A Case of Refractory Pulmonary Coccidioidomycosis Successfully Treated with Posaconazole Therapy

Coccidioidomycosis is an endemic fungal infection caused by the inhalation of the spores of Coccidioides species. Patients with underlying immunosuppressive illness can contract chronic or disseminated disease which requires prolonged systemic therapy. Pulmonary coccidioidomycosis remains as an illusory and abstruse disease, with increased prevalence that poses as a challenge for clinicians in developing an effective strategy for treatment. Here, we report successful treatment of a refractory case of chronic relapsing pulmonary coccidioidomycosis in a 50-year old woman with a thin-walled cavitary lung lesion who was ultimately treated with posaconazole.

Use of tigecycline for the management of Clostridium difficile colitis in oncology patients and case series of breakthrough infections

BACKGROUND

Clostridium difficile infection (CDI) is the most frequent cause of nosocomial diarrhoea in adults. Cancer patients, in particular, are at a higher risk for CDI. Limited clinical data exist regarding the use of tigecycline for the treatment of CDI, especially in patients with oncologic and haematologic malignancies.

AIM

To characterize the use of tigecycline for treatment of CDI in oncology patients at an academic cancer centre.

METHODS

This was a retrospective, single-centre, single-arm, chart review evaluating the use of tigecycline for the management of CDI in oncology patients at an academic cancer centre.

FINDINGS

The median age of CDI diagnosis in this patient group (N=66) was 65 years (range: 16-84) and the majority of patients had solid tumour malignancies. Fifty-six percent of patients had severe CDI, 70.3% of which were classified as having severe complicated disease. The median time to initiation of tigecycline therapy was 2 days (mean: 3.83) and the median number of tigecycline doses was 13 (range: 1-50). Twelve non-CDI breakthrough infections were observed, and four patients developed CDI while receiving tigecycline for non-CDI indications. The rate of death was 18% and the recurrence rate was 15.2%.

CONCLUSION

Tigecycline did not lead to overt benefits in outcomes of oncology patients with CDI when compared to historical data. In addition, several breakthrough CDIs were observed in patients who received the drug for a non-CDI indication. Further prospective research is needed to validate the use of tigecycline for management of CDI.

Current treatments for infection in neutropenic patients with hematologic malignancy

Neutropenic patients with cancer are a heterogeneous group of patients who carry a variable risk for infection. When such patients present with fever, appropriate empiric antibiotic therapy is initiated and continued until clinical improvement or clinical or microbiologic data direct a modification in treatment. As the duration of neutropenia increases, so does the need for antimicrobial modifications. Changes in therapy may include antimicrobials directed against gram-positive bacteria, resistant gram-negative bacteria, or fungi. Because of the high risk for colonization by vancomycin-resistant enterococci, vancomycin use is restricted as first-line empiric therapy unless the patient is at a high risk for serious gram-positive infection. Usually in the setting of neutropenia, gram-positive infections are of low virulence. Prophylactic antibiotic therapy may increase the selection of resistant strains and should be avoided. Antibiotic therapy should always be combined with prudent infection-control measures, such as aseptic practices, barrier isolation, handwashing, removal of infected catheters, and infection monitoring. In the immunocompromised patient with cancer and neutropenia, all infections should be treated, with the extent, duration, and site of treatment being directed by risk stratification and specific pathogen identification. Patients with neutropenia are at risk for severe morbidity and mortality related to infection.

New directions in antimicrobial therapy

The virulent microorganisms that we try to contain with new antimicrobial agents quickly find the gap in our defenses and exploit it. Resistance to all available antibiotics at the same time, however, rarely occurs. The authors report the most current antimicrobials used as monotherapy or in combination to successfully treat the more resistant pathogens. The higher mortality and subsequent cost to treat these infections are reviewed.

The detection of airborne Mycobacterium tuberculosis using micropore membrane air sampling and polymerase chain reaction

STUDY OBJECTIVES

Mycobacterium tuberculosis (MTb) bacilli are carried on airborne droplet nuclei produced by aerosolization that can occur from coughing, talking, or even singing. Because of their prolonged period of suspension, they can be filtered from the air onto a porous medium and readily detected using polymerase chain reaction (PCR).

DESIGN

Prospective cohort analysis.

SETTING

Samples of circulating air were collected over a 12-month period from within the rooms of 10 hospitalized patients who were under respiratory isolation to rule out MTb infection. A small laboratory pump was used to draw ambient air at a rate of 2 L/min over a 6-h period through a 0.2-microm polycarbonate membrane filter placed near the patient's bed. Analysis of the membrane filters was conducted using PCR. Sputum cultures for MTb were performed simultaneously, and the results of smears stained for acid-fast bacilli (AFB) were noted.

MEASUREMENTS AND RESULTS

MTb complex was successfully detected by PCR in six of seven patients in whom sputum MTb cultures were subsequently positive, and in zero of three with subsequently negative sputum cultures. Sampling in one patient with a positive culture, in whom PCR results were negative, was only carried out for 2 h due to pump malfunction. One of the six PCR-positive patients was AFB-smear negative at the time of air sampling.

CONCLUSIONS

Our preliminary findings indicate that the technique of Micropore membrane air sampling with PCR analysis has important applications in the epidemiology and diagnosis of MTb.

Women at risk: papanicolaou smear screening in Florida

In the South, especially Appalachia, the incidence of invasive cervical cancer has remained high relative to the rest of the United States. Populous Florida now stands third among states by incidence and fifth from last in Pap screening. During the 1994 survey, 2,059 Florida women chosen as a multi-stage cluster sample were interviewed concerning their use of screening Pap smears. Never-participation in screening percentages were significantly higher in Hispanic women (14.7%), those sharing household incomes of less than $10,000 (13.2%), and women limited to a high school education (10.7%), but not among respondents older than 64 years of age (8.7%). Despite continued annual physician contact by most, yearly Pap smears fell to only 57.0% among women aged 55-64 years. It is important that physicians target these women and use any appropriate clinical contact to educate them about risk factors for cervical cancer while encouraging regular, continued use of this life-saving test.

Identification of an amphotericin B resistant strain of Candida albicans using a rapid 3H-glucose incorporation microassay

Using a 3H-glucose incorporation assay, antifungal sensitivity testing undertaken on an isolate of Candida albicans cultured from the blood of a bone marrow transplant patient documented resistance to amphotericin B but sensitivity to fluconazole and itraconazole. Information obtained from in vitro antifungal sensitivity testing can be used to direct in vivo antifungal therapy. Widespread application of standardized in vitro antifungal sensitivity testing is needed.

Catheter-related complications of cancer therapy

Although the management of CVC-related infection appears complex and at times the literature seems to be contradictory, simple guidelines can direct the clinician in a stepwise fashion. Knowledge of the pathogenesis of each organism and the immune status of the host is crucial to decide whether catheter removal or retention is indicated. For example, in general, GNB bacteremia does not immediately prompt catheter removal in a neutropenic patient but does in a nonneutropenic host because of the gastrointestinal source of the former and a primary catheter source in the latter. In summary, as more CVCs are inserted in patients undergoing chemotherapeutic, antimicrobial, transfusional, and nutritional supportive care, novel approaches to prevention and treatment of the associated infectious complications inherent with such devices are needed. A multifaceted approach from impregnated catheters to local catheter-site antisepsis was reviewed. We may find, however, that as simple handwashing between patients is crucial to infection control, so too is a trained catheter-care team using total barrier precautions and ensuring proper local catheter maintenance critical to preventing CVC-related infections.

Primary cutaneous aspergillosis: case report and review of the literature

Primary cutaneous aspergillosis is an uncommon entity that may occur in immunosuppressed hosts, usually resulting from contact with contaminated medical devices used in patient care. The infection spreads locally with subsequent skin necrosis due to angioinvasion and thrombosis. We report primary cutaneous aspergillosis following contact with contaminated gauze, and we review the relevant literature.

The microbiology of colonization, including techniques for assessing and measuring colonization

Organisms living on our external and internal body surfaces are the first contact for many potentially pathogenic invaders. Factors that alter this microenvironment include antibiotics, the host immunity, and the various diseases of man and their treatment. Predicting when colonization leads to infection remains an important challenge for every clinician. The maintenance and breakdown of colonization resistance by changes in the native microflora and the body's natural mucosal coating by various extrinsic and intrinsic factors is reviewed in this article. Quantitative culture methods developed to improve the predictive value of a given sampling technique (most notably with bronchoscopy) is presented. Besides improving diagnostic capabilities, quantitative cultures can be used successfully as an epidemiologic tool for some outbreak investigations.

Laryngeal cryptococcus. Treatment with oral fluconazole

We treated a case of laryngeal Cryptococcus neoformans infection in a glucocorticosteroid-dependent patient with chronic obstructive pulmonary disease. To our knowledge, this is the first report of successful treatment of laryngeal cryptococcus using oral fluconazole as a single agent.

Case report: anaerobic meningitis caused by Peptostreptococcus magnus after head and neck surgery

Although anaerobic bacterial meningitis is uncommon, patients subjected to resection of head and neck malignancy appear at special risk. In this article, the authors report on a 72-year-old man in whom meningitis developed after extensive resection of the right sinuses for squamous cell carcinoma; initial treatment consisted of intravenous vancomycin and ceftazidime. Intravenous penicillin G was added after the fortuitous early finding of intracellular cocci in Wright-Giemsa stained cerebral spinal fluid submitted for cell count. Cerebral spinal fluid cultures then grew out a pure culture of Peptostreptococcus magnus. The patient had a complete recovery, without neurologic sequelae, recurrence of malignancy, or evidence of infection. Appropriate handling of cerebral spinal fluid specimens is crucial to ensure the correct diagnosis when anaerobic organisms are suspected.

Case report: cutaneous manifestations of cryptococcosis

Cutaneous cryptococcosis usually is associated with concurrent systemic infection and actually may develop before clinical manifestations of cryptococcal meningitis become apparent. It is rare for a cryptococcal infection to be localized only to the skin. A case of cutaneous cryptococcosis is described in an immunocompromised patient who initially had a rash and a positive serum cryptococcal antigen titer, but no central nervous system involvement. The papular pustular skin lesions disappeared after 8 weeks of therapy with amphotericin B, which was stopped secondary to progressive azotemia. Less than 2 months after therapy, the skin lesions recurred, again without evidence of systemic disease. Treatment with oral fluconazole resulted in a gradual resolution of the cutaneous lesions. The pathogenesis of cryptococcosis is discussed, with emphasis on the management of cutaneous cryptococcosis.

Liver abscess following blunt trauma: a case report and review of the literature

We report a case of Haemophilus paraphrophilus causing primary liver abscesses after blunt nonpenetrating trauma. A 32-year-old previously healthy white man sustained a back injury 2 months prior to admission with fever, chills, and night sweats. A computed tomography (CT) scan-directed needle aspirate of several hypoechoic hepatic lesions grew H paraphrophilus. Recent blunt trauma to the lower back may have contributed to the localization of this infection to an area of contusion or hematoma within the liver, followed by an episode of bacteremia that seeded the injury.

Hantavirus: an old bug learns new tricks

Hantaviruses are a diverse group of RNA arboviruses in the Bunyaviridae family. Although their role as the causative agents of HFRS has been well established, the recent outbreak of a new disease in the Southwest clearly demonstrates the protein clinical manifestations that this pathogen can produce. Furthermore, whereas hantaviruses have been characterized largely as focal agents in the production of geographically delimited diseases, recent trends indicate that endemic areas for the virus are expanding. Outbreaks often occur in clusters as a result of the epizoology of rodent hosts, but isolated cases of hantavirus-related disease also may be observed. Although hantaviruses have proven their pathogenic capability in other areas of the world, it was perceived widely that they were of little consequence to public health in the United States. However, as more is learned about the nature of this truly global infectious agent, its potential danger to mankind becomes increasingly apparent. It is hoped that continued research will elucidate all the facets of hantavirus-induced disease.

Pelvicobdominal actinomycosis associated with an intrauterine contraceptive device. A case of liver dissemination mimicking metastatic ovarian cancer

A rare case of pelvicoabdominal actinomycosis with liver dissemination is reported in a patient with an intrauterine contraceptive device (IUCD) in place for 10 years. Her initial preoperative diagnosis of metastatic ovarian cancer emphasizes the slow indolent destructive nature of actinomycosis mimicking a malignancy. A history of an indwelling IUCD for several years along with a pelvic mass should prompt consideration of actinomycosis as a possible etiology.

Special considerations for the patient undergoing allogeneic or autologous bone marrow transplantation

Improvements in the diagnosis, treatment, and prevention of infectious complications of bone marrow transplantation over the past two decades have markedly reduced the morbidity and mortality of this procedure. We are now able to begin early empiric antibiotic coverage with less toxic, but equally effective, antibacterial agents. Once believed to be uniformly fatal, complications such as CMV pneumonia are now considered treatable in at least half the cases with a combination of intravenous immunoglobulin and ganciclovir. Although probably the most controversial, prophylactic therapy has improved the outcome of patients undergoing bone marrow transplantation. The appropriate setting, agents to use, dose, and dose intervals will require further study in coming years. In the introduction to this article, we attempted to outline what is known about the immunobiology of bone marrow transplantation. A clear understanding of this process helps us recognize and anticipate the infectious complications encountered in this population of patients. It may also allow clinicians to focus more on immune augmentation as a means of prevention, as has been attempted with the newly available cytokines and the use of intravenous immunoglobulin infusions. Despite improvements in diagnosis, treatment, and prevention, infectious complications remain the leading cause of morbidity and mortality in the patient undergoing bone marrow transplantation. Future studies are required in this area to build on the successes of the last two decades.

Malassezia furfur folliculitis in cancer patients. The need for interaction of microbiologist, surgical pathologist, and clinician in facilitating identification by the clinical microbiology laboratory

Malassezia furfur (MF) is a lipophilic yeast which can be found as a member of the indigenous microbiota of human skin. In immunocompromised transplant patients, MF can cause a distinctive folliculitis which is a clinical look-alike to Candida folliculitis, the latter of more potentially devastating significance. Recovery of MF in culture is dependent upon the addition to culture media of an exogenous source of fatty acids, such as olive oil. The addition of an extra Sabourauds plate with an olive oil overlay to the routine set of media used to inoculate all skin biopsy specimens in order to detect MF is labor-intensive and not cost-effective. Thus, MF may not be isolated in cases of MF folliculitis unless the clinical microbiology laboratory is put on alert by the clinical suspicions of the attending physician, or by histopathologic findings suggestive of folliculitis revealed by review of surgical pathology slides. The clinical, pathological, and microbiological findings of two cases of MF folliculitis are presented where an interactive approach featuring communication between the microbiologist, the surgical pathologist, and the clinician guided the microbiology laboratory to the isolation and identification of isolates of MF that were clinically-relevant. These cases underscore how a combined approach which features communication between the laboratory and the clinical services always provides superior guidance in the diagnosis and therapy of infectious diseases.

Concurrent isolation of Candida krusei and Candida tropicalis from multiple blood cultures in a patient with acute leukemia

Reports of the concurrent isolation of more than one non-albicans species of Candida from blood cultures of immunocompromised patients with disseminated candidiasis are extremely infrequent. We report on the isolation of Candida krusei and Candida tropicalis from 17 blood cultures that were taken from a 67-year-old white man with a diagnosis of acute biphenotypic leukemia during a 2-week period of hospitalization for induction chemotherapy. Despite receiving high-dose amphotericin B throughout this period, the status of the patient worsened, and he experienced pancytopenia, hypernatremia, azotemia, and disseminated intravascular coagulation, which led to his death. Candida krusei and C tropicalis were isolated concurrently from 10 of the 17 blood cultures, while C krusei was the single isolate in three cultures and C tropicalis was isolated alone in four cultures. Each species manifested markedly different colonial morphological features. This case report serves to emphasize to microbiologists that they must exercise extreme suspicion when non-albicans species of Candida are isolated singly or concurrently from blood cultures in neutropenic patients, given the increasing clinical significance of these yeasts.

Haemophilus parainfluenzae endocarditis in a patient with mitral valve prolapse

Haemophilus parainfluenzae is a frequent cause of "culture-negative" endocarditis (i.e., endocarditis owing to a fastidious organism which may require longer incubation periods and/or enrichment media for detection compared to traditional pathogens). More cases will probably be identified with improvements in growth and isolation techniques. A case of H. parainfluenzae endocarditis is presented in a patient with mitral valve prolapse, which illustrates the difficulty in diagnosing endocarditis when initial blood cultures are negative. Particularly, it emphasizes the difficulty in selecting appropriate antibiotic therapy since beta-lactamase producing organisms are being isolated with increased frequency. This report is unique in that it documents successful treatment with a cephalosporin and what is, to our knowledge, the third reported case of a beta-lactamase producing H. parainfluenzae causing endocarditis. The authors believe that beta-lactamase stable second or third generation cephalosporins should constitute initial treatment of H. parainfluenzae endocarditis until sensitivity studies become available, since beta-lactamase production by this organism would nullify the effect of the previous agent of choice, ampicillin.

Case report: Yersinia enterocolitica necrotizing pneumonia in an immunocompromised patient

The authors report a rare case of Yersinia enterocolitica necrotizing pneumonia in an immunocompromised patient, who responded with resolution of the infection after 6 weeks of therapy with a third-generation cephalosporin but subsequently expired from the underlying lymphoma. In the few cases of Y. enterocolitica pulmonary infections that have been reported, the prognosis for cure of the infection is excellent with appropriate antibiotic therapy. Y. enterocolitica is likely to be recognized more frequently as a cause of serious infection in the growing immunosuppressed population. Early recognition and appropriate therapy can improve survival significantly.

Chromomycosis in a steroid-dependent patient with chronic obstructive pulmonary disease

Cutaneous chromomycosis developed in an elderly man with steroid-dependent chronic obstructive pulmonary disease. This patient had no history of foreign travel. Chromomycosis acquired in the United States is rare and may be seen in immunosuppressed patients, as exemplified by this case. Satisfactory response was observed in this patient with surgical debridement and continuing oral ketoconazole therapy.