Lesson of the month 1: A cough that doesn't fit the mould

Aspergillus disease has a wide spectrum of manifestations within the lungs; however invasive Aspergillus is most commonly associated with immunocompromise or pre-existing respiratory disease. Here we present a case of Aspergillus tracheobronchitis causing right middle lobe collapse, masquerading as late-onset asthma in a patient with no pre-existing risk factors following massive inhalation of Aspergillus spores from working with compost. This case highlights the importance of having a high index of suspicion for Aspergillus-related disease even in those with no traditional risk factors.

[Maxillary sinus infection by Bacillus licheniformis: a case report from Djibouti]

Aerobic, spore-forming gram-positive Bacillus spp infections are rare and reported mainly in immunocompromised hosts. We report a case of acute unilateral maxillary sinusitis, caused by Bacillus licheniformis, in a 35-year-old French soldier stationed in Djibouti. It was easily identifiable due to its typical culture and resistance profile. This case is interesting for two reasons: first, it is, to our knowledge, the first case of sinusitis attributed to this microbe, and second, it has rarely been described in immunocompetent patients without altered skin or mucous membranes.

[Pneumococcal arthritis in an immunocompetent adult]

Les infections à pneumocoques sont avant tout respiratoires, ORL et méningées. Les infections ostéoarticulaires à pneumocoque ont la particularité de survenir dans moins de 20% des cas chez l'adulte sain. Habituellement, un ou plusieurs facteurs favorisants sont retrouvés. Toutefois, nous rapportons lors de cette observation le cas d'une arthrite à Streptococcus pneumoniae chez un adulte immunocompétent sans facteurs prédisposant. Patient âgé de 66 ans, diabétique de type II, a été hospitalisé pour une décompensation acido-cétosique et une monoarthrite du genou droit. Ce patient était fébrile (39°C) et présentait un genou droit inflammatoire en flexion avec rougeur et chaleur locale et un choc rotulien. Une ponction articulaire avec d'autres examens ont été réalisés pour confirmation d'une arthrite septique à pneumocoque. Le résultat de la ponction articulaire réalisée a montré un liquide jaune citron trouble avec 480 000 leucocytes/mm³ à prédominance polynucléaires neutrophiles. L'examen direct a montré des coccis à Gram positif en diplocoque, la culture a permis d'isoler un Streptococcus pneumoniae sensible à la pénicilline G. L’évolution clinique et biologique de l'arthrite du genou était favorable. Un déficit immunitaire, un asplénisme anatomique ou fonctionnel peuvent être en cause. L'alcoolisme est un facteur favorisant mais le mécanisme n'est pas clairement élucidé. La présence de matériel prothétique, peut favoriser une localisation septique. Ces facteurs de risque doivent être systématiquement recherchés, notamment en cas d'infection grave ou récidivante, une antibioprophylaxie ou une vaccination pouvant être proposées chez les sujets à haut risque.

[Mycobacterium simiae pneumonia: a case report]

We report a case of Mycobacterium simiae pneumonia in an immunocompetent women aged 55 years, after a stay in Thailand. The diagnosis was based on culture isolation of non-tuberculous mycobacteria from bronchoalveolar lavage. The culture isolate was identified as M. simiae by biochemical and molecular methods. The patient was treated. Her condition remained stable for 5 years. During the sixth years, a relapse occurred, and a new treatment was prescribed. This is a rare case in view of the absence of any predisposing factor. M. simiae should be considered a possible causative agent of pulmonary disease, even in immunocompetent patients.

Visceral basidiobolomycosis: An overlooked infection in immunocompetent children

Visceral basidiobolomycosis is an unusual fungal infection of viscera caused by saprophyte Basidiobolus ranarum. It is very rare in healthy children and poses a diagnostic challenge due to the non-specific clinical presentation and the absence of predisposing factors. We report a case of gastrointestinal basidiobolomycosis in a 4-year-old healthy girl who presented with a short history of abdominal pain, bleeding per rectum, fever, and weight loss. The diagnosis was based on high eosinophilic count, classical histopathology findings of fungal hyphae (the Splendore-Hoeppli phenomenon), and positive fungal culture from a tissue biopsy. Fungal infection was successfully eradicated with a combined approach of surgical resection of the infected tissue and a well-monitored course of antifungal therapy. The atypical clinical presentation, diagnostic techniques, and the role of surgery in the management of a rare and lethal fungal disease in an immunocompetent child are discussed.

[Cold thoracic parietal abscess in immunocompetent individuals]

Les abcès froids de la paroi thoracique représentent une forme rare et inhabituelle de tuberculose extrapulmonaire. Sa fréquence est estimée à moins de 5% des tuberculoses ostéoarticulaires, évaluées elles-mêmes à 15% des tuberculoses extrapulmonaires. L'objectif de ce travail est de rapporter la prise en charge diagnostique et thérapeutique de cette localisation dans notre structure. Etude rétrospective portant sur 18 cas colligés au service des maladies respiratoires du centre hospitalier universitaire Ibn Rochd de Casablanca, sur une période de 13 ans. La moyenne d’âge était de 34 ans (21-57). Un antécédent de tuberculose traitée était relevé dans un cas. Le tableau clinique était révélé par l'apparition insidieuse d'une masse pariétale de taille, de consistance et de siège variables. A l'imagerie thoracique, l'abcès pariétal était associé à une lyse osseuse dans sept cas, une atteinte parenchymateuse et pleurale dans quatre cas chacune et des adénopathies médiastinales dans deux cas. La confirmation diagnostique était bactériologique et/ou histologique dans tous les cas. La sérologie du virus de l'immunodéficience humaineétait négative chez tous nos malades. L’évolution sous traitement antibacillaire couplé ou non à une résection chirurgicale était favorable chez tous nos malades. Malgré la fréquence de la tuberculose dans notre contexte, la localisation pariétale thoracique reste rare, survenant chez une population non immunodéprimée et non toxicomane, contrairement à ce qui est souvent rapporté dans la littérature. Les abcès froids tuberculeux représentent une forme rare de tuberculose extrapulmonaire dont l’évolution reste favorable sous traitement précoce et bien conduit.

Rare zoonotic infection with Microsporum persicolor with literature review

We report a case of dermatophytosis caused by Microsporum persicolor in a 38-year-old male from Poland. Direct microscopic examination revealed high amounts of fungal hyphae from the right elbow material. The mould recovered in multiple cultures was identified as Microsporum persicolor by molecular identification based on partial of β-tubulin gene (BT2), internal transcribed spacer, partial small ribosomal subunit (SSU) and large ribosomal subunit, partial translation elongation factor (TEF1) and RNA polymerase second largest subunit (RPB1) loci sequence data. The patient was treated with terbinafine. Clinical and mycological cure was achieved with this regimen and the patient was subsequently followed for 1 year without relapse. Microsporum persicolor is a very rare causative agent of dermatophytosis worldwide. The source of infection for the patient remained unclear and zoonotic transmission could not be confirmed.

Serum procalcitonin levels in patients with primary pulmonary coccidioidomycosis

RATIONALE

The serum procalcitonin assay has emerged as a promising biomarker to distinguish between bacterial and viral respiratory tract infections but has not been used to differentiate coccidioidomycosis from bacterial infection. A correlation between procalcitonin serum levels and coccidioidomycosis has never been reported.

OBJECTIVE

To determine any association between serum procalcitonin levels and primary pulmonary coccidioidomycosis.

METHODS

We identified and enrolled 20 immunocompetent patients with symptomatic primary pulmonary coccidioidomycosis of < 8 weeks' duration and performed a one-time procalcitonin assay, with a cutoff of < 0.25 μg/L indicating a nonbacterial infection.

MEASUREMENTS AND MAIN RESULTS

Nineteen of 20 patients (95%) had serum procalcitonin of < 0.25 μg/L. The median procalcitonin level was 0.05 μg/L (range, < 0.05-0.87 μg/L; interquartile range, 0.05-0.05 μg/L). Sixteen of 20 patients (80%) had undetectable procalcitonin of < 0.05 μg/L. The four patients with detectable procalcitonin had a median value of 0.2 μg/L (range, 0.09-0.87 μg/L).

CONCLUSIONS

In this pilot study, procalcitonin was not elevated in immunocompetent patients with primary pulmonary coccidioidomycosis at a median of 32 days after symptom onset. Larger prospective studies are needed to confirm this finding.

Case of cytomegalovirus colitis in an immunocompetent patient: a rare cause of abdominal pain and diarrhea in the elderly

Cytomegalovirus (CMV) colitis usually occurs in immunocompromised patients after undergoing organ transplantation or chemotherapy. We report the case of a 60-year-old immunocompetent Japanese woman who presented with abdominal pain and bloody diarrhea. She was initially diagnosed as having ischemic colitis with pseudomembranous colitis on the basis of her symptoms, Clostridium difficile antigen positivity, and colonoscopic findings, which showed ulcer formation from the sigmoid colon to rectum. In spite of bowel rest and administration of metronidazole, her symptoms did not improve. On follow-up colonoscopy, ulcerations remained unchanged. Biopsy of the ulceration revealed CMV-infected cells leading to a diagnosis of CMV colitis. CMV colitis is a rare but possible differential diagnosis in immunocompetent patients. We recommend endoscopic biopsy in a case of refractory abdominal pain and bloody diarrhea.

Disseminated Cryptococcal infection in an immunocompetent host mimicking plasma cell disorder: a case report and literature review

Cryptococcosis is a potentially fatal fungal infection caused mainly by Cryptocococcus neoformans (CN) species and it rarely infects immunocompetent hosts. The outcomes are better only if the condition is suspected and diagnosed early and treatment is instituted.

Adrenal and hepatic aspergillosis in an immunocompetent patient

Invasive aspergillosis, an infection most frequently induced by Aspergillus fumigatus and Aspergillus flavus, typically occurs in immunocompromised patients and is usually transmitted through inhalation of Aspergillus spores. As the lungs are by far the most common site involved in invasive aspergillosis and invasive aspergillosis in immunocompetent hosts is very rare, there have been a few case reports of extra-pulmonary, disseminated invasive aspergillosis in immunocompetent persons. Herein, we report a case of an adult, male, immunocompetent patient with disseminated invasive aspergillosis that successively spread from the right adrenal gland to the left hepatic lobe. The patient was successfully treated through surgical excisions of his adrenal and hepatic masses followed by voriconazole therapy. To our knowledge, this is the first case report of invasive aspergillosis affecting the adrenal glands.

[Cryptococcal meningitis and bone tuberculosis in an immunocompetent: a case]

Les auteurs rapportent un cas de cryptococcose neuroméningée (CNM) chez un patient de 39 ans, non infecté par le VIH suivi pour une tuberculose de hanche. Le tableau clinique était celui d'une méningite subaiguë. Le diagnostic a été possible grâce à la mise en évidence de cryptocoques dans le LCR. L’évolution a été satisfaisante sous fluconazole.

Non-healing genital herpes mimicking donovanosis in an immunocompetent man

Although atypical presentations of herpetic infection in immunocompetent individuals are common, they very rarely have the extensive, chronic and verrucous appearances seen in the immunocompromised host. We report a case of genital herpes manifesting as painless chronic non-healing genital ulcers with exuberant granulation tissue in an immunocompetent man. Owing to this morphology, the ulcers were initially mistaken for donovanosis. To the best of our knowledge, such a presentation of genital herpes in an immunocompetent individual has not been described previously.

Candida glabrata and Candida tropicalis in an immunocompetent patient: a case report

OBJECTIVE

To report a case of Candida glabrata and tropicalis pneumonia in an immunocompetent patient.

CASE SUMMARY

A 72-year-old male was transferred from an outside institution due to worsening respiratory status, acute kidney injury secondary to intravenous contrast media, sepsis, and pneumonia with fever and leukocytosis. Upon admission, he was initiated on treatment for hospital-acquired pneumonia, but was also concomitantly tested for many other opportunistic infections due to his recent month-long trip to Ecuador where he participated in a tribal treatment for neuropathy that involved direct exposure to dead guinea pigs. With completion of cultures and bronchoalveolar lavage, C. glabrata was identified in the blood culture and C. glabrata and C. tropicalis in the bronchoalveolar lavage specimen. One month later, he was admitted due to recurrent pneumonia. The patient unfortunately expired during the second admission, due to complications from chronic respiratory pulmonary disease and pneumonia.

DISCUSSION

Initially, this patient was treated for hospital-acquired pneumonia, but due to a recent trip to Ecuador, it was soon discovered that this patient had developed an invasive Candida pneumonia. His pulmonary biopsies showed growth of invasive C. glabrata and C. tropicalis, while his blood culture showed C. glabrata. Candida-related lower respiratory tract infections are exceptionally rare in immunocompetent patients and require histopathologic evidence to confirm the diagnosis. A second blood culture showed that the C. glabrata was still present and the patient had worsening leukocytosis, so micafungin was added to his antimicrobial therapy.

CONCLUSION

It is understood that pneumonia is rarely caused by Candida species in patients who are admitted to the hospital. However, health care professionals should be aware that Candida pneumonia should be suspected as part of the differential diagnosis even in immunocompetent patients, particularly if they have recently traveled outside the United States.

Lumbosacral actinomycosis in an immunocompetent individual: An extremely rare case

Actinomycosis is a gram positive commensal bacteria. In predisposed individuals like immunocompromised patients, it can cause myriad lesions involving virtually any organ of the body. Involvement of spinal cord with its compression is rare though. We are reporting here a case of 30-year-old immunocompetent male who presented with weakness of left lower limb. Radiologically differential diagnosis was tuberculosis or lymphoma of spinal cord. Histopathology showed actinomycotic colonies that were periodic Schiff (PAS) positive and revealed gram positive filamentous bacteria.

Misdiagnosis of invasive pulmonary aspergillosis: a clinical analysis of 26 immunocompetent patients

The clinical feature of invasive pulmonary aspergillosis (IPA) in immunocompromised patients is well studied in the past decades. While the manifestations of IPA in immunocompetent patients remain unclear. The purpose of this study was to determine the clinical and radiological manifestations of invasive pulmonary aspergillosis (IPA) in patients without immunosuppression, as well as the reasons for the misdiagnosis of IPA. We retrieved and retrospectively reviewed the records of 102 patients from whom surgical lung specimens of chronic inflammatory granulomas were harvested. 26 patients were eventually diagnosed with pulmonary aspergillosis on Grocott methenamine silver staining. We investigated these patients in detail. We found that the rate of misdiagnosis before the lung surgery was as high as 73%. The most common symptom was hemoptysis, and the main feature in radiology was nodule or mass lesion. Air crescent sign or Halo sign were not common in our study. The atypical radiological manifestations and non-specific clinical findings make the diagnosis of IPA difficult and lead to a high misdiagnosis rate.

Clinical in vestigation of misdiagnosis of invasive pulmonary aspergillosis in 26 immunocompetent patients

The clinical features of invasive pulmonary aspergillosis (IPA) in immunocompromised patients is well studied in the past decades. While the manifestations of IPA in immunocompetent patients remain unclear.The purpose of this study was to determine the clinical and radiological manifestations of invasive pulmonary aspergillosis (IPA) in patients without immunosuppression, as well as the reasons for the misdiagnosis of IPA. We retrieved and retrospectively reviewed the records of 102 patients from whom surgical lung specimens of chronic inflammatory granulomas were harvested. 26 patients were eventually diagnosed with pulmonary aspergillosis on Grocott methenamine silver staining. We investigated these patients in detail. We found that the rate of misdiagnosis before the lung surgery was as high as 73%. The most common symptom was hemoptysis, and the main feature in radiology was nodule or mass lesion. Air crescent sign or Halo sign were not common in our study. The atypical radiological manifestations and non-specific clinical findings make the diagnosis of IPA difficult and lead to a high misdiagnosis rate.

Unusual presentation of duodenal plasmablastic lymphoma in an immunocompetent patient: A case report and literature review

Plasmablastic lymphoma (PBL) is a rare and recently described entity of large B-cell lymphoma. It predominantly occurs in the oral cavity of human immunodeficiency virus (HIV)-positive patients and exhibits a highly aggressive clinical behavior without effective treatment. Recently, sporadic cases describing PBL in extraoral locations of HIV-negative patients have been reported; frequently in patients with underlying immunosuppressive states. To develop the understanding of PBL, the current study reports the unusual presentation of duodenal PBL and reviews the pathogenesis, immunohistochemical features, clinical and differential diagnoses, as well as the treatment of PBL as described in previous studies. The case of a 75-year-old female with duodenal PBL without definite immunosuppression is presented in the current report. The tumor was composed of large B-cell-like cells, and was positive for cluster of differentiation 138 and melanoma ubiquitous mutated-1, with ~80% of the tumor cells positive for Ki-67. The features of the tumor were as follows: Extraoral location, HIV-negative, immunoglobulin M λ-type M protein expression, light chain restriction (monoclonal) and Epstein-Barr virus-encoded small RNA-negative, which are considered to be unusual for PBL. These unusual features complicate the differentiation of PBL from other plasma cell diseases. To the best of our knowledge, this is the first study to report a case of duodenal PBL in an immunocompetent patient. To date, the standard treatment of PBL remains elusive, however, the most commonly administered chemotherapy treatments are CHOP [intravenous cyclophosphamide (750 mg/m², day 1), intravenous doxorubicin (50 mg/m², day 1), intravenous vincristine (1.4 mg/m², day 1) and prednisone (100 mg, days 1–50)]-like regimens. The patient was administered two cycles of CHOP chemotherapy for 56 days, however, ultimately succumbed as a result of disease progression. Therefore, PBL represents a diagnostic and therapeutic challenge. PBL must be considered in the differential diagnosis of gastrointestinal tumors in daily practice, even in immunocompetent patients. Furthermore, CHOP does not appear to be an optimal treatment regimen and more intensive regimens are required.

Characteristics of Cytomegalovirus Uveitis in Immunocompetent Patients

PURPOSE

To present the clinical characteristics of patients with anterior uveitis who had evidence of cytomegalovirus (CMV) infection on polymerase chain reaction PCR-based assays for viral DNA in aqueous samples.

METHODS

This was a retrospective observational case series of 16 patients with CMV infection on qualitative polymerase chain reaction PCR-based assays for viral DNA in aqueous samples. Case records of 16 patients were reviewed and relevant clinical information was collected using a standardized data sheet.

RESULTS

There were 10 male and 6 female patients, with 16 eyes included. The median age at the first attack was 52 years (range 27-77 years). Thirteen patients (81.3%) presented with an initial BCVA of 20/40 or better. Eleven eyes (68.8%) had anterior chamber inflammation of 1+ cells or less. Eight eyes (50.0%) had concomitant sectoral iris atrophy, while 2 eyes were noted to have heterochromic irides. Eleven patients (68.8%) presented with an elevated intraocular pressure. Seven patients (43.8%) had clinical features that led to a presumptive diagnosis of Posner-Schlossman syndrome, while 3 patients (18.8%) were initially diagnosed with Fuchs heterochromic iridocyclitis. Six patients were initially treated for uveitic glaucoma or anterior uveitis of unknown cause.

CONCLUSIONS

There is a spectrum of clinical manifestations of CMV anterior uveitis. A high index of suspicion of a possible viral etiology, especially CMV, and subsequent accurate identification of the virus involved are fundamental to the overall therapeutic approach.

Disseminated cutaneous herpes zoster in an immunocompetent elderly patient

Herpes zoster is a clinical syndrome which usually presents with a localized, vesicular rash in a dermatomal distribution. Cutaneous dissemination rarely occurs in immunocompetent patients, therefore little is known about the baseline demographic, clinical characteristics, management and outcome of these patients. Herein, we report a case of disseminated cutaneous herpes zoster in an immunocompetent patient along with a review and analysis of 28 cases previously reported in the literature.