Cerebral nocardiosis with osteomyelitis of skull vault complicating a primary neck lesion in an immunocompetent patient: a case report

Nocardia infection is an uncommon and rare condition in immunocompetent patient. A case of cutaneous nocardiosis complicated with osteomyelitis of the vault scalp in a 64-year-old man, with no remarkable past medical history, is reported. Treatment with trimethoprime-sulfamethoxazole than doxycycline for 12 months led to complete resolution and no evidence of recurrence was noted. Nocardia infection should be considered even in immunocomptent patients and doxycycline is a good alternative for treatment.

Disseminated Histoplasmosis in an Immunocompetent Patient After COVID-19 Pneumonia

Disseminated histoplasmosis can occur in immunocompromised patients such as in HIV disease and patients with medication-induced immunosuppression. Most of these patients present with fever, weight loss, hepatosplenomegaly, lymphadenopathy, and pancytopenia. There are increasing reports of coronavirus disease 2019 (COVID-19) pneumonia associated with fungal infections including aspergillus and mucormycosis. It is not typical for immunocompetent patients to present with disseminated fungal disease. We herein report a case of a 50-year-old immunocompetent male with a recent recovery from COVID-19 pneumonia who presented with fever and pancytopenia. Chest computed tomography (CT) demonstrated new-onset right upper lobe lung mass, subcarinal lymphadenopathy, and splenomegaly. Mediastinal lymph nodes and bone marrow biopsies were performed, and the patient was diagnosed with disseminated histoplasmosis. The association between COVID-19 pneumonia and fungal infections is increasingly reported. Diagnosis requires a high index of suspicion, especially in immunocompetent patients.

Rhino-orbital mucormycosis following COVID-19 in previously non-diabetic, immunocompetent patients

PURPOSE

To report a series of 13 immunocompetent patients who developed new-onset uncontrolled diabetes mellitus (DM) following COVID-19 infection and presented as rhino-orbital mucormycosis (ROM).

METHOD

Retrospective study.

RESULTS

A total of 127 patients of COVID-19 Associated Mucormycosis (CAM) were evaluated at four centres in India. All patients underwent endoscopic sinus debridement surgery and received systemic amphotericin-B therapy. Five patients (5/13; 38.4%) received retrobulbar amphotericin-B injections. Orbital exenteration was performed in advanced orbital involvement or progression of orbital disease in spite of maximal medical therapy. In his cohort, 13/127 (10.2%) patients presented with new onset DM, where one patient had bilateral disease. The mean age was 35.9 years (range: 20-51 years) and the mean duration from diagnosis of COVID-19 to the diagnosis of mucormycosis was 14.2 days. While 7/13 (53.8%) of the patients received systemic corticosteroids during the course of their treatment for COVID-19, six patients received no steroids or immunomodulators. The mean follow-up period was 9.2 weeks (range: 3-18 weeks) following discharge. Life salvage was possible in 100% of the cases. While overall globe salvage was possible in 42.8% (6/14 eyes), the globe could be preserved in 4/5 patients who received retrobulbar amphotericin-B injections.

CONCLUSIONS

Those involved in the care of COVID-19 patients should be aware about the possibility of recent-onset DM, even in patients without a history of corticosteroid therapy. Rarely, recent-onset DM following COVID-19 may present as rhino-orbital mucormycosis, which requires aggressive surgical and medical intervention.

Severe Postnatal Cytomegalovirus Enterocolitis in Immunocompetent Term Infants Requiring Total Parenteral Nutrition

Postnatal cytomegalovirus enterocolitis is uncommon in immunocompetent infants. We report a 10-week-old term boy with severe and prolonged secretory diarrhea, leading to dependence on total parenteral nutrition and a 10-week hospitalization. Cytomegalovirus enterocolitis was diagnosed based on duodenal biopsy in the context of marked viremia, and the child recovered promptly on initiation of ganciclovir. Collated case reports reveal delayed diagnoses as the norm but rapid improvement with antiviral treatment. Cytomegalovirus enterocolitis should be considered early as a differential diagnosis in infants with refractory diarrhea.

Rhino-Orbital mucormycosis in an immunocompetent pediatric patient with hyperglycemia of the hospitalized patient

INTRODUCTION

Acute invasive rhino-orbital mucormycosis usually affects diabetic or neutropenic patients, and only exceptionally develops in immunocompetent adults and children.

METHODOLOGY

A 12-years-old immunocompetent female, presented with complicated rhinosinusitis with a subperiosteal orbital abscess, without improvement after initial medical and surgical management, the patient also developed hyperglycemia of the hospitalized patient that represented a challenging and potentially lethal clinical scenario.

RESULTS

Diagnosed with an unsuspected rhino-orbital mucormycosis by direct microscopy and PCR, she survived after amphotericin B and surgical treatment.

CONCLUSIONS

In cases with torpid clinical evolution, even in apparently immunocompetent patients, appropriate multidisciplinary workup must be performed to rule out opportunistic etiologies including mucormycosis to improve survival.

Cutaneous Protothecosis with Meningitis Due to Prototheca wickerhamii in an Immunocompetent Teenager: Case Report and Literature Review

Human protothecosis is a rare infection caused by Prototheca spp., which are environmental achloric algae ubiquitously existing in nature. Members of the genus of Prototheca usually cause localized infection that affects the skin or wounds. Systemic infection is extremely rare and tends to occur in immunocompromised patients. Here, we report a case of cutaneous protothecosis and meningitis due to Prototheca wickerhamii in an immunocompetent teenager who obtained full-body tattoos at the time of infection. To the best of our knowledge, this is the first description of P. wickerhamii isolated from both skin tissue and cerebrospinal fluid. The data contained in this report will increase our understanding of this pathogen and elucidate the most optimal treatment.

Recurrent cutaneous hyalohyphomycosis secondary to Purpureocillium lilacinum in an immunocompetent individual

Purpureocillium lilacinum, previously classified as Paecilomyces lilacinus, is a ubiquitous hyaline hyphomycete considered to be an emerging opportunistic human pathogen that is resistant to traditional antifungal agents. This case report describes what is to our knowledge the only published case of P. lilacinum recrudescence in an immunocompetent host despite initial best-practice treatment with 10 weeks of voriconazole and surgical excision.

West Nile Viral Meningoencephalitis in an immunocompetent female: A case report from Western Rajasthan, India

BACKGROUND

West Nile virus (WNV) is a positive-sense single-stranded RNA virus of the family Flaviviridae and genus Flavivirus. The virus is transmitted primarily by the bite of Culex species mosquito and is of global concern. The infection is associated with a wide spectrum of signs and symptoms and is more fatal in the elderly, infants, and immunocompromised individuals.

CASE PRESENTATION

We report a case of WNV meningoencephalitis in an immunocompetent female who presented with features of acute meningitis with a 5-days history. After the radiological suspicion of viral meningoencephalitis, viral serology was performed and was reactive for IgM antibody against WNV, delaying the diagnosis for at least 5 days.

CONCLUSION

The purpose of this case report is to prime the treating physicians on the usefulness of viral serology in such a scenario. Viral serology is a simple and relatively rapid technique to diagnose or rule out the suspected viral cause of meningoencephalitis and minimize the time gap between diagnosis and start of supporting treatment wherever appropriate antivirals are not available for clinical use.

Cryptococcus neoformans in a child with CSF rhinorrhoea: A cytopathological diagnosis

Cryptococcosis is caused by Cryptococcus neoformans and is fatal in children. The fungus is known to enter respiratory tract by inhalation and localizes in lungs in immunocompetent host. Patients with immunocompromised state facilitate dissemination of disease. However, disseminated cases have been described in immunocompetent HIV-negative individuals. CSF rhinorrhoea as a predisposing cause of cryptococcal meningitis has been rarely reported. We hereby describe C. neoformans directly spreading to the meninges in 1 year child due to CSF rhinorrhoea and the fungus was detected on fluid cytology.

A case report of pneumonia due to non-tuberculous mycobacteria in an immunocompetent patient

Non-tuberculous mycobacteria are uncommon pathogens in immunocompetent individuals. We report an unusual case of pneumonia with pleural effusion caused by co-infection with two species of non-tuberculous mycobacteria in an immunocompetent man in Nigeria. The case highlights the possibility of the occurrence of a disease caused by these pathogens in an unusual host in a setting where they are rarely isolated as well as the challenges faced in diagnosis.

Human Cytomegalovirus Genome Diversity in Longitudinally Collected Breast Milk Samples

Reactivation and shedding of human cytomegalovirus (HCMV) in breast milk during lactation is highly frequent in HCMV-seropositive mothers. This represents a key transmission route for postnatal HCMV infection and can lead to severe disease in preterm neonates. Little is known about HCMV strain composition or longitudinal intrahost viral population dynamics in breast milk from immunocompetent women. We performed HCMV-specific target enrichment and high-throughput sequencing of 38 breast milk samples obtained in Germany between days 10 and 60 postpartum from 15 mothers with HCMV DNA lactia, and assembled HCMV consensus sequences de novo. The genotype distribution and number of HCMV strains present in each sample were determined by quantifying genotype-specific sequence motifs in 12 hypervariable viral genes, revealing a wide range of genotypes (82/109) for these genes in the cohort and a unique, longitudinally stable strain composition in each mother. Reactivation of up to three distinct HCMV strains was detected in 8/15 of mothers, indicating that a representative subset of the woman’s HCMV reservoir might be locally reactivated early during lactation. As described previously, nucleotide diversity of samples with multiple strains was much higher than that of samples with single strains. Breast milk as a main source of postnatal mother-to-infant transmission may serve as a repository for viral diversity and thus play an essential role in the natural epidemiology of HCMV.

Analyses of Clinical and Biological Data for French and Belgian Immunocompetent Patients Infected With Hepatitis E Virus Genotypes 4 and 3

Hepatitis E virus (HEV) genotypes 3 and 4 are the major causes of acute hepatitis in industrialized countries. Genotype 3 is mainly found in Europe and America, while genotype 4 is predominant in Asia. Several Japanese studies have suggested that genotype 4 is more virulent than genotype 3. We investigated this aspect by analyzing the clinical and biological data for 27 French and Belgian immunocompetent patients infected with HEV genotype 4. Their infections were probably acquired locally, since none of these patients reported traveling outside France or Belgium during the 2–8 weeks before symptoms onset. Each patient was matched for age (±5 years) and gender with two patients infected with HEV genotype 3. Bivariate analysis indicated that the HEV genotype 4-infected patients had significantly higher alanine aminotransferase (ALT) (2067 IU/L) and aspartate aminotransferase (AST) (1581 IU/L) activities and total bilirubin concentrations (92.4 μmol/L) than did those infected with HEV genotype 3 (1566 IU/L, p = 0.016; 657 IU/L, p = 0.003 and 47 μmol/L, p = 0.046) at diagnosis. In contrast, more patients infected with HEV genotype 3 reported dark urine (71% vs. 39%, p = 0.02) and experienced asthenia (89% vs. 58%, p < 0.01) than did those infected with HEV genotype 4. Two HEV genotype 4-infected patients died of multi-organ failure, while none of the genotype 3-infected patients died (p = 0.035). Finally, stepwise regression analysis retained only a greater increase in ALT (odds-ratio: 1.0005, 95% confidence interval: 1.00012–1.00084) and less frequent fever (odds-ratio = 0.1244; 95% confidence interval: 0.01887–0.82020) for patients infected with HEV genotype 4. We conclude that HEV-4 infections are likely to be associated with higher ALT activity than HEV-3 infections. Additional immunological and virological studies are required to confirm these findings and better understand the influence, if any, of genotype on HEV pathophysiology.

Herpes Zoster in an Immunocompetent Child without a History of Varicella

Herpes zoster is a relatively rare infectious disease in the pediatric population, as compared with adults, which is due to the reactivation of latent Varicella-Zoster virus. We report a 7-year-old child without any history of varicella, who first experienced skin pain and later presented skin lesions in dermatomal distribution. Finally, the patient was diagnosed with herpes zoster. We aim to emphasize that herpes zoster could occur in immunocompetent children and may be due to the reactivation of the vaccine strain or previous subclinical infection.

Case Report: Metagenomic Next-Generation Sequencing in Diagnosis of Talaromycosis of an Immunocompetent Patient

Background: Talaromycosis is a serious fungal infection which is rare in immunocompetent people. Since its clinical manifestations lack specificity, it is easy to escape diagnosis or be misdiagnosed leading to high mortality and poor prognosis. It is necessary to be alert to the disease when broad-spectrum antibiotics do not work well in immunocompetent patients. Case Presentation: A 79-year-old man was admitted to our Infectious Diseases Department for recurrent fever and cough. Before admission he has been treated with piperacillin-tazobactam, moxifloxacin followed by antituberculous agents in other hospitals while his symptoms were not thoroughly eased. During the first hospitalization in another hospital, he has been ordered a series of examination including radionuclide whole body bone imaging, transbronchial needle aspiration for subcarinal nodes. However, the results were negative showing no neoplasm. After being admitted to our hospital, he underwent various routine examinations. The initial diagnosis was bacterial pneumonia, and he was given meropenem injection and tigecycline injection successively, but there were no improvement of symptoms and inflammatory indicators. In the end, the main pathogen Talaromyces marneffei was confirmed using Metagenomic Next-Generation Sequencing (mNGS), and his clinical symptoms gradually relieved after targeted antifungal treatment using voriconazole. Conclusion: When empirical anti-infective treatment is ineffective, it is necessary to consider the possibility of opportunistic fungal infections on immunocompetent patients. mNGS, as a new generation of pathogenic testing methods, can often detect pathogenic bacteria faster than traditional methods, providing important help for clinical decision-making.

Hepatic Candidiasis in an Immunocompetent Patient: A Diagnostic Challenge

Hepatic candidiasis is a manifestation of disseminated candidiasis, which typically presents in immunocompromised patients. Focal hepatic candidiasis in immunocompetent patients, however, is infrequent/extremely rare. We present the case of an immunocompetent female patient who presented with respiratory distress and right-sided pleural effusion. The pleural fluid tap did not grow anything, and a contrast-enhanced computed tomography (CT) scan revealed a right liver lobe subcapsular collection. CT-guided aspiration and culture resulted in Candida albicans growth. The patient responded to oral fluconazole, and a follow-up CT scan demonstrated resolution of the collection. Although hepatic candidiasis rarely occurs in immunocompetent patients, it should be included in the differential diagnosis of hepatic abscesses, as timely diagnosis and management are crucial in conferring a good prognosis.

Chronic cystoisosporiasis in an immunocompetent adult: A case report

RATIONALE

Cystoisosporiasis is an intestinal infectious disease caused by a coccidian protozoa, Cystoisospora belli (C. belli). It can cause prolonged and refractory diarrhea most commonly in immunocompromised patients, while immunocompetent individuals usually exhibit no symptoms or self-limited diarrhea.

PATIENT CONCERNS

We herein report a case of chronic cystoisosporiasis in an immunocompetent patient. A 62-year-old man, who had been first diagnosed with cystoisosporiasis 15 years ago and had been treated with oral administration of trimethoprim-sulfamethoxazole (TMP-SMX), complained of persistent watery diarrhea. He was negative for anti-human immunodeficiency virus antibody and anti-human T-cell leukemia virus type 1 (HTLV-1) antibody.

DIAGNOSIS

Biopsy specimens from the duodenum revealed oocysts in the atrophic absorptive epithelium and protozoa were detected through stool examination, indicating the recurrence of cystoisosporiasis. Capsule endoscopy showed diffuse atrophic mucosa with white villi in the entire small intestine. We diagnosed him with chronic cystoisosporiasis that occurred in an immunocompetent adult.

INTERVENTIONS

Since oral administration of TMP-SMX and ciprofloxacin were ineffective, the intravenous administration of TMP-SMX was initiated.

OUTCOMES

Intravenous TMP-SMX exhibited a significant improvement.

LESSONS

This case indicates that even immunocompetent individuals may develop recurrent and refractory cystoisosporiasis. Furthermore, intravenous treatment of antibiotic agents should be considered when the impaired absorptive ability from the small intestine is suspected.

Leveraging the replication-competent avian-like sarcoma virus/tumor virus receptor-A system for modeling human gliomas

Gliomas are the most common primary intrinsic brain tumors occurring in adults. Of all malignant gliomas, glioblastoma (GBM) is considered the deadliest tumor type due to diffuse brain invasion, immune evasion, cellular, and molecular heterogeneity, and resistance to treatments resulting in high rates of recurrence. An extensive understanding of the genomic and microenvironmental landscape of gliomas gathered over the past decade has renewed interest in pursuing novel therapeutics, including immune checkpoint inhibitors, glioma-associated macrophage/microglia (GAMs) modulators, and others. In light of this, predictive animal models that closely recreate the conditions and findings found in human gliomas will serve an increasingly important role in identifying new, effective therapeutic strategies. Although numerous syngeneic, xenograft, and transgenic rodent models have been developed, few include the full complement of pathobiological features found in human tumors, and therefore few accurately predict bench-to-bedside success. This review provides an update on how genetically engineered rodent models based on the replication-competent avian-like sarcoma (RCAS) virus/tumor virus receptor-A (tv-a) system have been used to recapitulate key elements of human gliomas in an immunologically intact host microenvironment and highlights new approaches using this model system as a predictive tool for advancing translational glioma research.

Osteoarticular Cryptococcosis Successfully Treated with High-Dose Liposomal Amphotericin B Followed by Oral Fluconazole

Background

Skeletal involvement of Cryptococcus neoformans is infrequent and usually associated with disseminated cryptococcosis or underlying predisposing conditions. We present an atypical case of osteoarticular cryptococcosis in an immunocompetent patient.

Case Presentation

We herein report a case of bone and soft tissue cryptococcal infection in a 42-year-old male from Pakistan with well-controlled diabetes without other associated immunodeficiencies treated with antifungal therapy without surgical debridement. Furthermore, the patient developed toxidermia due to fluconazole use, so a fluconazole desensitization was performed. Therapeutic management also included the performance of therapeutic drug monitoring of fluconazole plasma concentrations.

Conclusion

To our knowledge, this is the first case of osteoarticular cryptococcosis treated with this treatment regimen. This strategy may be of interest to try to reduce hospital stay and associated complications.

Pulmonary mucormycosis masquerading as endobronchial tumour in an immunocompetent pregnant young lady

Pulmonary mucormycosis is a rare but rapidly progressing and life-threatening fungal infection, usually affecting immunocompromised patients. We report a case of a previously healthy young lady who presented with prolonged cough, weight loss, and haemoptysis. Imaging showed left hilar mass with infiltration into the left main bronchus and concurrent mediastinal lymphadenopathy. Flexible bronchoscopy revealed an endobronchial mass occluding the left main bronchus. Tumour debulking was performed using rigid bronchoscopy with cryoprobe and snares. Histopathological examination revealed inflamed tissue with fungal organism. Fungal polymerase chain reaction (PCR) confirmed Rhizopus microsporus. She was treated with two weeks of intravenous amphotericin-B with complete clinical and radiological resolution.

Progressive multifocal leukoencephalopathy in a patient with occult hypogammaglobulinemia experiencing bilateral visual impairment

INTRODUCTION

Progressive multifocal leukoencephalopathy (PML) is a rare, lethal, demyelinating disease classically seen in profoundly immunosuppressed individuals. It is caused by intracerebral infection by John Cunningham polyomavirus (JCV). We report a rare case of PML in a man with presumed immunocompetence at presentation experiencing bilateral painless visual impairment.

CASE DESCRIPTION

A 60-year-old man with a 3-week history of bilateral painless visual impairment attended our ophthalmology department. Unusually, he navigated around the room well and was able to read 4 of 13 Ishihara test plates in spite of a best-corrected visual acuity of counting fingers at 1 m bilaterally. Slit lamp examination, routine blood tests and optical coherence tomography (OCT) of the maculae and discs were unremarkable. Diffuse hyperintense white matter lesions on T2-weighted magnetic resonance imaging of the brain and detection of JCV within the parietal lobe tissue obtained by biopsy confirmed PML. Additional investigations identified an underlying hypogammaglobulinaemia, which may have initiated PML. He received intravenous immunoglobulin but passed away 2 months after diagnosis.

CONCLUSIONS

To our knowledge this case is one of only a handful worldwide to describe PML developing in a patient with presumed immunocompetence at presentation - there was no previous history of recurrent, chronic, or atypical infections. There has only been one other report of visual symptoms presenting as the primary complaint. The case illustrates the importance of ruling out organic, central nervous system pathology in patients presenting with visual loss and normal objective visual function tests such as slit lamp examination and OCT.

Streptomyces pneumonia in an immunocompetent adult - a rare isolate

Streptomyces belongs to the Actinomycetes group of bacteria which are gram-positive non acid-fast bacilli, widely recognised for their potential to produce antimicrobials active against bacterial, mycobacterial, parasitic and fungal infections. They commonly cause cutaneous infections following traumatic inoculation. Visceral infections are relatively rare and limited to immunocompro-mised hosts. We describe a case of Streptomyces pneumonia in a healthy immunocompetent female, who when investigated for voluntary kidney donation, resulted in the isolation of Streptomyces species from bronchial wash cultures. Streptomyces, a potential pathogen in immunocompetent hosts is frequently underdiagnosed. Once isolated, both physicians and microbiologists should pay attention to differentiate true infection from contamination.

Acute Disseminated Encephalomyelitis Related to a Cytomegalovirus Infection in an Immunocompetent Patient

Cytomegalovirus (CMV) infection can cause acute disseminated encephalomyelitis (ADEM). However, it is rare in immunocompetent people. We describe a 17-year-old patient who was brought with flu-like symptoms. After one week, she experienced rapidly progressive weakness in all four extremities, followed by coma. The neurologic examination showed no response to verbal and pain stimuli. A Babinski sign was noted in both lower extremities, along with clonus and hyperreflexia in all four limbs. Brain magnetic resonance imaging (MRI) demonstrated extensive areas of hyperintense signal on fluid-attenuated inversion recovery (FLAIR) sequences in the white matter which was asymmetrically distributed in both hemispheres, as well as in the brainstem and cerebellar peduncles, compatible with acute demyelinating lesions. Cerebrospinal fluid (CSF) showed mild lymphocytic pleocytosis and normal glucose levels. Polymerase chain reaction to herpes simplex virus was negative. Serum immunoglobulin G (IgG) and immunoglobulin M (IgM) were positive for cytomegalovirus. The patient was treated with methylprednisolone pulse therapy for five days. Subsequently, the patient showed neurologic improvement with the recovery of consciousness and muscle strength. In terms of prognosis, in patients with ADEM, the sooner the diagnosis, the better the outcome. The cornerstone of treatment is immunosuppression with steroids. Some patients require intravenous immunoglobulin G (IVIG) or plasmapheresis, and in refractory cases, cyclophosphamide is used. 

Disseminated Cryptococcal Disease in a Patient With Monoclonal Gammopathy of Undetermined Significance and Polycythemia Vera: A Case Report and Review of the Literature

Cryptococcosis is a life-threatening opportunistic infection caused by Cryptococcus gattii and Cryptococcus neoformans. It affects both immunocompetent and immunosuppressed hosts. Disseminated cryptococcal infection is rare in immunocompetent patients, but the cryptococcal disease's neurological sequelae may be more prominent in this group. We present a case of a 58-year-old male patient with medical comorbidities of monoclonal gammopathy of undetermined significance (MGUS) and polycythemia vera. The patient presented with gradual worsening of mental status over one week. He was found to have Cryptococcus neoformans meningoencephalitis and fungemia. The patient received two weeks of liposomal amphotericin B (LAmB) and flucytosine with excellent clinical response. He was discharged on high dose fluconazole, and he returned to the hospital in one week with new-onset hemiplegia and cryptococcomas on imaging. Prolonged intravenous (IV) treatment of six weeks duration resulted in significant clinical improvement and disease-free state at two years follow-up. This article aims to stress the importance of individualized prolonged IV treatment with liposomal amphotericin B and flucytosine despite good initial response in patients with polycythemia vera and MGUS. This is the first reported case of cryptococcal disease, to the best of our knowledge, in a patient with MGUS and the third case of cryptococcal infection in patients with polycythemia vera in a non-HIV non-transplant state. Prolonged individualized IV treatment should be considered in immunocompetent patients with the above conditions, as this condition, if not adequately treated and relapses, lead to high morbidity and mortality.