Disseminated Mycobacterium Avium Complex Myositis in a patient with Graft versus Host disease

Mycobacterium Avium Complex (MAC) is a ubiquitous environmental pathogen that was infrequently reported as a cause of disease prior to the HIV/AIDS epidemic. We present a case of MAC pyomyositis and bacteremia in a 59-year-old man with chronic lymphocytic leukemia in remission after an allogenic stem cell transplant. His post-transplant course was complicated by graft-vs-host disease, requiring treatment with oral steroids and ruxolitinib. In this report we review the literature on disseminated MAC infection in patients living with and without HIV. We also propose a potential mechanism by which this patient may have developed disseminated disease. Disseminated MAC myositis is uncommon in persons living without HIV and requires a high index of suspicion for timely diagnosis.

False positivity of monospot test in an immunocompetent elderly woman with acute cytomegalovirus infection

A 75-year-old woman presented with altered mental status, septic picture, and influenza-like symptoms. Initial investigations revealed atypical lymphocytosis, thrombocytopenia, elevated liver enzymes, and a positive monospot test result. Further investigation showed the Epstein-Barr virus viral capsid antibody IgM/IgG and Epstein-Barr virus DNA by polymerase chain reaction to be negative; however, interestingly her cytomegalovirus (CMV) IgM and IgG were positive, suggesting that her mononucleosis-like syndrome was due to acute CMV infection. Herein, we report the first case of a heterophile-positive mononucleosis syndrome caused by acute CMV infection in an elderly immunocompetent woman. This case conveys that monospot test can yield false-positive result in the setting of acute CMV infection.

Unveiling the hidden eagle: acute parotitis-induced eagle syndrome

Context:

A cervicofacial pain and foreign body sensation in pharynx associated with styloid process elongation is called Eagle syndrome. Typically, this syndrome is provoked by tonsillectomy or trauma. We report the first case of acute parotitis-induced Eagle syndrome.

Case Report:

A 65-year-old woman presented with right facial pain. CT scan of neck revealed asymmetric enhancement of the right parotid gland compatible with acute parotitis. All inflammation was resolved with antibiotics. However, the patient complained of pain in right mandibular region out of proportion to inflammation. Review CT found to have an asymmetrically long right styloid process measures. The diagnosis of acute parotitis-induced Eagle syndrome was established.

Conclusion:

Physicians should have a high index of suspicion for Eagle syndrome in patients with atypical neck pain and elongated styloid process since another significant manifestation of Eagle syndrome is carotid artery compression leading to recurrent syncope or stroke.

Pulmonary blastomycosis: a new endemic area in New York state

We describe three cases of pulmonary blastomycosis in patients from central New York State (NYS). Two of these cases occurred in 2012, and in patients who resided in the same county. Moreover, two of these cases manifested with acute respiratory distress syndrome and survived. Interestingly, one of the two received corticosteroids and was extubated within 1 week. To the best of our knowledge, these are the first cases of human blastomycosis to be reported from NYS and we propose that corticosteroids administration might reduce hospitalisation time and ventilator-associated complications, even though it is not currently recommended in standard treatment.

Protease inhibitor levels in hair strongly predict virologic response to treatment

OBJECTIVE

Antiretroviral (ARV) therapies fail when behavioral or biologic factors lead to inadequate medication exposure. The currently available methods to assess ARV exposure are limited. Levels of ARVs in hair reflect plasma concentrations over weeks to months, and may provide a novel method for predicting therapeutic responses.

DESIGN/METHODS

The Women's Interagency HIV Study, a prospective cohort of HIV-infected women, provided the basis for developing and assessing methods to measure commonly prescribed protease inhibitors (lopinavir/ritonavir and atazanavir) in small hair samples. We examined the association between hair protease inhibitor levels and initial virologic responses to therapy in multivariate logistic regression models.

RESULTS

ARV concentrations in hair were strongly and independently associated with treatment response for 224 women starting a new protease inhibitor-based regimen. For participants initiating lopinavir/ritonavir, the odds ratio (OR) for virologic suppression was 39.8 [95% confidence interval (CI) = 2.8-564] for those with lopinavir hair levels in the top tertile (>1.9 ng/mg) compared to the bottom (3.4 ng/mg) compared to the lowest (

CONCLUSION

Protease inhibitor levels in small hair samples were the strongest independent predictor of virologic success in a diverse group of HIV-infected adults. This non-invasive method for determining ARV exposure may have particular relevance for the epidemic in resource-poor settings due to the ease of collecting and storing hair.

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Key Words

• hair levels
• therapeutic drug monitoring
• antiretroviral exposure
• virologic response
• protease inhibitors
• atazanavir
• lopinavir
• wihs cohort

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MESH Headings

• Adult
• Atazanavir Sulfate
• CD4 Lymphocyte Count
• Drug Monitoring/methods
• Epidemiologic Methods
• Female
• HIV Infections/drug therapy
• HIV Infections/metabolism
• HIV Infections/virology
• HIV Protease Inhibitors/pharmacokinetics
• HIV Protease Inhibitors/therapeutic use
• Hair/metabolism
• Humans
• Lopinavir
• Middle Aged
• Oligopeptides/pharmacokinetics
• Oligopeptides/therapeutic use
• Patient Compliance
• Pyridines/pharmacokinetics
• Pyridines/therapeutic use
• Pyrimidinones/pharmacokinetics
• Pyrimidinones/therapeutic use
• Ritonavir/pharmacokinetics
• Ritonavir/therapeutic use
• Specimen Handling/methods
• Treatment Outcome
• Viral Load

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Grants

• M01 RR000079 NCRR NIH HHS
• UO1-AI-34994 NIAID NIH HHS
• UO1-AI-34989 NIAID NIH HHS
• U01 AI035004 NIAID NIH HHS
• K23 AI067065 NIAID NIH HHS
• UO1-CH-32632 OID CDC HHS
• U01 AI034989 NIAID NIH HHS
• M01 RR000071 NCRR NIH HHS
• UO1-AI-34993 NIAID NIH HHS
• U01 AI034994 NIAID NIH HHS
• K23 AI067065-03 NIAID NIH HHS
• UO1-AI-42590 NIAID NIH HHS
• U01 AI034993 NIAID NIH HHS
• K23 A1067065 PHS HHS
• MO1-RR-00083 NCRR NIH HHS
• U01 AI031834 NIAID NIH HHS
• UO1-AI-35004 NIAID NIH HHS
• K23 AI067065-02 NIAID NIH HHS
• U01 AI042590-12 NIAID NIH HHS
• MO1-RR-00079 NCRR NIH HHS
• UO1-AI-31834 NIAID NIH HHS
• M01 RR000083 NCRR NIH HHS
• MO1-RR-00071 NCRR NIH HHS
• U01 AI042590 NIAID NIH HHS

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Affiliation(s)

Monica Gandhi Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
Niloufar Ameli
Peter Bacchetti
Stephen J Gange
Kathryn Anastos
Alexandra Levine
Charles L Hyman
Mardge Cohen
Mary Young
Yong Huang
Ruth M Greenblatt

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Medical-resource use for suspected tuberculosis in a New York City hospital

OBJECTIVE

To compare resource use by diagnostic outcome among hospital admissions during which tuberculosis (TB) was suspected.

DESIGN

Retrospective study based on chart review and microbiology laboratory data.

SETTING

The department of medicine in a municipal hospital serving central Brooklyn, New York.

PARTICIPANTS

We identified all adult admissions in 1993 during which TB was suspected. We assigned each admission to one of four mutually exclusive groups defined by the results of microbiological tests (acid-fast bacilli [AFB] smear and culture): culture-positive and smear-positive (C+S+); culture-positive and smear-negative (C+S-); culture-negative and smear-positive (C-S+); or culture-negative and smear-negative (C-S-). Each admission was divided into two separate periods to which the utilization of medical resources was assigned: the diagnostic and the postdiagnostic periods, which were separated by the date of receipt of the first definitive culture report.

RESULTS

Data on 519 admissions (93 C+S+; 57 C+S-; 30 C-S+; and 339 C-S-) were analyzed. Although C+S+ were more likely than other groups to have an admitting diagnosis of TB, approximately one quarter of the admissions without TB (C-S+, C-S-) were admitted with the principal diagnosis of TB. For the four groups, C+S+, C+S-, C-S+, and C-S-, the respective rates of TB isolation and anti-TB treatment, and median lengths of isolation were 98%, 87%, and 34 days; 74%, 74%, and 7 days; 83%, 83%, and 15 days; and 44%, 29%, and 0 days. During the diagnostic period, the rate and length of isolation were similar in the AFB-smear-positive groups (C+S+ and C-S+). We estimated that admissions without culture-proven TB (C-S+ and C-S-) accounted for 3,174 (36%) of the 8,712 days of TB isolation expended and for 65% of the 16,671 days of anti-TB treatment. The vast majority of this resource consumption (2,737 [86%] of 3,174 days of isolation) occurred during the diagnostic period before a definitive culture result was known.

CONCLUSIONS

Our results suggest that prolonged diagnostic uncertainty and misclassification of cases due to false-positive and false-negative smears are associated with substantial medical-resource consumption. New diagnostic modalities that reduce the period of diagnostic uncertainty could reduce the utilization of resources later found to be unnecessary.

Tuberculosis reemerges: the captain remains aboard

The resurgence of tuberculosis and the emergence of multidrug resistant tuberculosis have led to renewed interest in this ancient disease. Advances in the field of molecular biology have increased our understanding of the epidemiology and transmission of infection. This has had a particular impact on the documentation of, and the subsequent development of guidelines to prevent, the nosocomial transmission of tuberculosis. Molecular techniques have dominated the efforts of investigators to improve diagnostic methods and therapeutic options. Recent information regarding the mechanism of developing protective immunity to tuberculosis may lead to the development of more effective vaccines and a role for immunotherapy in treatment. National and international organizations have formulated guidelines for the diagnosis and treatment of disease and infection. The development of a global response to the problem of tuberculosis in order to ensure the establishment of long-lasting control is needed.

Prevalence of asymptomatic nasopharyngeal carriage of Chlamydia pneumoniae in subjectively healthy adults: assessment by polymerase chain reaction-enzyme immunoassay and culture

Although Chlamydia pneumoniae is a well-described and common respiratory tract pathogen, up to 90% of infections with this organism are thought to be asymptomatic. Because asymptomatic infection with C. pneumoniae has not been studied in a systematic manner, we conducted a prospective study of healthy adults to establish the prevalence of asymptomatic infection. Nasopharyngeal swab specimens were obtained from 104 subjectively healthy people and evaluated by culture and polymerase chain reaction-enzyme immunoassay (PCR-EIA) for the presence of the organism. Serum obtained from 103 of these individuals was tested by microimmunofluorescence for the titer of specific antibody to C. pneumoniae. For two individuals, C. pneumoniae was identified in nasopharyngeal specimens by culture and/or PCR-EIA; one of these individuals had an IgG titer of 1:256, whereas the other had no detectable antibody. Of the remaining 101 individuals with negative culture and PCR-EIA results, 19 fulfilled presently accepted serological criteria for acute infection; i.e., the IgM titer was > or = 1:16, the IgG titer was > or = 1:512, or both. On the basis of our findings, we conclude that asymptomatic upper airway infection and carriage with C. pneumoniae occur among subjectively healthy persons; we also propose that such individuals may represent a reservoir for this organism in the community. Further, this study demonstrates that currently available diagnostic tests for C. pneumoniae may be unable to accurately distinguish between infection responsible for respiratory tract disease and that representing carriage.

Tuberculosis: a survey and review of current literature

Despite being a treatable and preventable disease, tuberculosis will kill an estimated 30 million people during the current decade. Tuberculosis is a global problem, and increases in case rates are occurring not only in the developing countries of the world but also in several industrialized nations, such as the United States. Coincident with the resurgence of tuberculosis in the United States, there has also been an alarming increase in the number and proportion of cases caused by strains of Mycobacterium tuberculosis that are resistant to multiple first-line drugs. The increase in multiple-drug resistant tuberculosis has re-taught physicians about the importance of pursuing and ensuring treatment until cure. The HIV epidemic is playing a pivotal and permissive role in the resurgence of tuberculosis morbidity and mortality in those populations where tuberculosis and HIV are prevalent and overlap. Co-infection with HIV distorts the natural history and clinical expression of tuberculosis. Molecular biology has yielded important insights into the mechanisms of drug resistance and provided powerful tools for the rapid diagnosis and epidemiologic study of this disease.

Diagnostic utility of PCR-enzyme immunoassay, culture, and serology for detection of Chlamydia pneumoniae in symptomatic and asymptomatic patients

To assess the utility of PCR-enzyme immunoassay (EIA) for diagnosis of acute infection with Chlamydia pneumoniae, we compared tissue culture, PCR-EIA, direct fluorescent-antibody (DFA) stain, and serology in studies with 56 patients with respiratory symptoms and 80 asymptomatic persons. Thirty-five patients were positive by either culture or PCR-EIA, and 101 were negative by both assays. Thirty specimens from symptomatic patients and one from an asymptomatic patient were culture positive; 23 of these were also PCR-EIA positive. Of the eight culture-positive, PCR-EIA-negative specimens, five were DFA negative and three were DFA positive. Four additional specimens were culture negative and PCR-EIA positive; of these, three were DFA positive and one was DFA negative. When we used culture- and/or DFA-positive results as a reference or "gold standard," the sensitivity and specificity of PCR were 76.5 and 99.0%, respectively. When we used PCR- and/or DFA-positive results as the reference, the sensitivity of culture was 87.5%. On the basis of single acute serum specimens, only 8 of these 35 patients had diagnostic antibody titers. Of the asymptomatic patients, 75% had immunoglobulin G or immunoglobulin M antibody to C. pneumoniae; 15 (18.8%) of these had antibody levels considered to be diagnostic of acute infection. This multicenter study indicates that culture and/or PCR-EIA is more reliable for prompt diagnosis of C. pneumoniae infection than single-point serology alone.

In vitro activities of five quinolones against Chlamydia pneumoniae

The in vitro susceptibilities of 10 strains of Chlamydia pneumoniae were determined for five quinolones, including ciprofloxacin, ofloxacin, fleroxacin, temafloxacin, and sparfloxacin. Sparfloxacin was the most active compound tested, followed by ofloxacin and temafloxacin. Ciprofloxacin and fleroxacin were the least active. The use of HEp-2 cells for testing C. pneumoniae resulted in larger inclusions but essentially the same endpoints as were seen with use of HeLa 229 cells.

Asymptomatic respiratory tract infection with Chlamydia pneumoniae TWAR

Chlamydia pneumoniae is a newly recognized organism associated with respiratory tract infections. Asymptomatic infection with C. pneumoniae, although it has been suggested to occur, has not been previously documented. We describe two asymptomatic individuals infected with this organism; these infections demonstrate that C. pneumoniae is able to establish a subclinical infection.

Studies on immune adherence (C3b) receptor activity of human erythrocytes: relationship between receptor activity and presence of immune complexes in serum

Human erythrocytes (E) have surface receptors for the third component of complement (C3b-IA receptors) which mediate immune adherence haemagglutination (IAHA). We have observed that E from patients with systemic lupus erythematosus had imparied or defective C3b receptor (C3b-R) activity when circulating immune complexes (CIC) were found in serum. This phenomenon has been investigated by a newly developed method involving competitive inhibition of IAHA in patients with immune complex diseases. IAHA involving sheep E coated with antibody and complement (EAC), and indicator human E was inhibited by lysates of E with normal C3b-R activity from healthy donors and a monkey. In contrast, the lysates of E from 95% of patients bearing CIC did not inhibit IAHA, which indicated such E had defective or impaired C3b-R activity. This phenomenon was supported by control studies in which IAHA was not inhibited by lysates of E with absent, inactivated or occupied C3b-R. In those patients, in whom CIC disappeared during immunosuppressive therapy, C3b-R activity slowly returned to normal levels. Moreover, it was observed that C3b-R activity of patients' E decreased with the reappearance of CIC during exacerbations of disease. These observations suggest that CIC are carried in vivo by the C3b-R of E as well as those of the mononuclear phagocyte system, and that the E C3b-R may also contribute to the clearance of CIC.