Case Reports in Infectious Diseases The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Pneumocystis Pneumonia Presenting as an Enlarging Solitary Pulmonary Nodule Sun, 28 Aug 2016 14:22:17 +0000 Pneumocystis pneumonia is a life threatening infection that usually presents with diffuse bilateral ground-glass infiltrates in immunocompromised patients. We report a case of a single nodular granulomatous Pneumocystis pneumonia in a male with diffuse large B-cell lymphoma after R-CHOP therapy. He presented with symptoms of productive cough, dyspnea, and right-sided pleuritic chest pain that failed to resolve despite treatment with multiple antibiotics. Chest X-ray revealed right lower lobe atelectasis and CT of chest showed development of 2 cm nodular opacity with ground-glass opacities. Patient underwent bronchoscopy and biopsy that revealed granulomatous inflammation in a background of organizing pneumonia pattern with negative cultures. Respiratory symptoms resolved but the solitary nodular opacity increased in size prompting a surgical wedge resection which revealed granulomatous Pneumocystis pneumonia infection. This case is the third documented report of Pneumocystis pneumonia infection within a solitary pulmonary nodule in an individual with hematologic neoplasm. Although Pneumocystis pneumonia most commonly occurs in patients with HIV/acquired immunodeficiency syndrome and with diffuse infiltrates, the diagnosis should not be overlooked when only a solitary nodule is present. Krunal Bharat Patel, James Benjamin Gleason, Maria Julia Diacovo, and Nydia Martinez-Galvez Copyright © 2016 Krunal Bharat Patel et al. All rights reserved. Acute and Fatal Isoniazid-Induced Hepatotoxicity: A Case Report and Review of the Literature Thu, 25 Aug 2016 13:13:02 +0000 This paper describes a case of an acute and fatal isoniazid-induced hepatotoxicity and provides a review of the literature. A 65-year-old female diagnosed with latent Mycobacterium tuberculosis infection was receiving oral isoniazid 300 mg daily. She was admitted to the hospital for epigastric and right sided flank pain of one-week duration. Laboratory results and imaging confirmed hepatitis. After ruling out all other possible causes, she was diagnosed with isoniazid-induced acute hepatitis (probable association by the Naranjo scale). After discharge, the patient was readmitted and suffered from severe coagulopathy, metabolic acidosis, acute kidney injury, hepatic encephalopathy, and cardiorespiratory arrest necessitating two rounds of cardiopulmonary resuscitation. Despite maximal hemodynamic support, the patient did not survive. A review of the literature, from several European countries and the United States of America, revealed a low incidence of mortality due to isoniazid-induced hepatotoxicity when used as a single agent for latent Mycobacterium tuberculosis infection. As for the management, the first step consists of withdrawing isoniazid and rechallenge is usually discouraged. Few treatment modalities have been proposed; however there is no robust evidence to support any of them. Routine monitoring for hepatotoxicity in patients receiving isoniazid is warranted to prevent morbidity and mortality. Wissam K. Kabbara, Aline T. Sarkis, and Paola G. Saroufim Copyright © 2016 Wissam K. Kabbara et al. All rights reserved. Plesiomonas shigelloides Septic Shock Leading to Death of Postsplenectomy Patient with Pyruvate Kinase Deficiency and Hemochromatosis Wed, 17 Aug 2016 09:48:57 +0000 Although Plesiomonas shigelloides, a water-borne bacterium of the Enterobacteriaceae family, usually causes self-limiting gastroenteritis with diarrhea, several cases of sepsis have been reported. We report the case of a 43-year-old male patient with hemochromatosis, pyruvate kinase deficiency, and asplenia via splenectomy who developed septic shock caused by P. shigelloides complicated by respiratory failure, renal failure, liver failure, and disseminated intravascular coagulation. Early aggressive antimicrobial therapy and resuscitation measures were unsuccessful and the patient passed away. We kindly suggest clinicians to implement early diagnosis of septic shock, empirical coverage with antibiotics, and prompt volume resuscitation based on the high mortality rate of P. shigelloides bacteremia. Mohammed Samannodi, Andrew Zhao, Yaser Nemshah, and Kevin Shiley Copyright © 2016 Mohammed Samannodi et al. All rights reserved. Refractory Toxic Shock-Like Syndrome from Streptococcus dysgalactiae ssp. equisimilis and Intravenous Immunoglobulin as Salvage Therapy: A Case Series Mon, 15 Aug 2016 14:28:51 +0000 Infections from Streptococcus dysgalactiae ssp. equisimilis (SDSE) can cause a wide variety of infections, ranging from mild cellulitis to invasive disease, such as endocarditis and streptococcal toxic shock-like syndrome (TSLS). Despite prompt and appropriate antibiotics, mortality rates associated with shock have remained exceedingly high, prompting the need for adjunctive therapy. IVIG has been proposed as a possible adjunct, given its ability to neutralize a wide variety of superantigens and modulate a dysregulated inflammatory response. We present the first reported cases of successful IVIG therapy for reversing shock in the treatment of SDSE TSLS. Marjan Islam, Dennis Karter, Jerry Altshuler, Diana Altshuler, David Schwartz, and Gianluca Torregrossa Copyright © 2016 Marjan Islam et al. All rights reserved. Ultrasonographic Diagnosis of Schistosoma mansoni Eggs in Rectum Sun, 07 Aug 2016 12:59:52 +0000 Schistosomiasis is a trematode infection endemic in more than 70 countries that affects an estimated 250 million people. We report the case of a 60-year-old healthy female referred for endoscopic ultrasound after rectal examination revealed granular lesions. Ultrasound revealed the presence of deep mucosal nodular lesions with calcified/hyperechoic inclusions. Histologic evaluation has confirmed the final diagnosis of chronic schistosomal colitis. In patients with nonspecific intestinal lesions without a suspected diagnosis of schistosomiasis, endoscopic ultrasound can be enlightening. Schistosomiasis is still an endemic infection in some parts of Brazil and other tropical regions, causing colorectal lesions with unspecific presentation. Fabio G. Rodrigues, Joao Batista Campos, Nivaldo Hartung Toppa, Steven D. Wexner, and Giovanna Dasilva Copyright © 2016 Fabio G. Rodrigues et al. All rights reserved. A Rare Complication of Trimethoprim-Sulfamethoxazole: Drug Induced Aseptic Meningitis Sun, 07 Aug 2016 09:43:59 +0000 Drug induced aseptic meningitis is a rare but challenging diagnosis, most commonly reported with nonsteroidal anti-inflammatory drugs and antibiotics. Trimethoprim/sulfamethoxazole is a sulfonamide that is widely used in clinical practice for the treatment and prophylaxis of various infections. Drug induced aseptic meningitis, when seen with trimethoprim/sulfamethoxazole, occurs predominantly in patients with some degree of immune compromise and is less commonly seen in immune competent individuals. The patient often exhibits the classic symptoms of meningitis. Early diagnosis is important, since the cessation of the antibiotic leads to rapid clinical improvement. Trimethoprim/sulfamethoxazole induced aseptic meningitis has been underreported to FDA/MED-WATCH program. Here we report two cases of trimethoprim/sulfamethoxazole: an immune competent individual and immune compromised individual, both of which presented with signs of meningitis and a negative infectious workup. Trimethoprim/sulfamethoxazole is an uncommon and mysterious adverse reaction to a commonly used antibiotic. It should be considered in the differential diagnosis of patients presenting with acute signs and symptoms of meningitis especially after infectious causes have been ruled out. Pinky Jha, Jeremiah Stromich, Mallory Cohen, and Jane Njeri Wainaina Copyright © 2016 Pinky Jha et al. All rights reserved. A Case of Fluoroquinolone-Resistant Leprosy Discovered after 9 Years of Misdiagnosis Sun, 07 Aug 2016 09:27:57 +0000 We report a case of misdiagnosed leprosy in a 21-year-old Malagasy male, who, improperly treated, developed secondary mycobacterial resistance to fluoroquinolone. The patient contracted the infection 9 years prior to the current consultation, displaying on the right thigh a single papulonodular lesion, which progressively spread to the lower leg, back, and face. Initial administration of ciprofloxacin and prednisolone led to temporary and fluctuating improvement. Subsequent long-term self-medication with ciprofloxacin and corticosteroid did not heal the foul and nonhealing ulcers on the legs and under the right sole. Histopathological findings were compatible with lepromatous leprosy. Skin biopsy was positive for acid-fast bacilli and PCR assay confirmed the presence of a fluoroquinolone-resistant strain of Mycobacterium leprae (gyrA A91V). After 6 months of standard regimen with rifampicin, clofazimine, and dapsone, clinical outcome significantly improved. Clinical characteristics and possible epidemiological implications are discussed. Onivola Raharolahy, Lala S. Ramarozatovo, Irina M. Ranaivo, Fandresena A. Sendrasoa, Malalaniaina Andrianarison, Mala Rakoto Andrianarivelo, Emmanuelle Cambau, and Fahafahantsoa Rapelanoro Rabenja Copyright © 2016 Onivola Raharolahy et al. All rights reserved. Tuberculous Empyema Necessitatis in a 40-Year-Old Immunocompetent Male Sun, 31 Jul 2016 06:41:20 +0000 Empyema necessitans (EN) is a kind of empyema that diffuses to extrapleural space and can involve chest pain. Tuberculosis (TB) is the most common cause of EN. This disease can be found in both immunocompromised and immunocompetent individuals but is usually seen in the immunocompromised individuals. Because of long duration and ambiguous symptoms of the disease, diagnosis can be hard. The disease can be treated both medically and surgically. Missing the disease can lead to undesirable effects on patient’s condition and health care setting. This problem can be seen in endemic area in which controlling of TB is hard. Report of the disease in local health care center for desirable treatment and health maintenance is necessary. We explained a rare case of pulmonary TB in a patient that was healthy in other fields and just showed the minimum systemic symptoms. The patient came with a mass in lower part of back of chest cage, with a mild pain. The imaging survey showed EN. Smear and Ziehl-Neelsen stains from subcutaneous aspiration were positive for TB. This case showed importance of clinical view and awareness of this silent but serious disease in endemic area especially for TB. Farhang Babamahmoodi, Lotfollah Davoodi, Roya Sheikholeslami, and Fatemeh Ahangarkani Copyright © 2016 Farhang Babamahmoodi et al. All rights reserved. A Case of Acinetobacter Septic Pulmonary Embolism in an Infant Tue, 26 Jul 2016 12:40:19 +0000 Case Characteristics. An 11-month-old girl presented with fever and breathlessness for 5 days. Patient had respiratory distress with bilateral coarse crepitations. Chest radiograph revealed diffuse infiltrations in the right lung with thick walled cavities in mid and lower zone. Computed tomography showed multiple cystic spaces and emboli. Blood culture grew Acinetobacter species. Intervention. Patient was treated with Meropenem and Vancomycin. Outcome. Complete clinical and radiological recovery was seen in child. Message. Blood cultures and CT of the chest are invaluable in the evaluation of a patient with suspected septic pulmonary embolism. With early diagnosis and appropriate antimicrobial therapy, complete recovery can be expected in patients with septic pulmonary embolism. Poonam Wade, Anitha Ananthan, Jane David, and Radha Ghildiyal Copyright © 2016 Poonam Wade et al. All rights reserved. A Rare Case of Streptococcus alactolyticus Infective Endocarditis Complicated by Septic Emboli and Mycotic Left Middle Cerebral Artery Aneurysm Thu, 21 Jul 2016 13:44:01 +0000 To date, S. alactolyticus endocarditis complicated by middle cerebral artery aneurysm has not been reported. We describe the case of a 65-year-old female with a history of hypertrophic cardiomyopathy with left ventricular outflow tract obstruction presenting with confusion and a apical holosystolic murmur. Angiography of the brain identified new bilobed left middle cerebral artery aneurysm. Serial blood cultures grew S. alactolyticus, and aortic and mitral valve vegetation were discovered on transesophageal echocardiography. The patient was treated with antimicrobial therapy, mitral and aortic valve replacements, and microsurgical clipping of cerebral aneurysm. This case serves to highlight the pathogenicity of a sparsely described bacterium belonging to the heterogenous S. bovis complex. Patricia Almeida, Jaclyn Railsback, and James Benjamin Gleason Copyright © 2016 Patricia Almeida et al. All rights reserved. Two Case Reports on Thalamic and Basal Ganglia Involvement in Children with Dengue Fever Mon, 11 Jul 2016 06:42:31 +0000 There have been increasing numbers of case reports of dengue infection with unusual manifestations. Such unusual manifestations including acute liver failure and encephalopathy could be manifested even in the absence of significant plasma leakage. Further, severe organ involvement including nervous system involvement indicates severe dengue infection. However, neurological manifestations of dengue fever are rare. This is the first case report of dengue infection with thalamic and basal ganglia involvement in Sri Lanka. Guwani Liyanage, Lihini Adhikari, Saraji Wijesekera, Maheshaka Wijayawardena, and Suchithra Chandrasiri Copyright © 2016 Guwani Liyanage et al. All rights reserved. Two Cases of Legionella pneumophila Pneumonia with Prolonged Neurologic Symptoms and Brain Hypoperfusion on Single-Photon Emission Computed Tomography Sun, 10 Jul 2016 09:19:49 +0000 Cerebral and cerebellar symptoms are frequently associated with Legionnaires’ disease. However, corresponding brain lesions are difficult to demonstrate using either computed tomography (CT) or magnetic resonance imaging (MRI). We report here two patients with Legionella pneumophila pneumonia accompanied by prolonged neurologic symptoms. In contrast to brain CT and MRI, which failed to detect any abnormalities, single-photon emission computed tomography (SPECT) showed multiple sites of hypoperfusion within the brains of both patients. These cases suggest that vasculopathy, which is detectable by SPECT, might be one of the causes of neurologic symptoms in patients with Legionnaires’ disease. Hiromitsu Ohta, Susumu Yamazaki, You Miura, Akira Seto, Minoru Kanazawa, and Makoto Nagata Copyright © 2016 Hiromitsu Ohta et al. All rights reserved. Treatment of Polymicrobial Osteomyelitis with Ceftolozane-Tazobactam: Case Report and Sensitivity Testing of Isolates Wed, 29 Jun 2016 10:42:40 +0000 Stenotrophomonas maltophilia is an inherently multidrug resistant (MDR) opportunistic pathogen with many mechanisms of resistance. SENTRY studies reveal decreasing sensitivities of S. maltophilia to trimethoprim-sulfamethoxazole and fluoroquinolones. Ceftolozane-tazobactam (Zerbaxa, Merck & Co., Inc.) a novel intravenous combination agent of a third-generation cephalosporin and β-lactamase inhibitor was demonstrated to have in vitro activity against many Gram-positive, Gram-negative, and MDR organisms. Data for ceftolozane-tazobactam’s use outside of Food and Drug Administration (FDA) approved indications has been limited thus far to two case reports which demonstrated its efficacy in pan-resistant Pseudomonas aeruginosa pneumonia. Herein, we describe the first published case of treatment of MDR S. maltophilia in polymicrobial osteomyelitis with long-term (>14 days) ceftolozane-tazobactam and metronidazole. Ceftolozane-tazobactam may offer a possible alternative for clinicians faced with limited options in the treatment of resistant pathogens including MDR S. maltophilia. Jeffrey C. Jolliff, Jackie Ho, Jeremiah Joson, Arash Heidari, and Royce Johnson Copyright © 2016 Jeffrey C. Jolliff et al. All rights reserved. Intravenous Drug Abuse by Patients Inside the Hospital: A Cause for Sustained Bacteremia Tue, 28 Jun 2016 15:03:45 +0000 Patients with history of intravenous drug abuse are noted to be at risk of several infections including HIV, endocarditis, and other opportunistic infections. We report the case of a patient with sustained Bacillus cereus bacteremia despite use of multiple antibiotic regimens during his inpatient stay. Our case highlights the importance of high suspicion for active drug use inside the hospital in such patients. This is important in order to minimize unnecessary diagnostic workup and provide adequate treatment and safe hospital stay for these patients. Noopur Goel, Lubna Bashir Munshi, and Braghadheeswar Thyagarajan Copyright © 2016 Noopur Goel et al. All rights reserved. First Case of Lung Abscess due to Salmonella enterica Serovar Abony in an Immunocompetent Adult Patient Sun, 26 Jun 2016 12:10:10 +0000 In healthy individuals, nontyphoidal Salmonella species predominantly cause a self-limited form of gastroenteritis, while they infrequently invade or cause fatal disease. Extraintestinal manifestations of nontyphoidal Salmonella infections are not common and mainly occur among individuals with specific risk factors; among them, focal lung infection is a rare complication caused by nontyphoidal Salmonella strains typically occurring in immunocompromised patients with prior lung disease. We describe the first case of a localized lung abscess formation in an immunocompetent healthy female adult due to Salmonella enterica serovar Abony. The patient underwent lobectomy and was discharged after full clinical recovery. This case report highlights nontyphoidal Salmonellae infections as a potential causative agent of pleuropulmonary infections even in immunocompetent healthy adults. Vassiliki Pitiriga, John Dendrinos, Emanuel Nikitiadis, Georgia Vrioni, and Athanassios Tsakris Copyright © 2016 Vassiliki Pitiriga et al. All rights reserved. Multidrug-Resistant Bacteroides fragilis Bacteremia in a US Resident: An Emerging Challenge Thu, 23 Jun 2016 13:31:35 +0000 We describe a case of Bacteroides fragilis bacteremia associated with paraspinal and psoas abscesses in the United States. Resistance to b-lactam/b-lactamase inhibitors, carbapenems, and metronidazole was encountered despite having a recent travel history to India as the only possible risk factor for multidrug resistance. Microbiological cure was achieved with linezolid, moxifloxacin, and cefoxitin. Cristian Merchan, Sunita Parajuli, Justin Siegfried, Marco R. Scipione, Yanina Dubrovskaya, and Joseph Rahimian Copyright © 2016 Cristian Merchan et al. All rights reserved. Autoantibodies in a Three-Year-Old Girl with Visceral Leishmaniasis: A Potential Diagnostic Pitfall Thu, 23 Jun 2016 10:30:42 +0000 Visceral leishmaniasis (VL), a life-threatening parasitic infection, is endemic in the Mediterranean region. Diagnosis of VL is based on epidemiologic, clinical, and laboratory findings. However, sometimes, clinical features and laboratory findings overlap with those of autoimmune diseases. In some cases, autoantibodies are detected in patients with VL and this could be a potential diagnostic pitfall. In this study, we have reported on a three-year-old girl from a VL-endemic area in Iran, who presented with prolonged fever and splenomegaly. Bone marrow examination, serologic tests, and the molecular PCR assay were performed; however, results were inconclusive. The levels of anti-double stranded DNA, cytoplasmic antineutrophil cytoplasmic autoantibody, and perinuclear antineutrophil cytoplasmic autoantibody were elevated and, at the end, splenic biopsy was performed. The splenic tissue PCR test detected the DNA of Leishmania infantum. The patient’s condition improved with anti-Leishmania therapy, and the autoantibodies disappeared within the following four months. Clinical presentations and laboratory findings of VL and autoimmune diseases may overlap in some patients. Gholamreza Pouladfar, Zahra Jafarpour, Amir Hossein Babaei, Bahman Pourabbas, Bita Geramizadeh, and Anahita Sanaei Dashti Copyright © 2016 Gholamreza Pouladfar et al. All rights reserved. Voriconazole-Induced Periostitis Mimicking Chronic Graft-versus-Host Disease after Allogeneic Stem Cell Transplantation Tue, 14 Jun 2016 10:57:31 +0000 Voriconazole is an established first-line agent for treatment of invasive fungal infections in patients undergoing allogeneic stem cell transplantation (ASCT). It is associated with the uncommon complication of periostitis. We report this complication in a 58-year-old female undergoing HSCT. She was treated with corticosteroids with minimal improvement. The symptoms related to periostitis can mimic chronic graft-versus-host disease in patients undergoing HSCT and clinicians should differentiate this from other diagnoses and promptly discontinue therapy. Karen Sweiss, Annie Oh, Damiano Rondelli, and Pritesh Patel Copyright © 2016 Karen Sweiss et al. All rights reserved. Haemophilus parainfluenzae Mural Endocarditis: Case Report and Review of the Literature Sun, 12 Jun 2016 09:21:07 +0000 Haemophilus parainfluenzae, which uncommonly causes endocarditis, has never been documented to cause mural involvement. A 62-year-old immunocompetent female without predisposing risk factors for endocarditis except for poor dentition presented with fever, emesis, and dysmetria. Echocardiography found a mass attached to the left ventricular wall with finger-like projections. Computed tomography showed evidence of embolic phenomena to the brain, kidneys, spleen, and colon. Cardiac MRI revealed involvement of the chordae tendineae of the anterior papillary muscles. Blood cultures grew Haemophilus parainfluenzae. The patient was treated successfully with ceftriaxone with resolution of symptoms, including neurologic deficits. After eleven days of antibiotics a worsening holosystolic murmur was discovered. Worsening mitral regurgitation on echocardiography was only found three weeks later. Nine weeks after presentation, intraoperative evaluation revealed chord rupture but no residual vegetation and mitral repair was performed. Four weeks after surgery, the patient was back to her baseline. This case illustrates the ability of Haemophilus parainfluenzae to form large mural vegetations with high propensity of embolization in otherwise normal cardiac tissue among patients with dental risk factors. It also underscores the importance of physical examination in establishing a diagnosis of endocarditis and monitoring for progression of disease. Luca T. Giurgea and Tim Lahey Copyright © 2016 Luca T. Giurgea and Tim Lahey. All rights reserved. A Case of Leukocytoclastic Vasculitis Caused by Listeria monocytogenes Bacteremia Sun, 29 May 2016 13:11:58 +0000 Importance. Infections can cause leukocytoclastic vasculitis. Observations. We report the case of a patient with a left ventricular assist device who presented with acute kidney injury and biopsy proven leukocytoclastic vasculitis. Blood cultures grew Listeria monocytogenes. The patient’s rash improved with treatment of the underlying Listeria infection. Conclusion. Clinicians should be aware that there are a number of broad categories of disease associated with the histologic finding of vasculitis, including infection. It is important to keep in mind the risk factors of a particular patient when formulating a differential diagnosis. This is the first reported case of Listeria bacteremia causing leukocytoclastic vasculitis. Daniel R. Bunker and Timothy Sullivan Copyright © 2016 Daniel R. Bunker and Timothy Sullivan. All rights reserved. Challenges in Treating Secondary Syphilis Osteitis in an Immunocompromised Patient with a Penicillin Allergy: Case Report and Review of the Literature Sun, 29 May 2016 11:19:09 +0000 Syphilis is a sexually transmitted infection that remains fairly commonplace. The introduction of penicillin aided in curbing the incidence of disease; however, with the advent of the human immunodeficiency virus (HIV), syphilis is now on a resurgence with sometimes curious presentations. We present a case of a 36-year-old Caucasian gentleman with untreated HIV who complained of a skin eruption and joint pains for 6 weeks, prompting the diagnosis of secondary syphilis osteitis. Skin lesions were reminiscent of “malignant” syphilis. CD4 count was 57 cells/μL. RPR was elevated with 1 : 64 titer and positive confirmatory TP-PA. Radiography of the limbs revealed polyostotic cortical irregularities corroborated on bone scintigraphy. The patient had an unknown penicillin allergy and was unwilling to conduct a trial of penicillin-based therapy. He was subsequently treated with doxycycline 100 mg twice daily for 6 weeks and commenced antiretroviral therapy, noting dramatic improvement in both the skin lesions and joint pains. Unfortunately, he defaulted on follow-up, precluding serial RPR and bone imaging. Penicillin allergies have proven to be quite a conundrum in such patients, without much recourse for alternative therapy. Doxycycline with/without azithromycin is other options worth considering. Robert Ali, Julio Perez-Downes, Firas Baidoun, Bashar Al Turk, Carmen Isache, Girish Mohan, and Charles Perniciaro Copyright © 2016 Robert Ali et al. All rights reserved. On-Treatment Elevation in Hepatic Transaminases during HCV Treatment with Ombitasvir, Paritaprevir, Dasabuvir, Ritonavir, and Ribavirin: A Case Series Thu, 26 May 2016 09:27:23 +0000 Eradication of chronic hepatitis C virus (HCV) infection is now possible with all oral antiviral medications, including the combination of ombitasvir, paritaprevir, dasabuvir, and ritonavir (PrOD) with or without ribavirin. While high rates of sustained virologic response (SVR) can be achieved, a small subset of patients experience on-treatment liver enzyme elevations, in particular women using concurrent estradiol-containing oral contraceptive medications (OCPs). Herein, we describe four cases of liver enzyme elevations within 2-3 weeks of PrOD initiation in African-American men infected with HCV genotype 1a or 1b. Three patients with varying degrees of hepatic fibrosis received a full treatment course without medication modification, achieved SVR, and experienced resolution of liver enzyme abnormalities. One patient with cirrhosis was switched mid-treatment to an alternate HCV regimen, experienced subsequent resolution of liver enzyme abnormalities, and achieved SVR. In summary, these cases suggest that all HCV patients treated with PrOD, independent of gender or concurrent medications, should have laboratory monitoring for liver enzyme elevations, with a particular emphasis on early monitoring in cirrhotic patients. Madelyne Bean, Lydia Tang, Shyam Kottilil, Kimberly L. Beavers, and Eric G. Meissner Copyright © 2016 Madelyne Bean et al. All rights reserved. Nocardia transvalensis Disseminated Infection in an Immunocompromised Patient with Idiopathic Thrombocytopenic Purpura Tue, 24 May 2016 13:49:01 +0000 Nocardia transvalensis complex includes a wide range of microorganisms with specific antimicrobial resistance patterns. N. transvalensis is an unusual Nocardia species. However, it must be differentiated due to its natural resistance to aminoglycosides while other Nocardia species are susceptible. The present report describes a Nocardia species involved in an uncommon clinical case of a patient with idiopathic thrombocytopenic purpura and pulmonary nocardiosis. Microbiological and molecular techniques based on the sequencing of the 16S rRNA gene allowed diagnosis of Nocardia transvalensis sensu stricto. The successful treatment was based on trimethoprim-sulfamethoxazole and other drugs. We conclude that molecular identification of Nocardia species is a valuable technique to guide good treatment and prognosis and recommend its use for daily bases diagnosis. Jorge García-Méndez, Erika M. Carrillo-Casas, Andrea Rangel-Cordero, Margarita Leyva-Leyva, Juan Xicohtencatl-Cortes, Roberto Arenas, and Rigoberto Hernández-Castro Copyright © 2016 Jorge García-Méndez et al. All rights reserved. Neurologic Adverse Events Associated with Voriconazole Therapy: Report of Two Pediatric Cases Tue, 24 May 2016 12:40:42 +0000 Although voriconazole, a triazole antifungal, is a safe drug, treatment with this agent is associated with certain adverse events such as hepatic, neurologic, and visual disturbances. The current report presents two cases, one a 9-year-old boy and the other a 17-year-old girl, who experienced neurologic side effects associated with voriconazole therapy. Our aim is to remind readers of the side effects of voriconazole therapy in order to prevent unnecessary investigations especially for psychological and ophthalmologic problems. The first case was a 9-year-old boy with cystic fibrosis and invasive aspergillosis that developed photophobia, altered color sensation, and fearful visual hallucination. The second case was a 17-year-old girl with cystic fibrosis and allergic bronchopulmonary aspergillosis, and she experienced photophobia, fatigue, impaired concentration, and insomnia, when the dose of voriconazole therapy was increased from 12 mg/kg/day to 16 mg/kg/day. The complaints of the two patients disappeared after discontinuation of voriconazole therapy. Our experience in these patients reminded us of the importance of being aware of the neurologic adverse events associated with voriconazole therapy in establishing early diagnosis and initiating prompt treatment. In addition, although serum voriconazole concentration was not measured in the present cases, therapeutic drug monitoring for voriconazole seems to be critically important in preventing neurologic side effects in pediatric patients. Sevliya Öcal Demir, Serkan Atici, Gülşen Akkoç, Nurhayat Yakut, Nilay Baş İkizoğlu, Ela Erdem Eralp, Ahmet Soysal, and Mustafa Bakir Copyright © 2016 Sevliya Öcal Demir et al. All rights reserved. Coccidioides immitis Cervical Lymphadenitis Complicated by Esophageal Fistula Mon, 23 May 2016 14:35:03 +0000 Coccidioidomycosis (valley fever) is caused by the dimorphic fungi Coccidioides immitis or Coccidioides posadasii. Most infections are asymptomatic or result in self-limited pneumonia; extrapulmonary dissemination via either hematogenous or lymphatic spread is rare. Here, we present a case of cervical C. immitis lymphadenitis that resulted in fistula formation to the esophagus via mediastinal extension. This case highlights a very unusual extrapulmonary manifestation of coccidioidomycosis, the difficulty in diagnosing coccidioidal infection when it is not suspected, and the importance of obtaining a thorough exposure history to assist with diagnosis. Michael Loudin, Daniel R. Clayburgh, and Morgan Hakki Copyright © 2016 Michael Loudin et al. All rights reserved. Respiratory Failure Associated with Ascariasis in a Patient with Immunodeficiency Sun, 22 May 2016 09:23:22 +0000 In industrialized countries, risk groups for parasitic diseases include travelers, recent immigrants, and patients with immunodeficiency following chemotherapy and radiotherapy and AIDS. A 66-year-old Polish male was admitted in December 2012 to the Department of Haematology in a fairly good general condition. On the basis of cytological, cytochemical, immunophenotypic, and cytogenetic analysis of bone marrow, the patient was diagnosed with acute myeloblastic leukemia. On the 7th day of hospitalization in the Department of Haematology, patient was moved to the Intensive Care Unit (ICU) due to acute respiratory and circulatory failure. In March 2013, 3 months after the onset of respiratory failures, a mature form of Ascaris spp. appeared in the patient’s mouth. This report highlights the importance of considering an Ascaris infection in patients with low immunity presenting no eosinophilia but pulmonary failure in the central countries of Europe. Lanocha Aleksandra, Zdziarska Barbara, Lanocha-Arendarczyk Natalia, Kosik-Bogacka Danuta, Guzicka-Kazimierczak Renata, and Marzec-Lewenstein Ewa Copyright © 2016 Lanocha Aleksandra et al. All rights reserved. Rhinoscleroma with Pharyngolaryngeal Involvement Caused by Klebsiella ozaenae Thu, 12 May 2016 14:23:09 +0000 Rhinoscleroma is a chronic, slowly progressive granulomatous bacterial infection that is endemic to the tropical world, namely, Central America and Africa. It is occasionally seen in the United States of America (USA). It predominately affects the nasal mucosa but can also involve the rest of the upper respiratory tract. The well-known causative agent for rhinoscleroma is the bacterium Klebsiella rhinoscleromatis, a subspecies of Klebsiella pneumoniae. However, Klebsiella ozaenae can also, albeit very rarely, cause rhinoscleroma. The diagnosis is confirmed by histopathology examination that shows the characteristic Mikulicz cells, considered pathognomonic for this infection. We report a patient with histologically proven rhinoscleroma with pharyngolaryngeal involvement in whom cultures yielded Klebsiella ozaenae. To the best of our knowledge, only two cases of rhinoscleroma due to Klebsiella ozaenae have been reported in the literature to date. Our case illustrates the importance of recognizing this infection in a nonendemic setting such as the USA. A lack of awareness and a delay in the diagnosis of this disease can lead to complications including upper airway obstruction, physical deformity, and, rarely, sepsis. In addition, it must be remembered that the treatment of rhinoscleroma is challenging and requires a prolonged course of antibiotics to achieve a definite cure and avoid relapses. J. Gonzales Zamora and A. R. Murali Copyright © 2016 J. Gonzales Zamora and A. R. Murali. All rights reserved. Blastocystis sp. Infection Mimicking Clostridium Difficile Colitis Mon, 09 May 2016 09:54:11 +0000 We report an unusual case of severe diarrhea related to Blastocystis sp. infection in a patient with end stage renal disease on hemodialysis. The patient was admitted due to profuse diarrhea associated with fever and leukocytosis. Pertinent stool work-up such as leukocytes in stool, stool culture, clostridium difficile toxin B PCR, and serology for hepatitis A, hepatitis B, and hepatitis C and cytomegalovirus screening were all negative. Ova and parasite stool examination revealed Blastocystis sp. The patient was given intravenous metronidazole with clinical improvement by day three and total resolution of symptoms by day ten. Gaby S. Gil, Shobhana Chaudhari, Ahmed Shady, Ana Caballes, and Joe Hong Copyright © 2016 Gaby S. Gil et al. All rights reserved. Tuberculous Gastric Abscess in a Patient with AIDS: A Rare Presentation Sat, 30 Apr 2016 13:47:46 +0000 Tuberculosis is a healthcare concern that affects millions of individuals around the globe. Coinfection with HIV has changed both the clinical presentation and the outcome of the disease dramatically in the last few decades. Extrapulmonary tuberculosis is seen more frequently in the immunocompromised host. An unusual case of gastric tuberculosis in an AIDS patient is reported here. A 49-year-old female with AIDS was admitted for fever and epigastric pain. A gastric submucosal abscess was observed on imaging and confirmed by biopsy showing numerous neutrophils and acid-fast bacilli. Aspirate grew Mycobacterium tuberculosis. This report highlights a very unusual presentation of tuberculosis in an immunodeficient patient. High clinical suspicion for opportunistic infections in unusual locations should be maintained in these patients presenting with clinical syndromes that do not respond to standard treatments. New diagnostic modalities facilitate accurate identification of these infections. Ekta Nayyar, Julian A. Torres, and Carlos D. Malvestutto Copyright © 2016 Ekta Nayyar et al. All rights reserved. Neuroinfection as a Mask of Lung Cancer: A Case Series Sat, 30 Apr 2016 11:10:36 +0000 Introduction. The diagnosis of lung cancer may still be difficult due to the fact that the first symptoms very often mimic symptoms of other diseases. Case Presentation. In this paper we present two cases, in which initial diagnosis of neuroinfection delayed proper diagnosis. Conclusion. Based on our experience we concluded that neurological symptoms in the area endemic for tick-borne diseases suggesting neuroinfection require careful differential diagnosis. Moreover, neurological symptoms in heavy smokers may be associated with metastases of lung cancer. Beata Kuklińska, Anna Moniuszko-Malinowska, Robert Mróz, Sławomir Pancewicz, and Joanna Zajkowska Copyright © 2016 Beata Kuklińska et al. All rights reserved.