Cryptococcal infection of the ventriculoperitoneal shunt in an immunocompetent patient

Patient: Male, 52 Final Diagnosis: Cryptococcal ventriculoperitoneal shunt infection Symptoms: Confusion • fever • Lethargy Medication: Amphotericin B • Flucytosine Clinical Procedure: Ventriculoperitoneal shunt removal Specialty: Infectious disease OBJECTIVE: Rare disease BACKGROUND: Ventriculoperitoneal shunting is an effective treatment for hydrocephalus. Ventriculoperitoneal shunt (VPS) infection is a common complication. Cryptococcus neoformans as an implicated organism is rare. In this report, we describe a patient with cryptococcal VPS infection. CASE REPORT: A 52-year-old male with normal pressure hydrocephalus, status post implantation of VPS one year prior to the presentation; who was admitted with a fever, lethargy and confusion for three days. He was treated empirically with intravenous cefepime and vancomycin for VPS infection. The CSF analysis from both the lumbar puncture and the VPS was significant for a low white blood count, low glucose and high protein. Other work-up including India ink and cryptococcal antigen was unrevealing. He remained febrile despite antibiotic treatment for 5 days. The CSF from the shunt was sent for analysis again and it demonstrated similar results from the prior study, but the culture was now positive for Cryptococcus neoformans. The patient was started on oral flucytosine and intravenous liposomal amphotericin B. The VPS was removed and an externalized ventricular catheter was placed. The patient showed rapid resolution of the symptoms. CONCLUSIONS: To date, there was a total of nine reported cases of cryptococcal VPS infection upon review of the literature. Our presenting case and the literature review highlight the difficulties in making an accurate diagnosis of cryptococcal shunt infection. There were case reports of false negative cryptococcal antigen tests with culture proven cryptococcal meningitis. The CSF culture from the shunt remains a mainstay for identifying cryptococcal shunt infection. Cryptococcal shunt infections are rare and early diagnosis and treatment is essential for patient management which involves shunt replacement with concomitant administration of intravenous antifungal medication. High clinical suspicion is crucial and shunt culture preferably from the valve is recommended

Hemobilia from biliary angiodysplasia diagnosed with cholangioscopy

Biliary angiodysplasia is extremely rare. Our background search revealed only a few case reports in the English literature. We present a case of angiodysplasia of the proximal common bile duct in a patient with subacute upper gastrointestinal bleeding and symptomatic anemia. A standard esophagogastroduodenoscopy with subsequent dedicated duodenoscopy revealed blood-stained bile draining from the major ampulla orifice. A contrast-enhanced magnetic resonance cholangiopancreatography was unrevealing for any pancreaticobiliary pathology. The patient subsequently underwent an endoscopic retrograde cholangiopancreatography and SpyGlass® cholangioscopy, which demonstrated intermittent bleeding from angiodysplasia in the proximal common bile duct

Blood culture utilization practices among febrile and/or hypothermic inpatients

BACKGROUND: Predictors associated with the decision of blood culture ordering among hospitalized patients with abnormal body temperature are still underexplored, particularly non-clinical factors. In this study, we evaluated the factors affecting blood culture ordering in febrile and hypothermic inpatients. METHODS: We performed a retrospective study of 15,788 adult inpatients with fever (≥ 38.3℃) or hypothermia (\u3c 36.0℃) from January 2016 to December 2017. We evaluated the proportion of febrile and hypothermic episodes with an associated blood culture performed within 24h. Generalized Estimating Equations were used to determine independent predictors associated with blood culture ordering among febrile and hypothermic inpatients. RESULTS: We identified 21,383 abnormal body temperature episodes among 15,788 inpatients (13,093 febrile and 8,290 hypothermic episodes). Blood cultures were performed in 36.7% (7,850/ 21,383) of these episodes. Predictors for blood culture ordering among inpatients with abnormal body temperature included fever ≥ 39℃ (adjusted odd ratio [aOR] 4.17, 95% confident interval [CI] 3.91-4.46), fever (aOR 3.48, 95% CI 3.27-3.69), presence of a central venous catheter (aOR 1.36, 95% CI 1.30-1.43), systemic inflammatory response (SIRS) plus hypotension (aOR 1.33, 95% CI 1.26-1.40), SIRS (aOR 1.26, 95% CI 1.20-1.31), admission to stem cell transplant / medical oncology services (aOR 1.09, 95% CI 1.04-1.14), and detection of abnormal body temperature during night shift (aOR 1.06, 95% CI 1.03-1.09) or on the weekend (aOR 1.05, 95% CI 1.01-1.08). CONCLUSION: Blood culture ordering for hospitalized patients with fever or hypothermia is multifactorial; both clinical and non-clinical factors. These wide variations and gaps in practices suggest opportunities to improve utilization patterns

Incidence and diagnostic yield of repeat urine culture in hospitalized patients: An opportunity for diagnostic stewardship

There is limited knowledge on the incidence, diagnostic yield, and cost associated with inappropriate repeat urine cultures. The factors that affect repeat urine culturing practices are not well understood. We conducted a retrospective study of adult inpatients who had ≥1 urine culture performed during their hospitalization between January 2015 and February 2018. We analyzed the proportion of inappropriate repeat urine cultures performed \u3c48 h after the index culture. We defined an inappropriate repeat urine culture to be a repeat urine culture performed following a negative index culture or a repeat urine specimen obtained from the same urinary catheter. Overall, 28,141 urine cultures were performed on 21,306 patients. There were 2,060 (7.3%) urine cultures repeated in \u3c48 h. Of these, 1,120 (54.4%) urine cultures were inappropriate. Predictors for inappropriate repeat urine cultures included collection of the initial urine sample for culture in the emergency department (adjusted odds ratio [aOR], 5.65; 95% confidence interval [CI], 4.70 to 6.78), male gender (aOR, 1.61; 95% CI, 1.42 to 1.84), congestive heart failure (aOR, 1.20; 95% CI, 1.03 to 1.38), and a longer hospital stay (aOR, 1.01 per day; 95% CI, 1.00 to 1.01). A patient with an index urine culture obtained from an indwelling catheter (aOR, 0.65; 95% CI, 0.53 to 0.80) was less likely to have an inappropriate repeat culture. Among 1,120 negative index urine cultures, only 4.7% of repeat cultures were positive for bacteriuria. The estimated laboratory charges for inappropriate repeat urine cultures were $16,800 over the study period. Among inpatients, over half of all urine cultures repeated in \u3c48 h were inappropriate. This offers an opportunity for diagnostic stewardship and optimization of antimicrobial use

Prognostic Factors and Treatment of Spinal Astrocytomas: A Multi-Institutional Cohort Analysis

Retrospective cohort analysis of patients with spinal astrocytoma from multi-institutional data and the literature