Cytomegalovirus (CMV) reactivation in Mycobacterium tuberculosis (TB) infection is rare and has been only reported in immunocompromised patients. In this case report, we describe a patient with Type 2 diabetes with acute on chronic abdominal pain found to have miliary TB with terminal ileitis and ascending colon ulcers with biopsy-positive TB and CMV. The decision was made not to treat the local CMV reactivation, and he improved solely on standard drug-susceptible antituberculous therapy. This is the first reported case of gastrointestinal TB and CMV coinfection in a patient without known classic immunodeficiency.
Hepatic tuberculosis is a rare form of extrapulmonary manifestation. This case report depicts a 6-year-old boy with Down syndrome who presented with prolonged fever, weight loss, and hepatomegaly. The investigation revealed liver abnormalities suggestive of a granulomatous process, with the initial diagnosis of bartonellosis and, later, tuberculosis, with molecular testing and culture from a fragment of the liver biopsy. He underwent treatment and exhibited an excellent clinical response. This case highlights the importance of including hepatic tuberculosis in the differential diagnosis of liver diseases in children, even in the absence of evident pulmonary signs, especially in endemic regions including Brazil.
Brucellosis commonly manifests with fever, arthralgia, and hepatosplenomegaly, whereas severe cholestatic hepatitis is exceedingly rare. We report a 54-year-old goat farmer who presented with a 4-day history of right upper quadrant tenderness, progressive jaundice, and generalized pruritus after consuming unpasteurized milk from his own herd, with which he also had daily close contact. Examination showed scleral icterus and mild lethargy without peritoneal signs. Laboratory investigation revealed profound, predominantly conjugated hyperbilirubinemia (total 25.1 mg/dL, direct 23 mg/dL) with a cholestatic enzyme pattern (alkaline phosphatase 565 U/L, gamma-glutamyl transferase 225 U/L; R factor 0.4) and only mild transaminase elevation, together with acute kidney injury, thrombocytopenia with an elevated mean platelet volume and no platelet aggregates, hypofibrinogenemia, a markedly elevated D-dimer, and scant schistocytes. Thrombotic microangiopathy was initially considered, but a positive direct antiglobulin test, overt coagulopathy, and absent reticulocytosis favored sepsis-associated disseminated intravascular coagulation, confirmed by an International Society on Thrombosis and Haemostasis score of 6. Marked hyperferritinemia prompted consideration of hemophagocytic lymphohistiocytosis, which was not substantiated. Cross-sectional abdominal imaging excluded mechanical obstruction and showed hepatosplenomegaly with subcentimeter splenic nodules and no hepatic focal lesions. Brucella melitensis grew from all three blood cultures, and Wright agglutination was positive at a titer of 1/160. Echocardiography excluded endocarditis, and magnetic resonance imaging excluded spondylodiscitis. Continuous venovenous hemodiafiltration was required for life-threatening uremia, and doxycycline plus rifampin was administered for 6 weeks, with near-complete biochemical normalization by the end of treatment. Brucellosis should be considered in patients with animal exposure who present with severe cholestatic jaundice and multiorgan involvement, since prompt combination antimicrobial therapy can achieve full recovery.
Introduction:Sepsis secondary to crusted scabies is a rare but life-threatening complication of Sarcoptes scabiei infestation, particularly in vulnerable and underserved populations. Misdiagnosis with other dermatological conditions may lead to inappropriate treatment and severe outcomes. Clinical Findings:A 50-year-old Indigenous man from the Brazilian Amazon presented with a one-year history of generalized pruritus, diffuse hyperkeratotic and crusted skin lesions, and progressive clinical deterioration. Diagnosis Interventions and Outcomes:The patient was initially misdiagnosed with Hansen's disease and atopic dermatitis and received prolonged corticosteroid therapy, which exacerbated his condition. Skin scraping confirmed crusted scabies, and blood cultures grew Staphylococcus aureus, establishing the diagnosis of sepsis secondary to skin infection. He was treated with oral ivermectin, topical 5% permethrin, and systemic antibiotics, with gradual tapering and discontinuation of corticosteroids. The patient achieved complete clinical recovery. Conclusion Take‐Home Message:This case highlights the critical importance of early recognition of crusted scabies and the risks associated with misdiagnosis and inappropriate immunosuppressive therapy. Prompt diagnosis and treatment are essential to prevent severe complications such as sepsis, particularly in resource-limited and endemic settings.
Background:Rhino-orbito-facial mucormycosis is a rapidly progressive, life-threatening fungal infection that predominantly affects patients with uncontrolled diabetes mellitus, particularly those with diabetic ketoacidosis (DKA). Early diagnosis remains challenging in resource-limited settings because initial manifestations often mimic bacterial sinusitis. Case Presentation:We report a 38-year-old woman with newly diagnosed diabetes mellitus presenting with left facial pain, swelling, and nasal discharge accompanied by mild DKA. She was initially treated for bacterial maxillary sinusitis with antibiotics and insulin therapy; however, progressive facial necrosis and subsequent orbital involvement prompted surgical debridement and histopathological examination, which confirmed mucormycosis. The patient underwent repeated surgical debridement, conventional amphotericin B therapy, and intensive glycemic control, resulting in complete clinical recovery without recurrence during 3 years of follow-up. Conclusion:This case highlights the diagnostic challenges of mucormycosis in resource-limited settings and emphasizes the importance of maintaining a high index of suspicion in diabetic patients whose facial or orbital symptoms worsen despite appropriate antibacterial therapy. Early histopathological confirmation, prompt antifungal treatment, and multidisciplinary management remain essential for improving outcomes, even when advanced diagnostic resources are limited.
Study Design:A case report of a lumbar epidural cystic lesion associated with discitis presenting with cauda equina syndrome. Objective:To describe a rare presentation of a lumbar epidural cystic lesion associated with Finegoldia magna discitis presenting with cauda equina syndrome, discuss diagnostic considerations, and highlight the overlap between cystic lesions and infectious epidural pathology. Summary of Background Data:Discal cysts are uncommon epidural lesions that typically communicate with the intervertebral disc and present with radiculopathy. Severe neurological deficits are unusual, but infectious causes should remain in the differential when findings are atypical. When cauda equina syndrome is suspected, emergent diagnosis and treatment are imperative. Methods:A 41-year-old male presented with persistent low back pain, bilateral lower extremity radiculopathy, saddle anesthesia, and bowel and bladder changes consistent with cauda equina syndrome. He reported no history of trauma or infectious symptoms. Magnetic resonance imaging revealed a 1.6 × 1.1 cm cystic mass at the L4-L5 disc level that extended into the spinal canal, along with an L5-S1 central disc herniation. He underwent emergent decompression and debridement of the L4-L5 disc space. Results:Histologic examination showed benign fibrocartilaginous tissue compatible with intervertebral disc material, and cultures grew Finegoldia magna (formerly known as Peptostreptococcus magnus). His neurologic symptoms and pain improved immediately after surgery, and he was discharged home on postoperative day four. He was followed clinically and with repeat magnetic resonance imaging, which demonstrated resolution of the cyst and discitis. Conclusions:Lumbar disc-associated epidural cystic lesions are rare but should be considered in the differential diagnoses in patients with lumbar radiculopathy and/or cauda equina syndrome, and urgent decompression should be performed. This case highlights diagnostic overlap between discal cyst and infectious epidural pathology. Level of Evidence:Level IV.
Background:Haemophilus parainfluenzae (H. parainfluenzae) is rare in periprosthetic joint infections (PJIs). While many cases are associated with a prior history suggestive of an oral source, many occur without an identifiable source or exposure. We review two patients who had concerns for PJI, later identified as H. parainfluenzae through intraoperative cultures. Case Report:Two patients presented with complaints of knee pain. The first, a 54-year-old male, was found on admission to have a knee PJI. The patient underwent debridement, antibiotics, and implant retention (DAIR) and was discharged on intravenous (IV) ceftriaxone after H. parainfluenzae was isolated on culture, with no resistance reported on susceptibilities. However, approximately 4 weeks later, the patient underwent a second DAIR due to persistent swelling and redness; cultures were negative at the time of the second surgery. He was treated with IV vancomycin and cefepime and placed on cefadroxil suppression therapy without additional surgery. The second patient, an 80-year-old male, had a history of prior knee PJI, methicillin-resistant staphylococcus aureus (MRSA) in 2009 and Streptococcus agalactiae in 2015. He presented with a draining sinus and pain over his knee. Resection arthroplasty and above knee amputation were offered, but he would only consent to DAIR; intraoperative cultures showed H. parainfluenzae. He was treated with IV ceftriaxone postoperatively and then oral suppression. Conclusions:Due to increasing resistance in this species worldwide, consideration should be taken when choosing antimicrobial therapy for H. parainfluenzae. From the limited data available, patients with PJI secondary to H. parainfluenzae have a better prognosis compared to PJI with other Gram-negative organisms.
Candida albicans is one of the critical priority fungal pathogens as classified by the World Health Organization. Fluconazole resistance in C. albicans is increasingly being reported from different parts of the world. The epidemiology of antifungal resistance in Pakistan is evolving. While fluconazole resistance is rarely reported in invasive candidemia, it has been identified in noninvasive Candida isolates. Here, we describe the first case of candidemia with fluconazole-resistant C. albicans with Y132H mutations in the ERG11 gene from Pakistan. A 36-year-old male patient with comorbid conditions, including diabetes mellitus, hypertension, and a recent history of critical COVID-19 pneumonia, presented to the hospital emergency department with septic shock secondary to Fournier's gangrene. Blood culture confirmed fluconazole-resistant C. albicans. Our case report underscores the urgent need for antifungal stewardship to prevent the escalating issue of antifungal resistance.
Introduction:Brucella is a Gram-negative coccobacillus responsible for a zoonotic infection that is endemic in the Mediterranean region, including Lebanon. Although it commonly presents with systemic and musculoskeletal manifestations, vascular complications such as deep vein thrombosis (DVT) are rarely reported. This case highlights an uncommon thrombotic complication of brucellosis and contributes to the limited literature on brucellosis-associated DVT, particularly in endemic regions. Case Presentation:We report the case of a previously healthy 33-year-old male from Bekaa, Lebanon, who presented with prolonged fever and bilateral lower limb pain and swelling. Doppler ultrasound confirmed bilateral DVT. Extensive investigations for thrombophilia, malignancy, and autoimmune diseases were unremarkable. Brucella indirect serology was strongly positive with a titer of 1:1280, confirming active infection. The patient was treated with streptomycin, rifampicin, doxycycline, and anticoagulation therapy, resulting in marked clinical improvement and sustained recovery during a 3-year follow-up period. Conclusion:This case report highlights the importance of considering brucellosis as a cause of unexplained DVT, mainly in endemic regions, especially in the absence of a family history of hypercoagulable disorders.
Introduction:Streptococcus canis is a rare zoonotic pathogen reported to cause human disease, including skin and soft tissue infections, bloodstream infections, and infective endocarditis. The majority of cases have been linked to contact with dogs, with a paucity of cases related to cats. It is generally susceptible to penicillin and vancomycin but exhibits a high rate of resistance to erythromycin and an inducible resistance to clindamycin. Case Presentation:A man in his sixties presented with fever, chills, and a diabetic foot ulcer that had been exposed to a cat. He was found to have S. canis primary bloodstream infection, which showed a typical susceptibility to beta-lactams and vancomycin, and resistance to clindamycin and macrolides. He was treated with ceftriaxone and had no recurrence at the 3-month follow-up. Conclusion:S. canis related to cat exposure is an extremely rare cause of human infection, in such cases, a beta-lactam antimicrobial should be initiated. In individuals with an allergy to beta-lactams, vancomycin should be used with avoidance of macrolides and clindamycin as empirical therapy due to the high resistance rate to these antimicrobials among S. canis.
Introduction:People living with HIV (PLWH) remain at increased risk of diffuse large B-cell lymphoma (DLBCL). Polatuzumab vedotin plus rituximab, cyclophosphamide, doxorubicin, and prednisone (Pola-R-CHP) has emerged as a standard first-line option for DLBCL in the general population, but the pivotal POLARIX trial excluded PLWH, leaving limited evidence on feasibility with contemporary antiretroviral therapy (ART). Case Presentation:A 61-year-old man presented with progressive anorexia and weight loss. With durable virologic suppression (plasma HIV-1 RNA below 20 copies/mL) and immune reconstitution (CD4+ T-cell count approximately 300 cells/µL) on bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF), he was diagnosed with nongerminal center B-cell DLBCL (Lugano stage II; International Prognostic Index score 2). Pola-R-CHP was administered every 21 days for six cycles (Cycle 1: inpatient and Cycles 2-6: outpatient), followed by two additional rituximab cycles, without ART modification. No grade 3-4 nonhematologic toxicity, febrile neutropenia, or serious infections occurred. HIV-1 RNA remained below 20 copies/mL throughout treatment, and CD4+ T-cell counts showed no clinically meaningful decline. End-of-treatment fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET-CT) demonstrated a partial metabolic response with two small residual FDG-avid foci (∼1 cm; SUVmax ∼4-5). At the last follow-up, the patient had no clinical or radiologic evidence of progression. Conclusion:Outpatient-delivered Pola-R-CHP appeared feasible in PLWH with virologic suppression and immune reconstitution receiving BIC/FTC/TAF, without virologic breakthrough or unexpected toxicity. Prospective inclusion of PLWH in polatuzumab-containing frontline studies is warranted.
Emphysematous pyelonephritis (EPN) is a severe, necrotizing infection that can affect the renal parenchyma, collecting system, or perinephric tissue. Although typically caused by enteric Gram-negative bacteria, infections secondary to Candida occur rarely. We present the case of a 72-year-old female who was transferred from an outside hospital with a chief complaint of abdominal pain in the setting of dislodged percutaneous nephrostomy tube for chronic hydronephrosis. Clinically, she presented without evidence of septic shock but was found to have elevated creatinine (6.04), concerning for acute renal failure. Urology was consulted and performed cystoscopy that showed a large bilateral mass consistent with fungal ball formation. Subsequent urine cultures speciated Candida tropicalis and Candida glabrata. Per infectious disease recommendations, the patient was initially started on treatment with fluconazole and flucytosine; however, fluconazole was switched to amphotericin B deoxycholate after sensitivities reported resistance to fluconazole for Candida tropicalis. Additionally, urology performed a bilateral percutaneous nephroscopy with ultrasonic lithotripsy for removal of her fungal bezoar on Day 22 of her hospitalization with subsequent nephrostograms that showed a patent genitourinary system. This case demonstrates successful treatment of EPN secondary to azole-resistant Candida species using combined systemic antifungal therapy and an endourologic approach. This avoided the use of percutaneous nephrostomy irrigation with amphotericin deoxycholate as recommended in current guidelines and prevented potential complications this procedure carries.
Anti-TNF-α therapies are associated with an increased risk of tuberculosis, mainly via the reactivation of latent Mycobacterium tuberculosis. Primary zoonotic Mycobacterium bovis infection is rare and diagnostically challenging, particularly in immunosuppressed patients. We report a case of disseminated Mycobacterium bovis infection in a man receiving long-term adalimumab for psoriasis, complicated by diagnostic delay, suspected hemophagocytic lymphohistiocytosis, and immune reconstitution inflammatory syndrome (IRIS), resulting in a challenging treatment course. Epidemiological history revealed recent travel to Turkey and ingestion of unpasteurized dairy products. This case highlights the need for ongoing exposure assessment, sustained clinical awareness, and individualized therapeutic strategies throughout immunomodulatory treatment.
Background:Necrotizing pneumonia is a severe and potentially fatal complication of community-acquired pneumonia, often associated with toxin-producing or drug-resistant pathogens. Rapid and accurate identification of these pathogens is crucial for timely intervention. Polymerase chain reaction (PCR)-based diagnostic tools, such as the BioFire FilmArray pneumonia panel, have significantly improved early pathogen detection, aiding in prompt and targeted treatment as in the presenting case. Case Report:We report a case of necrotizing pneumonia in a female adult who presented with severe respiratory distress. Initial testing identified coinfection with influenza and methicillin-resistant Staphylococcus aureus (MRSA) using the BioFire FilmArray pneumonia panel, which provided rapid and precise pathogen detection before admission. The patient developed worsening respiratory failure, requiring mechanical ventilation and intensive care. Despite the severity of the infection, early diagnosis and appropriate antimicrobial therapy tailored to the identified pathogens led to a significant clinical improvement, allowing for a favorable recovery. Conclusion:This case highlights the critical role of rapid molecular diagnostics in the early detection of coinfections in necrotizing pneumonia. The timely identification of influenza and MRSA facilitated targeted antimicrobial therapy, which was instrumental in preventing further complications and improving the patient's prognosis. As PCR-based diagnostics become more widely available, their integration into routine clinical practice can enhance the management of severe pneumonia cases, ultimately leading to better outcomes. Clinicians should maintain a high index of suspicion for coinfections in severe pneumonia and leverage rapid diagnostic tools to guide early and effective treatment strategies.
Background:Granulicatella adiacens (G. adiacens) is a nutritionally variant Streptococcus generally observed in the human mouth microbiota. Although G. adiacens is involved in bacterial endocarditis and bacteremia, bone and joint infections are extremely rare. In the present study, we reported the first known case of hip osteomyelitis related to G. adiacens. Moreover, a commentary on the available evidence was also performed. Case Presentation:A 59-year-old male with a former substance use disorder who initially complained of low back pain with a medical history negative for any other comorbidities, albeit absence seizures. After an accurate evaluation, hip osteomyelitis caused by G. adiacens was diagnosed. In our patient, neither bacteremia nor infectious endocarditis was reported, as well as previous oral surgery. The diagnosis of G. adiacens was performed through 16S rRNA gene sequencing. A three-stage surgery was performed based on surgical debridement and antibiotic-cemented spacer implant, antibiotic-cemented spacer renewal, spacer removal, and prosthesis implantation. Throughout the entire period, the patient received antibiotic therapy with doxycycline and cotrimoxazole. At the final follow-up, the patient was infection-free, but a poor hip function was reported. Conclusion:G. adiacens is rarely associated with bone osteomyelitis, probably because of the difficulty in culture isolation that might lead to misdiagnosis, especially in cases of polymicrobial infection. In our experience, debridement, prolonged antibiotics, and two-stage/three- stage prosthesis implantation could be considered as a treatment strategy for hip osteomyelitis involving G. adiacens.
Usutu virus (USUV) is a neurotropic flavivirus, phylogenetically related to West Nile virus (WNV), maintained in the environment through a bird-to-mosquito transmission cycle, with humans and other animals occasionally becoming infected. In recent years, different cases of human infections have been reported concomitantly with increased viral circulation in several European countries. Most USUV infections in humans remain asymptomatic; however, neuroinvasive disease has been reported, mainly in the elderly and the immunocompromised but also in healthy individuals. Herein, we report a case of severe USUV meningoencephalitis in an elderly patient treated with a short course of dexamethasone and discuss the potential role of steroids in light of the most recent literature on the pathogenetic mechanisms of arboviral encephalitis.
Background:Nocardiosis disproportionately affects immunocompromised hosts. Early identification of Nocardia infections is critical as delays can lead to worse outcomes. Species such as N. farcinica are associated with increased risk of dissemination and resistance. Diagnosis of opportunistic infections in immunocompromised populations relies on culture, antigen, or serologic methods that often have limited sensitivity or specificity. Plasma microbial cell-free DNA metagenomic next-generation sequencing (mNGS) offers a noninvasive approach for early diagnosis of opportunistic infections. Case Presentation:We report a case of pulmonary nocardiosis in an 87-year-old man with myelodysplastic syndrome and prolonged neutropenia diagnosed by plasma mNGS. He had been hospitalized multiple times with recurrent febrile neutropenia and respiratory symptoms. Standard noninvasive microbiologic workup was unrevealing, but lower respiratory specimens could not be readily obtained. Due to elevated risk of complications from invasive testing, plasma mNGS was used as a complementary tool and identified N. farcinica. Anti-Nocardia therapy was initiated, and his fevers resolved. Conclusion:mNGS is an emerging diagnostic tool that may identify Nocardia species from clinical specimens with a faster turnaround time than culture and enables rapid species identification. Although culture is still recommended for susceptibility testing, mNGS may expedite diagnosis in particular situations. This case supports the role of plasma mNGS as a complementary tool in the evaluation of febrile neutropenia and highlights its diagnostic potential.
Pyogenic ventriculitis is a rare and potentially fatal infection of the ventricular system. While most reported cases are nosocomial and catheter-associated, ventriculitis as a complication of community-acquired bacterial meningitis is uncommon, particularly in adults, and carries a poor prognosis. We report the case of an 82-year-old previously healthy and unvaccinated woman who presented with a one-day history of fever, confusion, and purulent left-sided otorrhea on a 2-week background of flu-like symptoms. Cranial computed tomography was consistent with otogenic meningitis complicated by pneumocephalus, and lumbar puncture confirmed purulent meningitis. Empirical therapy for meningitis with ceftriaxone, amoxicillin, metronidazole, and dexamethasone was initiated, and surgical source control of the otogenic focus was performed. Both blood and cerebrospinal fluid cultures grew Streptococcus pneumoniae with a penicillin minimum inhibitory concentration of < 0.03 mg/L. Serotyping by multiplex PCR with confirmatory Quellung reaction, performed at the Swiss National Reference Center for Invasive Pneumococci, identified Serotype 3. Despite penicillin G monotherapy, fever and impaired consciousness persisted, and repeat imaging revealed meningitis-associated pyogenic ventriculitis with intraventricular debris. Adjunctive rifampicin and a series of cerebrospinal fluid drainage interventions (lumbar drain followed by external ventricular drain) failed to substantially improve neurological outcome. Antibiotic therapy was continued for 9 weeks, after which the patient was transferred to long-term institutional care with severe residual neurological impairment. This case illustrates the diagnostic and therapeutic challenges of meningitis-associated pyogenic ventriculitis in adults and the disproportionate severity of disease caused by Serotype 3 S. pneumoniae, whose unusually thick mucoid capsule promotes immune evasion and the formation of viscous purulent debris that hampers source control. The case is consistent with Swiss surveillance data showing that Serotype 3 remains a leading cause of invasive pneumococcal disease in older adults and serves as a sentinel event highlighting persistent gaps in adult pneumococcal immunization.
Syphilis has become an increasing public health concern in recent times, with rising incidence globally. It is often referred to as the 'great imitator' due to its diverse clinical presentations across multiple stages. Neurosyphilis, a tertiary manifestation of Treponema pallidum infection, can present with neuropsychiatric features including rapid cognitive decline. It remains an important but potentially overlooked cause of cognitive impairment (CI). However, few cases document objective cognitive and functional improvement following treatment, especially within a short time frame. We describe the case of a 67-year-old man with rapid cognitive decline, displaying impairments in various cognitive domains: learning and memory, attention and executive functioning. The presence of Argyll-Robertson pupils combined with positive serological and cerebrospinal fluid testing confirmed a diagnosis of neurosyphilis. Following treatment with intravenous penicillin G, serial cognitive assessment demonstrated objective improvement in his cognition and functioning within 1 month of treatment. Our observation of such an improvement in neurosyphilis-driven CI in this time frame is a finding not commonly documented in associated literature. This case highlights the importance of thorough history taking, including a sexual history, alongside physical examination in diagnosing neurosyphilis. Additionally, it supports the importance of considering neurosyphilis when investigating patients with unexplained cognitive decline and suggests there is a degree of reversibility when treated promptly. Further research is needed to better characterise the treatability of neurosyphilis-related CI.
Brucellosis is a zoonotic infection caused by Brucella species, often leading to serious complications and presenting diagnostic challenges. A 45-year-old female patient presented with a headache that had persisted for two months and was recently accompanied by visual disturbances. Notably, the patient’s headache began 6 weeks postpartum, and she had no prior history of illness, medication use, or headaches. Imaging studies were normal, and cerebrospinal fluid (CSF) analysis revealed meningitis, with a positive Wright test. After excluding other potential causes and considering the patient’s consumption of local dairy products, the diagnosis of Brucella meningitis was confirmed. The patient was treated with a standard three-drug regimen for 6 months and was followed throughout the treatment period. Initially, her headache resolved, followed by improvement in visual symptoms. Follow-up serologic tests showed a declining trend in Brucella titers, and perimetry results returned to normal by the fourth month of treatment. This case underscores the importance of including Brucella in the differential diagnosis of patients with chronic meningitis, especially in endemic regions, and highlights the favorable outcomes associated with prompt treatment.
