Vertebral osteomyelitis and discitis are rare entities. Enterococci are a major cause of bacteremia and infective endocarditis. Enterococci spreading hematogenously to the spine is a rare phenomenon, with very few cases identified to date. This is the first report of 2 cases of vertebral osteomyelitis/discitis caused by Enterococcus faecalis in dialysis patients.
We report a case of a 79-year-old woman who was admitted to the hospital with a soft-tissue infection, caused by Actinomyces israelii. With no history of trauma to chest, we hypothesize that the organism disseminated hematogenously from an endogenous site, such as the oral cavity, gastrointestinal tract, or genital tract. Cutaneous actinomycosis is rare and is described following external trauma, usually to hands or feet; hypodermic needle exposure; and as part of postoperative wound infection.
Primary central nervous system lymphoma (PCNSL) is a rare form of non-Hodgkins lymphoma of the central nervous system and eye. It is over 1000 times greater in HIV positive than in non-HIV populations. The decline in its incidence since the introduction of the highly active anti-retroviral therapy (HAART) suggests an association of this tumor with severe and prolonged immunosuppression. Clinical presentation results from neurological deficits related to the site of the tumor. Systemic B symptoms are also common. The detection of EBV DNA from the CSF, by nested PCR, is a highly sensitive and specific for HIV-related PCNSL. We present the case of a 31-yearold African American man with medical history significant for AIDS who presented with one-month history of lack of energy and somnolence. CSF appearance was normal. MRI suggested primary CNS lymphomas or toxoplasmosis. CSF EBV DNA by PCR was found to be positive. The clinical presentation of PCNSL is similar to that of toxoplasmosis encephalitis in patients diagnosed with HIV. The initial differentiation between the two pathologies on presentation is important since treatment differs and early treatment has been shown to reduce mortality.
To the Editor: Splenic abscess is an uncommon clinical entity with an incidence of 0.14% to 0.7%.1 The common causative organisms are aerobic. Anaerobic organisms such as clostridial species are rarely implicated. We present a case of an elderly woman with splenic abscess that grew Clostridium perfringens. CASE REPORT A 64-year-old woman presented with a 2-week history of left upper quadrant abdominal pain associated with fever, nausea, vomiting, and diarrhea. She denied any history of recent antibiotic use, travel, or sick contacts. Patient had a colonoscopy 4 years before presentation which revealed a polypoid leiomyoma in the sigmoid colon; a follow-up colonoscopy a year later revealed hyperplastic polyps in the transverse colon that were removed. History was otherwise noncontributory. On examination, patient was in mild distress because of abdominal pain. Vital signs showed a temperature of 36.4°C and a pulse rate of 110/min. Abdominal examination was significant for left upper quadrant tenderness and splenomegaly. The rest of the physical examination finding was unremarkable. Laboratory data showed marked leukocytosis (white blood cell count of 21.8 × 103/mm3 with 82% neutrophils and 7% bands) and C-reactive protein of 17.5 mg/dL. The rest of the laboratory results were within normal limits. Chest radiograph revealed an elevated left hemidiaphragm. Computed tomography (CT) of the abdomen with contrast revealed an air-fluid level along the posterior part of the spleen consistent with an abscess (Fig. 1). The patient was empirically started on intravenous piperacillin-tazobactam and had a CT-guided percutaneous catheter drainage of the abscess. Abscess drain cultures were positive for C. perfringens, and the antibiotics were changed to ampicillin-sulbactam. Stool was negative for Clostridium difficile toxin. Blood cultures were negative. An echocardiogram of the heart revealed no valvular vegetations. Malignancy workup was negative. Colonoscopy revealed adenomatous polyps in the transverse colon, and she underwent polypectomy. The patient was discharged on intravenous clindamycin for dosage convenience. Her condition improved, and serial abdominal CT scans done over the next few weeks revealed a decrease in the abscess size. The drain was removed after she completed a 6-week course of antibiotics.FIGURE 1: Computed tomography of the abdomen with contrast showing air-fluid level in the spleen.She presented with similar complaints 4 weeks later. A repeat CT of the abdomen revealed recurrence of the splenic abscess. She then underwent splenectomy; dense adhesions were noted along the splenocolic ligament on exploratory laparotomy. She was discharged uneventfully on postoperative day 8. DISCUSSION Splenic abscess is rare with a subtle clinical presentation and requires a high index of suspicion. The most common clinical features are fever, left upper quadrant pain, and splenomegaly.2 Diagnosis is mainly radiological. Ultrasonography is a good noninvasive technique, but CT has the highest sensitivity and specificity.2 Aerobic organisms are the most common organisms isolated and include staphylococcus and streptococcus species, salmonella, and Escherichia coli1-3; anaerobes account for 10% only. Most of the cases reported in the past due to clostridial species had predisposing factors such as malignancy, colitis, hematologic diseases, diabetes, or trauma.4-7 A review of literature revealed 2 reported cases of splenic abscess due to C. perfringens6,8; one had trauma as a predisposing cause, and the other one speculated diabetic microvascular injury as a possible factor. The source of C. perfringens in our patient remained obscure except for the history of diarrhea suggesting colitis and repeated polypectomies with breach in colonic mucosa acting as a possible portal of entry.
A 55-year-old woman presented to the hospital with vomiting and epigastric pain for 3 weeks and coffee-ground vomitus for 1 day. She reported 6 kg of weight loss over a 1-month period. The patient had been sexually active with the same male partner for the past 20 years but reported her partner to be promiscuous. Physical examination was remarkable for epigastric tenderness. CT of the abdomen showed mural thickening of the stomach (figure 1). Upper endoscopy showed erythema and friable mucosa with nodularity (figure 2).Multiple biopsies revealed gastric syphilis with interstitial metaplasia, and immunostaining showed numerous Treponema pallidum (figures 3 and 4). Rapid plasma reagin (RPR) titre was 1:128 (normal: non-reactive). The patient received one dose of intramuscular penicillin G 2.4 million units and reported full resolution …
The next morning the patient had meningismus and a tempera-Fusobacterial Cerebritis and Myelitis Presenting as Acute ture of 100.4ЊF.An emergent lumbar puncture was performed, Paraplegia in an Elderly Man with Congenital Heartand this procedure yielded yellow-green purulent material.
A 59-year-old man presented to the emergency department with complaints of dysphagia, right-sided neck swelling, fever and chills. Physical examination was remarkable for fever and tender swelling over the right side of the neck. Laboratory investigations revealed leucocytosis with neutrophilia. CT of the neck showed right internal jugular vein thrombosis with an overlying abscess and a nodular opacity in the right lung apex with air locules. He underwent surgical drainage of the neck abscess. Aerobic cultures from the drainage and blood cultures grew Streptococcus anginosus . Given his initial complaint of dysphagia, upper endoscopy was performed which showed a mass in the upper oesophagus. Histopathology confirmed squamous cell carcinoma. The patient received 6 weeks of antibiotics therapy.
