Abstract Cryptococcal infections account for approximately 8% of all invasive fungal infections in solid organ transplant recipients and typically occur 16 to 21 months after transplantation. Cryptococcal infection should be considered for any transplant recipient who presents with altered sensorium and fever. Analysis should include opening pressure measurement, cryptococcal antigen testing, cell count with differential, and glucose and protein levels. Initial treatment should consist of a lipid formulation of amphotericin B and flucytosine for at least 2 weeks, followed by high-dose fluconazole for 8 weeks and then lower doses of fluconazole for 6 to 12 months or possibly longer.
A 39-year-old male, who recently underwent a composite valve graft of the aortic root and ascending aorta for bicuspid aortic valve and aortic root aneurysm, was hospitalized for severe sepsis, rhabdomyolysis (creatine kinase 29000 U/L), and severe liver dysfunction (AST > 7000 U/L, ALT 4228 U/L, and INR > 10). Cardiac magnetic resonance imaging (MRI) findings were consistent with sternal osteomyelitis with a 1.5 cm abscess at the inferior sternotomy margin, which was contiguous with pericardial thickening. Aspiration and culture of this abscess did not yield any organisms, so he was treated with vancomycin and cefepime empirically for 4 weeks. Because this patient was improving clinically on antibiotics and did not show external signs of wound infection, there was no compelling indication for sternectomy. This patient’s unusual presentation with osteomyelitis and rhabdomyolysis has never been reported and is crucial for clinicians to recognize in order to prevent delays in diagnosis.
Infection is a potentially life-threatening complication of cardiovascular implantable electronic device (CIED) therapy. Since the large majority of these cases are due to staphylococcal species, scant data exist for CIED infections (CIEDI) due to gram-negative bacilli (GNB). We retrospectively screened our institutional device database from 1992 to 2016 to identify cases of CIEDI due to GNB. Infections within 12 weeks following implantation or last invasive device manipulation were defined as early-onset. Relapse was described as infection with the same organism despite device explantation and appropriate antimicrobial therapy, based on susceptibility results. Of the 827 CIEDI cases during the study period, only 32 (4%) were caused by GNB. Median patient age was 65 years (SD±14), and 78 % (25/32) were male. Early-onset infection was the more common presentation [53% (17/32)]. Regardless of timing of onset, the majority [75% (24/32)] presented with generator pocket infection, of whom 3 (13%) had lead erosion. Five patients presented with bloodstream infection, 4 had concomitant pocket infection, and 1 had no signs of local infection. CIED-related endocarditis was seen in 9% (3/32) of patients. Two patients had a primary infection at a different anatomical site with the same causative organism 6 months prior to presentation. The most common organisms were Pseudomonas aeruginosa (22 %, 7/32) and Serratia species (19 % 6/32). Most (94 %, 30/32) patients underwent complete device removal. Antimicrobial duration was based on infection syndrome and 50% completed therapy with an oral antibiotic. Only 2 patients had infection relapse and one of them died due to septic shock following device extraction. CIEDI due to GNB are uncommon, and most patients present with early-onset generator pocket infection. Cure is achievable with complete device removal and pathogen-directed antimicrobial therapy. For local infection, patients can be switched to oral antimicrobials, based on susceptibility data, after device explanation to complete 10 to 14 days of treatment. Infection relapse is rare. M. R. Sohail, Medtronic Inc.: Consultant and Grant Investigator, Consulting fee and Research grant; Boston Scientific: Consultant, Consulting fee
Background.Pre-travel healthcare for immunocompromised travelers (ICTs) presents various challenges.ICTs are at high risk of travel-related infections, have contraindications to live vaccines, and may produce inadequate serologic responses to inactivated vaccines.Additionally, antimalarial and antidiarrheal medications may interact with immunosuppressants.Our study aims to assess pre-travel healthcare among ICTs at our Travel and Tropical Medicine Clinic (TTMC).Methods.This retrospective review of 321 ICTs from 2004 to 2015 included 134 solid organ transplant recipients (SOTRs), 121 autoimmune disease, 46 inflammatory bowel disease (IBD), and 20 human immunodeficiency virus (HIV) patients.Variables included duration and destination of travel, immunosuppressants, hepatitis A and B vaccinations and serologic tests, gamma-globulin use, antimalarial and antidiarrheal prophylaxis, live vaccinations, travel-related illnesses, and trip cancellations.Results.Three hundred twenty-one ICTs traveled abroad 453 times and visited 561 locations.The most popular travel region was sub-Saharan Africa (15.3%, 86 of 561 visits).A total of 38.9% (125 of 321 ICTs) traveled to malaria-endemic regions.A total of 37.4% (121 of 321) planned high-risk activities, and 4.7% (15 of 321) were advised to cancel such plans.A total of 7.8% (25 of 321) experienced travel-related illness.SOTRs were on the largest number (3) of immunosuppressants.A total of 5.3% (17 of 321) were counseled regarding interactions with antimalarial and antidiarrheal prescriptions.Adherence to hepatitis A and B vaccinations was 58.9% (93 completed, 158 recommended) and 49.2% (29 completed, 59 recommended), respectively.Postvaccination hepatitis A and B serologic testing was recommended in 19.3% (62 of 321) and 5.3% (17 of 321) of ICTs, respectively.Gamma-globulin was given for 4.4% (14 of 321).19.6% (63 of 321) had a medical exemption to yellow fever vaccination.Conclusion.Many ICTs continue to travel and some to high-risk and malaria-endemic regions.There is a low rate of vaccination and serologic testing for hepatitis A and B. Gamma-globulin use is infrequent.Although there was a low rate of travel-related illnesses and drug interactions, counseling for ICTs should emphasize adherence to pre-travel recommendations.
A 24-Year-Old Traveler With an Insect Bite and Rash (See page 1314 for the Photo Quiz.)Diagnosis: Cutaneous leishmaniasis.Cultures in "triple N" media (Novy-MacNeal-Nicolle) from the skin biopsy grew Leishmania panamensis, also confirmed with Leishmania polymerase chain reaction (PCR) and DNA sequencing.A wet mount obtained from cultures showed aggregates of Leishmania promastigotes (Figure 1).Biopsy showed epidermal ulceration and suppurative granulomas with many plasma cells with negative Gömöri methenamine silver, Gram, Periodic acid-Schiff, Giemsa, Fite, and acid-fast bacilli stains.He subsequently received a 10-day (total 30 mg/kg) course of intravenous liposomal amphotericin B. His lesions slowly regressed over 3 months.Leishmaniasis is a parasitic disease caused by >20 species of Leishmania, which are transmitted by female sandflies.Infection can lead to visceral, cutaneous (CL), or mucocutaneous (MCL) forms of leishmaniasis depending on the species [1,2].Viscerotropic species such as Leishmania donovani enter the reticuloendothelial system to cause the visceral form of leishmaniasis.Dermotropic species such as Leishmania major remain close to the inoculation site and cause CL.Certain species such as Leishmania (Viannia) braziliensis migrate to the oropharyngeal mucosa to cause MCL [2].Our patient was
A fit and healthy 22 year old of Asian ancestry, living in New Zealand with no previous history of asthma or dermatitis, visited the Gold Coast, Queensland, for a vacation. Having been cautioned about the intensity of the Australian sun, he arrived armed with a hat and new SPF130 sunscreen that he had obtained from Japan. On the third day of his vacation he noticed the appearance of many erythematous papules and some vesicles on the dorsum of the forearm, arm and the 'v' of the neck. His face was spared. On the fourth day, the papules coalesced to form swollen, warm, very pruritic, erythematous plaques (Figure 1). The patient commenced taking loratadine 10 mg per day, but did not improve after seven days of treatment.
A 26-year-old woman with paranoid schizophrenia was admitted to the medical intensive care unit with septic shock requiring intubation and mechanical ventilation. The source of septic shock was not identified despite obtaining CT of the chest/abdomen/pelvis, bronchoalveolar lavage and microbiological results for tracheal secretions, blood, urine and cervix. An indium-111 tagged white cell count scan was subsequently performed, revealing increased right anterior deltoid uptake. Owing to serial increases (up to 1310 U/L) in serum creatine kinase and a history of local intramuscular paliperidone injections for management of schizophrenia, surgical exploration was performed and identified necrotising skeletal muscle inflammation and extensive fat necrosis with an organising abscess, consistent with pyomyositis. A gram stain of purulent fluid revealed gram-positive cocci, but no organisms grew in culture. The patient recovered after 10 days of daptomycin and 7 weeks of wound care. Paliperidone injections were discontinued and oral risperidone was initiated.
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