoxinA (BTX) and sacral neuromodulation (SNM) are effective treatments for refractory urgency urinary incontinence/overactive bladder (UUI/OAB). BTX carries a risk of urinary tract infection (UTI), which is concerning for the development of multidrug resistant (MDR) UTI. We hypothesized that BTX might carry a higher risk of UTI and MDR UTI compared with SNM and that UTI and MDR UTI risk might increase after repeat BTX injection. METHODS: This retrospective cohort study included women undergoing BTX or SNM for refractory UUI/OAB in 2012-2016. UTI and MDR UTI were assessed up to 1 year post-treatment or until repeat treatment and compared between initial BTX and SNM and between repeat BTX injections. Univariate analyses included Chi-squared and Fisher's exact tests and generalized linear models (GLM) with logit link function. Multivariate analyses used GLM to assess the best predictor variables for any UTI. RESULTS: One hundred and one patients were included (28 BTX, 73 SNM). Rates of UTI (39.3% [95% CI 21.5, 59.4] BTX vs 37.0% [95% CI 26.0, 49.1] SNM) were similar in the two groups at all time intervals. One MDR UTI occurred after SNM. Risk of UTI did not increase with repeat BTX (11 out of 28 [39.3%], 6 out of 17 [35.3%], and 4 out of 7 [57.1%] after 1, 2, and ≥ 3 treatments respectively; p = 0.62). Multivariate analysis found that history of recurrent UTI (OR 2.5, 95%CI 0.98-6.39) and prolapse repair (OR 4.6, 95%CI 1.23-17.07) had increased odds of UTI. CONCLUSIONS: Rates of UTI were similar in patients undergoing BTX and SNM. MDR UTI was rare. Patients with prior prolapse repair or recurrent UTI may be at a higher risk of UTI after either procedure.

Myocardial infection due to Fusobacterium nucleatum.

Fusobacterium nucleatum is an anaerobic gram-negative bacillus, which inhabits the oropharynx, gastrointestinal tract, and female genital tract. Infections classically affect the head and neck. We report a patient with a myocardial mass due to F. nucleatum, initially thought to be a neoplasm, and discuss anaerobic cardiac infections.

Treatment approaches including fecal microbiota transplantation for recurrent Clostridium difficile infection (RCDI) among infectious disease physicians.

BACKGROUND: Clostridium difficile infection (CDI) was the most common nosocomial infection in the U.S. in 2010. Most cases of CDI respond to a standard course of antibiotics, but recurrent C. difficile infections (RCDI) are increasingly common. Given the lack of randomized clinical trials, it is important to understand how infectious disease physicians are managing RCDI to inform future clinical research. METHODS: An electronic survey was conducted among members of the Emerging Infections Network (EIN) in October 2012. Respondents were asked to answer specific questions about their treatment approaches toward patients with CDI, including fecal microbiota transplantation (FMT). RESULTS: The overall response rate was 621/1212 (51%). The vast majority of respondents had cared for small to moderate numbers of patients with CDI over the prior 6 months, and reported recurrence rates were consistent with published data. Preferred treatment regimens for RCDI showed significant variance from recommendations published in national guidelines. Eighty percent (424/527) of the respondents would consider FMT for patients with RCDI, and of 149 who had FMT available at their institution, 107 (72%) had actually treated >1 patient with FMT in the preceding year. However, significant barriers to institutional adoption of FMT remain for many respondents, despite very good success rates with its use. CONCLUSIONS: Physicians who regularly care for patients with CDI use a variety of treatment approaches for treating severe or recurrent CDI cases. The results of our survey demonstrate that FMT is used by a growing number of infectious disease providers as an effective and safe treatment alternative for patients with multiple recurrences of C. difficile infection.

The precision of human-generated hand-hygiene observations: a comparison of human observation with an automated monitoring system.

We compared the observations of nearly 1,400 hand-hygiene-related events recorded by an automated system and by human observers. Observation details differed for 38% of these events. Two likely explanations for these inconsistencies were the distance between the observer and the event and the busyness of the clinic.

Travel and tropical medicine practice among infectious disease practitioners.

BACKGROUND: Infectious disease specialists who evaluate international travelers before or after their trips need skills to prevent, recognize, and treat an increasingly broad range of infectious diseases. Wide variation exists in training and percentage effort among providers of this care. In parallel, there may be variations in approach to pre-travel consultation and the types of travel-related illness encountered. Aggregate information from travel-medicine providers may reveal practice patterns and novel trends in infectious illness acquired through travel. METHODS: The 1,265 members of the Infectious Disease Society of America's Emerging Infections Network were queried by electronic survey about their training in travel medicine, resources used, pre-travel consultations, and evaluation of ill-returning travelers. The survey also captured information on whether any of 10 particular conditions had been diagnosed among ill-returning travelers, and if these diagnoses were perceived to be changing in frequency. RESULTS: A majority of respondents (69%) provided both pre-travel counseling and post-travel evaluations, with significant variation in the numbers of such consultations. A majority of all respondents (61%) reported inadequate training in travel medicine during their fellowship years. However, a majority of recent graduates (55%) reported adequate preparation. Diagnoses of malaria, traveler's diarrhea, and typhoid fever were reported by the most respondents (84, 71, and 53%, respectively). CONCLUSIONS: The percent effort dedicated to pre-travel evaluation and care of the ill-returning traveler vary widely among infectious disease specialists, although a majority participate in these activities. On the basis of respondents' self-assessment, recent fellowship training is reported to equip graduates with better skills in these areas than more remote training. Ongoing monitoring of epidemiologic trends of travel-related illness is warranted.

Upward trend in dengue incidence among hospitalized patients, United States.

International travel and a global expansion of dengue fever have the potential to increase the incidence of dengue in the United States. We conducted a retrospective cohort analysis of trends in dengue among hospitalized patients by using the National Inpatient Sample (2000-2007); the number of cases more than tripled (p<0.0001).

The TGF-beta response to Leishmania chagasi in the absence of IL-12.

Cure of leishmaniasis requires a type 1 immune response characterized by IFN-gamma production. Leishmania major infection leads to a type 2 response suppressing cure of susceptible BALB/c mice, and L. major causes an exacerbated type 2 response in mouse strains with a gene knockout (KO) such that they lack IL-12p40 (IL-12KO mice). In contrast, type 1 responses are inhibited by TGF-beta without Th2 cell expansion in BALB/c mice infected with L. chagasi. We questioned whether the type 2 or the TGF-beta response would dominate during L. chagasi infection of IL-12KO mice. C57BL/6 mice developed self-resolving L. chagasi infection with abundant IFN-gamma. In contrast, L. chagasi disease was exacerbated and IFN-gamma was low in IL-12KO mice. Total TGF-beta was significantly higher in IL-12KO than control C57BL/6 mice, but IL-4 and IL-10 levels were similar. TGF-beta was further augmented in IL-12/IFN-gamma double-KO mice. Thus, in contrast to L. major, the TGF-beta response was exacerbated whereas type 2 cells were not expanded during L. chagasi infection of IL-12KO mice. We conclude that L. chagasi has an inherent propensity to elicit a prominent TGF-beta response that either suppresses, or is suppressed by, a type 1 response. We propose this be termed a "type 3" immune response, which can antagonize a type 1 response.