An atypical presentation of Salmonella enterica ser Dublin in an immunocompromised patient

Mycotic aneurysms of the carotid artery are a rare entity that can be fatal if not diagnosed promptly. We present a 60-year-old man with a tender left-sided neck mass due to a ruptured aneurysm of the left internal carotid artery. Cultures taken intraoperatively grew Salmonella enterica ser Dublin.

Association of Infections and Use of Fluoroquinolones With the Risk of Aortic Aneurysm or Aortic Dissection

IMPORTANCE

Prior observational studies have suggested that fluoroquinolone use may be associated with more than 2-fold increased risk of aortic aneurysm or aortic dissection (AA/AD). These studies, however, did not fully consider the role of coexisting infections and the risk of fluoroquinolones relative to other antibiotics.

OBJECTIVE

To estimate the risk of AA/AD associated with infections and to assess the comparative risk of AA/AD associated with fluoroquinolones vs other antibiotics with similar indication profiles among patients with the same types of infections.

DESIGNS, SETTINGS, AND PARTICIPANTS

This nested case-control study identified 21 651 176 adult patients from a nationwide population-based health insurance claims database from January 1, 2009, to November 30, 2015. Each incident case of AA/AD was matched with 10 control individuals by age, sex, and follow-up duration in the database using risk-set sampling. Analysis of the data was conducted from April 2019 to March 2020.

EXPOSURES

Infections and antibiotic use within a 60-day risk window before the occurrence of AA/AD.

MAIN OUTCOMES AND MEASURES

Conditional logistic regression was used to estimate the odds ratios (ORs) and 95% CIs comparing infections for which fluoroquinolones are commonly used with no infection within a 60-day risk window before outcome occurrence, adjusting for baseline confounders and concomitant antibiotic use. The adjusted ORs comparing fluoroquinolones with antibiotics with similar indication profiles within patients with indicated infections were also estimated.

RESULTS

A total of 28 948 cases and 289 480 matched controls were included (71.37% male; mean [SD] age, 67.41 [15.03] years). Among these, the adjusted OR of AA/AD for any indicated infections was 1.73 (95% CI, 1.66-1.81). Septicemia (OR, 3.16; 95% CI, 2.63-3.78) and intra-abdominal infection (OR, 2.99; 95% CI, 2.45-3.65) had the highest increased risk. Fluoroquinolones were not associated with an increased AA/AD risk when compared with combined amoxicillin-clavulanate or combined ampicillin-sulbactam (OR, 1.01; 95% CI, 0.82-1.24) or with extended-spectrum cephalosporins (OR, 0.88; 95% CI, 0.70-1.11) among patients with indicated infections. The null findings for fluoroquinolone use remained robust in different subgroup and sensitivity analyses.

CONCLUSIONS AND RELEVANCE

These results highlight the importance of accounting for coexisting infections while examining the safety of antibiotics using real-world data; the findings suggest that concerns about AA/AD risk should not deter fluoroquinolone use for patients with indicated infections.

Candida sp. Infections in Patients with Diabetes Mellitus

Candidiasis has increased substantially worldwide over recent decades and is a significant cause of morbidity and mortality, especially among critically ill patients. Diabetes mellitus (DM) is a metabolic disorder that predisposes individuals to fungal infections, including those related to Candida sp., due to a immunosuppressive effect on the patient. This review aims to discuss the latest studies regarding the occurrence of candidiasis on DM patients and the pathophysiology and etiology associated with these co-morbidities. A comprehensive review of the literature was undertaken. PubMed, Scopus, Elsevier’s ScienceDirect, and Springer’s SpringerLink databases were searched using well-defined search terms. Predefined inclusion and exclusion criteria were applied to classify relevant manuscripts. Results of the review show that DM patients have an increased susceptibility to Candida sp. infections which aggravates in the cases of uncontrolled hyperglycemia. The conclusion is that, for these patients, the hospitalization periods have increased and are commonly associated with the prolonged use of indwelling medical devices, which also increase the costs associated with disease management.

Aortic Aneurysm as a Complication of Granulomatosis with Polyangiitis Successfully Treated with Prednisolone and Cyclophosphamide: A Case Report and Review of the Literature

A 57-year-old Japanese man was admitted to the hospital with back pain and fever, multiple lung nodules, and abdominal aortic aneurysm (AAA). Laboratory tests performed at admission showed an increased proteinase 3 anti-neutrophil cytoplasmic antibody (PR3-ANCA) level. Video-associated thoracoscopic lung biopsy was performed; pathologic examination showed granulation tissue with necrosis and multinucleated giant cells. The diagnosis of granulomatosis with polyangiitis (GPA) was confirmed on the basis of the clinical presentation, laboratory findings, and lung biopsy. All symptoms were ameliorated, and the serum level of PR3-ANCA declined following treatment with prednisolone and cyclophosphamide. Although the association of GPA with AAA is rare, GPA may be included among the large vessel vasculitides that can give rise to aortic aneurysm.

Non-Tuberculous Mycobacterium Induced Pseudoaneurysm of the Common Carotid Artery

An 81-year-old male patient presented with complaint of a pulsating neck mass. The patient had a previous history of cervical lymphadenopathy by non-tuberculous mycobacterium infection. Rapid growth of the mass on admission and contrast enhanced computed tomography of the neck resulted in a diagnosis of non-tuberculous mycobacterium induced pseudoaneurysm. The patient underwent emergency open repair of the pseudoaneurysm. Pseudoaneurysm of the common carotid artery is regularly reported, but here we report a rare case of non-tuberculous mycobacterium induced pseudoaneurysm of the common carotid artery.

Femoral artery pseudoaneurysm due to Candida albicans in an injection drug user

Candida arteritis is an uncommon condition but important to recognize due to the risk of significant morbidity and the difficulty in management of the enduring fungal infection. The authors report a rare case of a man with a femoral artery pseudoaneurysm with persistent Candida albicans infection, as a complication of infective endocarditis. The 23-year-old man, with a history of chronic intravenous drug use and Type I diabetes mellitus, presented with left groin pain, paresthesia of his left foot, and a pulsatile mass in the inguinal region. On imaging, he was found to have a pseudoaneurysm of the left common femoral artery, which later ruptured. Further investigation revealed vegetations on the mitral and aortic valves as well. Initial blood cultures were negative. He underwent multiple surgical interventions including replacement of the mitral and aortic valves and resection of the left common femoral artery with autogenous revascularization. In addition, he was commenced on intravenous antifungal therapy. Postoperatively, he continued to experience significant pain in the left groin and had two episodes of rerupture of the femoral artery that was consequently surgically repaired. Histological examination of the resected valves revealed vegetations with a mixture of fungal elements and bacterial cocci. The femoral artery resection specimens revealed evidence of infectious arteritis and the presence and persistence of C. albicans organisms in subsequent specimens. This case highlights the importance of an accurate diagnosis and aggressive management of fungal mycotic aneurysms in at-risk populations.

Ruptured pseudo-aneurysm of a femoral artery in a drug abuser revealed by post-mortem CT angiography

A 35-year-old drug addict was found dead in a public toilet with a ruptured groin, which was later diagnosed to be a leaking pseudo-aneurysm. Investigation at the scene revealed impressive external hemorrhage related to a groin wound. Post-mortem computed tomography angiography demonstrated an aneurysm of the right femoral artery with leak of contrast liquid. Signs of blood loss were evident at autopsy, and histological examination revealed necrosis and rupture of the pseudo-aneurysm. Toxicological analyses were positive for methadone, cocaine, citalopram, and benzodiazepines. This is the first case report in the literature of a ruptured femoral pseudo-aneurysm with a post-mortem radiological diagnosis.