Emphysematous pyelonephritis (EPN) is an acute, life-threatening, necrotizing infection of the kidney. It is most often seen in diabetic patients with poor glucose control and urinary obstruction, and it also is seen in patients who have structural kidney disease. Although surgical intervention is the mainstay of therapy, percutaneous drainage may have a role in surgical patients who are at high risk. We present an uncommon case of EPN associated with Pasteurella multocida infection following embolization of a large renal tumor in a nondiabetic patient. Clinicians and radiologists should maintain a high index of suspicion in patients with structural kidney disease who present with acute or subacute symptoms.
Antiretroviral drug resistance and adverse events represent ongoing challenges in the management of HIV infection. The introduction of the integrase inhibitor raltegravir, the chemokine receptor antagonist maraviroc, the nonnucleoside reverse transcriptase inhibitor (NNRTI) etravirine, and the protease inhibitor (PI) darunavir represent important advances in the treatment of patients who have HIV/AIDS and extensive drug resistance or intolerance. Raltegravir has been shown to be as effective as efavirenz with the advantage of a better adverse-effect profile. Maraviroc has been shown to be effective-in combination therapy-for (early-stage) CCR5-tropic HIV-1 infection in adults with resistance to multiple agents. Etraviri-ne is designed to circumvent resistance to NNRTIs caused by certain viral mutations. Darunavir, like other PIs, prevents maturation of new virus particles. The pharmacokinetics, clinical evidence on efficacy, resistance, closing, and adverse effects of these new agents are discussed in this article. [Infect Med. 2009;26:113-120]
Aorto-cavitary fistulas (ACFs) are a rare complication of aortic valve endocarditis. The clinical course is usually complicated by the development of profound congestive heart failure (CHF). Precipitating factors include surgical trauma after placement of a prosthetic aortic valve, acute chest trauma, dissection of the aorta, and infective endocarditis. Diagnosis depends on visual confirmation of fistula formation. The transesophageal echocardiogram is superior to the transthoracic echocardiogram for the diagnosis of ACFs. Despite appropriate medical therapy, most patients will require surgical correction, and despite aggressive surgical therapy, mortality rates remain high. We describe a patient in whom Staphylococcus aureus endocarditis was associated with multiple ACFs. Symptoms resolved with surgical correction despite severe CHF. [Infect Med. 2009;26:94-96]
The CDC recommends that sexually active adolescent girls be screened for Chlamydia trachomatis infection at least annually and that all sexually active women aged 20 to 25 years and women aged 25 years or older who have risk factors also receive an annual screening.1 How well are these screening practices being observed and what are the implications?
A lung-protective ventilatory strategy should be considered when mechanical ventilation is required in patients with sepsis. Low tidal volume ventilation has been demonstrated to reduce mortality risk in this setting. After the initial resuscitation, a conservative fluid strategy is appropriate in critically ill patients with acute lung injury; this approach is associated. with improved oxygenation and fewer days of mechanical ventilation. Other recommended strategies include prophylaxis for deep venous thrombosis and. stress ulcer prophylaxis. The benefit of preventing upper GI bleeding must be weighed against the potential risk of ventilator-associated pneumonia. [Infect Med. 2009;26:189-192a]
Although coccidioidomycosis is often asymptomatic, it can have a variety of manifestations, including acute and chronic respiratory disease, osteoarticular destruction, and meningitis. The incidence of coccidioidomycosis is increasing as a result of travel and the influx of susceptible persons into the southwestern United States, where the fungal pathogens―Coccidioides immitis and Coccidioides posadasii―are endemic. Diagnostic methods include culture, serology, histopathological examination, and antigen detection, but all have limited sensitivity. Coccidioidomycosis can be successfully treated with azoles and amphotericin B; however, a prolonged duration of treatment may be required, relapse is common, and permanent disability and death may occur.
Ebola virus and Marburg virus are responsible for Ebola hemorrhagic fever (EHF) and Marburg hemorrhagic fever (MHF), respectively.
The incidence of secondary syphilis precipitating catastrophic antiphospholipid syndrome (CAPS) is not known despite that antiphospholipids react with reagin. We report a case of CAPS in a patient with secondary syphilis. CAPS should be considered in patients with secondary syphilis in whom thromboembolism occurs. Treatment must be prompt; a 50% mortality rate is associated with CAPS. [Infect Med. 2009;26:18-21,22]
Methicillin-resistant Staphylococcus aureus (MRSA) must be recognized now as one of the most common causes of infections acquired in the community. The majority of these infections involve the skin and soft tissue structures and confer significant morbidity on those affected.
Cytomegalovirus (CMV)-associated colonic vasculitis is a rare but serious complication of AIDS that usually presents with nonspecific abdominal pain, diarrhea, and weight loss. We report a case of CMV-associated colonic vasculitis in a patient who presented with abdominal pain and a mass. Although pseudotumors of the GI tract have been reported as a complication of CMV infection, this is the first case of CMV-associated vasculitis as the underlying pathology.
Klebsiella oxytoca hemorrhagic colitis and septicemia developed in a 39-year-old burn patient after she received piperacillin/tazobactarn for 5 days. Recently, K oxytoca has been associated with Clostridium difficile-negative hemorrhagic colitis. As such, K oxytoca infection should be included in the differential diagnosis of any patient in whom C difficile-negative hemorrhagic colitis develops after he or she is treated with antibiotics, especially penicillins. In contrast to many cases previously. reported, this case demonstrates that in patients with K oxytoca colitis, sepsis may develop, which requires prompt diagnosis and therapy modification. [Infect Med. 2009;26:154-156]
Scrub typhus, which is caused by Orientia tsutsugarrcushi, has various systemic manifestations, including GI symptoms. We describe one patient with scrub typhus who presented with symptoms that suggested acute appendicitis and another who presented with symptoms of acute cholecystitis. The first patient underwent appendectomy, which revealed no pathological findings in the appendix; subsequently, she was successfully treated with azithromycin and doxycycline. The other patient recovered after doxycycline treatment without cholecystectomy. Therefore, the clinical conditions related to acute surgical abdomen in patients with scrub typhus should be differentiated carefully to avoid unnecessary surgery.
The past decade has witnessed the introduction of several potent immunosuppressive agents in. the field of transplant medicine. However, complications such as infection and allograft rejection remain major causes of morbidity and mortality following solid organ transplant. Primary considerations when evaluating transplant recipients include a high index of suspicion for infection or malignancy; consideration of acute rejection, which may mimic infection; and vigilance for adverse drug reactions and drug interactions associated with immunosuppressive medications. Measures to prevent infection, including vaccination and prophylaxis, should be implemented whenever the opportunity arises. [Infect Med. 2009;26:41-46, 58]
A milestone has been reached in the treatment of sepsis-the institution of protocolized management that starts in the emergency department. Early goal-directed therapy, with targeted fluid resuscitation and measures of oxygen delivery, has been shown to improve survival in patients with septic shock. Although initiating aggressive fluid resuscitation is the first priority, it is also essential to obtain cultures rapidly and infuse broad-spectrum antibiotics. Norepinephrine is a more potent vasoconstrictor than dopamine and may be more effective in treating hypotension in patients with septic shock. Vasopressin is an effective second-line agent. Treatment with recombinant human activated protein C at 24 mu g/kg/h for 96 hours has been shown to reduce mortality in patients with sepsis; its benefit is greatest in the most acutely ill patients. (Infect Med. 2009;26):134-143)
During the past few years, several vaccines have been added to the adult immunization schedule. The human papillomavirus (HPV) vaccine is recommended for girls and women aged 11 to 26 years (minimum age, 9 years) to prevent cervical cancer, precancerous or dysplastic lesions, and genital lesions caused by HPV types 6,11,16, and 18. The tetravalent meningococcal conjugate vaccine is approved for use in persons 11 to 55 years of age; it produces higher antibody titers 3 years after vaccination than the meningococcal polysaccharide vaccine. The availability of the tetanus, diphtheria, and acellular pertussis vaccine for adults can help reduce the reservoir of pertussis in the general population and thereby decrease transmission to high-risk persons, such as unvaccinated or partially vaccinated infants. The zoster vaccine is recommended for adults 60 years and older; immunization reduces the incidence of herpes zoster and postherpetic neuralgia by more than 50%. [Infect Med. 2009;26:72-77, 81]
Histoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum, which is endemic to the Ohio and Mississippi river valleys. It is associated with a variety of manifestations, and its severity ranges from asymptomatic infection to severe disseminated illness.
