1
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Hill JA, Park SY, Gajurel K, Taplitz R. A Systematic Literature Review to Identify Diagnostic Gaps in Managing Immunocompromised Patients With Cancer and Suspected Infection. Open Forum Infect Dis 2024; 11:ofad616. [PMID: 38221981 PMCID: PMC10787371 DOI: 10.1093/ofid/ofad616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/05/2023] [Indexed: 01/16/2024] Open
Abstract
Patients with cancer are increasingly vulnerable to infections, which may be more severe than in the general population. Improvements in rapid and timely diagnosis to optimize management are needed. We conducted a systematic literature review to determine the unmet need in diagnosing acute infections in immunocompromised patients with cancer and identified 50 eligible studies from 5188 records between 1 January 2012 and 23 June 2022. There was considerable heterogeneity in study designs and parameters, laboratory methods and definitions, and assessed outcomes, with limited evaluation of diagnostic impact on clinical outcomes. Culture remains the primary diagnostic strategy. Fewer studies employing molecular technologies exist, but emerging literature suggests that pathogen-agnostic molecular tests may add to the diagnostic armamentarium. Well-designed clinical studies using standardized methodologies are needed to better evaluate performance characteristics and clinical and economic impacts of emerging diagnostic techniques to improve patient outcomes.
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Affiliation(s)
- Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sarah Y Park
- Medical Affairs, Karius, Inc, Redwood City, California, USA
| | - Kiran Gajurel
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | - Randy Taplitz
- Department of Medicine, City of Hope National Medical Center, Duarte, California, USA
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2
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Gajurel K, Ngo T, Fairman RT, McCurdy LH. Vaccination in Kidney Transplant Candidates. Transplant Direct 2023; 9:e1544. [PMID: 37781169 PMCID: PMC10540912 DOI: 10.1097/txd.0000000000001544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/10/2023] [Accepted: 08/26/2023] [Indexed: 10/03/2023] Open
Abstract
Background Kidney transplant (KT) candidates have historically low immunization rates against recommended vaccines. A retrospective single-center study of contemporary KT candidates was conducted to assess vaccination rates and vaccine uptake. Methods All KT candidates ≥18 y evaluated between January 1, 2020, and December 31, 2020, were retrospectively reviewed for history of prior vaccination against tetanus, diphtheria, and pertussis; 13-valent pneumococcal conjugate vaccine; 23-valent pneumococcal polysaccharide vaccine; and recombinant zoster vaccine. Positive hepatitis A IgG total, hepatitis B surface antibody, measles, mumps, rubella, and varicella IgG were assessed as surrogate markers of immunity. Vaccine uptake among vaccine-eligible candidates was also assessed. Results Among 150 KT candidates, the rate of prior vaccination against tetanus, diphtheria, and pertussis; 13-valent pneumococcal conjugate vaccine; 23-valent pneumococcal polysaccharide vaccine; and recombinant zoster vaccine (latter among patients ≥50 y) was found to be as low as 11%. Hepatitis A IgG total, hepatitis B surface antibody, measles, mumps, rubella, and varicella IgG seropositivity rates were 30%, 66%, 88%, 78%, 90%, and 96%, respectively. Only 7 (5%) of 150 patients had complete immunization or seropositivity. Five (3%) of 143 vaccine-eligible patients declined vaccination. Hepatitis A vaccine declination was relatively common with 15 (16%) of 94 vaccine-eligible patients declining it. Conclusions KT candidates have low baseline rates of prior immunization/seropositivity against most recommended vaccines. Overall vaccine uptake among eligible candidates was high.
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Affiliation(s)
- Kiran Gajurel
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, NC
| | - Tue Ngo
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, NC
| | | | - Lewis H. McCurdy
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, NC
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3
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Gajurel K, Ahrens WA. Medlar bodies of chromoblastomycosis. Transpl Infect Dis 2023; 25:e14047. [PMID: 36852755 DOI: 10.1111/tid.14047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/09/2023] [Accepted: 02/12/2023] [Indexed: 03/01/2023]
Affiliation(s)
- Kiran Gajurel
- Carolinas Medical Center, Atrium Health, North Carolina, USA
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4
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Lefemine A, Meredith J, Patel R, Fotiadis C, Shahid Z, Gajurel K, Roshdy D. 1468. Cidofovir Prescribing Patterns and Outcomes in Hospitalized Adults and Children. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Cidofovir (CDV) dosing is based on limited clinical evidence and varies by indication. The optimal dose to achieve a virologic response has not been established. Routine lab monitoring, renal dose adjustments, and co-administration with intravenous (IV) fluids and probenecid are recommended to limit CDV-associated nephrotoxicity but lack a standard approach.
Methods
This was a retrospective evaluation of patients admitted to Atrium Health’s Carolinas Medical Center or Levine Children’s Hospital who received at least one dose of CDV from August 1, 2014 through June 30, 2021. The primary objective was to describe CDV prescribing patterns. Secondary objectives included evaluating virologic response, nephrotoxicity, and IV fluid and probenecid use.
Results
A total of 38 adult and 26 pediatric patients were included and received 44 and 60 CDV doses, respectively. Adult dosing was variable, but the most common regimens for BK virus infections included CDV 0.5 mg/kg every other week for solid organ transplant recipients (Figure 1A-B) and 1 mg/kg weekly for stem cell transplant recipients (Figure 1C). Dosing for adenovirus infections was inconsistent (Figure 1D). All but one of the adult patients evaluated had a decrease in viral load during the first two weeks (Figure 2A-D). In pediatric patients, the most common CDV dose was 1 mg/kg three times weekly which was used in 67% of patients across all indications (Figure 1E-I). Three evaluated pediatric patients had an increase in viral load (Figure 2E-H), but no similarities in dosing or indication were noted. The rate of nephrotoxicity based on pre-defined increases in serum creatinine was 29% for adults and 14% for pediatric patients. Use of IV fluid boluses and probenecid was inconsistent in both adult and pediatric patients (Table 1). Of the patients that did not receive probenecid, only 16.7% of adults and no pediatric patients received a CDV dose > 1 mg/kg.
Conclusion
Evaluation of virologic response to CDV was limited by small sample size. However, high variability in prescribing patterns highlights the need for standardized, indication-specific dosing. Standardization of IV fluid and probenecid use along with guidance on CDV dose adjustments in patients with renal insufficiency may help decrease the risk of CDV-associated nephrotoxicity.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | | | | | | | | | - Kiran Gajurel
- Carolinas Medical Center , Atrium Health, Charlotte, North Carolina
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5
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Capraro GA, Ahrens WA, Gajurel K. A Healthy Adult With Tibial Swelling and Pain. Clin Infect Dis 2022; 74:933-937. [PMID: 35263431 DOI: 10.1093/cid/ciab599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - Kiran Gajurel
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina,USA
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6
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Ogunsiakan T, Fajgenbaum KD, Phadke G, Montgomery T, Gajurel K. 645. Rapid Diagnosis of Disseminated Mycobacterium kansasii infection in Renal Transplant Recipients Using Plasma Microbial Cell Free DNA Next Generation Sequencing. Open Forum Infect Dis 2021. [PMCID: PMC8644391 DOI: 10.1093/ofid/ofab466.842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Disseminated Mycobacterium kansasii infection is rare in kidney transplant recipients. The diagnosis may not be suspected readily due to non-specific clinical presentation. The diagnosis and treatment can be further delayed due to poor sensitivity of culture (especially of extra-pulmonary sites) and slow growth in culture media. Accurate and rapid diagnosis of disseminated M. kansasii infections in transplant recipients is important for antimicrobial management.
Methods
Two cases of disseminated M. kansasii infections with unusual presentation in which rapid diagnosis was made using the Karius test (KT) are presented. The KT is a CLIA certified/CAP-accredited next-generation sequencing (NGS) plasma test that detects microbial cell-free DNA (mcfDNA). After mcfDNA is extracted and NGS performed, human reads are removed, and remaining sequences are aligned to a curated database of >1400 organisms. Organisms present above a statistical threshold are reported.
Results
Case 1: A 31-year female kidney transplant recipient presented with a thyroglossal duct cyst, as well as swelling of her right metacarpophalangeal joint and left 3rd finger. AFB culture of the thyroglossal cyst aspiration done on post admission day (PAD) 2 took 27 days to be identified as M. kansasii (on PAD 29) whereas plasma sent for KT on PAD 5 reported a positive test for M. kansasii at 284 molecules/microliter (MPM) in 4 days (on PAD 9). Case 2: A 59-year male kidney transplant recipient presented with generalized weakness, arthralgia, pericardial effusion, cytopenia, weight loss and intermittent fevers. Plasma sent for KT on PAD 12 was reported positive for M. kansasii at 1314 MPM in 3 days (on PAD 15). PET CT done simultaneously was consistent with an infection of an old AV graft in the left upper extremity. The AFB culture of the resected graft was confirmed as M. kansasii in 22 days on PAD 36. After the KT was available (before confirmation of M. kansasii on culture), the first patient underwent modification of empiric treatment and the second patient was started on specific treatment for M. kansasii.
Table of M. kansasii cases
Rapid diagnosis of disseminated M. kansasii infection
Conclusion
Open-ended NGS plasma testing for mcfDNA identified disseminated M kansasii infection much earlier than standard microbiology and thus helped in initiation and modification of pathogen directed treatment.
Disclosures
All Authors: No reported disclosures
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Benamu E, Gajurel K, Anderson JN, Lieb T, Gomez CA, Seng H, Aquino R, Hollemon D, Hong DK, Blauwkamp TA, Kertesz M, Blair L, Bollyky PL, Medeiros BC, Coutre S, Zompi S, Montoya JG, Deresinski S. Plasma Microbial Cell-free DNA Next Generation Sequencing in the Diagnosis and Management of Febrile Neutropenia. Clin Infect Dis 2021; 74:1659-1668. [PMID: 33870413 PMCID: PMC9070798 DOI: 10.1093/cid/ciab324] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Indexed: 11/14/2022] Open
Abstract
Background Standard testing fails to identify a pathogen in most patients with febrile neutropenia (FN). We evaluated the ability of the Karius microbial cell-free DNA sequencing test (KT) to identify infectious etiologies of FN and its impact on antimicrobial management. Methods This prospective study (ClinicalTrials.gov; NCT02912117) enrolled and analyzed 55 patients with FN. Up to 5 blood samples were collected per subject within 24 hours of fever onset (T1) and every 2 to 3 days. KT results were compared with blood culture (BC) and standard microbiological testing (SMT) results. Results Positive agreement was defined as KT identification of ≥1 isolate also detected by BC. At T1, positive and negative agreement were 90% (9/10) and 31% (14/45), respectively; 61% of KT detections were polymicrobial. Clinical adjudication by 3 independent infectious diseases specialists categorized Karius results as: unlikely to cause FN (N = 0); definite (N = 12): KT identified ≥1 organism also found by SMT within 7 days; probable (N = 19): KT result was compatible with a clinical diagnosis; possible (N = 10): KT result was consistent with infection but not considered a common cause of FN. Definite, probable, and possible cases were deemed true positives. Following adjudication, KT sensitivity and specificity were 85% (41/48) and 100% (14/14), respectively. Calculated time to diagnosis was generally shorter with KT (87%). Adjudicators determined real-time KT results could have allowed early optimization of antimicrobials in 47% of patients, by addition of antibacterials (20%) (mostly against anaerobes [12.7%]), antivirals (14.5%), and/or antifungals (3.6%); and antimicrobial narrowing in 27.3% of cases. Clinical Trials Registration NCT02912117 Conclusion KT shows promise in the diagnosis and treatment optimization of FN.
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Affiliation(s)
- Esther Benamu
- School of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, CO, USA
| | - Kiran Gajurel
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Jill N Anderson
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Tullia Lieb
- Hematopoietic Malignancies Unit Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Carlos A Gomez
- Division of Infectious Diseases, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Hon Seng
- Cytovale, Inc, San Francisco, CA, USA
| | | | | | | | | | | | | | - Paul L Bollyky
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Bruno C Medeiros
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Steven Coutre
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Jose G Montoya
- The Dr. Jack S. Remington Laboratory for Specialty Diagnostics at the Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - Stan Deresinski
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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8
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Zeidan JH, Casingal V, Hippen B, Ahrens W, Lamm K, Gerber DA, Schmeltzer PA, Gajurel K. Donor-derived herpes simplex virus hepatitis in a kidney transplant recipient and review of the literature. Transpl Infect Dis 2021; 23:e13562. [PMID: 33432726 DOI: 10.1111/tid.13562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/31/2020] [Accepted: 12/29/2020] [Indexed: 11/26/2022]
Abstract
Donor-derived (DD) herpes simplex virus (HSV) hepatitis in solid organ transplant (SOT) recipients is extremely uncommon but carries a high mortality rate. The diagnosis is challenging due to the non-specific presentation and lack of clinical suspicion. We report a case of DDHSV hepatitis in a HSV2 pre-transplant seronegative kidney recipient who received the organ from a HSV2 seropositive donor. The case is highlighted by a few unusual features, namely severe thrombocytopenia and the development of cutaneous, oral and esophageal HSV lesions several weeks after symptom onset while recovering on appropriate treatment. A review of nine proven and probable DDHSV hepatitis cases (including eight previously published ones) showed that fever is a common presenting feature while gastrointestinal symptoms and cutaneous manifestations are uncommon. The symptoms almost always occurred within 2 weeks of transplant. Six out of the nine DDHSV hepatitis patients, including five patients who were on appropriate treatment, died within a month after transplant.
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Affiliation(s)
- Joseph H Zeidan
- Division of Gastroenterology, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Vincent Casingal
- Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | | | | | - Kevin Lamm
- Center for Liver Diseases and Liver transplantation, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - David A Gerber
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Paul A Schmeltzer
- Center for Liver Diseases and Liver transplantation, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Kiran Gajurel
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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9
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Edward P, Via WVL, Arshad M, Gajurel K. 670. Rapid, Non-invasive Detection of Invasive Mycoplasma hominis Infection using the Karius Test, A Next-Generation Sequencing Test for Microbial Cell-free DNA in Plasma. Open Forum Infect Dis 2020. [PMCID: PMC7776690 DOI: 10.1093/ofid/ofaa439.863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Mycoplasma hominis is typically associated with genital infections in women and is a rare cause of musculoskeletal infections often in immunocompromised hosts. Diagnosis of invasive Mycoplasma hominis infections are difficult due to challenges in culturing these organisms. Molecular diagnostics require an index of suspicion which may not be present at the time of tissue sampling. Accurate, rapid diagnosis of Mycoplasma hominis infections are important for antibiotic management. Methods Two cases of invasive Mycoplasma hominis infections are presented in which the Karius test (KT) was used to make the diagnosis. The KT is a CLIA certified/CAP-accredited next-generation sequencing (NGS) plasma test that detects microbial cell-free DNA (mcfDNA). After mcfDNA is extracted and NGS performed, human reads are removed and remaining sequences are aligned to a curated database of > 1400 organisms. Organisms present above a statistical threshold are reported. Case review was performed for clinical correlation. Results A young woman with lupus nephritis status post renal transplant developed persistent fever with progressive multifocal culture-negative osteoarticular infection despite empiric ceftriaxone. An adolescent female presented with an ascending pelvic infection progressing to purulent polymicrobial peritonitis (see table) requiring surgical debridement and cefipime, metronidazole and micafungin therapy; her course was complicated by progressive peritonitis/abscesses. Karius testing detected high-levels of Mycoplasma hominis mcfDNA in both cases – at 3251 molecules/microliter (MPM) in the first case and 3914 MPM in the second case. The normal range of Mycoplasma hominis mcfDNA in a cohort of 684 normal adults is 0 MPM. The patients rapidly improved with atypical coverage with doxycycline and levofloxaxin. Clinical findings in 2 patients with M. hominis infection detected by the Karius Test ![]()
Conclusion Open-ended, plasma-based NGS for mcfDNA provides a rapid, non-invasive method to diagnose invasive Mycoplasma hominis infection. This case series highlights the potential to diagnose infections caused by fastidious pathogens to better inform antimicrobial therapy and achieve favorable outcomes. Disclosures William V. La Via, MD, Karius (Employee)
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Affiliation(s)
| | | | - Mehreen Arshad
- Lurie Children’s Hospital/Northwestern Univ., Chicago, Illinois
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10
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Gajurel K. Persistently positive severe acute respiratory syndrome coronavirus 2 (SARS-COV2) nasopharyngeal PCR in a kidney transplant recipient. Transpl Infect Dis 2020; 22:e13408. [PMID: 32652872 PMCID: PMC7404596 DOI: 10.1111/tid.13408] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/05/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Kiran Gajurel
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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11
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Johnson MM, Gajurel K. Disseminated cryptococcosis with cutaneous manifestation. Transpl Infect Dis 2020; 23:e13412. [PMID: 32652825 DOI: 10.1111/tid.13412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/05/2020] [Indexed: 11/30/2022]
Abstract
Cutaneous cryptococcosis is uncommon. It is usually a result of disseminated infection and can present with a wide variety of skin lesions. We report a case of disseminated cryptococcosis in a kidney transplant recipient who presented with nodular lesions in the forehead following a bout of acute cellular rejection.
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Affiliation(s)
| | - Kiran Gajurel
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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12
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Zeidan JH, Kamionek M, Noell BC, Schmeltzer PA, deLemos AS, Gajurel K. Late onset CMV disease presenting as a colonic stricture in a liver transplant recipient. Transpl Infect Dis 2020; 22:e13259. [PMID: 32034980 DOI: 10.1111/tid.13259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/19/2019] [Accepted: 02/02/2020] [Indexed: 11/28/2022]
Abstract
Cytomegalovirus (CMV) is a common opportunistic infection in solid organ transplant (SOT) recipients in the first 6 months after transplant. Late onset CMV infection or disease outside the classical risk period is uncommon and can present with atypical signs and symptoms. Here, we report a case of late onset CMV presenting as a colonic stricture more than 10 years after liver transplantation in the absence of traditional CMV risk factors. We also briefly review CMV colitis presenting as a mass or stricture in SOT recipients.
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Affiliation(s)
- Joseph H Zeidan
- Division of Gastroenterology and Hepatology, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | | | - Bennett C Noell
- Transplant Center, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Paul A Schmeltzer
- Center for Liver Diseases and Liver transplantation, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Andrew S deLemos
- Center for Liver Diseases and Liver transplantation, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Kiran Gajurel
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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13
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McCurdy L, Wheat LJ, Block J, Gajurel K. Peripheral blood smear findings in a kidney transplant recipient with disseminated histoplasmosis and elevated Aspergillus galactomannan. Transpl Infect Dis 2019; 21:e13126. [PMID: 31169962 DOI: 10.1111/tid.13126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/07/2019] [Accepted: 06/02/2019] [Indexed: 11/28/2022]
Abstract
We report a case of disseminated histoplasmosis in a renal transplant recipient who presented with a nodular pulmonary lesion and elevated serum and bronchoalveolar lavage (BAL) Aspergillus galatomannan. This almost led to an erroneous diagnosis of invasive aspergillosis since the donor respiratory tract was known to be colonized with Aspergillus terreus. However, distinctive intracelluar Histoplasma yeasts on peripheral blood smear led to early diagnosis and appropriate treatment. The cross-reactivity between Aspergillus galactomannan and Histoplasma antigen is discussed further.
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Affiliation(s)
- Lewis McCurdy
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
| | | | - Jared Block
- Carolinas Pathology Group, Charlotte, North Carolina, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina, North Carolina, USA
| | - Kiran Gajurel
- Division of Infectious Diseases, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina, USA
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14
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Kaur A, Eberlein M, Klesney-Tait J, Durkin MM, Wheat LJ, Gajurel K. Rabbit Antithymocyte Globulin Causes Blastomyces and Histoplasma Antigenemia. Open Forum Infect Dis 2019; 6:ofz165. [PMID: 31065562 PMCID: PMC6499897 DOI: 10.1093/ofid/ofz165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/26/2019] [Indexed: 11/30/2022] Open
Abstract
Rabbit antithymocyte globulin (rATG) is known to yield false-positive Histoplasma antigenemia. The fourth generation MiraVista Histoplasma antigen assay was modified to block this effect (MiraVista Diagnostics, Indianapolis, Indiana). We report a case of rATG-induced false-positive Blastomyces and Histoplasma antigenemia in a lung transplant recipient despite modifications of these antigen assays.
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Affiliation(s)
- Amrit Kaur
- Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Michael Eberlein
- Division of Pulmonology and Occupational Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Julia Klesney-Tait
- Division of Pulmonology and Occupational Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | | | | | - Kiran Gajurel
- Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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15
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Poch J, Ince D, Thomas C, Dhakal R, Gajurel K. Unusual presentation of Q fever in a kidney-pancreas transplant recipient. Transpl Infect Dis 2018; 21:e13037. [PMID: 30548556 DOI: 10.1111/tid.13037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/29/2018] [Accepted: 12/03/2018] [Indexed: 01/17/2023]
Abstract
Q fever is uncommon in solid organ transplant (SOT) recipients. We describe a case of granulomatous lung disease as an unusual presentation of chronic Q fever in a kidney-pancreas transplant recipient.
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Affiliation(s)
- Joe Poch
- Division of Abdominal Transplant Surgery, Department of Surgery, Carver College of Medicine University of Iowa, Iowa City, Iowa
| | - Dilek Ince
- Division of Infectious Diseases, Carver College of Medicine University of Iowa, Iowa City, Iowa
| | - Christie Thomas
- Division of Nephrology, Carver College of Medicine University of Iowa, Iowa City, Iowa
| | - Reshika Dhakal
- Department of Internal Medicine, Carver College of Medicine University of Iowa, Iowa City, Iowa
| | - Kiran Gajurel
- Division of Infectious Diseases, Carver College of Medicine University of Iowa, Iowa City, Iowa
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16
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Benamu E, Gajurel K, Anderson JN, Lieb T, Gomez CA, Seng H, Aquino R, Hollemon D, Hong D, Blauwkamp T, Kertesz M, Blair L, Bollyky PL, Medeiros BC, Coutre S, Zompi S, Montoya JG, Deresinski S. 2294. Evaluation of the Karius Plasma Next-Generation Sequencing Cell-free Pathogen DNA Test to Determine the Etiology of Infection and Impact on Anti-Microbial Management in Patients with Severe Neutropenia and Fever. Open Forum Infect Dis 2018. [PMCID: PMC6253931 DOI: 10.1093/ofid/ofy210.1947] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Esther Benamu
- School of Medicine, Division of Infectious Diseases, University of Colorado Denver, Aurora, Colorado
| | - Kiran Gajurel
- Division of Infectious Diseases, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Jill N Anderson
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Tullia Lieb
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Carlos A Gomez
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Hon Seng
- Karius, Inc., Redwood City, California
| | | | | | | | | | | | | | - Paul L Bollyky
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Bruno C Medeiros
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Steven Coutre
- Division of Hematology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Jose G Montoya
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Stan Deresinski
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
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17
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Voruganti D, Gajurel K, Bhama JK, Cotarlan V. Ruptured Intracranial Mycotic Aneurysm in Infective Endocarditis With Left Ventricular Assist Device and Implantable Cardiac Defibrillator Device: A Clinical Course. Transplant Proc 2018; 50:4064-4066. [PMID: 30577316 DOI: 10.1016/j.transproceed.2018.08.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 08/29/2018] [Indexed: 01/16/2023]
Abstract
We report the first case of a ruptured intracranial aneurysm-related Staphylococcus epidermidis bacteremia in a patient supported by a continuous flow left ventricular assist device (LVAD). Mycotic aneurysms (MAs) are aneurysmal degeneration of the arterial wall as a result of infection. Current recommendations for management of intracranial mycotic aneurysms are based on a few retrospective case studies. There are only a few cases of intracranial MA reported in patients with LVAD infections caused by Pseudomonas aeruginosa and Klebsiella rhinos. Here, we describe the first case of a ruptured intracranial aneurysm caused by a less virulent organism (Staphylococcus epidermidis) and conclude that screening for asymptomatic MA should be strongly considered in patients with persistent LVAD- and implantable cardiac defibrillator pacemaker-associated infections.
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Affiliation(s)
- D Voruganti
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA.
| | - K Gajurel
- Division of Infectious Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - J K Bhama
- Department of Surgery, Division of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - V Cotarlan
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Cincinnati Hospitals, Cincinnati, OH
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18
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Abstract
Histoplasma capsulatum is a dimorphic fungus that most often causes asymptomatic infection in the immunocompetent population. In immunocompromised patients, including solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients, however, it is likely to cause severe life-threatening infection. Post-transplant histoplasmosis (PTH) in SOT is uncommon with an incidence of ≤1% and is even rarer in HCT patients. The majority of PTH in SOT is diagnosed in the first 2 years following transplantation. Histoplasmosis may result from endogenous reactivation of latent infection, de novo post-transplant acquisition, and donor-derived infection. Disseminated infection is common. Fever is the most common symptom and clinical features are often nonspecific, but patients with disseminated infection may present with a septic picture. Other features, including pancytopenia and hepatosplenomegaly, may not be prominent early in the course of illness. Contemporary histoplasma antigen assays are the most sensitive tests but cross-reactivity with antigens of other fungi, including with Aspergillus galactomannan, is not uncommon. Treatment should be continued for at least a year. Histoplasma antigen levels have prognostic value and can be used to monitor the response to therapy. The attributable mortality is approximately 10%. Routine screening of donors and recipients is not currently recommended.
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Affiliation(s)
- Kiran Gajurel
- Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Reshika Dhakal
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Stan Deresinski
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
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19
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Gajurel K, Dhakal R, Montoya JG. Toxoplasmosis in hematopoietic cell transplant recipients. Transpl Infect Dis 2017; 19. [PMID: 28605082 DOI: 10.1111/tid.12734] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 06/05/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Kiran Gajurel
- Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Reshika Dhakal
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Jose G Montoya
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Palo Alto Medical Foundation, Toxoplasma Serology Laboratory, Palo Alto, CA, USA
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20
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Abstract
Leishmaniasis occurs in <1% of solid organ and hematopoietic stem cell transplant recipients in endemic countries in which transplants are performed. Visceral leishmaniasis (VL) makes up the bulk of reported cases. The onset generally occurs months after transplantation and the mode of acquisition is often impossible to determine, but de novo vector-borne infection and reactivation of inapparent infection are thought to be the principal means. The potential role of clinically inapparent donor infection is uncertain and screening is not currently recommended, nor is it recommended for recipients from endemic areas, some of whom may have detectable circulating protozoan nucleic acid. While transplant recipients with VL often present with the non-specific findings of fever and cytopenia, the additional presence of hepatosplenomegaly in patients from endemic areas should lead to a directed diagnostic evaluation with bone marrow examination and PCR testing of marrow and peripheral blood having a high yield. Management may often be complicated by the presence of concomitant infections. A lipid formulation of amphotericin B is the preferred treatment, especially for VL, but the relapse rate in transplant recipients is approximately 25%. PCR monitoring of blood for either secondary prophylaxis or preemptive therapy requires further study.
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Affiliation(s)
- Kiran Gajurel
- Division of Infectious Diseases, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Reshika Dhakal
- University of Iowa, Carver College of Medicine, Iowa City, IA, USA
| | - Stan Deresinski
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
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21
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Ben Appenheimer A, Diekema DJ, Berriel-Cass D, Crook T, Daley CL, Dobbie D, Edmond M, Hellinger W, Ince D, Julian KG, Lampen R, Arbulu R, Cooper E, Curley E, De Sanctis J, Freer C, Strong M, Gajurel K, Hasan N, Walker S, Whitener C. Mycobacterium chimaera Outbreak Response: Experience From Four United States Healthcare Systems. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw195.10] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | - Tonya Crook
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Michael Edmond
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Dilek Ince
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | | | | | | | | | | | - Carol Freer
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Michael Strong
- National Jewish Medical and Research Center, Denver, Colorado
| | - Kiran Gajurel
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nabeeh Hasan
- National Jewish Medical and Research Center, Denver, Colorado
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22
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23
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Barakat MT, Gajurel K, Fischer K, Stevens K, Ozdalga E, Montoya JG. A Case of Meningococcal Pyomyositis in an Otherwise Healthy Adult. Open Forum Infect Dis 2016; 3:ofw087. [PMID: 27703989 PMCID: PMC5047391 DOI: 10.1093/ofid/ofw087] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/29/2016] [Indexed: 11/21/2022] Open
Abstract
The clinical spectrum of Neisseria meningitidis can range from nasopharyngeal colonization to life-threatening invasive diseases such as meningitis. However, its etiologic role in invasive pyomyositis (PM) has never been reported before in the English language. In this study, we report the first case of PM in the English language and the second case in the literature caused by N meningitidis.
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Affiliation(s)
| | - Kiran Gajurel
- Division of Infectious Disease & Geographic Medicine
| | | | | | | | - José G Montoya
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine; Toxoplasma Serology Laboratory, National Reference Center for the Study and Diagnosis of Toxoplasmosis, Palo Alto, California
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24
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Gajurel K, Gomez C, Dhakal R, Vogel H, Montoya J. Failure of primary atovaquone prophylaxis for prevention of toxoplasmosis in hematopoietic cell transplant recipients. Transpl Infect Dis 2016; 18:446-452. [DOI: 10.1111/tid.12532] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 11/10/2015] [Accepted: 01/31/2016] [Indexed: 11/29/2022]
Affiliation(s)
- K. Gajurel
- Division of Infectious Diseases and Geographic Medicine; School of Medicine; Stanford University; Stanford California USA
| | - C.A. Gomez
- Division of Infectious Diseases and Geographic Medicine; School of Medicine; Stanford University; Stanford California USA
| | - R. Dhakal
- Toxoplasma Serology Laboratory; National Reference Center for the Study and Diagnosis of Toxoplasmosis; Palo Alto California USA
| | - H. Vogel
- Department of Pathology; School of Medicine; Stanford University; Stanford California USA
| | - J.G. Montoya
- Division of Infectious Diseases and Geographic Medicine; School of Medicine; Stanford University; Stanford California USA
- Toxoplasma Serology Laboratory; National Reference Center for the Study and Diagnosis of Toxoplasmosis; Palo Alto California USA
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25
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Holmes I, Gajurel K, Montoya J. The Missing Tooth: A Curious Case of Postobstructive Pneumonia. Open Forum Infect Dis 2016; 3:ofw088. [PMID: 27419162 PMCID: PMC4943540 DOI: 10.1093/ofid/ofw088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 04/29/2016] [Indexed: 12/05/2022] Open
Abstract
Foreign body aspirations that are not recognized at the time of aspiration can lead to insidious symptoms that can present a diagnostic challenge. We report the case of a 70-year-old man presenting with postobstructive pneumonia 2 months after aspirating his own tooth during a meal. He had been mistakenly diagnosed with asthma and treated with bronchodilators before a computed tomography scan of the thorax revealed the impacted tooth in his left bronchus. We review the clinical features and microbiology of postobstructive pneumonia and discuss the rationale of its treatment.
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Affiliation(s)
| | - Kiran Gajurel
- Infectious Disease , Stanford Healthcare , Palo Alto, California
| | - Jose Montoya
- Infectious Disease , Stanford Healthcare , Palo Alto, California
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26
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Tan SK, Burgener EB, Waggoner JJ, Gajurel K, Gonzalez S, Chen SF, Pinsky BA. Molecular and Culture-Based Bronchoalveolar Lavage Fluid Testing for the Diagnosis of Cytomegalovirus Pneumonitis. Open Forum Infect Dis 2016; 3:ofv212. [PMID: 26885542 PMCID: PMC4752011 DOI: 10.1093/ofid/ofv212] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/24/2015] [Indexed: 11/12/2022] Open
Abstract
Background. Cytomegalovirus (CMV) is a major cause of morbidity and mortality in immunocompromised patients, with CMV pneumonitis among the most severe manifestations of infection. Although bronchoalveolar lavage (BAL) samples are frequently tested for CMV, the clinical utility of such testing remains uncertain. Methods. Retrospective analysis of adult patients undergoing BAL testing via CMV polymerase chain reaction (PCR), shell vial culture, and conventional viral culture between August 2008 and May 2011 was performed. Cytomegalovirus diagnostic methods were compared with a comprehensive definition of CMV pneumonitis that takes into account signs and symptoms, underlying host immunodeficiency, radiographic findings, and laboratory results. Results. Seven hundred five patients underwent 1077 bronchoscopy episodes with 1090 BAL specimens sent for CMV testing. Cytomegalovirus-positive patients were more likely to be hematopoietic cell transplant recipients (26% vs 8%, P < .0001) and less likely to have an underlying condition not typically associated with lung disease (3% vs 20%, P < .0001). Histopathology was performed in only 17.3% of CMV-positive bronchoscopy episodes. When CMV diagnostic methods were evaluated against the comprehensive definition, the sensitivity and specificity of PCR, shell vial culture, and conventional culture were 91.3% and 94.6%, 54.4% and 97.4%, and 28.3% and 96.5%, respectively. Compared with culture, PCR provided significantly higher sensitivity and negative predictive value (P ≤ .001), without significantly lower positive predictive value. Cytomegalovirus quantitation did not improve test performance, resulting in a receiver operating characteristic curve with an area under the curve of 0.53. Conclusions. Cytomegalovirus PCR combined with a comprehensive clinical definition provides a pragmatic approach for the diagnosis of CMV pneumonitis.
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Affiliation(s)
- Susanna K Tan
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine
| | | | - Jesse J Waggoner
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine
| | - Kiran Gajurel
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine
| | - Sarah Gonzalez
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Sharon F Chen
- Department of Pediatrics, Division of Infectious Diseases
| | - Benjamin A Pinsky
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine; Department of Pathology, Stanford University School of Medicine, Stanford, California
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27
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Tan SK, Gajurel K, Tung C, Albers G, Deresinski S, Montoya JG, Sheikh AY, Banerjee D, Ha R. Fatal acanthamoeba encephalitis in a patient with a total artificial heart (syncardia) device. Open Forum Infect Dis 2014; 1:ofu057. [PMID: 25734127 PMCID: PMC4281817 DOI: 10.1093/ofid/ofu057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 06/13/2014] [Indexed: 11/13/2022] Open
Abstract
Acanthamoeba encephalitis is an uncommon but often fatal infection complication. Here we report the first case of Acanthamoeba encephalitis in a patient with a Total Artificial Heart device.
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Affiliation(s)
- Susanna K Tan
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine , Stanford University School of Medicine
| | - Kiran Gajurel
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine , Stanford University School of Medicine
| | - Christie Tung
- Department of Neurology & Neurological Sciences , Stanford University School of Medicine
| | - Gregory Albers
- Department of Neurology & Neurological Sciences , Stanford University School of Medicine
| | - Stan Deresinski
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine , Stanford University School of Medicine
| | - Jose G Montoya
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine , Stanford University School of Medicine
| | - Ahmad Y Sheikh
- Department of Cardiothoracic Surgery , Stanford University School of Medicine
| | - Dipanjan Banerjee
- Department of Medicine, Division of Cardiovascular Medicine , Stanford University School of Medicine , California
| | - Richard Ha
- Department of Cardiothoracic Surgery , Stanford University School of Medicine
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