Case Reports in Infectious Diseases The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Three Cases of West Nile Encephalitis over an Eight-Day Period at a Downtown Los Angeles Community Hospital Thu, 28 May 2015 09:07:38 +0000 Since its introduction in New York City in 1999, the virus has spread throughout the entire North American continent and continues to spread into Central and Latin America. Our report discusses the signs and symptoms, diagnostics, and treatment of West Nile disease. It is important to recognize the disease quickly and initiate appropriate treatment. We present three cases of West Nile encephalitis at White Memorial Medical Center in East Los Angeles that occurred over the span of eight days. All three patients live within four to six miles from the hospital and do not live or work in an environment favorable to mosquitoes including shallow bodies of standing water, abandoned tires, or mud ruts. All the patients were Hispanic. Physicians and other health care providers should consider West Nile infection in the differential diagnosis of causes of aseptic meningitis and encephalitis, obtain appropriate laboratory studies, and promptly report cases to public health authorities. State governments should establish abatement programs that will eliminate sources that allow for mosquito reproduction and harboring. The public needs to be given resources that educate them on what entails the disease caused by the West Nile virus, what the symptoms are, and, most importantly, what they can do to prevent themselves from becoming infected. Adam Puchalski, Antonio K. Liu, and Byron Williams Copyright © 2015 Adam Puchalski et al. All rights reserved. Neurosyphilis: An Unresolved Case of Meningitis Thu, 14 May 2015 12:15:12 +0000 Neurosyphilis can cause both symptomatic and asymptomatic meningitis. However the epidemiology of modern neurosyphilis is not well defined because of the paucity of population-based data. The majority of neurosyphilis cases have been reported in HIV-infected patients. Here we present a case of early neurosyphilis/symptomatic syphilitic meningitis in a non-HIV patient who presented with rash but was mistakenly treated for early latent or secondary syphilis. Syphilis presenting with a skin rash and an extremely high RPR titer could indicate CNS infection rather than simply secondary syphilis because rash is a nonspecific manifestation of disseminated infection. Given the effectiveness of penicillin therapy, why is the rate of syphilis continuing to increase? Is it due to a failure of prevention or could it be also because of failure to diagnose and treat syphilis adequately, as in this case? Shagufta Ahsan and Joesph Burrascano Copyright © 2015 Shagufta Ahsan and Joesph Burrascano. All rights reserved. Kytococcus schroeteri Bacteremia in a Patient with Hairy Cell Leukemia: A Case Report and Review of the Literature Thu, 07 May 2015 11:08:01 +0000 The Kytococcus genus formerly belonged to Micrococcus. The first report of a Kytococcus schroeteri infection was in 2002 in a patient diagnosed with endocarditis. We report a case of central line associated Kytococcus schroeteri bacteremia in a patient with underlying Hairy Cell Leukemia. Kytococcus schroeteri is an emerging infection in the neutropenic population and in patients with implanted artificial tissue. It is thought to be a commensal bacterium of the skin; however, attempts to culture the bacteria remain unsuccessful. There have been a total of 5 cases (including ours) of K. schroeteri bacteremia in patients with hematologic malignancies and neutropenia and only 18 documented cases in any population. Four of the cases of bacteria in neutropenic patients have been fatal, but early detection and treatment could make a difference in clinical outcomes. Akshay Amaraneni, Devin Malik, Sakshi Jasra, Sreenivasa R. Chandana, and Deepak Garg Copyright © 2015 Akshay Amaraneni et al. All rights reserved. Presentation of AIDS with Disseminated Cutaneous and Visceral Leishmaniasis in Iran Tue, 05 May 2015 07:27:12 +0000 Leishmaniasis is an infectious disease in form of visceral (VL), cutaneous (CL), and mucocutaneous (MCL) leishmaniasis. Immunocompromised patients have increased risk of Leishmania infection, especially in endemic areas for visceral leishmaniasis, where in the world HIV/VL coinfection has become endemic. The case here suffers from both AIDS and visceral-cutaneous leishmaniasis. We report an Iranian woman with disseminated cutaneous and visceral leishmaniasis who became positive for HIV test. Mohammadali Davarpanah, Masumeh Rassaei, and Fatemeh Sari aslani Copyright © 2015 Mohammadali Davarpanah et al. All rights reserved. Exophiala Pneumonia Presenting with a Cough Productive of Black Sputum Tue, 05 May 2015 07:00:14 +0000 Exophiala species are black, yeast-like molds that can cause subcutaneous cysts as well as disseminated disease. Isolated pneumonia due to Exophiala species is extremely uncommon. We report a case of isolated Exophiala pneumonia in a patient with bronchiectasis who presented with worsening dyspnea and a cough productive of black sputum. The production of black sputum, known as melanoptysis, is an uncommon physical finding with a limited differential diagnosis. To our knowledge, this is the first reported case of Exophiala pneumonia presenting with a cough productive of black sputum. Yehuda Z. Cohen and Wendy Stead Copyright © 2015 Yehuda Z. Cohen and Wendy Stead. All rights reserved. Multifocal Tubercular Osteomyelitis with Tubercular Breast Abscess: An Atypical Presentation of Tuberculosis Mon, 04 May 2015 12:01:23 +0000 Tuberculosis of spine is common in a developing country like India. However, involvement of spine at multiple levels along with involvement of rib and tubercular breast abscess in an immunocompetent patient without any pulmonary involvement is extremely rare. Here we report a case of 53-year-old immunocompetent lady who presented with quadriparesis and MRI (magnetic resonance imaging) of spine revealed multiple lesions involving cervical, thoracic, lumbar, and sacral region without any involvement of intervertebral disc. On detailed examination she was found to have a lump in right breast. Fine needle aspiration cytology of both paravertebral collection and breast lump revealed presence of acid fast bacilli. She was put on antitubercular drug for one year and she responded well to therapy. Mita Bar, Tuhin Santra, Pradipta Guha, Neha Agrawal, Apu Adhikary, Anirban Das, and Chanchal Mahapatra Copyright © 2015 Mita Bar et al. All rights reserved. Differences in Method-Specific Vancomycin MICs and Induced Daptomycin Resistance in an Infective Endocarditis Patient Sun, 03 May 2015 13:00:37 +0000 Methicillin-resistant Staphylococcus aureus (MRSA) is a common nosocomial infection that has a high burden of morbidity and mortality. Vancomycin is the often-used antibiotic of choice when MRSA is suspected as a causative infectious agent. Recent studies have called into question the reliability of vancomycin as empiric therapy, especially in instances of bacteremia. The isolate’s minimum inhibitory concentration (MIC), the source of infection, modality of susceptibility testing, and antibiotic resistance are all issues that should be taken into consideration when formulating a care plan for a patient. We present a case that illustrates some of these issues clinicians are facing. David Benjamin Lash, Jeremiah Joson, and Arash Heidari Copyright © 2015 David Benjamin Lash et al. All rights reserved. Cutaneous and Skeletal Simultaneous Locations as a Rare Clinical Presentation of Tuberculosis Thu, 30 Apr 2015 17:24:10 +0000 Tuberculosis is a resurgent disease in most regions of the world, infecting one-third of the world’s population and having a multisystemic involvement. Incidence of extra-pulmonary tuberculosis has increased in the last few decades as a result of the Human Immunodeficiency Virus (HIV) infection. The authors report a clinical case of the rare concomitant cutaneous and skeletal tuberculosis in an immunocompetent patient transferred from endemic area. Aida Pereira, Ana Miranda, Frederico E. Santo, and Pedro Fernandes Copyright © 2015 Aida Pereira et al. All rights reserved. Anaerobic Spondylodiscitis due to Fusobacterium Species: A Case Report Review of the Literature Mon, 27 Apr 2015 13:46:11 +0000 Spondylodiscitis caused by Fusobacterium species is rare. Most cases of spontaneous spondylodiscitis are caused by Staphylococcus aureus and most postoperative cases are caused by Staphylococcus aureus or coagulase-negative staphylococci. Escherichia coli is the most common Gram-negative organism causing spondylodiscitis. Fusobacterium species are unusual causes for anaerobic spondylodiscitis. We report the case of a patient with spontaneous L2-L3 spondylodiscitis, vertebral osteomyelitis, and epidural abscess caused by Fusobacterium species and review the literature for patients with Fusobacterium spondylodiscitis. Tiffany N. Latta, Aimee L. Mandapat, and Joseph P. Myers Copyright © 2015 Tiffany N. Latta et al. All rights reserved. Group D Salmonella Urinary Tract Infection in an Immunocompetent Male Thu, 23 Apr 2015 12:44:20 +0000 A 62-year-old male with past medical history of benign prostatic hyperplasia presented to the emergency department with complaints of decreased urinary flow, inability to fully empty his bladder, and gross hematuria. Physical examination was unremarkable. Urinalysis revealed large amount of blood and more than 700 white blood cells suggesting a urinary tract infection. Urine culture grew group D Salmonella greater than 100,000 colony-forming units per mL. He was prescribed 6 weeks of trimethoprim/sulfamethoxazole and had resolution of symptoms. Retrospectively, he reported a 3-day history of watery diarrhea about a week prior to onset of urinary symptoms that was presumed to be the hematogenous source in this case. Urinary tract infection from nontyphoidal Salmonella (NTS) is rare and is usually associated with immunosuppression, chronic diseases, such as diabetes or structural abnormalities of the genitourinary tract. Genitourinary tract abnormalities previously reported in the literature that predispose to nontyphoidal Salmonella urinary tract infection include nephrolithiasis, chronic pyelonephritis, retrovesicular fistula, urethrorectal fistula, hydrocele, and post-TURP. We present an exceedingly uncommon case of 62-year-old male with group D Salmonella urinary tract infection predisposed by his history of benign prostatic hyperplasia. Asad Jehangir, Dilli Poudel, Shoaib Bilal Fareedy, Ahmed Salman, Anam Qureshi, Qasim Jehangir, and Richard Alweis Copyright © 2015 Asad Jehangir et al. All rights reserved. Neuroinvasive Cryptococcosis in an Immunocompetent Patient with a Negative Spinal Fluid Cryptococcus Antigen Tue, 14 Apr 2015 06:35:14 +0000 58-year-old man presented with headache, nausea, vomiting, and gait disturbance. Brain MRI showed meningeal enhancement and herniation. Serum Cryptococcus antigen was positive but spinal fluid antigen and cultures were negative. A cerebellar biopsy revealed nonencapsulated Cryptococcus. He completed antifungal therapy. Serum Cryptococcus antigen titer decreased. He had a full neurological recovery. Rocio C. Garcia-Santibanez, Veenu Gill, Stanley Yancovitz, and DeWitt Pyburn Copyright © 2015 Rocio C. Garcia-Santibanez et al. All rights reserved. How an Opportunistic Infection Can Mess with Your Brain and Take Your Breath Away: A Rare Case of Simultaneous Lung and Brain Abscess due to Streptococcus anginosus Wed, 01 Apr 2015 10:33:28 +0000 Streptococcus anginosus (S. anginosus) is considered a friendly bug and is a one of many different bacteria that constitute the normal flora of the oral cavity. Nevertheless, it has been infrequently associated with more invasive infections, like lung abscess. It is extremely rare to have multisystemic involvement with S. anginosus group. We present a unique case of pulmonary and brain abscess due to S. anginosus in an immunocompetent patient. Farah Al-Saffar, Daisy Torres-Miranda, Saif Ibrahim, and Adil Shujaat Copyright © 2015 Farah Al-Saffar et al. All rights reserved. A Case of Fatal Gastrointestinal Anthrax in North Eastern Iran Tue, 31 Mar 2015 08:33:46 +0000 Background. Bacillus species are aerobic or facultative anaerobic, gram-positive, or gram-variable spore-forming rods. They are ubiquitous in the environmental sources. Bacillus anthracis may usually cause three forms of anthrax: inhalation, gastrointestinal, and cutaneous. The gastrointestinal (GI) anthrax develops after eating contaminated meat. In this paper we report septic intestinal anthrax. Case Presentation. We report an isolation of Bacillus anthracis from blood culture of patient with intestinal anthrax. Bacillus anthracis was isolated from a blood culture of a 34-year-old man who had a history of severe abdominal pain, bloody diarrhea, nausea, vomiting, fever, sweating, and lethargy within 4 to 5 days after eating the meat of domestic goat. He had evidence of severe infection and septic shock and did not respond to treatments and subsequently expired 9 hours after hospitalization. Conclusion. Gastrointestinal anthrax is characterized by rapid onset, fever, and septicemia. Rapid diagnosis and prompt initiation of antibiotic therapy can help in survival. Most of previous cases of septicemic anthrax were related to injection drug users but, in our case, septicemia occurred after gastrointestinal anthrax. Seyed Ahmad Hashemi, Amir Azimian, Sara Nojumi, Tahereh Garivani, Saghar Safamanesh, and Majid Ghafouri Copyright © 2015 Seyed Ahmad Hashemi et al. All rights reserved. Multisite Infection with Mycobacterium abscessus after Replacement of Breast Implants and Gluteal Lipofilling Sun, 29 Mar 2015 13:59:29 +0000 Introduction. Medical tourism for aesthetic surgery is popular. Nontuberculous mycobacteria (NTM) occasionally cause surgical-site infections. As NTM grow in biofilms, implantations of foreign bodies are at risk. Due to late manifestation, infections occur when patients are back home, where they must be managed properly. Case Report. A 39-year-old healthy female was referred for acute infection of the right gluteal area. Five months before, she had breast implants replacement, abdominal liposuction, and gluteal lipofilling in Mexico. Three months postoperatively, implants were removed for NTM-infection in Switzerland. Adequate antibiotic treatment was stopped after seven days for drug-related hepatitis. At entrance, gluteal puncture for bacterial analysis was performed. MRI showed large subcutaneous collection. Debridement under general anaesthesia was followed by open wound management. Total antibiotic treatment was 20 weeks. Methods. Bacterial analysis of periprosthetic and gluteal liquids included Gram-stain plus acid-fast stain, and aerobic, anaerobic and mycobacterial cultures.  Results. In periprosthetic fluid, Mycobacterium abscessus, Propionibacterium, and Staphylococcus epidermidis were identified. The same M. abscessus strain was found gluteally. The gluteal wound healed within six weeks. At ten months’ follow-up, gluteal asymmetry persists for deep scarring. Conclusion. This case presents major complications of multisite aesthetic surgery. Surgical-site infections in context of medical tourism need appropriate bacteriological investigations, considering potential NTM-infections. Eva Rüegg, Alexandre Cheretakis, Ali Modarressi, Stephan Harbarth, and Brigitte Pittet-Cuénod Copyright © 2015 Eva Rüegg et al. All rights reserved. A Man with Unilateral Endophthalmitis: A Case of Disseminated Nocardiosis Mon, 23 Mar 2015 09:29:06 +0000 We present the case of a patient with an infection by Nocardia which manifested itself with monocular endophthalmitis. Nocardia infection is not common and ocular involvement is one of the most uncommon presentations. In these cases it is very important to make an early diagnosis and intensive treatment to prevent the visual prognosis. N. Navarrete-Navarrete, J. Escobar Sevilla, M. Toribio García, F. Urbano, J. M. Sabio, and J. Jiménez-Alonso Copyright © 2015 N. Navarrete-Navarrete et al. All rights reserved. Pseudomonas aeruginosa Acquisition in Cystic Fibrosis Patients in Context of Otorhinolaryngological Surgery or Dentist Attendance: Case Series and Discussion of Preventive Concepts Wed, 18 Mar 2015 11:09:27 +0000 Introduction. P. aeruginosa is the primary cause for pulmonary destruction and premature death in cystic fibrosis (CF). Therefore, prevention of airway colonization with the pathogen, ubiquitously present in water, is essential. Infection of CF patients with P. aeruginosa after dentist treatment was proven and dental unit waterlines were identified as source, suggesting prophylactic measures. For their almost regular sinonasal involvement, CF patients often require otorhinolaryngological (ORL) attendance. Despite some fields around ORL-procedures with comparable risk for acquisition of P. aeruginosa, such CF cases have not yet been reported. We present four CF patients, who primarily acquired P. aeruginosa around ORL surgery, and one around dentist treatment. Additionally, we discuss risks and preventive strategies for CF patients undergoing ORL-treatment. Perils include contact to pathogen-carriers in waiting rooms, instrumentation, suction, drilling, and flushing fluid, when droplets containing pathogens can be nebulized. Postsurgery mucosal damage and debridement impair sinonasal mucociliary clearance, facilitating pathogen proliferation and infestation. Therefore, sinonasal surgery and dentist treatment of CF patients without chronic P. aeruginosa colonization must be linked to repeated microbiological assessment. Further studies must elaborate whether all CF patients undergoing ORL-surgery require antipseudomonal prophylaxis, including nasal lavages containing antibiotics. Altogether, this underestimated risk requires structured prevention protocols. Jochen G. Mainz, Andrea Gerber, Michael Lorenz, Ruth Michl, Julia Hentschel, Anika Nader, James F. Beck, Mathias W. Pletz, and Andreas H. Mueller Copyright © 2015 Jochen G. Mainz et al. All rights reserved. A Novel Mycobacterium cosmeticum-Like Bacterium Isolated from the Ear Swab of a Patient with Otitis Externa Tue, 17 Mar 2015 12:59:05 +0000 We describe the identification and characterization of a novel nontuberculous mycobacterium (NTM), isolated from an ear swab of an adult male patient with chronic otitis externa. Genetically, the bacterium is most closely related to Mycobacterium cosmeticum; however, growth and biochemical features indicate that it is distinctly different. Here, we highlight for the first time an unusual NTM that is a probable cause of ear infection. Jeanette W. P. Teo, Janet W. S. Cheng, Roland Jureen, and Raymond T. P. Lin Copyright © 2015 Jeanette W. P. Teo et al. All rights reserved. Giant Thyroid Abscess Related to Postpartum Brucella Infection Mon, 16 Mar 2015 16:21:17 +0000 Thyroid gland infection, although rare, may be a life threatening disease. Thyroid abscess, arising from acute suppurative thyroiditis (AST), is a rare clinic condition depending on widespread use of antibiotics. Infection may involve one or both lobes and abscess formation may not be apparent until late stage of the progress of illness. Thyroid left lobe is more often affected than the right one. Brucellosis, especially obvious in endemic areas, is a widely seen zoonosis around the world. Although brucella infection can affect many organs through various complications, thyroid gland infection is rare. We aimed to present ultrasonography (USG) and magnetic resonance images (MRI) of a case with an acute thyroiditis which rapidly developed and grew fast on the left half of the neck during the first postpartum month. As far as we know from literature reviewing, our case is the first case report of a thyroid abscess arising from brucella infection which is developed in first postpartum period with images of ultrasonography and MRI. Zülküf Akdemir, Erbil Karaman, Hüseyin Akdeniz, Cem Alptekin, and Harun Arslan Copyright © 2015 Zülküf Akdemir et al. All rights reserved. Fulminant Shigellosis in a HIV Patient Wed, 04 Mar 2015 14:01:56 +0000 Infectious enterocolitis caused by shigella is usually self-limiting and seldom requires antibiotics treatment. It is uncommon to develop fulminant shigellosis requiring surgery. We report a rare case of fulminant shigellosis in a HIV patient with recurring infection which could not be managed with intravenous antibiotics. CT reviewed extensive colonic wall thickening and stranding with evidence of pneumatosis coli. The patient eventually required a Hartmann procedure. Although fulminant shigellosis is uncommon, thorough assessment and vigilant management are warranted in immunosuppressed patient. Siang Mei Sally Ooi Copyright © 2015 Siang Mei Sally Ooi. All rights reserved. Brain Abscess after Percutaneous Therapy for Trigeminal Neuralgia Tue, 03 Mar 2015 11:37:19 +0000 We report a case of brain abscess following the percutaneous treatment for trigeminal neuralgia. This procedure envisages the access with a needle into the middle cranial fossa through the oral cavity. Thus, in this case, the bacterial infection can be more likely ascribed to the possible contamination of the needle inside the oral cavity rather than to other frequent and more controllable causes of infection like an imperfect sterilization of surgical instruments or an inadequate antiseptic preparation of both operator’s hands and patient’s skin. The subsequent brain abscess was treated with antibiotic therapy (Vancomycin 2 gr a day and Meropenem 8 g a day for 22 days before the surgical procedure and 30 days after, until complete normalization of laboratory parameters, clinical parameters, and neurological symptoms) and surgical drainage, although the culture of the abscess capsule and the purulent material resulted sterile. In conclusion, the percutaneous therapy for trigeminal neuralgia can be objectively related to risks, even if performed by expert hands. Therefore, it is important that the patient should be advised regarding risks/benefits and/or septic complications of such procedures, even if they occur very seldom. An association of surgery and antibiotic therapy results as effective treatment for this pathologic condition. Michele Acqui, Pietro Familiari, Alessandro Pesce, Giada Toccaceli, and Antonino Raco Copyright © 2015 Michele Acqui et al. All rights reserved. Lichen Planus Induced by Pegylated Interferon Alfa-2a Therapy in a Patient Monitored for Delta Hepatitis Tue, 03 Mar 2015 07:49:37 +0000 Interferons are used for treatment of chronic hepatitis B. They can induce or exacerbate some skin disorders, such as lichen planus. In this study, as we know, we presented the first case developing lichen planus while receiving interferon treatment due to delta hepatitis. A 31-year-old male patient presented to our outpatient clinic with HBsAg positivity. With his analyses, HBV DNA was negative, anti-delta total was positive, ALT was 72 U/L (upper limit 41 U/L), and platelet was 119 000/mm3. He was therefore started on subcutaneous pegylated interferon alfa-2a therapy at 180 mcg/week for delta hepatitis. At month 4 of therapy, the patient developed diffuse eroded lace-like lesions in oral mucosa, white plaques on lips, and itchy papular lesions in the hands and feet. Lichen planus was considered by the dermatology clinic and topical treatment (mometasone furoate) was given. The lesions persisted at month 5 of therapy and biopsy samples were obtained from oral mucosal lesions and interferon dose was reduced to 135 mcg/week. Biopsy demonstrated nonkeratinized stratified squamous epithelium; epithelial acanthosis, spongiosis, and apoptotic bodies were observed in the epidermis and therefore lichen planus was considered. At month 6 of therapy, lesions did not improve and even progressed and interferon treatment was therefore discontinued. Safak Kaya, Eyup Arslan, Birol Baysal, Sule Nergiz Baykara, Ozlem Ceren Uzun, and Sehmuz Kaya Copyright © 2015 Safak Kaya et al. All rights reserved. Family Outbreaks of Nontyphoidal Salmonellosis following a Meal of Guinea Pigs Mon, 02 Mar 2015 13:37:20 +0000 Salmonella outbreaks have been linked to a wide variety of foods, including recent nationwide outbreaks. Guinea pig (Cavia porcellus), also known as cuy or cobayo, has long been a popular delicacy and ceremonial food in the Andean region in South America. This case report describes three family outbreaks of nontyphoidal salmonellosis, each occurring after a meal of guinea pigs. We believe this case report is the first to describe a probable association between the consumption of guinea pig meat and human salmonellosis. Physicians should be aware of the association of Salmonella and the consumption of guinea pigs, given the increasing immigration of people from the Andean region of South America and the increasing travel to this region. John B. Fournier, Kimberly Knox, Maureen Harris, and Michael Newstein Copyright © 2015 John B. Fournier et al. All rights reserved. Disseminated Nocardiosis: A Successful Blind Strategy of Treatment in an HIV Infected Patient Mon, 02 Mar 2015 10:42:52 +0000 Background. Nocardiosis is a rare disease that mainly affects severely immunocompromised patients. Symptoms are nonspecific and microbiological isolation is difficult, hiding the diagnosis. Treatment should be guided by species and susceptibility testing. Findings. We report a clinical case of a disseminated nocardiosis in a patient with HIV and HVB infections. Interpretation. Diagnosis should be presumed early and microbiological conditions should be optimized, in order to identify the species and achieve antibiotic susceptibility testing. This is a very important step to choose an effective therapeutic regimen or alternative options. Ana C. Guerra, Dário Batista, Maria J. Aleixo, Paulo Saraiva, and Maria J. Aguas Copyright © 2015 Ana C. Guerra et al. All rights reserved. Bone Marrow Granuloma in Typhoid Fever: A Morphological Approach and Literature Review Thu, 19 Feb 2015 11:40:16 +0000 Typhoid fever is one of the few bacterial infections in humans where bone marrow evaluation is routinely recommended. However, the morphological aspect of typhoid fever in bone marrow has been rarely described in the literature. We describe a 25-year-old male patient who presented with prolonged fever suspected to be of tubercular etiology. Bone marrow examination showed well-formed histiocytic and epithelioid granulomas and erythrophagocytosis; and the bone marrow aspirate culture grew Salmonella typhi A. In view of potential clinical implications, typhoid fever should be considered as a differential diagnosis to tuberculosis in the evaluation of prolonged fever; especially in high prevalent areas. We suggest that erythrophagocytosis may serve as a morphological marker in typhoid granulomas in the bone marrow; and bone marrow culture should be submitted in every suspected case for appropriate patient management. Kavitha Muniraj, Somanath Padhi, Manjiri Phansalkar, Periyasami Sivakumar, Renu G’Boy Varghese, and Reba Kanungo Copyright © 2015 Kavitha Muniraj et al. All rights reserved. Meningitis, Clinical Presentation of Tetanus Wed, 18 Feb 2015 07:54:11 +0000 Background. Tetanus is an acute disease caused by a neurotoxin produced by Clostridium tetani. Tetanus immunization has been available since the late 1930s but sporadic cases still occur, usually in incompletely vaccinated or unvaccinated individuals. Case Report. An elderly previously vaccinated female contracted tetanus following foot injury. Clinically she presented with meningitis causing diagnostic and therapeutic delays. Why Should Physician Be Aware of This? Even in developed countries the differential diagnosis of meningitis, especially in the elderly, should include tetanus. Treatment in intensive care unit is required. General population might benefit from vaccine boosters and education on this potentially fatal disease. Anna Moniuszko, Agata Zajkowska, Ewa Tumiel, Krzysztof Rutkowski, Piotr Czupryna, Sławomir Pancewicz, Ryszard Rutkowski, Agnieszka Zdrodowska, and Joanna Zajkowska Copyright © 2015 Anna Moniuszko et al. All rights reserved. Cutaneous Ulcer as Leading Symptom of Systemic Cytomegalovirus Infection Mon, 16 Feb 2015 06:47:35 +0000 Cytomegalovirus (CMV) infection rarely manifests with skin ulcerations. We describe a case report of a 64-year-old woman with chronic immunosuppression for treatment of mixed connective tissue disease, presenting with new onset leg ulcerations after a recent change in immunosuppressive regimen. She subsequently developed fulminant hepatitis, encephalopathy, and pancytopenia and was found to have severe systemic CMV viremia. Skin ulcer biopsy was positive by immunohistochemical staining for CMV infected endothelial cells. Both systemic disease and skin ulcer rapidly improved after stopping immunosuppression and administering intravenous ganciclovir. New onset skin ulcers in an immunosuppressed individual, especially with recent changes in immunosuppressive regimen, should raise the suspicion of reactivation of CMV. Richard F. Guo, Frew H. Gebreab, Emily Hsiang-Ho Tang, Zhe Piao, Steve S. Lee, and Mario L. Perez Copyright © 2015 Richard F. Guo et al. All rights reserved. Primary Cutaneous Cryptococcosis Treated with Debridement and Fluconazole Monotherapy in an Immunosuppressed Patient: A Case Report and Review of the Literature Mon, 02 Feb 2015 14:34:14 +0000 Cryptococcus neoformans is an opportunistic yeast present in the environment. Practitioners are familiar with the presentation and management of the most common manifestation of cryptococcal infection, meningoencephalitis, in patients with AIDS or other conditions of immunocompromise. There is less awareness, however, of uncommon presentations where experience rather than evidence guides therapy. We report a case of primary cutaneous cryptococcosis (PCC) in a patient who had been immunosuppressed by chronic high-dose corticosteroid for the treatment of severe asthma. This case highlights the importance of early recognition of aggressive cellulitis that fails standard empiric antibiotic treatment in an immunocompromised patient. It also demonstrates successful treatment of PCC with a multispecialty approach including local debridement and fluconazole monotherapy. Jennifer Wang, Luther Bartelt, Deborah Yu, Anjali Joshi, Bradley Weinbaum, Tiffany Pierson, Michael Patrizio, Cirle A. Warren, Molly A. Hughes, and Gerald Donowitz Copyright © 2015 Jennifer Wang et al. All rights reserved. Brucella Endocarditis as a Late Onset Complication of Brucellosis Mon, 02 Feb 2015 08:43:51 +0000 Brucella endocarditis (BE) is a rare but life threatening complication of brucellosis. We present a case report of a patient with relapsing brucellosis complicated with aortic valve endocarditis. The patient underwent valve replacement and required prolonged antibiotic treatment because of rupture of the noncoronary leaflet and development of congestive heart failure. Since the onset of endocarditis in patients with brucellosis is not known, proper follow-up is required in order to identify any late onset complications, especially in endemic areas. Panagiotis Andriopoulos, Christos Antoniou, Panagiota Manolakou, Athanassios Vasilopoulos, George Assimakopoulos, and Maria Tsironi Copyright © 2015 Panagiotis Andriopoulos et al. All rights reserved. Pneumonia by Listeria monocytogenes: A Common Infection by an Uncommon Pathogen Sat, 31 Jan 2015 16:52:41 +0000 Infections by Listeria monocytogenes typically occur in infants, the elderly, pregnant women, and immunosuppressed subjects. Pulmonary infections in adults are extremely uncommon and only few reports can be found in the literature. We here report a case of Listeria pneumonia in an 85-year-old female patient and we discuss our diagnostic and therapeutic approach. Despite being rare and in most cases difficult to be identified, Listeria pneumonia should always be considered in immunosuppressed patients, presenting with fever and symptoms from the lower respiratory system. Theocharis Koufakis, Marianneta Chatzopoulou, Anastasios Margaritis, Maria Tsiakalou, and Ioannis Gabranis Copyright © 2015 Theocharis Koufakis et al. All rights reserved. Lemierre’s Syndrome: Recognising a Typical Presentation of a Rare Condition Tue, 27 Jan 2015 10:31:37 +0000 Lemierre’s syndrome is a rare complication following an acute oropharyngeal infection. The aetiological agent is typically anaerobic bacteria of the genus Fusobacterium. The syndrome is characterised by a primary oropharyngeal infection followed by metastatic spread and suppurative thrombophlebitis of the internal jugular vein. If left untreated, Lemierre’s syndrome carries a mortality rate of over 90%. Whilst relatively common in the preantibiotic era, the number of cases of Lemierre’s syndrome subsequently declined with the introduction of antibiotics. With the increase of antibiotic resistance and a greater reluctance to prescribe antibiotics for minor conditions such as tonsillitis, there are now concerns developing about the reemergence of the condition. This increasing prevalence in the face of an unfamiliarity of clinicians with the classical features of this “forgotten disease” may result in the misdiagnosis or delay in diagnosis of this potentially fatal illness. This case report illustrates the delay in diagnosis of probable Lemierre’s syndrome in a 17-year-old female, its diagnosis, and successful treatment which included the use of anticoagulation therapy. Whilst there was a positive outcome, the case highlights the need for a suspicion of this rare condition when presented with distinctive signs and symptoms. James A. Coultas, Neena Bodasing, Paul Horrocks, and Anthony Cadwgan Copyright © 2015 James A. Coultas et al. All rights reserved.