Case Reports in Infectious Diseases The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Acute Hemolysis with Renal Failure due to Clostridium Bacteremia in a Patient with AML Tue, 27 Sep 2016 12:45:14 +0000 We present a case of acute hemolytic anemia, renal failure, and Clostridium perfringens bacteremia in a patient with acute myelogenous leukemia. The high fatality of C. perfringens bacteremia requires that clinicians recognize and rapidly treat patients at risk for this infection. Although other hemolytic processes are in the differential diagnosis of these events, the presence of high fever, chills, and rapidly positive blood cultures may help narrow the diagnosis. Most cases of C. perfringens bacteremia have a concomitant coinfection, which makes broad spectrum empiric therapy essential. There is a high mortality rate of C. perfringens infections associated with leukemia. R. M. Medrano-Juarez, D. Sotello, M. A. Orellana-Barrios, L. D’Cuhna, J. D. Payne, and K. Nugent Copyright © 2016 R. M. Medrano-Juarez et al. All rights reserved. Typical Facial Lesions: A Window of Suspicion for Progressive Disseminated Histoplasmosis—A Case of Asian Prototype Mon, 26 Sep 2016 16:36:33 +0000 Histoplasmosis is caused by a dimorphic fungus Histoplasma capsulatum in endemic areas, mainly America, Africa, and Asia. In India, it is being reported from most states; however, it is endemic along the Ganges belt. We report a case of an apparently immunocompetent male who presented with 3-month history of fever, cough, and weight loss with recent onset odynophagia and had hepatosplenomegaly and mucocutaneous lesions over the face. The differential diagnosis of leishmaniasis, tuberculosis, leprosy, fungal infection, lymphoproliferative malignancy, and other granulomatous disorders was considered, but he succumbed to his illness. Antemortem skin biopsy and bone marrow aspiration along with postmortem liver, lung, and spleen biopsy showed disseminated histoplasmosis. This case highlights the need for an early suspicion of progressive disseminated histoplasmosis in the presence of classical mucocutaneous lesions even in an immunocompetent patient suffering from a febrile illness. Cure rate approaches almost 100% with early treatment, whereas it is universally fatal if left untreated. Prasan K. Panda, Siddharth Jain, Rita Sood, Rajni Yadav, and Naval K. Vikram Copyright © 2016 Prasan K. Panda et al. All rights reserved. Empyema Secondary to Actinomyces meyeri Treated Successfully with Ceftriaxone Followed by Doxycycline Mon, 26 Sep 2016 12:14:21 +0000 Actinomycosis is a relatively rare infection caused by Gram-positive bacteria. We present the case of a 54-year-old, previously healthy, male patient with a history of severe penicillin allergy who developed severe pneumonia and empyema caused by Actinomyces meyeri. Presenting symptoms included productive cough, right upper quadrant pain, and chills and rigors. He required drainage of the empyema via tube and prolonged antibiotic treatment with intravenous ceftriaxone for 2 weeks followed by oral doxycycline for 6 months. Etienne Paris, Tonio Piscopo, and Karen Cassar Copyright © 2016 Etienne Paris et al. All rights reserved. Posttraumatic Skin and Soft-Tissue Infection due to Pseudomonas fulva Mon, 26 Sep 2016 09:16:47 +0000 We report a case of posttraumatic skin and soft-tissue infection in a patient with a left thigh wound after a traffic accident. Pseudomonas fulva was isolated from a wound aspirate and was identified to the species level by Maldi-tof. The patient responded to drainage, debridement of wound, and two weeks of intravenous antibiotic therapy. Follow-up after 3 weeks was satisfactory with healthy cover of the injured area. Fernando Cobo, Gemma Jiménez, Javier Rodríguez-Granger, and Antonio Sampedro Copyright © 2016 Fernando Cobo et al. All rights reserved. Chromobacterium violaceum Septicaemia and Urinary Tract Infection: Case Reports from a Tertiary Care Hospital in South India Thu, 22 Sep 2016 11:21:08 +0000 Chromobacterium violaceum is a gram negative oxidase positive bacillus that causes human infections infrequently. It is a normal inhabitant of soil and stagnant water of the tropical and subtropical areas. In humans, it can cause infections ranging from life threatening sepsis with metastatic abscesses to skin infections and urinary tract infections. The organism is notoriously resistant to most cephalosporins and Ampicillin. Fluoroquinolones and aminoglycosides show good in vitro susceptibility. High mortality rates associated with these infections necessitate prompt diagnosis and appropriate antimicrobial therapy. Here we present three cases of Chromobacterium violaceum infection from Government Medical College Kozhikode, Kerala. Vishnu Kaniyarakkal, Shabana Orvankundil, Saradadevi Karunakaran Lalitha, Raji Thazhethekandi, and Jahana Thottathil Copyright © 2016 Vishnu Kaniyarakkal et al. All rights reserved. Escherichia coli Meningitis after Rotavirus Gastroenteritis in an Infant Wed, 21 Sep 2016 09:26:46 +0000 Although rotavirus gastroenteritis is quite common in the pediatric population, secondary bacterial sepsis following rotavirus infection is a rare clinical entity. Gram-negative bacilli are the fifth most common cause of meningitis in infants but this infection rarely occurs after gastroenteritis. Here, we report a 2.5-month-old infant who developed Escherichia coli (E. coli) meningitis after acute rotavirus gastroenteritis. The 2.5-month-old male infant with fever, vomiting, and watery diarrhea that started 1 day earlier was admitted to the hospital. Rotavirus antigen in stool sample was positive. He was hospitalized, and fever was measured at 39.5°C on the second day. Lumbar puncture was done for suspicion of meningitis, and cerebrospinal fluid (CSF) findings suggested meningitis. Intravenous vancomycin and cefotaxime were started empirically. Since E. coli reproduction was seen in blood culture and CSF culture, treatment was continued with cefotaxime. The patient was discharged with minimal midlevel hydrocephalus findings in cranial ultrasonography and magnetic resonance imaging following 21 days of antibiotics treatment. Septicemia development following rotavirus gastroenteritis is an extremely rare clinical condition. It is vital to start prompt antibiotic treatment as soon as the diagnosis of secondary bacterial infection is made because of high mortality and morbidity rates. Gamze Ozgurhan, Oznur Vermezoglu, Didem Ocal Topcu, Adem Karbuz, Aysel Vehapoglu, and Bulent Hacihamdioglu Copyright © 2016 Gamze Ozgurhan et al. All rights reserved. Therapeutic Drug Monitoring of Meropenem in Neonate with Necrotizing Enterocolitis: A Challenge Thu, 15 Sep 2016 11:11:57 +0000 Necrotizing enterocolitis (NEC) continues to be a major cause of neonatal morbidity and mortality. We describe the added value of therapeutic drug monitoring by presenting the case of a preterm infant with severe NEC treated with meropenem. Dosing strategy will achieve adequate patient outcome when treating pathogens with elevated MIC. As safe as meropenem is, there are not enough data for 40 mg/kg, every 8 h infused over 4 h; accordingly, strict monitoring of blood levels is mandatory. Based on our findings, a 4 h prolonged infusion of 40 mg/kg meropenem, every 8 h, will achieve an adequate patient outcome. Steven De Keukeleire, Daniëlle Borrey, Wim Decaluwe, and Marijke Reynders Copyright © 2016 Steven De Keukeleire et al. All rights reserved. A Case of Mycobacterium riyadhense in an Acquired Immune Deficiency Syndrome (AIDS) Patient with a Suspected Paradoxical Response to Antituberculosis Therapy Wed, 14 Sep 2016 14:19:44 +0000 A 30-year-old male patient with acquired immune deficiency syndrome (AIDS) on highly active antiretroviral therapy (HAART) presented with clinical picture suggestive of pulmonary tuberculosis. He was commenced on antituberculosis therapy (ATT) with signs of improvement. Then he developed cervical lymph node abscess which was drained. Steroid was started for presumed paradoxical response to ATT which results in clinical regression. The culture result revealed Mycobacterium riyadhense. This report addresses the rarity of this bacteria in medical literature. It reviews clinical presentations and medical treatment particularly in the setting of coinfections. Maged Omar Al-Ammari, Samar Assem Badreddine, and Hani Almoallim Copyright © 2016 Maged Omar Al-Ammari et al. All rights reserved. Disseminated Cryptococcal Disease in a Patient with Chronic Lymphocytic Leukemia on Ibrutinib Wed, 14 Sep 2016 13:58:33 +0000 Cryptococcus is a unique environmental fungus that can cause disease most often in immunocompromised individuals with defective cell-mediated immunity. Chronic lymphocytic leukemia (CLL) is not known to be a risk factor for cryptococcal disease although cases have been described mainly in patients treated with agents that suppress cell-mediated immunity. Ibrutinib is a new biologic agent used for treatment of CLL, mantle cell lymphoma, and Waldenstrom’s macroglobulinemia. It acts by inhibiting Bruton’s tyrosine kinase, a kinase downstream of the B-cell receptor critical for B-cell survival and proliferation. Ibrutinib use has not been associated previously with cryptococcal disease. However, recent evidence suggested that treatments aimed at blocking the function of Bruton’s tyrosine kinase could pose a higher risk for cryptococcal infection in a mice model. Here, we report the first case of disseminated cryptococcal disease in a patient with CLL treated with ibrutinib. When evaluating possible infection in CLL patients receiving ibrutinib, cryptococcal disease, which could be life threatening if overlooked, could be considered. Koh Okamoto, Laurie A. Proia, and Patricia L. Demarais Copyright © 2016 Koh Okamoto et al. All rights reserved. External Otitis: An Unusual Presentation in Neonates Wed, 14 Sep 2016 13:57:50 +0000 Acute otitis externa (AOE) is an infection of the external auditory canal, the auricle, and the outer surface of the tympanic membrane. Although AOE is one of the most common otologic conditions encountered in pediatric population, it is known to primarily affect children older than 2 years. We report a case of AOE caused by Staphylococcus aureus in a 23-day-old neonate. A 23-day-old female infant presented to our neonatology clinic with irritability and discharge from the right ear. There were yellow otorrhea, mild erythema, and edema of right external ear canal. There was no sign of otitis media on otoscopy. The results of laboratory tests were insignificant. The discharge culture grew colonies of methicillin-sensitive Staphylococcus aureus. After 48 hours of treatment with intravenous cloxacillin, significant improvement was observed. The present case highlights an unusual presentation of staphylococcal infection in a neonate. This is the first case of methicillin-sensitive Staphylococcus aureus otitis externa in an immunocompetent newborn. Peymaneh Alizadeh Taheri, Shima Rostami, and Manelie Sadeghi Copyright © 2016 Peymaneh Alizadeh Taheri et al. All rights reserved. Rapidly Progressive Spontaneous Spinal Epidural Abscess Mon, 05 Sep 2016 06:08:25 +0000 Spinal epidural abscess (SEA) is a rare disease which is often rapidly progressive. Delayed diagnosis of SEA may lead to serious complications and the clinical findings of SEA are generally nonspecific. Paraspinal abscess should be considered in the presence of local low back tenderness, redness, and pain with fever, particularly in children. In case of delayed diagnosis and treatment, SEA may spread to the epidural space and may cause neurological deficits. Magnetic resonance imaging (MRI) remains the method of choice in the diagnosis of SEA. Treatment of SEA often consists of both medical and surgical therapy including drainage with percutaneous entry, corpectomy, and instrumentation. Abdurrahman Aycan, Ozgür Yusuf Aktas, Feyza Karagoz Guzey, Azmi Tufan, Cihan Isler, Nur Aycan, İsmail Gulsen, and Harun Arslan Copyright © 2016 Abdurrahman Aycan et al. All rights reserved. Q Fever Risk in Patients Treated with Chronic Antitumor Necrosis Factor-Alpha Therapy Tue, 30 Aug 2016 16:02:00 +0000 Q fever is a zoonotic bacterial disease caused by Coxiella burnetii. Tumor necrosis factor-alpha (TNF-α) plays a pivotal role in the defense against infection with this Gram-negative coccobacillus. Theoretically, patients who are treated with anti-TNF-α medications are at risk for developing chronic Q fever. We present two patients who developed Q fever while being treated with anti-TNF-α agents and discuss the significance of timely diagnosis of C. burnetii infection in these patients. Julianna Hirsch, Anna Astrahan, Majed Odeh, Nizar Elias, Itzhak Rosner, Doron Rimar, Lisa Kaly, Michael Rozenbaum, Nina Boulman, and Gleb Slobodin Copyright © 2016 Julianna Hirsch et al. 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.