Actinomyces Israelii – A Rare Cause of Bacterial Peritonitis

Background: Actinomyces, a filamentous, gram-positive, facultative anaerobic bacterium, is part of the commensal flora of the oral cavity, gastrointestinal tract and the female genital tract. Actinomyces have low virulence potential and cause opportunistic infection associated with injury to the mucosal barrier, such as that occurring from surgery, trauma, peritoneal dialysis catheter, viscus perforation or intrauterine devices. Infections associated with actinomyces are often reported by imaging studies as masses, pseudotumors or abscesses. Fistulas and sinus tract formation are not uncommon. Primary peritonitis with actinomyces is very rare. We report a case of Actinomyces peritonitis in an elderly gentleman with a history of pancreatic cancer. Case Report: An 88 year-old man with history of adenocarcinoma of the pancreatic head diagnosed 15 months ago, malignant biliary stricture with common bile duct stent on palliative chemotherapy, presents to the emergency department with 1-2 weeks of worsening abdominal pain, anorexia and malaise. The patient was afebrile, tachycardic and hypotensive. Initial labs include elevated WBC, AKI, LFT and lactic acidosis. Abdominal imaging showed cirrhotic liver, cholecystitis and increasing ascites with peritoneal enhancement. Empiric Ceftriaxone and Metronidazole were initiated. A cholecystostomy tube was placed by interventional radiology. Bile fluid culture was positive for Klebsiella pneumoniae and streptococcus species. Paracentesis was performed and fluid analysis showed 43,000 WBC with \u3e 95% neutrophils. The patient progressed to septic shock following the procedures and broad spectrum antibiotics with vancomycin and pipercillin-tazobactam were initiated. Five days later, ascetic fluid culture revealed Actinomyces israelii. The patient was started on Ampicillin-Sulbactam with plan for six months of antibiotic therapy. The patient was discharged in stable condition with scheduled follow up with infectious diseases. Conclusion: Peritonitis due to Actinomyces is very rare, and should remain in the differential diagnosis especially in cases of peritonitis not responding to typical empiric antibiotics therapy for primary peritonitis. Primary pelvic-abdominal peritonitis without abscess formation is very rare yet possible. The therapy of choice for actinomycosis is high-dose penicillin for 2-4 weeks, followed by 2-6 months of oral antibiotics to prevent recurrence.https://scholarlycommons.henryford.com/merf2019caserpt/1121/thumbnail.jp

Nocardia farcinica: No Farce Bacteremia

Nocardia species are gram-positive, aerobic, partially acid-fast organisms with a beaded branching growth pattern. This species is commonly found in soil, dust, decomposing vegetation, salt and fresh water. Nocardia species are opportunistic bacteria, acquired either through inhalation of airborne spores or direct skin inoculation. The typical patient population includes cases of neoplasms, solid organ and hematopoietic stem cell transplant on immunosuppression, HIV infection, and long-term steroid use. Of all the nocardiosis cases, 22-39% of patients are immunocompetent. Although rare, Nocardia bacteremia, in conjunction with disseminated disease, has a 50% mortality rate. The usual clinical tableau consists of severe pulmonary disease, a frequent mimicker of lung tumors and tuberculosis, and central nervous system infections, such as brain abscess or meningitis. Here we present a case of Nocardia bacteremia with systemic nocardiosis in an HIV/AIDS patient. The patient is a 48 year-old African American male with a history of untreated HIV due to lack of insurance. He presented to the ED with worsening cough, shortness of breath, generalized weakness and fatigue over the past two months along with a left axillary abscess. The patient was in septic shock on arrival with hypotension, tachycardia, leukocytosis and blood cultures positive for Nocardia farcinica. An X-ray of the chest revealed a left lower lobe pneumonia with positive sputum cultures for the same species. The axillary abscess was excised with cultures returning positive for Nocarida farcinica as well. In addition, the infection also manifested with skin lesions and bilateral ring enhancing brain lesions on MRI. The patient was started on Vancomycin, Cefepime, Bactrim and Azithromycin upon arrival. After cultures returned, he was switched to IV Amikacin, Bactrim and Meropenem for a duration of one-year total.The most common Nocardia spp. responsible for infections in humans are N. asteroides (80-90%) followed by N.brasiliens, N. farcinica and N. nova. Nocardiosis usually affects the lungs, followed by the central nervous system, with skin, soft tissue and pleura, less commonly involved. Nocardia farcinica is known to be multi-drug resistant and more prone to dissemination. AIDS patients with a CD4 count /uL and those not on HAART or Bactrim for PCP prophylaxis are at a higher risk for dissemination. Diagnosing these patients can be cumbersome due to the length of time it takes for Nocardia to grow in blood cultures: median incubation time is four days. The median total duration of treatment is 75 days with sulfonamide-based antibiotics, such as Bactrim, followed by carbapenems.https://scholarlycommons.henryford.com/merf2020caserpt/1082/thumbnail.jp

Effect of Inflammatory Bowel Disease-Related Characteristics and Treatment Interventions on Cardiovascular Disease Incidence

BACKGROUND: An association between inflammatory bowel disease (IBD) and cardiovascular diseases has been shown in multiple studies. However, little is known about the effect of IBD-related characteristics on cardiovascular events. METHODS: The authors conducted a retrospective, nested case-control study of IBD patients who presented to the institution from 2000 to 2004, allowing for a 10-year follow-up period. One hundred eleven patients who developed cardiovascular events (cases) and 222 patients who did not develop cardiovascular events (cases) were included in the study after matching for Framingham cardiovascular risk score (2008). Relationships between predictor variables and cardiovascular outcome were assessed by conditional logistic regression. RESULTS: The cases and controls were similar in age, gender, smoking and cholesterol level. There was no difference in disease subtype (ulcerative colitis or Crohn\u27s disease). On conditional logistic regression, thiopurine treatment (odds ratio [OR]: 0.42, 95% confidence interval [CI]: 0.19-0.87; P = 0.02) was associated with decreased cardiovascular events and tumor necrosis factor alpha antagonist use (OR: 2.63, 95% CI: 1.49-4.63; P = 0.001) was associated with increased cardiovascular events. Although not statistically significant, disease-related surgery (OR: 0.57, 95% CI: 0.32-1.02; P = 0.06) was associated with decreased cardiovascular events and disease-related hospitalization (OR: 1.58, 95% CI: 0.96-2.57; P = 0.07) was associated with increased incidence of cardiovascular disorders. CONCLUSIONS: The authors observed decreased incidence of cardiovascular diseases in patients with IBD who were treated with thiopurines and increased incidence of cardiovascular outcomes among patients treated with tumor necrosis factor alpha antagonist

Increasing Incidence of MDROs: An Emerging Global Concern

Introduction: With massive efflux of civilians from violence-stricken countries, the high rates of colonization with multidrug-resistant organisms (MDROs) amongst the refugees is an emerging global concern. Our report describes two Middle Eastern patients who suffered severe traumatic injuries in their home countries, subsequently developing chronic wounds. Upon arrival to the United States, the patients sought treatment in our institution for wound infection with MDRO. Materials and methods: Clinical data was collected from the patients’ charts. Identification and susceptibility testing were performed as part of routine identification/susceptibility test in the clinical microbiology laboratory. MICs performed by manual microbroth dilution according to Clinical and Laboratory Standards Institute (CLSI) guidelines.Time kill curves used to determine in vitro synergy of Pseudomonas aeruginosa isolate in various antibiotic combinations (½ x MIC meropenem plus ½ x MIC colistin, ½ x MIC meropenum plus ½ x MIC colistin plus ½ x MIC rifampin and ½ x MIC meropenem plus ½ x MIC ceftazidime/avibactam). Mueller Hinton II broth was used. Samples were serially diluted at 0, 4 and 24 hours and plated on TSA II agar. Time kill curves were constructed, plotting colony counts over time, with synergy being defined as ≥2-log10 decrease in CFU/ml between the combination and its most active constituent after 24h, the number of surviving organisms in the presence of combination must be ≥2 log10 CFU/ml below the starting inoculum. Results: Patient 1 came from Syria, and patient 2 from Yemen. Both patients’ wound infections were healthcare-associated, with underlying chronic osteomyelitis. Both had multiple risk factors for MDRO, including multiple prior surgeries and antibiotic courses. Patient 1 culture grew CRE Klebsiella and MDR Morganella, and later ESBL Escherichia coli. Patient 2 culture grew Pseudomonas aeruginosa sensitive only to colistin. Patient 1 was treated with ertapenem. Patient 2 received rifampin+meropenen+colistin, the only antibiotic combination demonstrating synergistic killing. Both patients required prolonged therapy, and on follow up were doing well. Conclusions: Colonization with MDRO amongst Middle Eastern immigrants is an alarming phenomenon.In vitro experiments with available antibacterial agents may assist in the choice of therapy for MDRO strains when conventional options are exhausted.https://scholarlycommons.henryford.com/merf2019basicsci/1001/thumbnail.jp

Vasopressin use in septic shock and effect on mortality.

Vasopressin use in shock and effect on mortality Background: Septic shock is a leading cause of mortality in the United States. Hemodynamic support with intravenous vasopressors such as norepinephrine have been associated with reduced mortality. Whilevasopressin has emerged as an adjunct vasoconstrictor in the treatment of these septic patients, its effect on mortality remains uncertain. In our institution, the routine use of vasopressin was restricted in 2014 due to cost. We hypothesized that decreased access to vasopressin would have no effect on mortality in patients with septic shock. Methods:Our study included 1257 consecutive patientswith septic shock and requiring vasopressors who were admitted between 1/1/2014 and 6/29/2016. Of these, 557 were admitted after 1/1/2014 but prior to 9/1/2014, when vasopressin was still widely available (pregroup). The remaining 700 patients were admitted between 9/1/2014 and 6/29/2016, when vasopressin use was restricted (post-group). Patients \u3e18 years of age with admission diagnosis of septic shock requiring at least 5 mcg/min of norepinephrine were included. Regression was used to control for confounders including severity of illness and doses of vasopressors. Results: 1257 consecutive patients assessed for the study period (pre-group n=557, post-group n=700). Mean norepinephrine levels were lower in the pre-group (35 vs 49 mcg/min respectively, pvalue= 0.047) while more patients in the post-group receiveda secondary agent, epinephrine. (10.6% vs. 4.7% respectively, p \u3c 0.001). There was no difference in overall mortality between groups, after controlling for severity of illness (OR [95% CI], 0.861 [0.68-1.08]; p=0.202). Similarly, there was no difference in mortality in a subgroup of patients on higher doses of norepinephrine (OR [95% CI], 0.802 [0.61-1.06]; p=0.123). Conclusion: There was no difference in mortality for patients treated for septic shock in our ICU regardless of the restriction of vasopressin. In addition, sub-group analysis suggests that resorting to epinephrine in absence of vasopressin had no impact on mortality. Our study results are consistent with previous trials that did not find a mortality difference with the use of vasopressin

Cryptococcal eosinophilic meningitis in a patient with sarcoidosis

A 51-year-old African-American man with underlying pulmonary, hepatic and splenic sarcoidosis, reported a 3-day history of headache, neck stiffness and photophobia. He was not using medication for chronic sarcoidosis. Physical examination was significant for nuchal rigidity. Lumbar puncture revealed marked eosinophilia in the cerebrospinal fluid, which, on further analysis, demonstrated a positive cryptococcal antigen. HIV antibody and PCR tests were negative. Bronchoscopy and fungal blood cultures were also negative. The patient was started on amphotericin B and flucytosine, with significant clinical improvement. He recovered well without any neurological sequelae and remained symptom-free at 2-week follow-up. Cryptococcal central nervous infections are uniformly fatal if left untreated. Prompt diagnosis and treatment is essential, to prevent the associated high morbidity and mortality

HSV Acute Retinal Necrosis – A Painful Threat to Vision

Ocular Herpes Simplex (HSV) is a serious infection with variable clinical manifestations ranging from isolated blepharitis and keratitis to vision-threatening uveitis and acute retinal necrosis (ARN). Previously described risk factors include preceding neurosurgery, older age and high-dose corticosteroids. The presence of keratitis is a valuable diagnostic sign, however, when absent, the differential is wide, encompassing autoimmune and idiopathic etiologies. We report the cases of two patients who presented with acute painful vision loss, who subsequently were diagnosed with HSV-2 panuveitis and ARN.Case 1: A 33 year-old healthy female with three prior episodes of unilateral iritis without definitive etiology, presented to her ophthalmologist with painful red eye and photophobia similar to her previous iritis flare-ups. On initial exam, she had conjunctival injection and 2+ cells in the anterior chamber. A clinical diagnosis of anterior uveitis was made, and topical steroid therapy was initiated. However, compared to her prior episodes, her symptoms progressed over the next 3 days and on subsequent exam, she had evidence of vitritis and retinitis. She was diagnosed with panuveitis and ARN, initially most suspicious for endogenous bacterial endophthalmitis. However, a diagnostic vitreous fluid PCR revealed HSV-2 infection. Upon further questioning, she reported recurrent painful ulcers in the inguinal region. Case 2: A 27 year-old, 30-week pregnant female presented to the eye clinic with 3 days of right eye pain, photophobia and blurry vision. Ocular exam showed periorbital swelling, panuveitis, disc edema, phlebitis, and focal retinitis with macular hemorrhages. She was started empirically on Acyclovir, and received intravitreal Ganciclovir+Foscarnet injections. Aqueous and vitreous fluid PCR were HSV-2 positive; other infectious and rheumatological etiologies were ruled out. Despite maximal therapy, her vision deteriorated to Count Fingers within 36 hours, and over days her ARN progressed to retinal detachment, requiring surgical management. Despite aggressive measures, her visual acuity only marginally improved. HSV panuveitis and ARN are rare but can occur in young, immunocompetent hosts. High index of suspicion is key to correct diagnosis. In cases of clinical uncertainty, ocular fluid PCR has high sensitivity. The sequela of misdiagnosing such aggressive and potentially treatable infection can be vision-threatening.https://scholarlycommons.henryford.com/merf2019caserpt/1034/thumbnail.jp

Treatment and Outcomes of Daptomycin-Nonsusceptible MRSA Bloodstream Infection

Introduction: Daptomycin (dap) is approved as an alternative to vancomycin (van) for therapy of MRSA bloodstream infection (BSI). Cases of therapy failure associated with the emergence of daptomycin-nonsusceptible (DNS) MRSA strains have been documented. Information on the treatment and outcome of DNS MRSA BSI is scarce. This study describes the treatment and outcome of patients (pts) with DNS MRSA BSI at our healthcare center. Methods: This is a retrospective review of pts with DNS MRSA BSI at a tertiary healthcare center in Detroit, MI, between 9/24/2005 and 3/31/2018. The variables collected were: source of BSI, inpatient and discharge antibiotic therapy, BSI duration, in-hospital and 90-day mortality, and 90-day MRSA BSI recurrence. Results: A total of 32 non-duplicate pts with DNS MRSA BSI were identified. One pt with an inaccessible chart was excluded. The source of BSI was endovascular in 9 (29%) pts, secondary BSI in 14 (45%), central-line associated in 3 (10%)). A total of 24 different antibiotic regimens were used to treat DNS MRSA BSI. Conclusion: A variety of therapeutic regimens were used to treat DNS MRSA BSI in our cohort. Vancomycin monotherapy was used most commonly for both inpatient and discharge therapy, followed by daptomycin + ceftaroline. The overall 90-day mortality was 35%.https://scholarlycommons.henryford.com/merf2019clinres/1006/thumbnail.jp

Predictors of Thiopurine Treatment Failure in Biologic-Naïve Ulcerative Colitis Patients

INTRODUCTION: Thiopurines (azathioprine and 6-mercaptopurine) have been used in the management of UC patients for over three decades. Nearly half of patients with UC treated with thiopurines fail to achieve remission or lose remission during treatment. Factors associated with thiopurine failure are poorly understood. The primary aim of our study was to investigate patient-related factors which are associated with thiopurine failure. METHODS: TNF-alpha antagonist-naïve patients with histological diagnosis of UC, receiving thiopurine therapy, with follow-up data from 1 to 3 years were included in the study. Data regarding demographics, laboratory results, and disease characteristics were collected. The primary endpoint was failure of thiopurine therapy, defined as treatment with steroids, therapeutic escalation to TNF-alpha antagonist therapy, or need for surgery. RESULTS: Of the 563 patients identified using ICD-9 codes, 78 TNF-alpha antagonist-naïve patients with a histological diagnosis of UC, receiving thiopurine treatment, were identified. Over the three-year follow-up period, 38 patients failed thiopurine treatment. On adjusted Cox regression, BMI \u3c 25 kg/m(2) (HR 3, 95 % CI 1.55-5.83; p value = 0.001) was significantly associated with thiopurine failure. Furthermore, although not statistically significant, there was a strong trend toward thiopurine failure among patients with serum albumin level \u3c 4 g/dL (HR 1.98, 95 % CI 0.97-4; p value = 0.06), non-smoking status (HR 2.2, 95 % CI 0.96-5.06; p value = 0.06), and higher degree of colon inflammation (HR 1.49, 95 % CI 0.96-2.32; p value = 0.08). DISCUSSION: Our results show that low body mass index is associated with increased risk of failure of thiopurine treatment. Furthermore, there was a strong trend toward thiopurine failure among patients with low serum albumin level (\u3c4gm/dL). These factors should be considered as markers of non-response to thiopurine monotherapy for patients with moderately severe ulcerative colitis