Successful treatment of systemic Exophiala dermatitidis infection in a patient with chronic granulomatous disease.

Exophiala dermatitidis, one of the saprophytic dematiaceous fungi, is a rare cause of human infection that, when invasive, is nearly always fatal. Besides the more common subcutaneous infection usually caused by traumatic inoculation, infection can also spread hematogenously, in which case the organism has a distinct neurotropism. A patient with autosomal recessive chronic granulomatous disease of childhood who was found to have a progressive pulmonary and central nervous system infection with E. dermatitidis responded to an aggressive, multifaceted therapeutic approach. Scanning electron microscopy of the cultured conidiogenous cells confirmed that the manner of conidiogenesis is typical of the genus Exophiala. We report the first successful treatment of an infection involving the lungs and central nervous system by a combination of surgical resection of the pulmonary source and medical therapy with amphotericin B, flucytosine or ketoconazole, and transfused white cells, followed by a prolonged course of fluconazole.     

Multifocal phaeohyphomycosis caused by Exophiala xenobiotica in a kidney transplant recipient

In recent years, black fungi have been increasingly reported as causing opportunistic infections after solid organ transplantation. Here, we report a case of insidious, relentless, and multifocal Exophiala xenobiotica infection in a kidney transplant recipient that eventually required multiple surgical excisions along with oral and intravenous antifungal combination therapy using liposomal amphotericin B and posaconazole. We compare the present case with all previously reported cases of Exophiala infection after kidney transplantation.     

Phaeohyphomycotic infections in solid organ transplant patients

Phaeohyphomycoses are darkly pigmented fungi that rarely cause infection in immunocompetent persons. In the past 2 decades these fungi increasingly have been reported as pathogens that cause significant morbidity and mortality in the immunocompromised host, especially solid organ transplant recipients. Clinical manifestations range from superficial lesions to disseminated infections. Exophiala spp. and Alternaria spp. account for the great majority of these infections. Treatment should include complete surgical excision of the lesions that are accessible combined with antifungal therapy, especially when invasive or systemic infection is present. Itraconazole usually suffices if only subcutaneous lesions are present; however, if the infection is systemic or it involves the central nervous system, the addition of amphotericin B is required. New investigational azoles also should be considered in these types of infections. This is a very heterogenous group of fungi and as such the sensitivities to antifungal agents is variable. Therefore, sensitivities should be obtained on every fungal isolate.     

Pleuropulmonary infection due to Clostridium subterminale

Clostridial pleuropulmonary infection in a patient with suspected pulmonary embolism is described. Clostridium subterminale was recovered as the sole pathogen on several occasions despite antibiotic therapy. The patient died of cardiac failure after a complicated course in hospital. Clostridium subterminale is a rare pathogen and has not so far been reported as the sole cause of pleuropulmonary infection.     

Breakthrough Exophiala dermatitidis infection during prophylactic administration of micafungin during second umbilical cord blood transplantation after graft failure

Exophiala dermatitidis infections in patients with hematological malignancies are very rare. Our patient had a blood stream infection caused by E. dermatitidis following the second umbilical cord blood transplantation (UCBT) after graft failure during the first UCBT. To our knowledge, this is the first report describing a breakthrough fungal infection caused by E. dermatitidis during the prophylactic administration of micafungin (MCFG). Therefore, MCFG‐treated patients should be monitored for breakthrough E. dermatitidis infection during hematopoietic stem cell transplantation.     

Pulmonary infection with Mycobacterium neoaurum identified by 16S ribosomal DNA sequence

Mycobacterium neoaurum infection has rarely been found in humans, and only a limited number of cases have been reported. We describe the first case of pulmonary infection with M. neoaurum. We speculate that unrecognized aspiration and long-term corticosteroid therapy predisposed our patient to this rare mycobacterial infection.     

Colonic histoplasmosis in acquired immunodeficiency syndrome

Colonic histoplasmosis is a rare entity. There have been four previous reported cases within the population of patients with human immunodeficiency virus (HIV) infection. Because of the increasing incidence of HIV infection within regions where histoplasmosis is endemic, this condition may become more common. Gastrointestinal histoplasmosis has protean clinical manifestations, and symptoms are often nonspecific. Any patient with HIV infection who has unexplained GI symptoms should undergo evaluation for possible histoplasmosis. Aggressive long-term amphotericin B therapy has been effective in HIV patients with histoplasmosis. Resection or diversion of symptomatic colonic strictures caused by histoplasmosis may be necessary in addition to medical therapy.     

Successful treatment of disseminated Fusarium infection after autologous bone marrow transplantation for acute myeloid leukemia

Disseminated Fusarium is a rare but life-threatening infection of severely immunocompromised patients. A fatal outcome has been described in all reported cases of Fusarium infection occurring after bone marrow transplantation. We describe a patient who developed disseminated Fusarium infection with a secondary fungal endophthalmitis after an autologous bone marrow transplant for acute myeloid leukemia. This infection was successfully eradicated after neutrophil recovery by prolonged systemic administration of amphotericin B as well as aggressive local therapy including enucleation of the affected eye. The patient remains free of both leukemia and fungal disease more than 4 years after transplant.     

Bell''s palsy during interferon therapy for chronic hepatitis C infection in patients with haemorrhagic disorders

Two adult patients with life-long severe haemorrhagic disorders commenced on interferon-alpha2b therapy for chronic hepatitis C infection. Both developed Bell's palsy several weeks after commencing therapy, They were started on steroids and, in addition, the first patient discontinued interferon-alpha2b therapy while the second patient elected to continue with therapy. In both cases facial paralysis improved over the ensuing weeks. Bell's palsy is often idiopathic but has been reported. in association with herpesviruses. It is not a recognised complication of chronic hepatitis B or C infection, or interferon-alpha2b therapy. However, the interferons are associated with numerous adverse reactions including various neuropsychiatric manifestations and neurological syndromes. There are several reports of nerve palsies, including optic tract neuropathy, occurring during interferon therapy, and immune-based mechanisms are thought to play a role in the aetiopathogenesis. No reports of Bell's palsy in association with interferon therapy were identified in our literature search, although one possible case has been reported to the Committee of Safety in Medicine. Although Bell's palsy in our patients may have occurred by chance, a neuropathic effect of interferon-alpha2b on the facial nerve cannot be excluded and we urge physicians using interferons to be aware of this potential side-effect.     

Iatrogenic emphysematous pyelonephritis in a renal transplant patient

Abstract: Emphysematous pyelonephritis (EPN) is a rare condition that typically occurs in patients with diabetes mellitus, urinary tract obstruction, or immunosuppression such as solid organ transplant recipients. It has high mortality and frequently requires nephrectomy to achieve cure, although percutaneous drainage has been reported to be successful in some patients. We report a renal transplant recipient with underlying diabetes mellitus who developed iatrogenic EPN. The patient initially presented with dyspnea and was admitted for cardiac evaluation. There was no evidence of urinary tract infection at the time of admission. The patient developed high‐grade fever 3 days after admission. Despite intravenous (IV) antibiotic therapy, the patient developed acute renal failure requiring hemodialysis. Studies revealed Klebsiella bacteremia and EPN. We believe that urinary tract infection was precipitated by urinary bladder catheterization performed on the day of admission. Despite 2 weeks of IV antibiotic therapy, infection persisted with progressive extension of gas into the perinephric space on repeat imaging. The patient underwent a transplant nephrectomy with subsequent clinical recovery. This case illustrates that antibiotics alone are often inadequate to cure and preserve renal function in EPN despite immediate therapy. Furthermore, this patient underscores the risk of serious infection precipitated by urinary bladder catheterization in immunocompromised patients.     

Successful outcome of severe aplastic anemia following Epstein-Barr virus infection

Severe aplastic anemia has been reported in children following Epstein-Barr virus (EBV) infection. The pathophysiology of disease is not known, but an immunologic mechanism is suspected because of the rapid response to steroids. A patient with severe aplastic anemia following EBV infection experienced bone marrow recovery after treatment with high-dose prednisone. After reviewing the literature it is concluded that steroid therapy is indicated in this select group of patients.     

Septicemia, rash, and pulmonary infiltrates secondary to Corynebacterium group JK infection

This report describes a leukemic patient undergoing induction therapy in whom a Corynebacterium JK infection developed while he was leukopenic. The clinical triad of perirectal inflammation, skin lesions, and interstitial lung infiltrates, which has not previously been reported, is discussed. Characteristics of the organism and postulated routes of infection as well as treatment are explored.     

Spinal infection with Mycobacterium xenopi

M. xenopi is well recognised as a pulmonary pathogen, but musculoskeletal infection is rare. Spinal infection is reported in a patient with systemic lupus erythematosus who was on corticosteroid therapy.     

Bilateral leg swelling as the initial and predominant presentation of HIV and associated pulmonary arterial hypertension

Although mortality from HIV has decreased over the last several years as a result of effective antiretroviral therapy, the infection continues to pose significant morbidity. Pulmonary arterial hypertension (PAH), for instance, has been reported to occur in the setting of established HIV infection on only rare occasions and carries a universally poor prognosis. The current case report is unique in describing a previously well patient who presents initially with complaints of debilitating leg swelling and is subsequently diagnosed with HIV and associated PAH.     

Osteonecrosis multifocal asociada a infección por el virus de la inmunodeficiencia humana

The osteonecrosis has emerged in the last years as a potentially disabling osteoarticular complication in HIV-infected patients. There is a high prevalence of traditional risk factors for osteonecrosis development in these patients, but they also have factors associated to HIV infection in itself and the high activity antiretroviral therapy. The HIV-associated osteonecrosis often affects the hips, with a trend to bilaterally, but concomitant affection of 3 or more locations (multifocal osteonecrosis) has been infrequently reported. We present the case of a 49-years-old male patient, with long duration HIV infection and antiretroviral therapy, who developed osteonecrosis with concomitant affection of hips, knees, heels and tarsus.     

Exophiala jeanselmei infection in solid organ transplant recipients: report of two cases and review of the literature

M.H. Lief, D. Caplivski, E.J. Bottone, S. Lerner, C. Vidal, S. Huprikar. Exophiala jeanselmei infection in solid organ transplant recipients: report of two cases and review of the literature.
Transpl Infect Dis 2011: 13: 73–79. All rights reserved Abstract: Dematiaceous fungi are an opportunistic pathogen seen in solid organ transplant recipients. We report 2 cases of Exophiala infection and review the medical literature to summarize the spectrum of disease this pathogen can cause in this patient population.     

Calcific Constrictive Pericarditis With Refractory Hypokalemia in a Patient With Gitelman’s Syndrome

Calcific constrictive pericarditis can be idiopathic or associated with radiation therapy, surgery, infection, or autoimmune disorders. Gitelman’s syndrome is a distal renal tubular defect involving the thiazide-sensitive luminal sodium chloride cotransporter and has been associated with nephrolithiasis and chondrocalcinosis. There has not been any case of calcific constrictive pericarditis reported so far in association with Gitelman’s syndrome. We have reported a male patient with persistent hypokalemia and refractory ascites diagnosed with calcific constrictive pericarditis and Gitelman’s syndrome.     

Disseminated Nocardia brasiliensis infection with septic arthritis.

An unusual case of disseminated Nocardia brasiliensis infection is presented. The patient, who had been receiving chronic dexamethasone therapy for 4 years, had pneumonia and septic arthritis of the left knee due to N. brasiliensis. To our knowledge, this is the first report from the United States of a synovial joint infection with this organism. Disseminated disease due to N. brasiliensis is infrequently reported; it is most often seen in the immunocompromised patient and is often unresponsive to therapy.     

Ileal perforation caused by cytomegalovirus infection in a critically ill adult

Cytomegalovirus (CMV) infection of the gastrointestinal (GI) tract is common and is most often seen in patients with acquired immunodeficiency syndrome (AIDS), inflammatory bowel disease, or those receiving immunosuppressive therapy. CMV infection of the small bowel accounts for only 4.3% of all CMV infections of the GI tract. Isolated cases of small bowel perforation due to CMV have been reported in AIDS patients, and all but one patient has died. This article reports the first case of an ileal perforation due to transfusion-associated CMV infection in a critically-injured non-AIDS patient. Immediate surgical resection and antiviral therapy led to complete recovery. The development of abdominal pain, fever, watery diarrhea, and GI bleeding in a critically ill patient should prompt the clinician to consider the diagnosis of CMV enteritis. If standard stool pathogens and Clostridium difficile toxin studies are nondiagnostic, endoscopic evaluation and CMV serology should be obtained. If CMV infection is confirmed, ganciclovir therapy should be initiated without delay. If bowel perforation occurs. prompt surgical resection is indicated. A heightened level of suspicion for CMV infection in multiply injured trauma victims and other critically ill patients, with earlier recognition of potential small bowel involvement, can hopefully decrease the incidence of bowel perforation, which is usually a fatal event.     

Infliximab therapy for HIV positive Crohn's disease: A case report

Anti-TNF-alpha is now established as a major player in the treatment of Crohn's disease, however the use of anti-TNF-alpha therapy in patients concomitantly having HIV infection and Crohn's disease is a relatively unexplored subject. There is generally some apprehension and anxiety to use infliximab in patients with HIV. One case has been reported in literature of usage of anti-TNF-alpha in HIV positive patient with Crohn's disease who was on anti-retroviral therapy. We report for the first time the successful usage of infliximab in treating Crohn's disease in an HIV positive patient who is not on any anti-retroviral treatment.