Cryptococcal Pleuritis in an Immunocompetent Patient: A Case Report and Literature Review

Cryptococcosis, primarily an opportunistic infection, often occurs in immunocompromised patients but can also affect immunocompetent individuals. Cryptococcosis typically manifests in the lungs, but pleurisy is rare, particularly in immunocompetent patients. This report details a case of cryptococcal pleuritis in a 74-year-old immunocompetent male with a history of heart failure, presenting initially with pleural effusion. Diagnostic challenges arose due to the initial absence of intrapulmonary lesions. The diagnosis was eventually established through a surgical biopsy and tissue culture, revealing Cryptococcus neoformans. This case underscores the complexity of diagnosing cryptococcal infections, particularly in immunocompetent patients, and highlights the need for considering cryptococcosis in differential diagnoses of lymphocyte-predominant exudative pleural effusions.

Streptococcus agalactiae Meningitis in an Immunocompetent Adult: A Case Report and Literature Review

Streptococcus agalactiae is a rare cause of meningitis in healthy adults. We herein report a case of culture-negative Streptococcus agalactiae meningitis in a healthy adult which was diagnosed using the FilmArray Meningitis and Encephalitis Panel. A healthy 22-year-old man presented with a fever, headache, and neck stiffness. Despite negative results from blood and cerebrospinal fluid cultures, the diagnosis was confirmed using the FilmArray Meningitis and Encephalitis Panel. The patient was treated with dexamethasone, vancomycin, and ceftriaxone, and thereafter recovered completely. This report highlights the importance of being aware that Streptococcus agalactiae meningitis can occur in healthy individuals, and summarizes these features.

Herpes Zoster in a 13-Year-Old Male Without Prior Varicella Infection

Herpes zoster (HZ) typically presents following reactivation of latent varicella-zoster virus (VZV) in adult and geriatric patients with a history of prior varicella infection. Primary VZV infection in patients compliant with vaccine schedules and without any immunocompromising condition is rare, with reactivation leading to HZ being even rarer. This case report details one such example involving a 13-year-old immunocompetent and fully immunized male with HZ despite no history of VZV infection, as well as possible explanatory mechanisms for this uncommon presentation. This case report contributes to a growing body of literature on atypical HZ presentations in pediatric populations without any history of prior VZV infection or exposure.

An Unusual Case of an Immunocompetent Adult Diagnosed With Cytomegalovirus Colitis

Cytomegalovirus (CMV) infections are typically considered opportunistic in individuals with immunosuppressive conditions such as human immunodeficiency virus/acquired immunodeficiency syndrome, underlying malignancies, organ or bone marrow transplantation, and those receiving chemotherapeutics or steroids. Nevertheless, there is a significant increase in reported instances of CMV infections globally, suggesting that even individuals with a healthy immune system might experience these infections. In such cases, the primary symptoms are typically related to the gastrointestinal system, such as ulcerative colitis, pseudopolyps, tumors, and ischemic and hemorrhagic enterocolitis. We present a unique instance of severe CMV colitis in a patient with a fully functioning immune system. The diagnosis of CMV colitis was determined through the histological analysis of biopsy tissues acquired during colonoscopy.

Cytomegalovirus detected by qPCR in iris and ciliary body of immunocompetent corneal donors

BACKGROUND

Cytomegalovirus (CMV) can cause a wide panel of ocular infections. The involvement of CMV as a cause of anterior uveitis in the immunocompetent patient is recent and remains poorly understood.

OBJECTIVE

To investigate the presence of CMV in anterior uveal tissues of immunocompetent corneal donors.

STUDY DESIGN

We collected aqueous humor, iris, and ciliary body from both eyes of 25 donors died at the Limoges University Hospital between January 2020 and July 2021. CMV serology was determined for all patients from post-mortem blood sample. Ocular tissues were split in 2 fragments for qPCR and 2 for histological analysis. CMV genomes copies were quantified by Multiplex qPCR after DNA extraction.

RESULTS

16 of 25 patients (64%) displayed positive CMV serology, with a median age of 67 years. Viremia was positive in 3 of 16 (19%) CMV-positive patients. No CMV DNA copies were found from the aqueous humor samples. CMV DNA was detected in iris and ciliary body of 28 of 32 eyes of seropositive donors, and 5 of 18 eyes of seronegative donors. The median viral copy number [IQR] was 2.41 × 102 [8.91 × 101 - 1.01 × 103] copies/1 × 106 cells in the CMV-positive group and 0.00 [0.00 - 3.54 × 102] copies/1 × 106 cells in the CMV-negative group (p<0.001). Histology and immunohistochemistry did not reveal any CMV lesions from any sample.

CONCLUSION

CMV DNA was found in iris and ciliary body of immunocompetent seropositive patients, but also, although less frequently, from seronegative donors. These results highlight mechanisms of infection, latency and reactivation of CMV in ocular tissues.

Correlation of clinical, laboratory, and short-term outcomes of immunocompromised and immunocompetent COVID-19 patients with semi-quantitative chest CT score findings: A case-control study

BACKGROUND

As the effects of immunosuppression are not still clear on COVID-19 patients, we conducted this study to identify clinical and laboratory findings associated with pulmonary involvement in both immunocompromised and immunocompetent patients.

METHODS

A case-control of 107 immunocompromised and 107 immunocompetent COVID-19 patients matched for age and sex with either positive RT-PCR or clinical-radiological findings suggestive of COVID-19 enrolled in the study. Their initial clinical features, laboratory findings, chest CT scans, and short-term outcomes (hospitalization time and intensive care unit [ICU] admission) were recorded. In addition, pulmonary involvement was assessed with the semi-quantitative scoring system (0-25).

RESULTS

Pulmonary involvement was significantly lower in immunocompromised patients in contrast to immunocompetent patients, especially in RLL (p = 0.001), LUL (p = 0.023), and both central and peripheral (p = 0.002), and peribronchovascular (p = 0.004) sites of lungs. Patchy (p < 0.001), wedged (p = 0.002), confluent (p = 0.002) lesions, and ground glass with consolidation pattern (p < 0.001) were significantly higher among immunocompetent patients. Initial signs and symptoms of immunocompromised patients including dyspnea (p = 0.008) and hemoptysis (p = 0.036), respiratory rate of over 25 (p < 0.001), and spo2 of below 93% (p = 0.01) were associated with higher pulmonary involvement. Total chest CT score was also associated with longer hospitalization (p = 0.016) and ICU admission (p = 0.04) among immunocompromised patients.

CONCLUSIONS

Pulmonary involvement score was not significantly different among immunocompromised and immunocompetent patients. Initial clinical findings (dyspnea, hemoptysis, higher RR, and lower Spo2) of immunocompromised patients could better predict pulmonary involvement than laboratory findings.

Mucin-1-Targeted Chimeric Antigen Receptor T Cells Are Effective and Safe in Controlling Solid Tumors in Immunocompetent Host

The chimeric antigen receptor (CAR) T-cell therapy in solid epithelial tumors has been explored, however, with limited success. As much of the preclinical work has relied on xenograft models in immunocompromised animals, the immune-related efficacies and toxicities may have been missed. In this study, we engineered syngeneic murine CAR T cells targeting the tumor form of human mucin-1 (tMUC1) and tested the MUC1 CAR T cells' efficacy and toxicity in the immunocompetent human MUC1-expressing mouse models. The MUC1 CAR T cells significantly eliminated murine pancreatic and breast cancer cell lines in vitro. In vivo, MUC1 CAR T cells significantly slowed the mammary gland tumor progression in the spontaneous PyVMT×MUC1.Tg (MMT) mice, prevented lung metastasis, and prolonged survival. Most importantly, there was minimal short or long-term toxicity with acceptable levels of transient liver toxicity but no kidney toxicity. In addition, the mice did not show any signs of weight loss or other behavioral changes with the treatment. We also report that a single dose of MUC1 CAR T-cell treatment modestly reduced the pancreatic tumor burden in a syngeneic orthotopic model of pancreatic ductal adenocarcinoma given at late stage of an established tumor. Taken together, these findings suggested the further development of tMUC1-targeted CAR T cells as an effective and relatively safe treatment modality for various tMUC1-expressing solid tumors.

Fever of Unknown Origin: A Case Report of Hepatic Phlegmon in an Immunocompetent Patient

Methicillin-resistant Staphylococcus aureus (MRSA) hepatic phlegmon is a rare cause of fever of unknown origin (FUO) in an immunocompetent patient from a high-income country (HIC). MRSA hepatic phlegmon is typically linked to protein malnutrition and chronic gastrointestinal infections in low- to middle-income countries while immunodeficiencies such as chronic granulomatous disease (CGD) are a more common cause in a HIC. Clinical manifestations of hepatic phlegmon can be vague and nonspecific making a complete FUO workup critical during evaluation. We report a case of MRSA hepatic phlegmon in an immunocompetent patient with a nonspecific history and physical exam findings. A 14-year-old male presented with an 11-day history of fever with mild bilateral upper quadrant abdominal pain. The patient also has mild upper quadrant pain with palpation. The patient was diagnosed with a hepatic phlegmon on abdominal ultrasound and computed tomography (CT) of the abdomen. He was started on antibiotics and Interventional Radiology placed drains into the phlegmon and performed vancomycin drain washes. Inflammatory markers were initially elevated and trended down with interventions. The patient did well with treatment and was back to baseline during outpatient follow-up with the Infectious Disease team. This case illustrates the importance of a complete workup in patients with FUO.

CMV neuroretinitis in an immunocompetent patient: a unique case report

Aim: To report a case of cytomegalovirus (CMV) neuroretinitis observed in an immunocompetent patient. Materials and methods: The patient presented with a complaint of diminution of vision in both eyes (BE) and had a traumatic cataract in the right eye (RE). Fundus examination of the left eye (LE) revealed an active white, fluffy lesion with an overlying retinal hemorrhage patch with a macular star. The diagnosis of CMV neuroretinitis was established, and the patient commenced treatment with valganciclovir. Results: The patient exhibited no underlying risk factors. Subsequently, a positive response to oral valganciclovir treatment was observed. Discussion: Cytomegalovirus (CMV) neuroretinitis is typically associated with immunocompromised individuals, such as those with HIV/AIDS. The patient's presentation with a traumatic cataract in the right eye and a distinctive fundus appearance in the left eye posed a diagnostic challenge. The absence of common risk factors for CMV infection necessitated a thorough examination and consideration of rare infectious etiologies. The positive response to valganciclovir reinforces its efficacy in managing CMV-related ocular conditions. This case emphasized the necessity for ophthalmologists to maintain a high index of suspicion for CMV and other unusual pathogens when faced with neuroretinitis in patients who do not present with typical systemic immunosuppressive conditions. Early diagnosis and appropriate antiviral therapy prevent potential complications and preserve vision in such atypical presentations. Conclusion: This case underscores the importance of considering rare infectious agents in immunocompetent patients when encountering neuroretinitis, particularly in the absence of typical symptoms or signs of the disease. Abbreviations: CMV = Cytomegalovirus, BE = Both eyes, RE = Right eye, LE = Left eye, CBC = Complete Blood Count, ESR = Erythrocyte Sedimentation Rate, VDRL = Venereal Disease Research Laboratory, FTA-ABS = Fluorescent Treponemal Antibody Absorption, PPD = Purified Protein Derivative, ANA = Anti-Nuclear Antibodies, RF = Rheumatoid Factor, ACE = Anti Converting Enzyme, Ig G = Immunoglobulin G, HSV = Herpes simplex virus.

Immunocompetent isolated cerebral mucormycosis presenting with obstructive hydrocephalus: illustrative case

BACKGROUND

Isolated cerebral mucormycosis is rare in immunocompetent adults and is only sparsely reported to be associated with obstructive hydrocephalus.

OBSERVATIONS

Here, the authors report a case of obstructive hydrocephalus secondary to central nervous system mucormycosis without other systems or rhino-orbital involvement and its technical surgical management. A 23-year-old, incarcerated, immunocompetent patient with history of intravenous (IV) drug use presented with syncope. Although clinical and radiographic findings failed to elucidate an infectious pathology, endoscopy revealed an obstructive mass lesion at the level of the third ventricle, which, on microbiological testing, was confirmed to be Rhizopus fungal ventriculitis. Perioperative cerebrospinal fluid diversion, endoscopic third ventriculostomy, endoscopic biopsy technique, patient outcomes, and the literature are reviewed here. The patient received intrathecal and IV amphotericin B followed by a course of oral antifungal treatment and currently remains in remission.

LESSONS

The patient's unique presentation and diagnosis of isolated cerebral mucormycosis reveal this pathogen as a cause of ventriculitis and obstructive hydrocephalus in immunocompetent adult patients, even in the absence of infectious sequelae on neuroimaging.

Vibrio fluvialis Bacteremia in an Immunocompetent Patient with Acute Cholangitis

Vibrio fluvialis is a bacterium that can be found in both seawater and freshwater, and it is responsible for causing gastroenteritis and cholangitis. V. fluvialis bacteremia has rarely been reported. We report a case of V. fluvialis bacteremia due to cholangitis in an immunocompetent adult who was exposed to seawater regularly as a sushi chef. The increased risk of V. fluvialis entry into the body resulting from frequent consumption of raw fish and regular exposure to seawater, bile outflow impairment caused by transient inflammation of the bile duct, and the presence of multiple bile acid resistance-related genes in V. fluvialis may lead to the development of acute cholangitis and subsequent bacteremia in immunocompetent patients.

A Rare Case of a Retroperitoneal Abscess Due to Trichosporon spp. in an Immunocompetent Patient

This report discusses a rare case of retroperitoneal infection caused by Trichosporon spp. in a 68-year-old immunocompetent woman following a nephrectomy. Trichosporon spp. was identified through meticulous mycological examination. This case challenges the typical association of Trichosporon infections with immunocompromised patients, emphasizing its potential pathogenicity in immunocompetent individuals. The importance of accurate identification, especially in postoperative infections and broad-spectrum antibiotic contexts, is highlighted, emphasizing the need for a thorough diagnostic approach in such cases.

Human Herpesvirus 8-Positive Multicentric Castleman Disease in an Immunocompetent Patient: A Diagnostic Challenge

We present a clinical case of a 79-year-old male admitted to inpatient care for longstanding asthenia and respiratory symptoms. Associated features were polyserositis, multiple enlarged lymphatic nodules, acute kidney injury, and heart failure. The patient's recent medical history revealed SARS-CoV-2 vaccination a week prior and an upper respiratory tract infection. The laboratory results from thoracentesis were compatible with a transudate, with no immunological stain. Epstein-Barr virus polymerase chain reaction (PCR) was positive. The thoracic, abdominal, and pelvic CT scans revealed multiple enlarged lymphatic nodules, worsening the pre-existent polyserositis and hepatosplenomegaly. The patient began to show signs of neurologic symptoms and deterioration of the global health status. An enlarged lymphatic nodule was excised and the pathology showed human herpesvirus 8 multicentric Castleman disease. The disease evolved rapidly into hematological dysfunction and blood transfusions were necessary. Even though the patient was started on high-dose rituximab therapy combined with etoposide, the disease evolved into multiorgan dysfunction with a fatal outcome.

Invasive Pulmonary Aspergillosis in an Immunocompetent Patient: An Atypical Presentation

Invasive pulmonary aspergillosis (IPA) is a severe fungal infection primarily affecting immunocompromised individuals. However, rare cases of IPA in immunocompetent patients have been reported, presenting diagnostic and therapeutic challenges. Here, we present a case of a 41-year-old immunocompetent male who presented with fever, cough with mucoid expectoration, and breathlessness. Despite the absence of traditional risk factors, imaging and laboratory findings led to the diagnosis of IPA. Prompt initiation of antifungal therapy resulted in clinical improvement. This case highlights the importance of considering IPA in the differential diagnosis of respiratory symptoms, even in immunocompetent individuals.

Cytomegalovirus Retinitis Associated With Intravitreal Dexamethasone Implant Injection

Purpose: To describe an immunocompetent patient with cytomegalovirus (CMV) retinitis after dexamethasone implant injection and review previously documented cases. Methods: A review of case reports and literature was performed. Results: A 75-year-old man presented with acute decreased vision in the left eye. He had a vitrectomy and membrane peeling for an epiretinal membrane with recurrent cystoid macular edema and was receiving intravitreal dexamethasone implant injections at an outside hospital. The visual acuity in the left eye was hand motions, and an examination found patchy retinal whitening with hemorrhages. Aqueous polymerase chain reaction was positive for CMV. The laboratory evaluation was negative for immunodeficiencies. He was treated successfully with intravitreal and oral antivirals; however, his vision remained poor at most recent follow-up. A literature review found 8 previous cases of CMV retinitis after dexamethasone implant injection, although most had underlying immune dysregulation. Conclusions: CMV retinitis after intravitreal dexamethasone implant injection is rare. Awareness of this complication is essential because of the risk for devastating blindness.

All Eyes and Ears: A Case of Neurosyphilis Presenting With Simultaneous Ocular and Otic Involvement

This report details a case of neurosyphilis manifesting as concurrent ocular and otosyphilis, an uncommon presentation of the disease. Here, we describe the diagnosis and treatment of a 27-year-old immunocompetent Caucasian male who presented with uveitis and tinnitus. Physical exam was consistent with uveitis and audiometric testing revealed bilateral sensorineural hearing loss. Serum rapid plasma reagin (RPR) was reactive at 1:512 with a follow-up cerebrospinal fluid (CSF) venereal disease research laboratory (VDRL) test likewise reactive at 1:2, confirming neurosyphilis. The patient was treated with intravenous penicillin G with improvement of symptoms and with subsequent improvement of serum and CSF RPR. However, he ultimately represented with recurrent symptoms and fluctuating serum RPR levels, necessitating repeat treatment and ongoing clinical monitoring. Neurosyphilis can occur at any point during the course of a syphilis infection and may present with a variety of nonspecific findings. This case documents a particularly uncommon instance of simultaneous ocular and otosyphilis, a presentation of neurosyphilis that has only been described a handful of times.

Tuberculosis of the Iliac Bone and Acetabulum With Iliopsoas, Obturator Internus, and Obturator Externus Abscesses in an Immunocompetent Indian Female: An Extremely Rare Case

Skeletal tuberculosis is a rare form of extrapulmonary tuberculosis. Due to non-specific clinical features, these cases are often diagnosed very late, ultimately affecting treatment outcomes. The present case is a very rare case of tuberculosis of the iliac bone and acetabulum with iliopsoas, obturator internus, and obturator externus abscesses in an Indian female. She reported pain in her right hip and a limp. It was a difficult diagnosis, especially due to the rare involvement of bones and muscles in the absence of any lesions in the lungs. Nevertheless, the diagnosis was achieved by a detailed radiometric and laboratory workup. She was initiated on antituberculous treatment per her weight for 12 months.

Cytomegalovirus Diseases of the Gastrointestinal Tract in Immunocompetent Patients: A Narrative Review

Cytomegalovirus (CMV) is a potential pathogen that causes gastrointestinal (GI) tract diseases regardless of host immunity. In contrast to immunocompromised individuals, immunocompetent patients lack a comprehensive overview of the gastrointestinal manifestations. This study aims to provide a comprehensive summary of the current evidence regarding presentations, diagnostics, management, risk assessment, and outcomes in immunocompetent patients with CMV GI disease. A thorough literature search of English publications up to April 2022 was conducted across electronic databases to identify relevant articles, with eligible case series selected for detailed analysis. The majority of immunocompetent patients affected by CMV GI disease are typically elderly, critically ill, or burdened with comorbidities that compromise immunity. Clinical presentations range from subtle symptoms to severe surgical conditions, including instances of mortality. Specific clinical presentations, blood test results, or endoscopic features are lacking, necessitating reliance on histopathological tests such as immunohistochemistry staining for diagnosis. While antiviral therapy may offer benefits in improving outcomes, careful individual assessment is warranted due to diverse comorbidities and potential side effects. Mortality rates vary considerably based on underlying medical conditions and therapeutic approaches. It is imperative for clinicians to maintain vigilance for CMV GI disease among high-risk groups, despite their baseline immunocompetence, in order to enhance clinical outcomes.

Establishment of a Human Immunocompetent 3D Tissue Model to Enable the Long-Term Examination of Biofilm-Tissue Interactions

Different studies suggest an impact of biofilms on carcinogenic lesion formation in varying human tissues. However, the mechanisms of cancer formation are difficult to examine in vivo as well as in vitro. Cell culture approaches, in most cases, are unable to keep a bacterial steady state without any overgrowth. In our approach, we aimed to develop an immunocompetent 3D tissue model which can mitigate bacterial outgrowth. We established a three-dimensional (3D) co-culture of human primary fibroblasts with pre-differentiated THP-1-derived macrophages on an SIS-muc scaffold which was derived by decellularisation of a porcine intestine. After establishment, we exposed the tissue models to define the biofilms of the Pseudomonas spec. and Staphylococcus spec. cultivated on implant mesh material. After 3 days of incubation, the cell culture medium in models with M0 and M2 pre-differentiated macrophages presented a noticeable turbidity, while models with M1 macrophages presented no noticeable bacterial growth. These results were validated by optical density measurements and a streak test. Immunohistology and immunofluorescent staining of the tissue presented a positive impact of the M1 macrophages on the structural integrity of the tissue model. Furthermore, multiplex ELISA highlighted the increased release of inflammatory cytokines for all the three model types, suggesting the immunocompetence of the developed model. Overall, in this proof-of-principle study, we were able to mitigate bacterial overgrowth and prepared a first step for the development of more complex 3D tissue models to understand the impact of biofilms on carcinogenic lesion formation.

Multisystemic Disease in a Child and Successful Recovery With Antiviral Treatment

Cytomegalovirus (CMV), a member of the Herpesviridae family, typically causes asymptomatic infections or mild mononucleosis-like syndromes in immunocompetent individuals. However, severe manifestations are well-documented in immunocompromised populations. This case report presents a previously healthy seven-year-old girl with a rare and complex presentation of primary CMV infection leading to severe multiorgan involvement, hepatosplenomegaly, cholestasis, bicytopenia, and a prolonged disease course. The patient's condition prompted an exhaustive diagnostic investigation, ruling out other potential causes. The diagnosis was confirmed by positive CMV IgM and IgG antibodies and a significantly elevated CMV DNA viral load. Treatment with intravenous ganciclovir resulted in a remarkable recovery. The case underscores the importance of considering CMV as a potential etiology of hepatitis, even in immunocompetent children, and the challenges of diagnosing complicated CMV infections. While guidelines for treating CMV in immunocompetent individuals are lacking, this report suggests that antiviral therapy may be beneficial in severe cases. Further research is needed to establish clear treatment protocols for such instances. This report contributes to the limited body of literature on severe CMV-induced hepatitis in immunocompetent children, emphasizing the need for heightened clinical awareness and timely interventions to prevent progression to acute liver failure.

Primary cutaneous nocardiosis in an immunocompetent host

Nocardiosis is a rare opportunistic infection that is classically observed in immunocompromised patients but can also affect immunocompetent individuals. It tends to involve the lung, central nervous system, and skin and is often misdiagnosed.

Staphylococcus aureus Bacteremia With Disseminated Multiple Foci and Pyomyositis in an Immunocompetent Patient: A Case Report

Pyomyositis is an uncommon primary infection of skeletal muscle resulting in muscle inflammation followed by pus formation. Pyomyositis is typically caused by Staphylococcus aureus (S. aureus), and most cases are associated with skin penetration and/or immunosuppressive conditions in tropical or even temperate climates. We report a previously healthy, immunocompetent 44-year-old man who presented with fever and right lower back pain. He had received an analgesic injection for his back pain 12 days prior to this visit. His clinical course was further complicated by the coexistence of multiple muscular abscesses, renal infarction, and septic arthritis of the right shoulder. He underwent computed tomography-guided drainage of the abscess. The abscess and blood cultures were positive for methicillin-susceptible S. aureus. The patient responded well to prolonged treatment with cefazolin and cephalexin and was discharged 12 weeks after initial admission.

First report of a post-pneumonectomy nocardia empyema

Post-pneumonectomy empyema (PPE) is an uncommon but serious complication that carries significant therapeutic challenges. We present a late-onset PPE due to Nocardia nova in an immunocompetent individual. Nine years after a right pneumonectomy for non-small cell lung cancer, surveillance scans revealed new right pleural thickening and FDG avidity concerning for recurrence. Thoracoscopic pleural biopsies were negative for malignancy, but tissue cultures grew N. nova. Nocardia empyema is rare with few reported cases. Most occur in immunocompromised hosts, and all were associated with pulmonary or disseminated nocardiosis. Our case describes the first report of a PPE secondary to Nocardia.

Nocardia brasiliensis Pyomyositis in an Immunocompetent Patient Following Gardening Activity

Nocardia pyomyositis in immunocompetent patients is a rare occurrence. The diagnosis may be missed or delayed with the risk of progressive infection and suboptimal or inappropriate treatment. We present the case of a 48-year-old immunocompetent firefighter diagnosed with pyomyositis caused by Nocardia brasiliensis acquired by direct skin inoculation from gardening activity. The patient developed a painful swelling on his right forearm that rapidly progressed proximally and deeper into the underlying muscle layer. Ultrasound imaging of his right forearm showed a 7-mm subcutaneous fluid collection with surrounding edema. Microbiologic analysis of the draining pus was confirmed to be N brasiliensis by Matrix-Assisted Laser Desorption/Ionization Time-of-Flight (MALDI-TOF) Mass Spectrometry. After incision and drainage deep to the muscle layer to evacuate the abscess and a few ineffective antibiotic options, the patient was treated with intravenous ceftriaxone and oral linezolid for 6 weeks. He was then de-escalated to oral moxifloxacin for an additional 4 months to complete a total antibiotic treatment duration of 6 months. The wound healed satisfactorily and was completely closed by the fourth month of antibiotic therapy. Six months after discontinuation of antibiotics, the patient continued to do well with complete resolution of the infection. In this article, we discussed the risk factors for Nocardia in immunocompetent settings, the occupational risks for Nocardia in our index patient, and the challenges encountered with diagnosis and treatment. Nocardia should be included in the differential diagnosis of cutaneous infections, particularly if there is no improvement of "cellulitis" with traditional antimicrobial regimens and the infection extends into the deeper muscle tissues.

Cytomegalovirus colitis in immunocompetent hosts: A case report and literature review

Key Clinical Message

Rectal bleeding can manifest cytomegalovirus (CMV) colitis even in immunocompetent patients, which can be cured with ganciclovir treatment.

Abstract

Cytomegalovirus (CMV) is an opportunistic virus widely affecting immunocompromised patients. Different manifestations varied from asymptomatic in immunocompetent individuals to end organ involvement, such as colitis in those with immunodeficiency. Despite the rarity of CMV colitis in immunocompetent hosts, we should consider it when the other conditions have been excluded. In this article, we have described a case of CMV colitis in an immunocompetent host and have performed a literature review on this entity. An immunocompetent 70-year-old female was admitted to the hospital with recurrent rectal bleeding. After various evaluations including laboratory analysis, stool examination, and colonoscopy, we have detected superficial lesions. Pathology and polymerase chain reaction reports favored CMV involvement. Her condition continues to improve after intravenous ganciclovir infusion. Rectal bleeding can manifest CMV colitis even in immunocompetent patients, which can be cured with ganciclovir treatment.