BACKGROUND:COVID-19 testing safeguards the health of children with medical complexity (CMC) through several key mechanisms, such as the implementation of clinical action plans and COVID-19-directed therapies. However, testing utility is limited by barriers to access and perceptions surrounding use. This study investigated associations between rurality and COVID-19 testing access, intent, motivators, and concerns for caregivers of CMC. METHODS:We conducted a cross-sectional survey (April - June 2022) of English- and Spanish-speaking caregivers of children with at least one complex chronic condition between ages 5-17 at an academic medical center in the Midwestern USA. Rurality was dichotomized using Rural-Urban Commuting Area codes. Outcomes represented COVID-19 testing access, intent, motivators, and concerns. Covariates included demographic and clinical characteristics. Unadjusted and adjusted logistic regression analyses examined associations between rurality and each outcome. RESULTS:Among 1,432 responses (response rate 49%), 359 (25%) were classified as rural. Respondents had varied education, income, and insurance levels. In the multivariable models, rural and urban caregivers reported similarly high testing access, but rural caregivers had significantly less testing intent (adjusted Odds Ratio [95% CI]: 0.53, [0.40, 0.71]). Notably, rural caregivers were significantly more likely to indicate "It will be difficult to get needed healthcare if my child has it" (2.49 [1.19, 5.18]). CONCLUSIONS:While rural and urban CMC caregivers reported generally high access and ease of COVID-19 testing, potentially modifiable factors exist to improve testing intention and decrease barriers, including communication regarding testing utility and timing as well as access to effective treatment response upon testing positive.

Background Cellulitis is misdiagnosed in 19 % to 34 % of emergency department (ED) cases resulting in excess healthcare spending and threatening patient safety. The objectives of this planned secondary analysis was to report the proportion of cellulitis misdiagnosis in the ED. Secondarily, we evaluated the potential impact of diagnostic adjuncts on misdiagnosis rates. Methods We prospectively enrolled ED patients presenting with acute lower extremity dermatologic complaints involving visible erythema (potential cellulitis). We abstracted the treating physician's diagnosis from the medical chart. Consensus diagnosis was determined by a group of six independent, multidisciplinary physicians. The treating ED physician's diagnosis was compared to the consensus panel diagnosis to identify errors. We evaluated the potential impact of two individual diagnostic adjuncts, skin surface temperature measurement and the ALT-70 score, plus a combination of both, on reducing cellulitis diagnostic errors Results The final sample included 201 patients. The diagnosis assigned by the treating physician and consensus panel was discordant in 50 of 201 cases (24.9 %). Among patients with an ED physician diagnosis of cellulitis, 35.6 % were overdiagnosed (48/135). In cases diagnosed as cellulitis, utilization of skin surface temperature, the two-level ALT-70 and the combination measure would have yielded an absolute reduction in cellulitis overdiagnosis by 8.9 %, 5.7 % and 13.0 % of cases respectively Conclusion Consistent with other reports, we observed a high rate of cellulitis overdiagnosis, highlighting the need for diagnostic support interventions. Proposed diagnostic adjuncts had an overall positive theoretical impact on overdiagnosis and should be evaluated in prospective interventional trials

Background: Common biologic samples used to diagnose COVID-19 include nasopharyngeal, nasal, or oropharyngeal swabs, and salivary samples. The performance characteristics of a sucked "lollipop" swab to detect SARSCoV-2 virus is assessed in four small sub-studies. Methods: In each sub-study, a flocked swab was sucked for 20 s and submitted for PCR detection of SARS-CoV-2 virus. Results: Across all studies, 52 of 69 (75.4%) COVID-19 positive participants had positive "lollipop" swabs. Twelve of the 17 COVID-19 positive participants with negative "lollipop" swabs had known corresponding cycle threshold values of >37 from their nasal/nasopharyngeal swabs, an indication of low viral load at time of sampling. In a paired samples sub-study, the sensitivity and specificity of the "lollipop" swabs were 100% and 98%. Conclusions: "Lollipop" swabs performed satisfactorily especially in individuals with acute infection of COVID-19. "Lollipop" swabs are a simple method of sample collection for detecting SARS-CoV-2 virus and warrants additional consideration.

BACKGROUND:Probiotics are synthetic oral supplements containing live bacterial and fungal species hypothesized to help with various gastrointestinal conditions. However, they can cause infection if the organism spreads outside of the gastrointestinal tract. The aim of this study was to identify and describe patients who experienced systemic infections caused by probiotic use. METHODS:This study was a retrospective chart review of pediatric and adult patients at academic medical centers who received probiotics and subsequently developed positive cultures from a sterile site for probiotic-related species. Two individuals completed the chart reviews to determine if the probiotic was the true cause of the infection. RESULTS:Lactobacillus, Bifidobacterium, and Saccharomyces cultures were reviewed, with a total of 71, 8, and 2 cultures isolated from sterile sites for each organism, respectively. Further review revealed 23 Lactobacillus cultures from 13 unique patients who were taking Lactobacillus-containing probiotics. Four patients without gastrointestinal tract compromise were included in the final analysis, including 1 patient whose culture was confirmed as identical to the probiotic. Types of infections included meningitis and bacteremia. Targeted antimicrobial therapy included ampicillin, ampicillin-sulbactam, and piperacillin-tazobactam, with total durations of therapy ranging from 10 to 22 days. No patients had mortality attributed to Lactobacillus infection. CONCLUSIONS:Probiotics are not harmless supplements as they come with risk of serious infection as demonstrated in this review. Before use, the risks of probiotics should be considered carefully for each individual patient. Clinicians should consider avoiding probiotics in hospitalized patients, especially those with vascular or extra-ventricular access devices.

Importance:Cellulitis is misdiagnosed in up to 30% of cases due to mimic conditions termed pseudocellulitis. The resulting overuse of antibiotics is a threat to patient safety and public health. Surface thermal imaging and the ALT-70 (asymmetry, leukocytosis, tachycardia, and age ≥70 years) prediction model have been proposed as tools to help differentiate cellulitis from pseudocellulitis. Objectives:To validate differences in skin surface temperatures between patients with cellulitis and patients with pseudocellulitis, assess the optimal temperature measure and cut point for differentiating cellulitis from pseudocellulitis, and compare the performance of skin surface temperature and the ALT-70 prediction model in differentiating cellulitis from pseudocellulitis. Design, Setting, and Participants:This prospective diagnostic validation study was conducted among patients who presented to the emergency department with acute dermatologic lower extremity symptoms from October 11, 2018, through March 11, 2020. Statistical analysis was performed from July 2020 to March 2021 with additional work conducted in September 2023. Main Outcomes and Measures:Temperature measures for affected and unaffected skin were obtained. Cellulitis vs pseudocellulitis was assessed by a 6-physician, independent consensus review. Differences in temperature measures were compared using the t test. Logistic regression was used to identify the temperature measure and associated cut point with the optimal performance for discriminating between cellulitis and pseudocellulitis. Diagnostic performance characteristics for the ALT-70 prediction model, surface skin temperature, and both combined were also assessed. Results:The final sample included 204 participants (mean [SD] age, 56.6 [16.5] years; 121 men [59.3%]), 92 (45.1%) of whom had a consensus diagnosis of cellulitis. There were statistically significant differences in all skin surface temperature measures (mean temperature, maximum temperature, and gradients) between cellulitis and pseudocellulitis. The maximum temperature of the affected limb for patients with cellulitis was 33.2 °C compared with 31.2 °C for those with pseudocellulitis (difference, 2.0 °C [95% CI, 1.3-2.7 °C]; P < .001). The maximum temperature was the optimal temperature measure with a cut point of 31.2 °C in the affected skin, yielding a mean (SD) negative predictive value of 93.5% (4.7%) and a sensitivity of 96.8% (2.3%). The sensitivity of all 3 measures remained above 90%, while specificity varied considerably (ALT-70, 22.0% [95% CI, 15.8%-28.1%]; maximum temperature of the affected limb, 38.4% [95% CI, 31.7%-45.1%]; combination measure, 53.9% [95% CI, 46.5%-61.2%]). Conclusions and Relevance:In this large diagnostic validation study, significant differences in skin surface temperature measures were observed between cases of cellulitis and cases of pseudocellulitis. Thermal imaging and the ALT-70 both demonstrated high sensitivity, but specificity was improved by combining the 2 measures. These findings support the potential of thermal imaging, alone or in combination with the ALT-70 prediction model, as a diagnostic adjunct that may reduce overdiagnosis of cellulitis.

Schools provide important services that cannot be provided virtually to children with medical complexity and children with intellectual and developmental disabilities, yet these children are among the most at risk from coronavirus disease 2019 (COVID-19). To keep schools open for children with medical complexity and/or intellectual and developmental disabilities during the COVID-19 pandemic, we implemented severe acute respiratory syndrome coronavirus 2 testing at 3 sites across the United States. We evaluated testing strategies for staff and students at each site, including specimen source (nasopharyngeal or saliva), test type (polymerase chain reaction or rapid antigen), and frequency and type (screening versus exposure/symptomatic) of testing provided. Among the greatest barriers to severe acute respiratory syndrome coronavirus 2 testing in these schools was the engagement of caregivers and challenges navigating legal guardianship for consenting adult students. Additionally, variability in testing strategies nationally and in the community, as well as surges in viral transmission across the United States during the course of the pandemic, led to testing hesitancy and variable participation rates. Essential to the successful implementation of testing programs is building a trusted relationship with school administrators and guardians. Leveraging our experiences with COVID-19 and forming lasting school partnerships can help keep schools for vulnerable children safe in future pandemics.

OBJECTIVES:The chronic conditions and functional limitations experienced by children with medical complexity (CMC) place them at disproportionate risk for COVID-19 transmission and poor outcomes. To promote robust vaccination uptake, specific constructs associated with vaccine hesitancy must be understood. Our objective was to describe demographic, clinical, and vaccine perception variables associated with CMC parents' intention to vaccinate their child against COVID-19. METHODS:We conducted a cross-sectional survey (June-August 2021) for primary caregivers of CMC between ages 5 to 17 at an academic medical center in the Midwest. Multivariable logistic regression examined associations between vaccination intent and selected covariates. RESULTS:Among 1330 families, 65.8% indicated vaccination intent. In multivariable models, demographics had minimal associations with vaccination intent; however, parents of younger children (<12 years) had significantly lower adjusted odds of vaccination intent (adjusted odds ratio [95% confidence interval]: 0.26 [0.17-0.3]) compared to parents of older children (≥12 years). CMC with higher severity of illness, ie, those with ≥1 hospitalization in the previous year (versus none) or >1 complex chronic condition (vs 1), had higher adjusted odds of vaccination intent (1.82 [1.14-2.92] and 1.77 [1.16-2.71], respectively). Vaccine perceptions associated with vaccine intention included "My doctor told me to get my child a COVID-19 vaccine" (2.82 [1.74-4.55]); and "I'm concerned about my child's side effects from the vaccine" (0.18 [0.12-0.26]). CONCLUSIONS:One-third of CMC families expressed vaccine hesitation; however, constructs strongly associated with vaccination intent are potentially modifiable. Pediatrician endorsement of COVID-19 vaccination and careful counseling on side effects might be promising strategies to encourage uptake.

Abstract Objective To compare clinical documentation of skin warmth to patient report and quantitative skin surface temperatures of patients diagnosed with cellulitis in the emergency department (ED). Methods Adult patients (≥18 years) presenting to the ED with an acute complaint involving visible erythema of the lower extremity were prospectively enrolled. Those diagnosed with cellulitis were included in this analysis. Participant report of skin warmth was recorded and skin surface temperature values were obtained from the affected and corresponding unaffected area of skin using thermal cameras. Average temperature (Tavg) was extracted from each image and the difference in Tavg between the affected and unaffected limb was calculated (Tgradient). Clinical documentation of skin warmth was compared to patient report and measured skin warmth (Tgradient >0°C). Results Among 126 participants diagnosed with cellulitis, 110 (87%) exhibited objective warmth (Tgradient >0°C) and 58 (53%) of these cases had warmth documented in the physical examination. Of those with objective warmth, 86 (78%) self‐reported warmth and 7 (6%) had warmth documented in their history of present illness (HPI) (difference = 72%, 95% confidence interval [CI]: 62%–82%; P < 0.001). A significant difference was observed for Tavg affected when warmth was documented (32.1°C) versus not documented (31.0°C) in the physical examination (difference = 1.1°C, 95% CI: 0.29–1.94; P = 0.0083). No association was found between Tgradient and patient‐reported or HPI‐documented warmth. Conclusions The majority of ED‐diagnosed cellulitis exhibited objective warmth, yet significant discordance was observed between patient‐reported, clinician‐documented, and measured warmth. This raises concerns over inadequate documentation practices and/or the poor sensitivity of touch as a reliable means to assess skin surface temperature. Introduction of objective temperature measurement tools could reduce subjectivity in the assessment of warmth in patients with suspected cellulitis.

People experiencing homelessness (PEH) are at increased risk for coronavirus disease 2019 (COVID-19) infection. This study assessed COVID-19 vaccination coverage among vaccine-eligible PEH (5 years and older) stratified by demographic characteristics. PEH were less likely to complete a primary vaccination series than the Dane County population (32.0%; 95% confidence interval [CI], 30.3%-33.8% vs 82.4%; 95% CI, 82.3%-82.5%) and were less likely to have received a booster when eligible (30.8%; 95% CI, 27.8%-33.9% vs 67.2%; 95% CI, 67.1%-67.4%). Vaccination rates were lowest among young PEH and PEH of color.

The REstarting Safe Education and Testing program for children with medical complexity was implemented in May 2021 at the University of Wisconsin to evaluate the feasibility of in-home rapid antigen COVID-19 testing among neurocognitively affected children. Parents or guardians administered BinaxNOW rapid antigen self-tests twice weekly for three months and changed to symptom and exposure testing or continued surveillance. In-home testing was feasible: nearly all (92.5%) expected tests were conducted. Symptomatic testing identified seven of nine COVID-19 cases. School safety perceptions were higher among those opting for symptom testing. Clinical Trials.gov identifier: NCT04895085. (Am J Public Health. 2022;112(S9):S878-S882. https://doi.org/10.2105/AJPH.2022.306971).

The Blastomyces species complex causes blastomycosis, which is an invasive fungal infection that infects humans and animals. The defining biologic feature of Blastomyces is the ability to reversibly switch between hyphal (22–25°C) and yeast (37°C) forms in response to temperature. Blastomyces typically causes pulmonary, skin, and bone infections in immunocompetent and immunocompromised patients. Diagnosis of blastomycosis is challenging because it mimics other infections. Treatment involves 6–12 months of antifungal drug therapy. Advances in the laboratory regarding pathogenesis and host immune responses are beginning to enter the clinical realm.

Introduction: Blastomycosis is endemic in Wisconsin with Blastomyces dermatitidis and B. gilchristii responsible for infections. Urine antigen testing is a non-invasive diagnostic method for blastomycosis with up to 93% test sensitivity. However, the test’s sensitivity has not been evaluated with relationship to B. gilchristii infections. Methods: We aimed to assess physician use of the urine antigen assay and its sensitivity to B. gilchristii and B. dermatitidis infections in a retrospective study. Culture confirmed clinical cases of blastomycosis from 2008-2016 were identified within Marshfield Clinic Health System (MCHS) and UW Hospital and Clinics (UWHC) medical records. Clinical data were abstracted from each medical record and included the following: patient demographics, presence of immune compromising and underlying medical conditions, treatment drugs, presence of isolated pulmonary or disseminated disease, death, urine antigen testing, timeframe of testing, and quantitative test values (EIA units or ng/mL). Results: A total of 140 blastomycosis cases were included in this study, with MCHS contributing 114 cases to the study and UWHC contributing 26 cases. The majority of UWHC cases (n=22; 85%) were caused by B. dermatitidis and the majority of MCHS cases (n=73; 64%) were caused by B. gilchristii. UWHC physicians were significantly more likely to treat with multiple drugs during the course of infection and were more likely to prescribe amphotericin B and voriconazole. Urine antigen testing was more frequently used at UWHC (n=24; 92%) than MCHS (n=51; 45%; P < 0.00001). In this study, the urine antigen assay demonstrated 79% sensitivity. Sensitivity was significantly associated with the timeframe of testing (P < 0.05), with most true positive urine antigen tests (83%) being performed ≤ 7 days from diagnosis. In this study, the urine antigen assay was capable of detecting both B. dermatitidis and B. gilchristii at about equal sensitivity. Urine antigen concentration (ng/mL) trended higher in B. dermatitidis infections. Conclusion: This study found that the urine antigen assay is capable of detecting both species of Blastomyces at about the same sensitivity. We recommend continued use of the urine antigen assay for diagnosis of blastomycosis and recommend that the assay be used early in the diagnostic process to minimize the chance of false negative results.

BACKGROUND:There is very little data on long-term immune recovery responses in patients on suppressive antiretroviral therapy (ART) in the setting of sub-Saharan Africa (SSA). Thus, we sought to determine CD4+ T-cell, CD8+ T-cell and CD4/CD8 ratio responses in a cohort of HIV infected individuals on sustained suppressive ART followed up for more than a decade. METHODS:The cohort comprised adult patients who started ART between 2001 and 2007 and followed for up to 14 years. Trends in median CD4+ T-cells, CD8+ T-cells and CD4/CD8 ratio were reviewed retrospectively. Poisson regression models were used to identify factors associated with achieving normalized T-cell biomarkers. Kaplan-Meier curves were used to estimate the probability of attaining normalized counts while on suppressive ART. RESULTS:A total of 227 patients with a median duration of follow-up on ART of 12 (IQR: 10.5-13.0) years were included. CD4 cell count increased from baseline median of 138 cells (IQR: 70-202) to 555 cells (IQR: 417-830). CD4 cell increased continuously up until 5 years, after which it plateaued up until 14 years of follow up. Only 69.6% normalized their CD4 cell count within a median of 6.5 (IQR: 3.0-10.5) years. In addition, only 15.9% of the cohort were able to achieve the median reference CD4+ T-cell threshold count in Ethiopians (≈760 cells/μL). CD8+ T-cell counts increased initially until year 1, after which continuous decrease was ascertained. CD4/CD8 ratio trend revealed continuous increase throughout the course of ART, and increased from a median baseline of 0.14 (IQR: 0.09-0.22) to a median of 0.70 (IQR: 0.42-0.95). However, only 12.3% normalized their ratio (≥ 1.0) after a median of 11.5 years. In addition, only 8.8% of the cohort were able to achieve the median reference ratio of healthy Ethiopians. CONCLUSION:Determination of both CD4+ and CD8+ T-cells, along with CD4/CD8 ratio is highly relevant in long-term follow-up of patients to assess immune recovery. Monitoring ratio levels may serve as a better biomarker risk for disease progression among patients on long-term ART. In addition, the findings emphasize the relevance of initiation of ART at the early stage of HIV-1 infection.

BACKGROUND:Blastomyces is a dimorphic fungus that infects persons with or without underlying immunocompromise. To date, no study has compared the clinical features and outcomes of blastomycosis between immunocompromised and immunocompetent persons.METHODS:A retrospective study of adult patients with proven blastomycosis from 2004-2016 was conducted at the University of Wisconsin. Epidemiology, clinical features, and outcomes were analyzed among solid-organ transplantation (SOT) recipients, persons with non-SOT immunocompromise (non-SOT IC), and persons with no immunocompromise (NIC).RESULTS:A total of 106 cases met the inclusion criteria including 74 NIC, 19 SOT, and 13 non-SOT IC (malignancy, HIV/AIDS, idiopathic CD4+ lymphopenia). The majority of patients (61.3%) had at least 1 epidemiologic risk factor for acquisition of Blastomyces. Pneumonia was the most common manifestation in all groups; however, immunocompromised patients had higher rates of acute pulmonary disease (P = .03), more severe infection (P = .007), respiratory failure (P = .010), and increased mortality (P = .02). Receipt of SOT primarily accounted for increased severity, respiratory failure, and mortality in immunosuppressed patients. SOT recipients had an 18-fold higher annual incidence of blastomycosis than the general population. The rate of disseminated blastomycosis was similar among NIC, SOT, and non-SOT IC. Relapse rates were low (5.3-7.7%).CONCLUSIONS:Immunosuppression had implications regarding the acuity, severity, and respiratory failure. The rate of dissemination was similar across the immunologic spectrum, which is in sharp contrast to other endemic fungi. This suggests that pathogen-related factors have a greater influence on dissemination for blastomycosis than immune defense.

BACKGROUND:The role of CD4/CD8 ratio on the incidence of tuberculosis (TB) in patients on antiretroviral therapy (ART) is unknown. Thus, we sought to determine whether the CD4/CD8 ratio was associated with development of TB in a cohort of HIV infected individuals on ART followed up for more than a decade in the setting of sub-Saharan Africa (SSA).METHODS:The cohort comprised adult patients who started ART between 2001 and 2007 and followed for up to 15 years. Clinical data were collected in retrospective manner. Patients with an AIDS defining illness or a CD4 count <200 cell/μL were started with a combination of ART. The participants have clinic visits every 6 months and/or as needed. Poisson regression models were used to identify factors associated with development of incident TB. Kaplan-Meier curves were used to estimate the probability of incident TB while on ART.RESULTS:A total of 347 patients with a median duration of follow-up on ART of 11.5 (IQR: 10.0-12.5) years were included. Incident TB developed in 47 patients during the 3259 person-years of follow-up, the majority (76.6%) occurred within five year of ART initiation. On univariate analysis, poor ART adherence (RR:2.57, 95% CI: 1.28-5.17), time-updated CD4 cell count of lower than 200 (RR: 4.86, 95%CI 2.33-10.15), or CD4 cell count between 200 and 500 (RR: 4.68, 95% CI: 2.17-10.09), time-updated CD8 cell count lower than 500 (RR: 2.83 95% CI 1.31-6.10), or CD8 cell count over 1000 (RR: 2.23, 95% CI: 1.12-4.45), time-updated CD4/CD8 ratio of less than 0.30 (RR: 6.00, 95% CI: 2.96-12.14), lack of normalization of CD4 T-cell count (RR: 6.13, 95% CI: 2.20-17.07), and virological failure (RR: 2.35 (95% CI: 1.17-4.71) were all associated with increased risk of incident TB. In multivariate analysis, however, time-updated CD4/CD8 ratio of less than 0.30 (adjusted RR: 4.08, 95% CI: 1.31-12.68) was the only factor associated with increased risk of developing incident TB (p = 0.015). Similar results were obtained in a sensitivity analysis by including only those virally suppressed patients (n = 233, 69% of all patients). In this group, CD4/CD8 ratio of less than 0.30 was associated with development of incident TB (adjusted RR: 4.02, 95% CI: 1.14-14.19, p = 0.031). Overall, the incidence rate of TB in patients with an updated CD4/CD8 ratio of less than 0.30 was more than 5-fold higher when compared with those with a ratio more than 0.45.CONCLUSION:Low CD4/CD8 ratio is independently associated with an increased risk of incident TB despite viral suppression. CD4/CD8 ratio may serve as a biomarker for identifying patients at risk of TB in patients on ART in the setting of SSA.

Coronavirus disease 2019 lead to wide-spread quarantines and cancelations. The impact of these measures on other, noncoronavirus disease 2019, infectious diseases was analyzed within Dane County, Wisconsin. The incidence of streptococcal pharyngitis and acute otitis media decreased during quarantine while gonorrhea increased. Quarantine had the expected result for infections spread via the respiratory route but a different effect from those transmitted through sexual activity.

This review article focuses on the mechanisms underlying temperature adaptation and virulence of the etiologic agents of blastomycosis, Blastomyces dermatitidis, Blastomyces gilchristii, and Blastomyces percursus. In response to temperature, Blastomyces undergoes a reversible morphologic switch between hyphae and yeast known as the phase transition. The conversion to yeast for Blastomyces and related thermally dimorphic fungi is essential for virulence. In the yeast phase, Blastomyces upregulates the essential virulence factor, BAD1, which promotes attachment to host cells, impairs activation of immune cells, and blunts cytokine release. Blastomyces yeast also secrete dipeptidyl-peptidase IVA (DPPIVA), a serine protease that blunts the action of cytokines released from host immune cells. In vivo transcriptional profiling of Blastomyces yeast has uncovered genes such as PRA1 and ZRT1 involved in zinc scavenging that contribute to virulence during murine pulmonary infection. The discovery and characterization of genes important for virulence has led to advances at the bedside regarding novel diagnostics, vaccine development, and new targets for drug discovery.

Journal of Hospital MedicineVolume 15, Issue 2 p. 111-115 Clinical Care Conundrum A Plea to Reconsider the Diagnosis Joseph A McBride MD, Corresponding Author Joseph A McBride MD jmcbride@medicine.wisc.edu Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WisconsinCorresponding Author: Joseph A. McBride, MD; E-mail: jmcbride@medicine.wisc.edu; Telephone 608-263-8431Search for more papers by this authorBryce Binstadt MD, PhD, Bryce Binstadt MD, PhD Department of Pediatrics, University of Minnesota, Minneapolis, MinnesotaSearch for more papers by this authorRaheel Ahmed MD, PhD, Raheel Ahmed MD, PhD Department of Neurosurgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WisconsinSearch for more papers by this authorMustafa K Baskaya MD, Mustafa K Baskaya MD Department of Neurosurgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WisconsinSearch for more papers by this authorAndrew PJ Olson MD, Andrew PJ Olson MD Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota Department of Medicine, University of Minnesota, Minneapolis, MinnesotaSearch for more papers by this authorEllen Wald MD, Ellen Wald MD Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WisconsinSearch for more papers by this author Joseph A McBride MD, Corresponding Author Joseph A McBride MD jmcbride@medicine.wisc.edu Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WisconsinCorresponding Author: Joseph A. McBride, MD; E-mail: jmcbride@medicine.wisc.edu; Telephone 608-263-8431Search for more papers by this authorBryce Binstadt MD, PhD, Bryce Binstadt MD, PhD Department of Pediatrics, University of Minnesota, Minneapolis, MinnesotaSearch for more papers by this authorRaheel Ahmed MD, PhD, Raheel Ahmed MD, PhD Department of Neurosurgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WisconsinSearch for more papers by this authorMustafa K Baskaya MD, Mustafa K Baskaya MD Department of Neurosurgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WisconsinSearch for more papers by this authorAndrew PJ Olson MD, Andrew PJ Olson MD Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota Department of Medicine, University of Minnesota, Minneapolis, MinnesotaSearch for more papers by this authorEllen Wald MD, Ellen Wald MD Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WisconsinSearch for more papers by this author First published: 18 December 2019 https://doi.org/10.12788/jhm.3348Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume15, Issue2February 2020Pages 111-115 RelatedInformation

Streptococcus pyogenes, also known as group A beta-hemolytic strep, is a Gram positive coccus responsible for several million infections every year. The types of infections vary widely from pharyngitis to myositis, but all can advance to severe life threatening invasive disease. Of those infected, approximately 1100 to 1600 people die each year due to invasive disease. Why certain individuals contract severe infections is not known, but many strains of Streptococcus pyogenes are known to produce toxins and superantigens. Invasive Streptococcus pyogenes infections have been shown to cause significant morbidity and rapid mortality. In many cases, patients expire before full antemortem testing can be performed, causing physicians and families to look to forensic pathologists for answers. Understanding the pathogenesis of invasive group A strep infections, relevant gross and microscopic findings, and proper culturing techniques is critical for forensic pathologists to diagnosis this condition and assist in the education and protection of the communities they serve.

A 62-year-old woman with hypertension and depression presented to a urology clinic with a 15-month history of episodic dysuria, hematuria, and polyuria. She reported suprapubic discomfort but no flank pain, nausea, or early satiety.