Management of infections in critically ill returning travellers in the intensive care unit-II: clinical syndromes and special considerations in immunocompromised patients

This position paper is the second ESCMID Consensus Document on this subject and aims to provide intensivists, infectious disease specialists, and emergency physicians with a standardized approach to the management of serious travel-related infections in the intensive care unit (ICU) or the emergency department. This document is a cooperative effort between members of two European Society of Clinical Microbiology and Infectious Diseases (ESCMID) study groups and was coordinated by Hakan Leblebicioglu and Jordi Rello for ESGITM (ESCMID Study Group for Infections in Travellers and Migrants) and ESGCIP (ESCMID Study Group for Infections in Critically Ill Patients), respectively. A relevant expert on the subject of each section prepared the first draft which was then edited and approved by additional members from both ESCMID study groups. This article summarizes considerations regarding clinical syndromes requiring ICU admission in travellers, covering immunocompromised patients.

Acute invasive fungal rhinosinusitis: our experience with 18 cases

Acute invasive fungal rhinosinusitis (AIFRS) is a rapidly progressive life threatening infection that is seen most commonly among immunocompromised patients. We present a case series of 18 patients clinically and histopathologically diagnosed with AIFRS with a mean follow-up of 9.11 ± 2.51 months (range 6-17). Demographic data, apparent symptoms and signs, underlying disorders, and outcomes are discussed. The mean age was 39.56 ± 20.66 years (range 2-75). The most common underlying diseases were diabetes mellitus (50 %) and leukemia (44.44 %). Mucosal biopsy confirmed fungal invasion of the nasal mucosa in all cases. The main fungi were Rhizopus oryzae (55.56 %), Absidia mucor (16.67 %), and Aspergillus fumigatus (27.78 %). Headache and facial pain (77.8 %), facial paresthesia (55.6 %), and ophthalmoplegia (33.3 %) were the most common symptoms and signs. Computed tomography and endoscopic findings showed various stages of sinonasal (100 %), pterygopalatine fossa (55.56 %), orbital (44.45 %), and cerebral (5.56 %) involvement. All patients underwent serial surgical debridement (3.78 ± 1.80 times; range 2-8) simultaneously with systemic antifungal therapy and proper management of the underlying disease. The most extreme case with brain involvement survived and recovered with no evidence of recurrent disease following treatment. All patients were considered cured after two endoscopic negative histopathologic evaluations. Three patients (16.67 %) died, one from uncontrolled leukemia and two due to renal failure. AIFRS is a potentially fatal condition, however, early diagnosis and management of the underlying disease accompanied with systemic antifungal and aggressive serial surgical intervention appears to be effective in reducing mortality in most patients.

Cutaneous squamous cell carcinoma of the scalp in the immunocompromised patient: review of 53 cases

OBJECTIVE

We analyzed outcomes from immunocompromised patients with scalp squamous cell carcinoma (SCC) treated with surgical excision with and without radiation in order to explore 3-year disease-free survival and overall survival.

STUDY DESIGN

The study design was a retrospective chart review.

SETTING

This study was conducted in a private practice setting.

SUBJECTS AND METHODS

The study included 53 immunocompromised patients with an average age of 63.2 years, with scalp squamous cell carcinoma. Pre-operative imaging dictated the extent of resection. Patients with bony involvement received wide local excision including full-thickness craniectomy and cranioplasty. Patients without bony involvement underwent wide local excision and outer-table calvarial resection. All patients were recommended to have post-operative radiation. Patients were followed for a minimum of 3 years.

RESULTS

A total of 53 patients were included in the study. Six patients had pre-operative CT showing bone involvement and were treated with full-thickness craniectomy along with post-operative radiation. Fourteen patients without bone involvement on pre-operative CT were found to have positive bone involvement on final pathology. Forty-five patients underwent post-operative radiation. Patients treated with adjuvant radiation demonstrated a 3-year survival of 80 % and the overall survival was 62 %. In the surgery-only group, the 3-year survival was 62.5 % and the overall survival was 32.5 %.

CONCLUSIONS

Immunocompromised patients with scalp SCC have a poor prognosis. Early detection and treatment are crucial. Based on our results, we recommend wide local excision with at least outer-table calvarial resection, and post-operative radiation. Despite aggressive therapy, patients may still have distant, local, or regional recurrence.

LEVEL OF EVIDENCE

level 2b (retrospective cohort).

Bilateral periprosthetic joint infection with Ureaplasma urealyticum in an immunocompromised patient

This case study discusses how we diagnosed and treated a patient with a late haematogenous bilateral periprosthetic joint infection (PJI) after total knee arthroplasties caused by Ureaplasma urealyticum. This has never been reported before. We will discuss how we used a PET-CT, synovial fluid cell count, and synovial fluid analysis by 16S rRNA gene sequencing to diagnose this PJI. We will also discuss how we treated this patient to obtain full recovery.

Immunisation of the immunocompromised child

Immunocompromised children have a higher risk of developing infections and associated higher rates of mortality and morbidity. Although this group could benefit the most from vaccine administration, specific considerations regarding immunisations are required. This review is a summary of the vaccines that are relevant to the immunocompromised host, covering both live and non-live vaccines. The burden of disease, safety, immunogenicity/effectiveness and specific recommendations for each vaccine are described as well as specific guidelines from different organisations.

Comparison of hemagglutination inhibition and microbead array assays for the measurement of influenza antibody levels in HIV-infected adults

INTRODUCTION

Determining vaccine responsiveness is challenging in immune compromised individuals. The microbead array (MBA) assay is a rapid, inexpensive test for evaluating influenza vaccine immunogenicity. MBA performance was compared to hemagglutination inhibition assay (HAI) utilizing HIV seropositive vaccine recipient specimens.

METHODS

CTN 253 evaluated standard dose, single antigen, inactivated split adjuvanted (AS03(A)) H1N1 influenza vaccine (Arepanrix) vs standard dose plus booster. CTN237 evaluated three doses of a seasonal, trivalent killed split non-adjuvanted influenza vaccine (Fluviral). Samples of convenience from 75 CTN 253 and 58 CTN 237 participants were evaluated by MBA and HAI. MBA seroreactivity cut-offs of 500 and 1000 mean fluorescent intensity were used to compare those derived by HAI [titer ≥40 (seroprotection) and 4-fold titer increase from baseline (seroconversion)].

RESULTS

CTN253: Using a MBA cut-off of 500, 75% and 59% had seroreactive titers at visit 2 and 78% and 61% at visit 3 for the single versus double dose study arms. Many participants were categorized differently by the HAI and MBA tests, with raw agreement of 59% at visit 2 and 57% at visit 3. CTN 237: Baseline MBA medians (IQR) were 803 (12-2626) for the A/Brisbane strain and 460 (14-1758) for the B/Florida strain. Using a cut-off of 500 yielded for the A/Brisbane strain seroreactivity rates of 44%, 58%, and 63% were observed for the three doses of vaccine tested. The raw agreement was 47%. B/Florida strain analyses yielded similar results. For all strains assessed in both studies, no relationship between MBA values and baseline variables was identified.

CONCLUSION

The concordance of results between the MBA assay and the HAI assay is very low. MBA assay may be more sensitive than the HAI assay suggesting that it was either detecting more false-positive results and/or that the HAI assay had more false negative.

Oral mucormycosis in an 18-month-old child: a rare case report with a literature review

Oral mucormycosis is a fungal infection observed mainly in elderly immunocompromised patients. In rare instances, the disease occurs in healthy individuals and those patients that are below preschool age. Although this condition mainly involves the maxilla, it may also manifest in any part of the oral cavity based on the source of infection. Mucormycosis of the maxilla spreads rapidly, leading to necrosis of the palatal bone and palatal perforation. Such patients are usually rehabilitated using bone grafting or free flap surgeries. However, when surgeries are delayed, palatal prosthesis is an interim treatment modality that can prevent nasal regurgitation and aspiration of food or fluids. Palatal prostheses also help with mastication, speech, and swallowing. The present case describes a rare case of oral mucormycosis in an 18-month-old male involving the maxilla that was managed by palatal prosthesis.

Abdominal Pain in the Immunocompromised Patient-Human Immunodeficiency Virus, Transplant, Cancer

Patients with human immunodeficiency virus, those who are posttransplant, and those undergoing chemotherapy are populations who are immunocompromised and present to the emergency department with abdominal pain related to their disease processes, opportunistic infections, and complications of treatment. Emergency department practitioners must maintain vigilance, as the physical examination is often unreliable in these patients. Cross-sectional imaging and early treatment of symptoms with aggressive resuscitation is often required.

Scedosporium apiospermum infections and the role of combination antifungal therapy and GM-CSF: A case report and review of the literature

Scedosporium apiospermum, a ubiquitous environmental mold, is increasingly reported as causing invasive fungal disease in immunocompromised hosts. It poses a therapeutic challenge due to its intrinsic resistance to traditional antifungals and ability to recur despite demonstrating susceptibility. We present an immunocompromised patient with a cutaneous S. apiospermum infection that disseminated despite treatment with voriconazole, the drug of choice. Adding echinocandins and GM-CSF provided partial recovery, indicating a potential synergistic role of dual-antifungal and immunotherapeutic agents.

Use of Extracorporeal Membrane Oxygenation for the Treatment of Influenza-Induced Acute Respiratory Distress Syndrome in Immunocompromised Adults

Influenza infection in the adult immunocompromised hosts can have severe presentations and rapid progression to lower respiratory tract infection requiring mechanical ventilation, and it even can progress to acute respiratory distress syndrome. Little is known about the role of extracorporeal membrane oxygenation for management in this setting. We present a review of the current literature on the subject.

Travel-related health risks in moderately and severely immunocompromised patients: a case-control study

BACKGROUND

The number of immunocompromised persons travelling to tropical countries is increasing. The hypothesis is that this population is at increased risk of travel-related health problems but there are few data to support it. The objective was to assess the risk of travel-related health problems in immunocompromised persons when compared with the general population of travellers.

METHODS

A retrospective matched case-control study was performed. Cases were moderately or severely immunocompromised persons travelling to tropical countries and controls were non-immunocompromised persons, matched for demographic and travel characteristics. All participants responded to a phone questionnaire, asking them about any health problem they may have encountered while travelling or during the month following their return. The primary outcome was the incidence of a significant clinical event defined as repatriation, hospitalization during the travel or during the month following the return if due to a travel-related health problem and medical consultations during the trip.

RESULTS

One hundred and sixteen moderately or severely immunocompromised cases [HIV infection (15), active cancer (25), splenectomized (20), solid organ transplant recipients (4) and use of systemic immunosuppressive medication (52)] and 116 controls were included. Incidence rates of significant clinical events were higher in immunocompromised travellers (9/116, 7.8%) than in controls (2/116, 1.7%) [OR = 4.8 , 95% CI 1.01-22.70; P = 0.048]. Most cases were related to infectious diseases (5/9, 55.5%), others were pulmonary embolism (2/9, 22%), inflammatory disease and trauma (1/9, 11.1% each). There was no significant difference between the two groups regarding common health problems.

CONCLUSION

Moderately and severely immunocompromised travellers are at increased risk of developing a serious health problem during or after a trip in a tropical country. They should be well informed about the specific risks they are particularly prone to. Travel medicine health professionals should favour effective preventive measures for immunocompromised travellers and envisage stand-by antibiotic treatment.

Sepsis-induced long-term immune paralysis--results of a descriptive, explorative study

Background

Long-lasting impairment of the immune system is believed to be the underlying reason for delayed deaths after surviving sepsis. We tested the hypothesis of persisting changes to the immune system in survivors of sepsis for the first time.

Methods

In our prospective, cross-sectional pilot study, eight former patients who survived catecholamine-dependent sepsis and eight control individuals matched for age, sex, diabetes and renal insufficiency were enrolled. Each participant completed a questionnaire concerning morbidities, medications and infection history. Peripheral blood was collected for determination of i) immune cell subsets (CD4⁺, CD8⁺ T cells; CD25⁺ CD127^- regulatory T cells; CD14⁺ monocytes), ii) cell surface receptor expression (PD-1, BTLA, TLR2, TLR4, TLR5, Dectin-1, PD-1 L), iii) HLA-DR expression, and iv) cytokine secretion (IL-6, IL10, TNF-α, IFN-γ) of whole blood stimulated with either α-CD3/28, LPS or zymosan.

Results

After surviving sepsis, former patients presented with increased numbers of clinical apparent infections, including those typically associated with an impaired immune system. Standard inflammatory markers indicated a low-level inflammatory situation in former sepsis patients. CD8⁺ cell surface receptor as well as monocytic HLA-DR density measurements showed no major differences between the groups, while CD4⁺ T cells tended towards two opposed mechanisms of negative immune cell regulation via PD-1 and BTLA. Moreover, the post-sepsis group showed alterations in monocyte surface expression of distinct pattern recognition receptors; most pronouncedly seen in a decrease of TLR5 expression. Cytokine secretion in response to important activators of both the innate (LPS, zymosan) and the adaptive immune system (α-CD3/28) seemed to be weakened in former septic patients.

Conclusions

Cytokine secretion as a reaction to different activators of the immune system seemed to be comprehensively impaired in survivors of sepsis. Among others, this could be based on trends in the downregulation of distinct cell surface receptors. Based on our results, the conduct of larger validation studies seems feasible, aiming to characterize alterations and to find potential therapeutic targets to engage.

Intractable hiccups due to herpetic esophagitis in an immunocompromised patient

Introduction

Herpes virus family's association with visceral lesions is well established. Herpes simplex virus presentations vary based on immune status. Intractable hiccups due to herpes simplex esophagitis, to the best of our knowledge have been described twice in the literature. We present a 68 year-old immunocompromised male with intractable hiccups for 10 months.

Case

68 year-old male with end-stage renal disease and multiple myeloma presented with coffee ground emesis and hiccups of ten months duration. A year earlier, he received cycles of bortezomib and dexamethasone, remaining on lenalidomide. During chemotherapy, he developed pneumococcal meningitis and subsequently intractable hiccups. Preceding admission, endoscopy showed duodenitis and esophagitis. Proton-pump inhibitor therapy was initiated; however, biopsy was not performed.

During admission, hiccups often occurred every few seconds while off anti-emetics, persisting despite therapy. Exam showed cachexia/temporal wasting, aphthous stomatitis and abdominal tenderness. MRI of brain/spine, CT of neck, chest, abdomen and neurological evaluation were unremarkable. Endoscopy revealed gastritis and esophagitis with mucosal tears. Biopsy revealed intra-nuclear inclusions with multi-nucleated cells, consistent with herpes virus, later confirmed as herpes simplex by immunostaining. Hiccups and emesis resolved after of 2 days of intravenous acyclovir. 21 days of treatment were completed with oral valacyclovir. He remained free of hiccups during the remaining hospital stay and follow up.

This case illustrates an exceptionally rare presentation of herpetic esophagitis in an immunocompromised host. As novel immunotherapeutic/suppressive agents continue to emerge, the evolving role of herpes virus prophylaxis and diagnosis of atypical presentations in new host populations is a topic of growing importance.

Genomic characterization and assessment of the virulence and antibiotic resistance of the novel species Paenibacillus sp. strain VT-400, a potentially pathogenic bacterium in the oral cavity of patients with hematological malignancies

BACKGROUND

Paenibacillus sp. strain VT-400, a novel spore-forming bacterium, was isolated from patients with hematological malignancies.

METHODS

Paenibacillus sp. strain VT-400 was isolated from the saliva of four children with acute lymphoblastic leukemia. The genome was annotated using RAST and the NCBI Prokaryotic Genome Annotation Pipeline to characterize features of antibiotic resistance and virulence factors. Susceptibility to antibiotics was determined by the Kirby-Bauer disc diffusion method. We used a mouse model of pneumonia to study virulence in vivo. Mice were challenged with 7.5 log10-9.5 log10 CFU, and survival was monitored over 7 days. Bacterial load was measured in the lungs and spleen of surviving mice 48 h post-infection to reveal bacterial invasion and dissemination.

RESULTS

Whole-genome sequencing revealed a large number of virulence factors such as hemolysin D and CD4+ T cell-stimulating antigen. Furthermore, the strain harbors numerous antibiotic resistance genes, including small multidrug resistance proteins, which have never been previously found in the Paenibacillus genus. We then compared the presence of antibiotic resistance genes against results from antibiotic susceptibility testing. Paenibacillus sp. strain VT-400 was found to be resistant to macrolides such as erythromycin and azithromycin, as well as to chloramphenicol and trimethoprim-sulphamethoxazole. Finally, the isolate caused mortality in mice infected with ≥8.5 log10 CFU.

CONCLUSIONS

Based on our results and on the available literature, there is yet no strong evidence that shows Paenibacillus species as an opportunistic pathogen in immunocompromised patients. However, the presence of spore-forming bacteria with virulence and antibiotic resistance genes in such patients warrants special attention because infections caused by spore-forming bacteria are poorly treatable.

Legionellosis in Transplantation

Legionella species are emerging opportunistic pathogens in hematopoietic stem cell and solid organ transplant recipients, associated with significant morbidity and mortality. The clinical and radiological features of Legionella infections can mimic other opportunistic pathogens in these profoundly immunocompromised patients. Diagnosis in transplant patients is challenging as non-pneumophila Legionella infections, for which these patients are at risk, cannot be identified using the urinary antigen test. Changes in management of transplant recipients and changes in Legionella epidemiology suggest that the number of transplant patients potentially exposed to Legionella spp. may be on the rise. Yet, evidence-based, transplant-specific guidelines for managing and preventing Legionella infections are not currently available. In this article, we review the epidemiology, clinical features, diagnostic challenges, treatment options, and preventive strategies of Legionella infections in these high-risk patient populations.

Full coding hepatitis E virus genotype 3 genome amplification method

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A new amplification method for the complete HEV coding genome was described.

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HEV genome organization and function were reviewed.

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Polymorphic amino acids of each HEV genome region were analyzed in reference sequences.

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Complete coding HEV sequence of an immunocompromised patient with acute infection was analyzed.

Hepatitis E virus (HEV) genotype 3 produces zoonotic infection associated with the consumption of infected animals. HEV infections can become chronic in immunocompromised (IC) patients. The viral genome has three well defined open reading frames (ORF1, ORF2 and ORF3) within which various domains and functions have been described. This paper (i) describes a new method of complete sequencing of the HEV coding region through overlapping PCR systems, (ii) establishes a consensus sequence and polymorphic positions (PP) for each domain, and (iii) analyzes the complete coding sequence of an IC patient. With regard to the consensus, a high percentage of PP was observed in protease (PP = 19%) and the X domain (PP = 22%) within ORF1, the N-terminal region of the S domain (PP = 22%) in ORF2, and the P1 (PP = 35%) and P2 (PP = 25%) domains in ORF3. In contrast, the ORF1 Y, ORF2 S, ORF2 M and ORF3 D1 domains were conserved in the reference sequences (0.40, 1, 0.70 and 0% of PP, respectively). The sequence from the IC patient had more mutations in the RpRp (D1235G, Q1242R, S1454T, V1480I, I1502 V, K1511R, G1373 V, E1442D, V1693 M), the terminal ORF2 S- domain (F10L, S26T, G36S, S70P, A105 V, I113 V), the X domain (T938 M, T856 V, S898A) and the helicase (S1014N, S975T, Q1133 K).

Prevention and treatment of Encephalitozoon cuniculi infection in immunosuppressed rabbits with fenbendazole

This study was conducted to evaluate the efficacy of oral administration of fenbendazole (20 mg/kg body weight) prior to and after experimental infection of immunosuppressed rabbits with Encephalitozoon cuniculi. A total of thirty rabbits were divided into five groups: NN (non-immunosuppressed; non-infected), IN (immunosuppressed; non-infected), IPI (immunosuppressed; protected-infected), ITI (immunosuppressed; treated-infected), and II (immunosuppressed; infected) groups. Fenbendazole was administered as a prophylactic for seven successive days before infection with E. cuniculi and as a treatment for four weeks initiated on the 28th day post-challenge (PC). Experimental rabbits were infected with intraperitoneal injection of 2 × 105E. cuniculi spores. Parameters evaluated were body weight, detection of spores in urine, serum antibody assay, hematological, biochemical and histopathological changes. The IPI and ITI groups showed a significant better final bwt than the II group. Spores were detected in urine of all infected rabbits from the 28th day PC until the end of the study. The IPI group showed the least values of antibodies (IgG) compared to the ITI and II groups. Concerning histopathological changes, the intensity of the lesions was marked particularly in the II rabbits and to a lesser extent in the ITI rabbits. Noticeable improvement was found in the IPI rabbits. It could be concluded that fenbendazole was effective to some extent in protection of rabbits against E. cuniculi infection, while when administered as a therapeutic no significant effects were observed.

Prevalence of Intestinal Coccidial Infections among Different Groups of Immunocompromised Patients

BACKGROUND

Cryptosporidium and Isospora are known as one of the main cause of diarrhea in both immunocompetent and immunocompromised subjects, all over the world. Incidence of enteropathogens such as Cryptosporidium spp. and Isospora belli considerably has increased, since immunodeficiency virus (HIV) rapidly disseminated. In addition, cancer patients are highly susceptible to opportunistic infections. This study aimed to estimate the prevalence of cryptosporidiosis and isosporiasis in immunocompromised patients in Tehran.

METHODS

This study carried out on patients admitted to Imam Khomeini hospital during 2013-2014. Stool samples collected from 350 immunocompromised patients. Formol-ether concentration was performed for all stool samples. Zeil-Neelsen technique was applied to stain the prepared smears and finally, all slides were examined by light microscope.

RESULTS

Out of 350 patients, 195 (55.7%) and 155 (44.3%) were male and female, respectively. Cryptosporidium oocysts were detected in 3 (0.9%) samples including one sample from HIV+/AIDS patients and 2 samples from organ transplant recipients. Isospora oocysts were detected in 4 (1.1%) samples consisting 2 HIV+/AIDS patients, one patients suffering from malignancy and one patients with other immunodeficiency diseases.

CONCLUSION

Cryptosporidium sp, and I. belli are the most prevalent gastrointestinal parasitic protozoans that infect a broad range of individuals, particularly those patients who have a suppressed or deficient immunity system.

Atypical presentation of Legionella pneumonia among patients with underlying cancer: A fifteen-year review

BACKGROUND

Immunocompromised patients, especially those receiving treatment with corticosteroids and cytotoxic chemotherapy are at increased risk for developing Legionella pneumonia.

OBJECTIVE

The aim of this study was to determine clinical and radiographic characteristics of pulmonary infection due to Legionella in persons undergoing treatment for cancer and stem cell transplant (SCT) recipients.

METHODS

Retrospective review of Legionella cases at MSKCC over a fifteen-year study period from January 1999 and December 2013. Cases were identified by review of microbiology records.

RESULTS

During the study period, 40 cases of Legionella infection were identified; nine among these were due to non-pneumophila species. Most cases occurred during the summer. The majority [8/9, (89%)] of patients with non-pneumophila infection had underlying hematologic malignancy, compared to 18/31 (58%) with Legionella pneumophila infections. Radiographic findings were varied-nodular infiltrates mimicking invasive fungal infection were seen only among patients with hematologic malignancy and hematopoietic stem cell transplant (SCT) recipients and were frequently associated with non-pneumophila infections (50% vs 16%; P = 0.0594). All cases of nodular Legionella pneumonia were found incidentally or had an indolent clinical course.

CONCLUSIONS

Legionella should be considered in the differential diagnosis of nodular lung lesions in immunocompromised patients, especially those with hematologic malignancy and SCT recipients. Most cases of nodular disease due to Legionella are associated with non-pneumophila infections.

Diagnostic performance of a multiplex PCR assay for meningitis in an HIV-infected population in Uganda

Meningitis remains a worldwide problem, and rapid diagnosis is essential to optimize survival. We evaluated the utility of a multiplex PCR test in differentiating possible etiologies of meningitis. Cerebrospinal fluid (CSF) from 69 HIV-infected Ugandan adults with meningitis was collected at diagnosis (n=51) and among persons with cryptococcal meningitis during therapeutic lumbar punctures (n=68). Cryopreserved CSF specimens were analyzed with BioFire FilmArray® Meningitis/Encephalitis panel, which targets 17 pathogens. The panel detected Cryptococcus in the CSF of patients diagnosed with a first episode of cryptococcal meningitis by fungal culture with 100% sensitivity and specificity and differentiated between fungal relapse and paradoxical immune reconstitution inflammatory syndrome in recurrent episodes. A negative FilmArray result was predictive of CSF sterility on follow-up lumbar punctures for cryptococcal meningitis. EBV was frequently detected in this immunosuppressed population (n=45). Other pathogens detected included: cytomegalovirus (n=2), varicella zoster virus (n=2), human herpes virus 6 (n=1), and Streptococcus pneumoniae (n=1). The FilmArray Meningitis/Encephalitis panel offers a promising platform for rapid meningitis diagnosis.

Outcomes of Influenza Infections in Hematopoietic Cell Transplant Recipients: Application of an Immunodeficiency Scoring Index

Hematopoietic cell transplant (HCT) recipients have lower immune response to influenza vaccination and are susceptible to lower respiratory tract infection (LRI) and death. We determined clinical characteristics and outcomes of laboratory-confirmed influenza, including 2014/H3N2 infection, in 146 HCT recipients. An immunodeficiency scoring index (ISI) was applied to identify patients at high risk for LRI and death. Thirty-three patients (23%) developed LRI and 7 (5%) died within 30 days of diagnosis. Most patients received antiviral therapy (83%); however, only 18% received it within 48 hours of symptom onset. The incidence of LRI was significantly higher in the ISI high-risk group than it was in the low-risk group (P < .001). Receiving early antiviral therapy was associated with a substantial reduction in LRI for all ISI risk groups with the greatest risk reduction observed in the high-risk group. When compared with previous seasons, no significant differences in patient outcomes were observed during the 2014/H3N2 season; however, antiviral therapy was more promptly initiated in the latter season. The ISI that was originally developed for respiratory syncytial virus may help identify HCT recipients at risk for progression to LRI and mortality after influenza infection. These patients should be monitored more closely. Early initiation of antiviral therapy for influenza in HCT recipients, regardless of the ISI risk group, may improve morbidity as well as mortality.

Development and validation of a Pneumocystis jirovecii real-time polymerase chain reaction assay for diagnosis of Pneumocystis pneumonia

BACKGROUND

Pneumocystis jirovecii (PJ), a pathogenic fungus, causes severe interstitial Pneumocystis pneumonia (PCP) among immunocompromised patients. A laboratory-developed real-time polyermase chain reaction (PCR) assay was validated for PJ detection to improve diagnosis of PCP.

METHODS

Forty stored bronchoalveolar lavage (BAL) samples (20 known PJ positive [PJ+] and 20 known PJ negative [PJ-]) were initially tested using the molecular assay. Ninety-two sequentially collected BAL samples were then analyzed using an immunofluorescence assay (IFA) and secondarily tested using the PJ real-time PCR assay. Discrepant results were resolved by retesting BAL samples using another real-time PCR assay with a different target. PJ real-time PCR assay performance was compared with the existing gold standard (ie, IFA) and a modified gold standard, in which a true positive was defined as a sample that tested positive in two of three methods in a patient suspected to have PCP.

RESULTS

Ninety of 132 (68%) BAL fluid samples were collected from immunocompromised patients. Thirteen of 92 (14%) BALs collected were PJ+ when tested using IFA. A total of 40 BAL samples were PJ+ in the present study including: all IFA positive samples (n=13); all referred PJ+ BAL samples (n=20); and seven additional BAL samples that were IFA negative, but positive using the modified gold standard. Compared with IFA, the PJ real-time PCR had sensitivity, specificity, and positive and negative predictive values of 100%, 91%, 65% and 100%, respectively. Compared with the modified gold standard, PJ real-time PCR had a sensitivity, specificity, and positive and negative predictive values of 100%.

CONCLUSION

PJ real-time PCR improved detection of PJ in immunocompromised patients.

Delftia acidovorans: A rare pathogen in immunocompetent and immunocompromised patients

Delftia acidovorans is an aerobic, nonfermenting Gram-negative bacillus. It is usually a nonpathogenic environmental organism and is rarely clinically significant. Although D acidovorans infection most commonly occurs in hospitalized or immunocompromised patients, there are also several reports documenting the infection in immunocompetent patients. The present article describes a B cell lymphoblastic leukemia patient with D acidovorans pneumonia who was successfully treated with antibiotic therapy. The present report indicates that unusual pathogens may be clinically significant in both immunocompromised and immunocompetent patients. D acidovorans is often resistant to aminoglycosides; therefore, rapid detection of this microorganism is important.

Mouse papillomavirus MmuPV1 infects oral mucosa and preferentially targets the base of the tongue

In 2010, a new mouse papillomavirus, MmuPV1, was discovered in a colony of NMRI- Foxn1(nu)/Foxn1(nu) athymic mice in India. This finding was significant because it was the first papillomavirus to be found in a laboratory mouse. In this paper we report successful infections of both dorsal and ventral surfaces of the rostral tongues of outbred athymic nude mice. We also report the observation that the base of the tongue, the area of the tongue often targeted by cancer-associated high-risk papillomavirus infections in humans, is especially susceptible to infection. A suitable animal model for the study of oral papillomavirus infections, co-infections, and cancers has long been sought. The work presented here suggests that such a model is now at hand.

Corynebacterium macginleyi: A cause of ventilator associated pneumonia in an immunocompromised patient

Purpose and Importance

Corynebacterium macginleyi, a lipophilic diphtheroid from the genus Corynebacteria, is a known cause of conjunctivitis. It was recently reported as a cause of serious infections in immunocompromised individuals. It has never been reported as a cause of ventilator-associated pneumonia, that which carries a high burden and risk of mortality. Our report intends to increase awareness of a potentially lethal nosocomial bacterial infection.

Observations

This case reports on a 73 year old lady with metastatic lung adenocarcinoma on chemotherapy, who was hospitalized for dyspnea and diffuse pulmonary infiltrates in 2011. Trans-bronchial biopsies revealed cryptogenic organizing pneumonia. The patient improved with steroids. Failure to wean ensued with a bronchopleural fistula, increase in secretions, oxygen requirements, and appearance of new infiltrates. Two mini-BAL cultures yielded gram positive pleomorphic rods with palisade arrangement, diagnosed as C. macginleyi. Vancomycin therapy was initiated. She improved and was successfully extubated.

Conclusion and relevance

Non-diphtheria Corynebacteria usually form normal flora. If isolated, they are often dismissed as contaminants. C. macginleyi has emerged as a life-threatening nosocomial infection. Prompt identification and treatment are required. It is resistant to quinolones. Thus far, vancomycin is the preferred treatment.

Fatal Case of Pericardial Effusion Due to Myroides Odoratus: A Rare Case Report

Myroides spp., previously known as Flavobacterium odoratum, are rare clinical isolates and are often considered non-pathogenic. Natural habitat includes soil, fresh and marine waters, in foods and in sewage treatment plants. We present an unusual case of fatal pericardial effusion due to Myroides odoratus in a patient suffering from chronic kidney disease and undergoing maintenance haemodialysis. This case is presented to show the increasing incidence of rare isolates causing localized and systemic infections and due to their high intrinsic resistance to many antibiotics they can be fatal. Thus isolation of these pathogens is of great clinical importance.

Control of norovirus outbreak on a pediatric oncology unit

BACKGROUND

Patients undergoing treatment for cancer with chemotherapy and hematopoietic stem cell recipients are at risk for severe morbidity caused by norovirus (NV).

METHODS

We describe a NV outbreak on the Memorial Sloan Kettering Cancer Center's pediatric oncology unit. Stool testing for diagnosis of NV was performed by real-time polymerase chain reaction (PCR).

RESULTS

Twelve NV cases occurred; 7 were hospital acquired. Twenty-five health care workers reported NV compatible illness. Patient-to-patient transmission occurred once. The practices of the Centers for Disease Control and Prevention were supplemented with electronic surveillance, surrogate screening for NV, and heightened cleaning. Two additional cases occurred after implementation of interventions. Long-term shedding was detected in 2 patients.

CONCLUSION

We describe interventions for controlling NV on a pediatric oncology unit. High-risk chronic shedders pose ongoing transmission risks. PCR is a valuable diagnostic tool but may be overly sensitive. Surrogate markers to assess NV burden in stool and studies on NV screening are needed to develop guidelines for high-risk chronic shedders.

A case report on management of synergistic gangrene following an incisional abdominal hernia repair in an immunocompromised obese patient

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Synergistic gangrene is generated from bacterial colonies present in necrotic tissues. Within our case, continual removal of the necrotic burden was essential in wound bed preparation, reducing contamination and tissue destruction.

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In surgery, wide necrotic wound debridement, early and repetitive wound drainages with the use of a large pore polypropylene mesh with a detailed surgical follow up is recommended.

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This case has demonstrated how a planned multidisciplinary action can produce prosperous results in a severely obese immunocompromised patient with an SSI, following an incisional hernia repair.

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Our selective case is unique within current literature, being the first to illustrate mesh salvage in a morbid obese patient with chronic lymphoblastic leukaemia.

Introduction

We present a case on conservative management of salvaging the mesh in an immunocompromised morbidly obese patient, who developed a synergistic gangrene infection following a primary open mesh repair of an incisional hernia.

Presentation of case

Our patient presented with a surgical wound infection, comorbidities were Chronic Lymphoblastic Leukemia (CLL), Body Mass Index (BMI) of 50, hypertension and diet controlled type-2 diabetes. In surgery, wide necrotic wound debridement, early and repetitive wound drainages with the use of a large pore polypropylene mesh and a detailed surgical follow up was required. High dose intravenous broad-spectrum antibiotic treatment and Negative Pressure Wound Therapy (NPWT) was administrated in combination with adopting a multidisciplinary approach was key to our success.

Discussion

Stoppa Re et al. complied a series of 360 ventral hernia mesh repairs reporting an infection rate of 12% that were managed conservatively. However, our selective case is unique within current literature, being the first to illustrate mesh salvage in a morbid obese patient with CLL. Recent modifications in mesh morphology, such as lower density, wide pores, and lighter weight has led to considerable improvements regarding infection avoidance.

Conclusion

This case has demonstrated how a planned multidisciplinary action can produce prosperous results in a severely obese immunocompromised patient with an SSI, following an incisional hernia repair.

Chronic norovirus infection in a patient with a past history of Burkitt lymphoma

The noroviruses are a leading cause of gastroenteritis worldwide. Although the illness is normally mild and self-limiting, there is a growing literature documenting the chronic excretion of norovirus in the immunocompromised. The aim of the current study was to examine the molecular features of chronic norovirus excretion in an immunocompromised patient with a past history of Burkitt lymphoma. During the 241 day course of the study from December 2013 to August 2014, seven faecal specimens were collected from the patient, tested for norovirus by RT-PCR and further analysed in the open reading frame (ORF) 1 and ORF 2 regions. All seven specimens were positive for norovirus by RT-PCR. Molecular sequencing in the polymerase (ORF 1) and capsid (ORF 2) regions indicated that the norovirus could be classified as GII.4 (2006b)/GII.4 (unknown). No significant mutation was found in the ORF 1 or ORF 2 regions analysed over the period of the study. The current report appears to be the first to document chronic norovirus excretion in a patient with a past history of Burkitt lymphoma. It is also the first to indicate long term norovirus excretion in a given individual need not involve major genetic change in key regions of the genome.

Malignant otitis externa in a healthy non-diabetic patient

A healthy 60-year-old male was initially treated for external otitis, and subsequently received multiple surgeries including abscess drainage, temporal bone debridement, canaloplasty of the external auditory meatus, and fistula excision and was treated with numerous antibiotics at another hospital over a 1-year period. He was seen at our hospital on February 14, 2014 with a complaint of a non-healing wound behind the left ear and drainage of purulent fluid. He had no history of diabetes mellitus or compromised immune function. Computed tomography (CT) and magnetic resonance imaging (MRI) studies at our hospital showed osteomyelitis involving the left temporal, occipital, and sphenoid bones, the mandible, and an epidural abscess. Routine blood testing and tests of immune function were normal, and no evidence of other infectious processes was found. He was diagnosed with malignant otitis externa (MOE). Bone debridement and incision and drainage of the epidural abscess were performed, and vancomycin was administered because culture results revealed Corynebacterium jeikeium, Corynebacterium xerosis, and Enterococcus faecalis. MOE should be considered in healthy patients with external otitis who fail initial treatment.

Update on the spectrum of histoplasmosis among hispanic patients presenting to a New York City municipal hospital: A contemporary case series

Histoplasma capsulatum is the most common endemic mycosis worldwide. Although most of the globe's largest urban hubs fall outside this organism's regions of endemicity, clinicians practicing in a metropolis like New York City or Los Angeles must nevertheless remain vigilant for histoplasmosis because of the large immigrant population that is served by its hospitals. H. capsulatum infection ranges from asymptomatic pulmonary infection to life-threatening diffuse pneumonia with dissemination. The early years of the AIDS epidemic first introduced U.S. clinicians working in areas previously unfamiliar with histoplasmosis to newly immunocompromised patients from endemic regions presenting with disseminated H. capsulatum originally acquired in their home countries. Improvement in HIV prevention and therapeutics has reduced the frequency of such cases. Herein we report three cases of histoplasmosis encountered in our New York City institution over the last three years to emphasize that awareness of this infection remains mandatory for the frontline urban clinician.

Infectious diseases approach to immunocompromised patients in the pediatric intensive care unit

The diagnosis and management of infectious diseases in the immunocompromised patient can be challenging, especially when that patient is critically ill. In the diagnostic approach to the immunocompromised patient, clinicians will need to integrate the risks particular to the immunodeficiency with the risks associated with hospital-associated exposures. The potential infectious diagnoses are expanded in the immunocompromised patients, most notably to include diseases due to opportunistic infections, such as fungi, latent viruses, and opportunistic Gram-positive and Gram-negative bacteria. In addition, prior hospital and antibiotic exposure increases the likelihood that these patients will have infections due to resistant organisms. When an infection is diagnosed, the approach to treatment in the immunocompromised patient is also dependent on the degree and type of immunodeficiency, and optimal treatment strategies are often not well studied. This review focuses on general principles that can be used in the diagnosis and management of immunocompromised, critically ill patients with suspected or proven infection and highlights in detail the approach to infections of the blood stream and respiratory tract.

Attitude, knowledge and factors associated with influenza and pneumococcal vaccine uptake in a large cohort of patients with secondary immune deficiency

BACKGROUND

Immunocompromised patients are at increased risk for severe influenza and invasive pneumococcal diseases. Population-specific vaccine recommendations are thus warranted. This study aimed to estimate the prevalence and predictors of influenza and pneumococcal vaccine uptake in a large cohort of patients with secondary immune deficiency.

METHODS

An anonymous online survey was submitted to the members of 11 French associations of immunocompromised patients. The questionnaire included questions concerning underlying disease, care and treatment, flu and pneumococcal vaccine uptake, attitudes and knowledge about vaccination. Factors associated with vaccine uptake were assessed by multivariate logistic regression.

RESULTS

Among the 10,897 solicited patients, 3653 agreed to participate (33.5%): 75% were female, 20% aged 65+, 79% were followed for an autoimmune disease, 13% were solid organ recipients or waiting for transplantation and 8% were treated for hematological malignancies. 3109 (85%) participants were treated with immunosuppressive therapy. Self-reported vaccine uptake was 59% (95%CI [57-60]) against seasonal influenza and 49% (95%CI [47-50]) against pneumococcal diseases. Better knowledge of and favorable attitudes toward vaccination were positively associated with vaccine uptake while being treated with a biological therapy was negatively associated.

CONCLUSION

Despite specific recommendations regarding immunocompromised patients, influenza and pneumococcal vaccination rates do not reach recommended levels. Targeted information campaigns on vaccination toward these populations should be implemented to improve vaccine coverage and thus reduce the burden of infections.

Fecal microbiota transplantation (FMT) for Clostridium difficile infection: focus on immunocompromised patients

Clostridium difficile infection (CDI) is an emerging problem worldwide associated with significant morbidity, mortality, recurrence rates and healthcare costs. Immunosuppressed patients, including HIV-seropositive individuals, solid organ transplant recipients, patients with malignancies, hematopoietic stem cell transplant recipients, and patients with inflammatory bowel disease are increasingly recognized as being at higher risk of developing CDI where it may be associated with significant complications, recurrence, and mortality. Fecal microbiota transplantation (FMT) has proven to be an effective and safe procedure for the treatment of recurrent or refractory CDI in immunocompetent patients by restoring the gut microbiota and resistance to further recurrences. During the last two years the first data on FMT in immunocompromised patients began to appear in the medical literature. Herein we summarize the use of FMT for the treatment of CDI with a focus on immunocompromised patients.

Updates in vaccination: recommendations for adult inflammatory bowel disease patients

Treatment regimens for inflammatory bowel disease (IBD) incorporate the use of a variety of immunosuppressive agents that increase the risk of infections. Prevention of many of these infections can be achieved by the timely and judicious use of vaccinations. IBD patients tend to be under-immunized. Some of the contributing factors are lack of awareness regarding the significance of vaccinating IBD patients, misperception about safety of vaccinations in immunocompromised patients, ambiguity about the perceived role of the gastroenterologist in contrast to the primary care physician and unavailability of vaccination guidelines focused on IBD population. In general, immunocompetent IBD patients can be vaccinated using standard vaccination recommendations. However there are special considerations for IBD patients receiving immunosuppressive therapy, IBD travelers and pregnant women with IBD. This review discusses current vaccination recommendations with updates for adult IBD patients. Centers for Disease Control and Prevention 2013 vaccination guidelines with 2014 updates and the Advisory Committee on Immunization Practices recommendations have been highlighted as a primary source of recommendations.

Survival following lung resection in immunocompromised patients with pulmonary invasive fungal infection

OBJECTIVES

Pulmonary invasive fungal infections (IFIs) are associated with high mortality in patients being treated for haematological malignancy. There is limited understanding of the role for surgical lung resection and outcomes in this patient population.

METHODS

This is a retrospective cohort of 50 immunocompromised patients who underwent lung resection for IFI. Patient charts were reviewed for details on primary malignancy and treatment course, presentation and work-up of IFI, reasons for surgery, type of resection and outcomes including postoperative complications, mortality, disease relapse and survival. Analysis was also performed on two subgroups based on year of surgery from 1990-2000 and 2001-2014.

RESULTS

The median age was 39 years (range: 5-64 years). Forty-seven patients (94%) had haematological malignancies and 38 (76%) underwent haematopoietic stem cell transplantation (HSCT). Surgical indications included haemoptysis, antifungal therapy failure and need for eradication before HSCT. The most common pathogen was Aspergillus in 34 patients (74%). Wedge resections were performed in 32 patients (64%), lobectomy in 9 (18%), segmentectomy in 2 (4%) and some combination of the 3 in 7 (14%) for locally extensive, multifocal disease. There were 9 (18%) minor and 14 (28%) major postoperative complications. Postoperative mortality at 30 days was 12% (n = 6). Acute respiratory distress syndrome was the most common cause of postoperative death. Overall 5-year survival was 19%. Patients who had surgery in the early period had a median survival of 24 months compared with 5 months for those who had surgery before 2001 (P = 0.046). At the time of death, 15 patients (30%) had probable or proven recurrent IFI. Causes of death were predominantly related to refractory malignancy, fungal lung disease or complications of graft versus host disease (GVHD). Patients who had positive preoperative bronchoscopy cultures had a trend towards worse survival compared with those with negative cultures (hazard ratio: 1.80, P = 0.087).

CONCLUSIONS

Surgical resection of IFI in immunocompromised patients is associated with high perioperative mortality. Long-term survival is limited by recurrent malignancy, persistent fungal infection and GVHD but has improved in recent years. Selection for surgical resection is difficult in this patient population, but should be carefully considered in those who are symptomatic, or have failed antifungal treatment.

Immunisation in children and adolescents with inflammatory bowel disease

Inflammatory bowel disease (IBD) patients may be at a higher risk for developing infections due to underlying disease, malnutrition, surgery, or immunosuppressive therapy. Therefore, protecting this group against infections is of particular importance. Immunisation against vaccine-preventable diseases is strongly recommended. This article for the first time summarises data on immunogenicity and safety of vaccines in IBD children and provides an update on some important issues regarding immunisation in these group of children.

Pneumocystis jirovecci pneumonia in connective tissue diseases: Comparison with other immunocompromised patients

INTRODUCTION

Pneumocystis jirovecci pneumonia (PJP) is an opportunistic fungal infection occurring in immunocompromised patients, such as those with human immunodeficiency virus (HIV), organ transplantation, malignancies and connective tissue diseases (CTDs). Risk factors for PJP are not well characterised, leading to uncertainty regarding the indications for antimicrobial prophylaxis and monitoring. This study compared differences between patients with and without CTDs who developed PJP.

METHODS

Retrospective data was collected for all subjects with a positive toludine blue O stain or a positive P. jirovecci PCR and a concurrent respiratory illness that was clinically consistent with PJP between 2002 and 2013 at the Royal Melbourne Hospital, Australia. Sub-groups were assigned according to the underlying disease. Peripheral blood results were retrieved from an in-house pathology database.

RESULTS

Eleven of 90 subjects (12.2%) diagnosed with PJP had underlying CTDs. The CTDs group was more likely to have been exposed to corticosteroids (100% versus 35.2%, p < 0.001) and other iatrogenic immunosuppression (90.9% versus 24.6%, p < 0.001). After adjusting for age and gender, the CTDs group had greater lymphopaenia (0.17 versus 0.58 × 10(9)/L; p = 0.034) and were older (69.6 versus 50.6 years; p < 0.001) than the non-CTD group. Excluding renal transplant recipients, people with CTDs also had lower eGFR than the non-CTD group (65 versus 80; p = 0.015).

CONCLUSIONS

CTDs contributed to a significant proportion of total PJP diagnoses. Clinicians treating CTDs must be vigilant for PJP, particularly in older patients with exposure to corticosteroids or other iatrogenic immunosuppression, lymphopaenia and renal impairment; factors which may lower the clinical threshold for initiating prophylaxis.

Surgical Site Infection Caused by Aeromonas hydrophila in a Patient with Underlying Malignancy

Aeromonas skin and soft tissue infections in cancer patients can lead to serious life threatening conditions such as cellulitis, necrotizing fasciitis and myonecrosis. We report here a case of surgical site infection, post radical mastectomy, in a 58-year-old female with carcinoma breast. Cultures of exudates from the wound grew Aeromonas hydrophila on repeated occasions. Recovery was uneventful following targeted antimicrobial therapy and regular dressing of the wound. Early suspicion, diagnosis, and treatment with potent antibiotics are needed to prevent any further complications resulting from infection by this emerging pathogen.

Toxoplasmosis of spinal cord in acquired immunodeficiency syndrome patient presenting as paraparesis: a rare entity

Although brain has been the most common site for toxoplasma infection in acquired immunodeficiency syndrome patients, involvement of spinal cord by toxoplasma has been rarely found. Spinal cord toxoplasmosis can present as acute onset weakness in both lower limbs associated with sensory and bladder dysfunction. A presumptive diagnosis can be made in patients with CD4 count <100/mm(3) based on a positive serum Toxoplasma gondii IgG antibodies, no recent prophylaxis against toxoplasmosis, intramedullary ring enhancing lesion in spinal cord supported by similar lesions in brain parenchyma. Institutions of antitoxoplasma treatment in such patients result in prompt clinical response and therefore avoiding the need of unnecessary invasive diagnostic tests. Here, we report a case of toxoplasmic myelitis in immunocompromised patient presenting as myelopathy who showed significant clinical improvement after starting antitoxoplasma treatment. Hence toxoplasmic myelitis should be considered in toxoplasma seropositive immunocompromised patients presenting as myelopathy and imaging studies showing ring enhancing intramedullary lesion.

Zoonotic disease risks for immunocompromised and other high-risk clients and staff: promoting safe pet ownership and contact

Pets can be a source of disease (zoonoses) for humans. The disease risks associated with pet contact are highest among young children, the elderly, pregnant women, and immunocompromised hosts. These individuals and household members display limited knowledge of pet-associated disease, rarely recall receipt of pet-associated disease information, and report pet ownership practices that are often at odds with established disease prevention recommendations. Veterinary staff are in a key position to promote safe pet ownership and contact practices. Encouraging and safeguarding client disclosure of immunocompromising health conditions and promoting veterinarian-physician communications are critical for effectively providing this service.

Bacteremia caused by Eggerthella lenta in an elderly man with a gastrointestinal malignancy: A case report

Eggerthella lenta is an anaerobic, Gram-positive bacillus commonly found in the human digestive tract. Occasionally, it can cause life-threatening infections. Bacteremia due to this organism is always clinically significant and is associated with gastrointestinal diseases and states of immune suppression. The authors report a case involving an elderly man with a newly diagnosed gastrointestinal malignancy who developed bacteremia caused by E lenta, treated successfully using empirical therapy with vancomycin and piperacillin-tazobactam, followed by directed therapy with metronidazole once the identity and antibiotic susceptibility of the organism was established. The present case reinforces the connection between E lenta bacteremia with gastrointestinal malignancy and highlights the importance of searching for a source of bacteremia due to this organism.

Prevalence of cryptosporidiosis in renal transplant recipients presenting with acute diarrhea at a single center in Pakistan

Background: Cryptosporidium is an intracellular protozoan organism which causes diarrhea, both in immunocompetent and immunocompromised hosts. Renal transplant recipients are prone to develop a variety of infections including protozoal infections.

Objectives: The aim of this study was to determine the prevalence of cryptosporidiosis in our renal transplant recipients presenting with acute diarrhea.

Patients and Methods: During six months of the study, 644 renal transplant recipients presented with acute diarrhea. Single stool sample was obtained for detailed analysis including gross and microscopic examination for red blood cells, pus cells, ova, cysts, and protozoa. The modified Ziehl-Neelsen (ZN) staining was done to identify the oocysts of cryptosporidia.

Results: Out of 644 renal transplant patients, oocysts of cryptosporidia were identified in 343 patients (53%). Detailed stool analysis of these patients showed the presence of numerous pus cells in 27 (7.9%) patients, co-infection with giardia intestinalis cysts in 15 (4.3%), and entamoeba histolytica cysts in 10 (2.9%). In all, out of 343 patients, 43 (12.5%) had dual infection with bacteria and protozoa in addition to cryptosporidiosis.

Conclusions: Cryptosporidium is an important pathogen causing acute diarrhea in renal transplant recipients in our set up. Stool examination is usually negative for pus cells. It is recommended that in all transplant recipients presenting with acute diarrhea modified ZN staining should be done to rule out cryptosporidiosis in highly endemic areas like Pakistan.

Invasive diagnostic strategies in immunosuppressed patients with acute respiratory distress syndrome

Immunosuppression predisposes the host to development of pulmonary infections, which can lead to respiratory failure and the development of acute respiratory distress syndrome (ARDS). There are multiple mechanisms by which a host can be immunosuppressed and each is associated with specific infectious pathogens. Early invasive diagnostic modalities such as fiber-optic bronchoscopy with bronchoalveolar lavage, transbronchial biopsy, and open lung biopsy are complementary to serologic and noninvasive studies and assist in rapidly establishing an accurate diagnosis, which allows initiation of appropriate therapy and may improve outcomes with relative safety.

Cost-effectiveness of seasonal influenza vaccination in pregnant women, health care workers and persons with underlying illnesses in Belgium

Risk groups with increased vulnerability for influenza complications such as pregnant women, persons with underlying illnesses as well as persons who come into contact with them, such as health care workers, are currently given priority (along with other classic target groups) to receive seasonal influenza vaccination in Belgium. We aimed to evaluate this policy from a health care payer perspective by cost-effectiveness analysis in the three specific target groups above, while accounting for effects beyond the target group. Increasing the coverage of influenza vaccination is likely to be cost-effective for pregnant women (median €6589 per quality-adjusted life-year (QALY) gained [€4073-€10,249]) and health care workers (median €24,096/QALY gained [€16,442-€36,342]), if this can be achieved without incurring additional administration costs. Assuming an additional physician's consult is charged to administer each additional vaccine dose, the cost-effectiveness of vaccinating pregnant women depends strongly on the extent of its impact on the neonate's health. For health care workers, the assumed number of preventable secondary infections has a strong influence on the cost-effectiveness. Vaccinating people with underlying illnesses is likely highly cost-effective above 50 years of age and borderline cost-effective for younger persons, depending on relative life expectancy and vaccine efficacy in this risk group compared to the general population. The case-fatality ratios of the target group, of the secondary affected groups and vaccine efficacy are key sources of uncertainty.

Strongyloidiasis in immigrants in Southern Spain

OBJECTIVE

To analyse clinical and epidemiological characteristics of immigrant patients diagnosed with strongyloidiasis in our area.

METHODS

An analyse was performed on patients with strongyloidiasis seen in the Tropical Medicine Unit of the "Hospital de Poniente" in Almeria (Spain), from April 2004 to May 2012.

RESULTS

A total of 320 patients were diagnosed with Strongyloides stercoralis infection, and 284 out of 314 patients (90.4%) had a positive specific serology. Forty-two percent of the patients reported symptoms and 45% had eosinophilia. The serological results were monitored in some of the patients, confirming a loss of antibodies in all 20 patients studied.

CONCLUSIONS

Strongyloidiasis is a parasitic disease increasingly diagnosed in developed countries due to increased migratory flows from endemic areas. Often being asymptomatic, its diagnosis and treatment may prevent fatal outcomes, especially in immunocompromised patients.

Human metapneumovirus pneumonia in patients with hematological malignancies

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25% of hematological patients with a positive HMPV test have pneumonia.

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HMPV pneumonia can occur in the course of several hematological conditions.

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HMPV can cause pneumonia as a single pathogen.

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Lung HRCT scan may be suggestive of HMPV pneumonia.

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The outcome of HMPV pneumonia is good despite no antiviral treatment.

Background

Human metapneumovirus (HMPV) has recently emerged as a cause of respiratory infections in hematological patients. Clinical data are lacking to guide the management of HMPV pneumonias.

Objectives

To characterize the clinical and radiographic presentation and outcome of HMPV pneumonias diagnosed in hematological patients.

Study design

We screened the patients with a positive HMPV respiratory test in two French teaching hospitals between 2007 and 2011. Among them, the medical charts from the hematological patients who presented with HMPV pneumonia were reviewed.

Results

Among the 54 patients with several underlying hematological conditions who were positive for HMPV, we found 13 cases of HMPV pneumonias. HMPV could be the cause of pneumonia as a single pathogen without associated upper respiratory infection. Centrilobular nodules were constant on lung computed tomography scans. No patients died despite the absence of administration of antiviral treatments.

Conclusions

Our data provide further insights in the diagnosis and management of HMPV pneumonias in this setting.

Prolonged shedding of pandemic influenza A (H1N1) 2009 virus in a pancreas-after-kidney transplant recipient

Prolonged shedding of influenza virus has been reported in immunocompromised patients. Delayed viral clearance may contribute to antiviral resistance and nosocomial transmission. We report a case of a pancreas-after-kidney transplant recipient who had detectable pandemic influenza A virus for 12 months. Pyrosequencing analysis detected the H275Y mutation, which is associated with resistance to oseltamivir.

Pulmonary infection with caseating mediastinal lymphadenitis caused by Mycobacterium gordonae

It is often difficult to discern true mycobacterial infection from colonization due to Mycobacterium gordonae (M. gordonae) since this organism is ubiquitous and is commonly an innocuous saprophyte. This study reports a rare case of caseating hilar adenopathy and pulmonary disease caused by M. gordonae in a patient with chronic obstructive pulmonary disease (COPD) and rheumatoid arthritis (RA) on maintenance steroids and methotrexate. Pathologic exam and cultures of lymph node excision biopsy and bronchoalveolar lavage (BAL) confirmed the diagnosis. Triple antimycobacterial therapy with azithromycin, ethambutol and rifabutin was administered. The patient had significant clinical and radiologic improvement and follow-up cultures confirmed microbiologic cure. Mycobacterium gordonae can be a rare cause of significant pulmonary infection, and positive sputum or BAL cultures for M. gordonae should not be automatically discarded and considered as nonpathogenic contaminants or colonizing organisms, especially in immunocompromised hosts with comorbidities. A detailed review of the case and relevant literature is provided.

Vaccination of healthcare personnel: spotlight on groups with underlying conditions

Healthcare personnel (HCP) are at increased risk of acquiring vaccine-preventable diseases (VPDs). Vaccination protects HCP and their patients from nosocomial transmission of VPDs. HCP who have underlying diseases (e.g., immunocompromised, HIV-infected, or those with chronic diseases) and HCP in particular phases of life (e.g., pregnant, elderly) require special consideration in regards the provision of vaccines. On the one hand, live virus vaccines may be contraindicated (e.g., pregnant HCP, immunocompromised HCP), while on the other hand, vaccines not routinely recommended (e.g., pneumococcal) may be indicated (e.g., elderly or immunocompromised HCP). It is not known how many HCP with underlying conditions require special consideration in the healthcare setting. This is an important issue, because the risk for serious morbidity, complications and mortality for HCP with underlying conditions will only increase. The prevention of nosocomial infections requires comprehensive occupational safety programs. The healthcare system must engage HCP and occupational physicians to ensure sufficient vaccination rates as part of an effective nosocomial infection prevention and HCP safety strategy.