Background: Opportunistic fungal infections caused by Aspergillus and Candida followed by infecti... more Background: Opportunistic fungal infections caused by Aspergillus and Candida followed by infections with Fusarium, Rhizopus, Mucor, and Alternaria species are an important cause of morbidity and mortality in patients with hematological malignancies. Cutaneous mucormycosis infections are rare, and the incidence, outcomes, and factors associated with survival in the setting of hematological malignancies are not clear. Methods: A literature search was conducted for all cases of primary cutaneous mold infections in patients with hematological malignancy, of which 50 cases were found. Our case of a patient with a hematological malignancy who sustained a cat bite that in turn caused a primary cutaneous mold infection is also included. Results: In the 51 cases identified, 66.7% were neutropenic upon presentation, and 54.9% were male with an average age of 32 years. Aspergillus species (33.3%) was the most cited followed by Rhizopus species (19.6%). Overall mortality rate was 29.4% and was observed more frequently in patients with neutropenia (60.0%) and without surgical intervention (73.3%). Survival rate was higher (35.3%) for cases utilizing both antifungal and surgical intervention. The antifungal agent with the highest survival rate was amphotericin B and its formulations (58.8%). Conclusions: Neutropenia within hematological malignancies demonstrate a risk for developing severe cutane-ous fungal infections, of which primary cutaneous mucormycosis can carry significant mortality. Combination antifungal therapy and surgical debridement appears to be associated with higher survival outcomes and warrants further investigation.
Worldwide, marijuana (cannabis) is a widely used drug. The incidence of marijuana smoking is incr... more Worldwide, marijuana (cannabis) is a widely used drug. The incidence of marijuana smoking is increasing and is second only to tobacco as the most widely smoked substance in the general population. It is also the second most commonly used recreational drug after alcohol. Some adverse effects of marijuana smoking have been documented; however, the number of studies on the pulmonary effects of marijuana in individuals with leukemia is limited. In our case series, we report on 2 men with acute myeloid leukemia with miliary nodular lung patterns on computed tomography of the chest due to heavy marijuana use. We also report on 2 patients with acute lymphocytic leukemia who had a history of smoking marijuana and then developed lung opacities consistent with mold infection.
A 35-year-old woman sought care for a fever and sore throat that she'd had for 4 days. She denied... more A 35-year-old woman sought care for a fever and sore throat that she'd had for 4 days. She denied symptoms of cough, rhinorrhea, or sputum production. The patient's medical history included severe recurrent streptococcal pharyngitis as a child and teenager. At the age of 17, she developed a fever of 105° F with associated delirium, dysphagia, nausea, and vomiting, and missed several days of school. She also lost 82 pounds, developed oral thrush, and continued to feel fatigued for approximately a year. After her primary care physician noted a heart murmur on physical exam, she was sent for echocardiog-raphy and diagnosed with rheumatic fever secondary to streptococcal pharyngitis. Eighteen years (and numerous streptococcal infections) later, the patient was at our facility and we were ordering a rapid antigen detection test (RADT) for her current illness. The throat specimen was positive for group A ß-hemolytic streptococcus (GAS). The patient's 8-year-old daughter also had a sore throat, fever, and positive RADT; her symptoms resolved with oral amoxicillin for 10 days. The patient's husband was also treated successfully with oral amoxicillin/clavulanate for 10 days for similar symptoms. The patient herself, however, was unsuccessfully treated with oral amoxicillin 500 mg twice daily for 7 days. She was then given oral amoxicillin/clavulanate 875 mg twice daily for 14 days, but received no relief. Even after receiving clindamycin 600 mg twice daily for 10 days, she had minimal relief and remained positive for GAS on repeat RADT. It was at this point that tonsillectomy was considered as a possible treatment modality for her refractory GAS pharyngitis. ❚ The patient consented to the procedure and underwent a tonsillectomy. She has remained asymptomatic for 2 years and there have been no reported outbreaks of GAS infection in her household. DISCUSSION Streptococcal pharyngitis is an infection of the oropharynx and/or nasopharynx that is caused by Streptococcus pyogenes (also known as GAS). It is one of the most frequent illnesses encountered by primary care physicians, and primarily occurs in children ages 5 to 15 years. 1,2 The signs and symptoms of GAS pharyngitis include an abrupt onset of a sore throat, tonsillar exudate, tender cervical adenopathy, and fever. (The classic presentation of GAS pharyngitis in a different patient can be seen in the FIGURE.) ❚ Throat cultures are the gold standard for the diagnosis of GAS pharyngitis, but results take 24 to 48 hours, which can delay appropriate treatment. Therefore, the use of the RADT is often preferred clinically. 1 RADT is not recommended for children and adults who show clinical symptoms that are highly suggestive of a viral illness, such as cough, rhinor-rhea, hoarseness, or oral ulcers. A negative RADT in children and adolescents necessitates a throat culture to confirm the diagnosis.
In the past decades, viridans group Streptococci (VGS) have emerged as an important cause of bact... more In the past decades, viridans group Streptococci (VGS) have emerged as an important cause of bacteremia in neutropenic patients with cancer. The clinical course of VGS bacteremia can be devastating including septic shock and adult respiratory distress syndrome (ARDS). It has been suggested that septicemia with VGS triggers the development of noncardiogenic pulmonary edema in patients with pre-existing damage of the lungs due to aggressive cytotoxic treatment.
Thus, the preemptive administration of corticosteroid to patients diagnosed with VGS bacteremia with early onset of respiratory failure has been employed to prevent ARDS. While this management strategy has been suggested in the literature, little published data are available to validate this practice. In this study, we sought to review the benefit of early administration of corticosteroid to patients who developed symptom or early signs of respiratory failure while being neutropenic with VGS bacteremia.
The use of hematopoietic stem cell transplant (HSCT) for the treatment of hematological malignanc... more The use of hematopoietic stem cell transplant (HSCT) for the treatment of hematological malignancies has continued to grow over the last 10 years. The development of new treatment strategies has minimized the severity and duration of immune suppression following transplantation. This article will review the management and challenges of the most common encountered infections after HSCT.
Of the 3 main soil-associated bacteria, Nocardia, Actinomyces, and Streptomyces, the latter is th... more Of the 3 main soil-associated bacteria, Nocardia, Actinomyces, and Streptomyces, the latter is the least well known. It rarely causes infection in humans. The most common infection with Streptomyces is myce-toma acquired through traumatic inoculation. Even less common is Streptomyces infection without direct soil exposure. The focus of our study is Streptomyces infections in immunocompromised patients with cancer.
Obesity is currently one of the most common chronic diseases and has become a major health concer... more Obesity is currently one of the most common chronic diseases and has become a major health concern in Western countries. Consequently, rise of bariatric surgery nationwide, has been increasing. The Roux-en-Y gastric bypass (RYGB) is a type of surgery indicated in the treatment of morbid obesity. At our institution, we report a case of a 48-year-old female with a history of morbid obesity, who underwent RYGB 13 years ago for weight loss, and was admitted to the hospital for abdominal pain. Upper endoscopy then revealed small bowl cancer.
Secondary syphilis has been known since the late 19th century as the great imitator; however, som... more Secondary syphilis has been known since the late 19th century as the great imitator; however, some experts now regard cutaneous lymphoma as the great imitator of skin disease. Either disease, at times an equally fastidious diagnosis, has reported to mimic each other even. It is thus vital to consider these possibilities when presented with a patient demonstrating peculiar skin lesions. No other manifestation of secondary syphilis may pose such quandary as a rare case of rupioid syphilis impersonating cutaneous lymphoma. We present such a case, of a 36-year-old HIV positive male, misdiagnosed with aggressive cutaneous lymphoma, actually exhibiting rupioid syphilis thought secondary to immune reconstitution inflammatory syndrome (IRIS).
Background: New research on rhinovirus (RV) has elevated the role of the virus as a significant c... more Background: New research on rhinovirus (RV) has elevated the role of the virus as a significant contributor to respiratory complications in immunocompromised patients. Although RV has been implicated to cause morbidity and mortality in immunocompromised patients, its role has been difficult to characterize due to a limited availability of conventional diagnostics. Recent developments in polymerase chain reaction techniques have enabled better detection of RV and thus a means to better study its impact on immunocompromised patients.
Materials and Methods: We performed a retrospective analysis of patients with hematologic malignancy at the Moffitt Cancer Center in Tampa, Fla, with a positive nasopharyngeal swab polymerase chain reaction for RV with symptomatic infection. The patients were identified based on the presence of hematologic malignancy, with or without a history of stem cell transplantation (SCT). The patient's clinical notes including age, SCT transplant date, symptoms, chest x-ray, chest computed tomography scan, cancer type, medications, and laboratory values were collected. Results: Among patients with RV infection, 97.5% (78/80) had a mild illness. Of those patients, all had resolution of symptoms by 30 days after the onset of symptoms. A total of 16.25% (13/80) had evidence of pneumonia on imaging studies, and a total of 56.25% (45/80) had evidence of lymphopenia versus only 28.75% (23/80) with evidence of neutropenia. The overall mortality was 2.5% (2/80) with both patients having evidence of coinfection with another pathogen at the time. Conclusions: Our study found that the overall mortality associated with RV was low but that coinfection was rarely associated with mortality. Rhinovirus infection is benign, and patients can proceed to transplant before they clear the virus. Cryptogenic organizing pneumonia may be a rare but serious complication after RV infection, especially after SCT. However, the main cause of morbidity and possible mortality is secondary infections with other viruses, bacteria, or molds.
Background: Rapidly growing mycobacterium (RGM) is a group of ubiquitous organisms mostly found i... more Background: Rapidly growing mycobacterium (RGM) is a group of ubiquitous organisms mostly found in soil and water. In the immunocompromised population, they are considered to be opportunistic and cause systemic illness, which leads to higher mortality. Methods: Our study entailed a retrospective chart review conducted at the Moffitt Cancer Center. The computerized epidemiology report provided by the microbiology laboratory identified patients who had been diagnosed with an RGM infection from January 1990 to October 2008. Results: Of the 45 patients included, 24 were women and 21 were men. The median age of these patients was 58 years. Twenty-one (46.7%) of the 45 patients had a hematologic malignancy consisting of multiple myeloma, acute and chronic leukemia, myelodysplastic syndrome, and lymphoma. We collected data from 10 patients (22.2%) who had breast cancer and five (11.1%) with lung cancer. Eight of the patients (17.8%) had other forms of malignancy consisting of ovarian, thyroid, skin, sinuses, scalp, and gastrointestinal malignancies. Of the 45 cases analyzed, 4 species of RGM were identified including 26 cases (57.8%) of Mycobacterium abscessus, 13 (28.9%) with Mycobacterium fortuitum, two (4.4%) with Mycobacterium chelonae, and two (4.4%) with Mycobacterium mucogenicum. Two patients (4.4%) were diagnosed with Mycobacterium abscessus/chelonae complex. Conclusions: Our study demonstrates the diversity of malignancies associated with RGM infections. We add 45 more documented cases to the current collection of data correlating malignancies and RGM infections. Future research regarding treatment options for RGM infections is much needed due to high levels of resistance and limited treatment options.
We report a case of advanced basal cell carcinoma and cra-nial osteomyelitis. His skull bone seem... more We report a case of advanced basal cell carcinoma and cra-nial osteomyelitis. His skull bone seemed to be destroyed due to osteo-myelitis, and the underlying dura was exposed with a unique color of the wound surface due to pigment-producing bacteria.
Propionibacterium acnes is a pleomorphic, gram-positive organism that is part of the normal skin ... more Propionibacterium acnes is a pleomorphic, gram-positive organism that is part of the normal skin microbiota and lies deeply seated in the pilosebaceous glands, especially those of the scalp and face. After Staphylococcus aureus and Staphylococcus epidermidis, P. acnes is the organism most commonly isolated from wounds following craniotomies. We present the case of a delayed P. acnes brain abscess that mimicked an accompanying recurrent glioblastoma multiforme and that was successfully treated with meropenem. Late onset of P. acnes brain abscess following neurosurgery should be considered in the differential diagnosis of recurrent brain tumors. Magnetic resonance imaging is helpful in distinguishing brain abscess from tumor recurrence. If drainage and high-dose intravenous penicillin or ampicillin treatment prove unsatisfactory, meropenem offers an attractive alternative, providing a good penetration into the cere-brospinal fluid, ready entry into brain abscesses, and a very wide spectrum of antimicrobial activity.
This article on prophylaxis in hematopoietic stem cell transplantation (HSCT) patients is written... more This article on prophylaxis in hematopoietic stem cell transplantation (HSCT) patients is written with the following goals in mind. First of all it is to provide data on the current guidelines for the prophylactic therapy with the evidence-based approach in mind. Secondly, it is to serve as a reference and guide for the health care providers who care for HSCT patients and a reference for the HSCT recipients and their family members. Prophylaxis for the various infections, which are commonly encountered in the HSCT patients, is discussed in this article.
Background. Nutritionally variant Streptococci (NVS), Abiotrophia and Granulicatella are implicat... more Background. Nutritionally variant Streptococci (NVS), Abiotrophia and Granulicatella are implicated in causing endocarditis and blood stream infections more frequently than other sites of infection. Neutropenia and mucositis are the most common predisposing factors for infection with other pathogens in cancer patients. In this study, we investigated the clinical characteristics of NVS bacteremia in cancer patients and identified risk factors and outcomes associated with these infections. Materials and Methods. We retrospectively reviewed all cases of NVS bacteremia occurring from June 1999 to April 2014 at H. Lee Moffitt Cancer Center and Research Institute. The computerized epidemiology report provided by the microbiology laboratory identified thirteen cancer patients with NVS bacteremia. We collected data regarding baseline demographics and clinical characteristics such as age, sex, underlying malignancy, neutropenic status, duration of neutropenia, treatment, and outcome. Results. Thirteen patients were identified with positive NVS blood stream infection. Ten patients (77%) had hematologic malignancies, including chronic lymphocytic leukemia (CLL)(1), multiple myeloma (MM)(1), acute myelogenous leukemia (AML)(4), and non-Hodgkin's lymphoma (NHL)(4). The non-hematologic malignancies included esophageal cancer(2) and bladder cancer (1). Conclusion. NVS should be considered as a possible agent of bacteremia in cancer patients with neutropenia and a breach in oral, gastrointestinal and genitourinary mucosa (gingivitis/mucositis).
The incidence of nontyphoidal Salmonella (NTS) infection is increasing worldwide. It has been wel... more The incidence of nontyphoidal Salmonella (NTS) infection is increasing worldwide. It has been well documented that immunosuppressed patients are vulnerable to severe and invasive NTS infection. T-cell immu-nodeficiency is commonly observed in cancer patients, and cell-mediated immunity is essential in clearing NTS infection and prevention. In this study, we retrospectively reviewed 10 cases at our institution during a 2-year period.
Background: This study examined the characteristics and risk factors associated with non-Candida ... more Background: This study examined the characteristics and risk factors associated with non-Candida fungemia. It is important to diagnose early and distinguish from Candida species because of the high mortality rate in non-Candida yeast fungemia. Materials and Methods: We performed a retrospective analysis of patients with cancer from 1999 to 2014 at Moffitt Cancer Center in Tampa, Florida with a positive blood cultures for non-Candida yeast.Nine patients were identified. Types of malignancy included both hematological and solid tumors. All patients received cytotoxic chemotherapy and were on prophylactic antifungal therapy. Five patients were diagnosed with Trichosporon species. Risk factors included prolonged neutropenia, hematological malignancy, hematopoietic stem cell transplantation (HSCT), chemotherapy and immunosuppressive therapy. We found a very high mortality rate in patients with non-Candida yeast fungemia with refractory and end-stage cancer. This demonstrated the need for early identification of non-Candida fungemia. In addition, many of these patients had prolonged neutropenia and a refractory malignancy as significant risk factors. Results: There were 9 patients with positive blood cultures for non-Candida yeasts in our study. The most common non-Candida yeasts were Trichosporon species. The majority of the patients had a hematological malignancy. All patients received cytotoxic chemotherapy, and most of them were refractory to treatment with end-stage hematological malignancy. Prolonged neutropenia was found in the majority of the patients receiving chemotherapy. All patients were receiving potent antifungal therapy, such as liposomal amphotericin B, micafungin, posaconazole, or voriconazole, either alone or in combination, when breakthrough infection occurred. The central venous catheter was removed in all patients. However, prolonged fungemia persisted in all patients despite removal. We found a very high mortality rate in patients with non-Candida yeast fungemia with refractory malignancy. Yeast-related sepsis was the cause of death in most of the patients. Ongoing neutropenia was found at the time of death in most of the patients with yeast-related death. Conclusions: Non-Candida yeast fungemia is rare but associated with significant mortality. They usually occurred as breakthrough fungemia while on antifungal prophylaxis. Thus, in vitro susceptibility testing should be performed on all isolates, and antifungal therapy should be modified or broadened pending identification and susceptibly results. Without resolution of neutropenia and oncologic control of the malignancy, outcomes are poor.
NF-κB essential modulator (NEMO) is a kinase integral to the macrophage TNF-α pathway, which lead... more NF-κB essential modulator (NEMO) is a kinase integral to the macrophage TNF-α pathway, which leads to the intracellular destruction of Mycobacteria species. Defects in the NEMO pathway result in spectrum of diseases, including but not limited to ectodermal dysplasia, Mendelian susceptibility to mycobacterial diseases, and incontinentia pigmenti. In addition, paucity of NEMO can lead to the inability to mount a proper immune response against opportunistic pyogenic and mycobacterial infections, leading to dissemination to various organ systems. This manuscript will discuss the numerous clinical manifestations of NEMO deficiency, the differential diagnosis of atypical mycobacterial infections in immunocompetent adults, and feature a case report of rare isolated susceptibility to disseminated atypical mycobacteria due to a mutation in the first exon of the NEMO gene.
Background: Opportunistic fungal infections caused by Aspergillus and Candida followed by infecti... more Background: Opportunistic fungal infections caused by Aspergillus and Candida followed by infections with Fusarium, Rhizopus, Mucor, and Alternaria species are an important cause of morbidity and mortality in patients with hematological malignancies. Cutaneous mucormycosis infections are rare, and the incidence, outcomes, and factors associated with survival in the setting of hematological malignancies are not clear. Methods: A literature search was conducted for all cases of primary cutaneous mold infections in patients with hematological malignancy, of which 50 cases were found. Our case of a patient with a hematological malignancy who sustained a cat bite that in turn caused a primary cutaneous mold infection is also included. Results: In the 51 cases identified, 66.7% were neutropenic upon presentation, and 54.9% were male with an average age of 32 years. Aspergillus species (33.3%) was the most cited followed by Rhizopus species (19.6%). Overall mortality rate was 29.4% and was observed more frequently in patients with neutropenia (60.0%) and without surgical intervention (73.3%). Survival rate was higher (35.3%) for cases utilizing both antifungal and surgical intervention. The antifungal agent with the highest survival rate was amphotericin B and its formulations (58.8%). Conclusions: Neutropenia within hematological malignancies demonstrate a risk for developing severe cutane-ous fungal infections, of which primary cutaneous mucormycosis can carry significant mortality. Combination antifungal therapy and surgical debridement appears to be associated with higher survival outcomes and warrants further investigation.
Worldwide, marijuana (cannabis) is a widely used drug. The incidence of marijuana smoking is incr... more Worldwide, marijuana (cannabis) is a widely used drug. The incidence of marijuana smoking is increasing and is second only to tobacco as the most widely smoked substance in the general population. It is also the second most commonly used recreational drug after alcohol. Some adverse effects of marijuana smoking have been documented; however, the number of studies on the pulmonary effects of marijuana in individuals with leukemia is limited. In our case series, we report on 2 men with acute myeloid leukemia with miliary nodular lung patterns on computed tomography of the chest due to heavy marijuana use. We also report on 2 patients with acute lymphocytic leukemia who had a history of smoking marijuana and then developed lung opacities consistent with mold infection.
A 35-year-old woman sought care for a fever and sore throat that she'd had for 4 days. She denied... more A 35-year-old woman sought care for a fever and sore throat that she'd had for 4 days. She denied symptoms of cough, rhinorrhea, or sputum production. The patient's medical history included severe recurrent streptococcal pharyngitis as a child and teenager. At the age of 17, she developed a fever of 105° F with associated delirium, dysphagia, nausea, and vomiting, and missed several days of school. She also lost 82 pounds, developed oral thrush, and continued to feel fatigued for approximately a year. After her primary care physician noted a heart murmur on physical exam, she was sent for echocardiog-raphy and diagnosed with rheumatic fever secondary to streptococcal pharyngitis. Eighteen years (and numerous streptococcal infections) later, the patient was at our facility and we were ordering a rapid antigen detection test (RADT) for her current illness. The throat specimen was positive for group A ß-hemolytic streptococcus (GAS). The patient's 8-year-old daughter also had a sore throat, fever, and positive RADT; her symptoms resolved with oral amoxicillin for 10 days. The patient's husband was also treated successfully with oral amoxicillin/clavulanate for 10 days for similar symptoms. The patient herself, however, was unsuccessfully treated with oral amoxicillin 500 mg twice daily for 7 days. She was then given oral amoxicillin/clavulanate 875 mg twice daily for 14 days, but received no relief. Even after receiving clindamycin 600 mg twice daily for 10 days, she had minimal relief and remained positive for GAS on repeat RADT. It was at this point that tonsillectomy was considered as a possible treatment modality for her refractory GAS pharyngitis. ❚ The patient consented to the procedure and underwent a tonsillectomy. She has remained asymptomatic for 2 years and there have been no reported outbreaks of GAS infection in her household. DISCUSSION Streptococcal pharyngitis is an infection of the oropharynx and/or nasopharynx that is caused by Streptococcus pyogenes (also known as GAS). It is one of the most frequent illnesses encountered by primary care physicians, and primarily occurs in children ages 5 to 15 years. 1,2 The signs and symptoms of GAS pharyngitis include an abrupt onset of a sore throat, tonsillar exudate, tender cervical adenopathy, and fever. (The classic presentation of GAS pharyngitis in a different patient can be seen in the FIGURE.) ❚ Throat cultures are the gold standard for the diagnosis of GAS pharyngitis, but results take 24 to 48 hours, which can delay appropriate treatment. Therefore, the use of the RADT is often preferred clinically. 1 RADT is not recommended for children and adults who show clinical symptoms that are highly suggestive of a viral illness, such as cough, rhinor-rhea, hoarseness, or oral ulcers. A negative RADT in children and adolescents necessitates a throat culture to confirm the diagnosis.
In the past decades, viridans group Streptococci (VGS) have emerged as an important cause of bact... more In the past decades, viridans group Streptococci (VGS) have emerged as an important cause of bacteremia in neutropenic patients with cancer. The clinical course of VGS bacteremia can be devastating including septic shock and adult respiratory distress syndrome (ARDS). It has been suggested that septicemia with VGS triggers the development of noncardiogenic pulmonary edema in patients with pre-existing damage of the lungs due to aggressive cytotoxic treatment.
Thus, the preemptive administration of corticosteroid to patients diagnosed with VGS bacteremia with early onset of respiratory failure has been employed to prevent ARDS. While this management strategy has been suggested in the literature, little published data are available to validate this practice. In this study, we sought to review the benefit of early administration of corticosteroid to patients who developed symptom or early signs of respiratory failure while being neutropenic with VGS bacteremia.
The use of hematopoietic stem cell transplant (HSCT) for the treatment of hematological malignanc... more The use of hematopoietic stem cell transplant (HSCT) for the treatment of hematological malignancies has continued to grow over the last 10 years. The development of new treatment strategies has minimized the severity and duration of immune suppression following transplantation. This article will review the management and challenges of the most common encountered infections after HSCT.
Of the 3 main soil-associated bacteria, Nocardia, Actinomyces, and Streptomyces, the latter is th... more Of the 3 main soil-associated bacteria, Nocardia, Actinomyces, and Streptomyces, the latter is the least well known. It rarely causes infection in humans. The most common infection with Streptomyces is myce-toma acquired through traumatic inoculation. Even less common is Streptomyces infection without direct soil exposure. The focus of our study is Streptomyces infections in immunocompromised patients with cancer.
Obesity is currently one of the most common chronic diseases and has become a major health concer... more Obesity is currently one of the most common chronic diseases and has become a major health concern in Western countries. Consequently, rise of bariatric surgery nationwide, has been increasing. The Roux-en-Y gastric bypass (RYGB) is a type of surgery indicated in the treatment of morbid obesity. At our institution, we report a case of a 48-year-old female with a history of morbid obesity, who underwent RYGB 13 years ago for weight loss, and was admitted to the hospital for abdominal pain. Upper endoscopy then revealed small bowl cancer.
Secondary syphilis has been known since the late 19th century as the great imitator; however, som... more Secondary syphilis has been known since the late 19th century as the great imitator; however, some experts now regard cutaneous lymphoma as the great imitator of skin disease. Either disease, at times an equally fastidious diagnosis, has reported to mimic each other even. It is thus vital to consider these possibilities when presented with a patient demonstrating peculiar skin lesions. No other manifestation of secondary syphilis may pose such quandary as a rare case of rupioid syphilis impersonating cutaneous lymphoma. We present such a case, of a 36-year-old HIV positive male, misdiagnosed with aggressive cutaneous lymphoma, actually exhibiting rupioid syphilis thought secondary to immune reconstitution inflammatory syndrome (IRIS).
Background: New research on rhinovirus (RV) has elevated the role of the virus as a significant c... more Background: New research on rhinovirus (RV) has elevated the role of the virus as a significant contributor to respiratory complications in immunocompromised patients. Although RV has been implicated to cause morbidity and mortality in immunocompromised patients, its role has been difficult to characterize due to a limited availability of conventional diagnostics. Recent developments in polymerase chain reaction techniques have enabled better detection of RV and thus a means to better study its impact on immunocompromised patients.
Materials and Methods: We performed a retrospective analysis of patients with hematologic malignancy at the Moffitt Cancer Center in Tampa, Fla, with a positive nasopharyngeal swab polymerase chain reaction for RV with symptomatic infection. The patients were identified based on the presence of hematologic malignancy, with or without a history of stem cell transplantation (SCT). The patient's clinical notes including age, SCT transplant date, symptoms, chest x-ray, chest computed tomography scan, cancer type, medications, and laboratory values were collected. Results: Among patients with RV infection, 97.5% (78/80) had a mild illness. Of those patients, all had resolution of symptoms by 30 days after the onset of symptoms. A total of 16.25% (13/80) had evidence of pneumonia on imaging studies, and a total of 56.25% (45/80) had evidence of lymphopenia versus only 28.75% (23/80) with evidence of neutropenia. The overall mortality was 2.5% (2/80) with both patients having evidence of coinfection with another pathogen at the time. Conclusions: Our study found that the overall mortality associated with RV was low but that coinfection was rarely associated with mortality. Rhinovirus infection is benign, and patients can proceed to transplant before they clear the virus. Cryptogenic organizing pneumonia may be a rare but serious complication after RV infection, especially after SCT. However, the main cause of morbidity and possible mortality is secondary infections with other viruses, bacteria, or molds.
Background: Rapidly growing mycobacterium (RGM) is a group of ubiquitous organisms mostly found i... more Background: Rapidly growing mycobacterium (RGM) is a group of ubiquitous organisms mostly found in soil and water. In the immunocompromised population, they are considered to be opportunistic and cause systemic illness, which leads to higher mortality. Methods: Our study entailed a retrospective chart review conducted at the Moffitt Cancer Center. The computerized epidemiology report provided by the microbiology laboratory identified patients who had been diagnosed with an RGM infection from January 1990 to October 2008. Results: Of the 45 patients included, 24 were women and 21 were men. The median age of these patients was 58 years. Twenty-one (46.7%) of the 45 patients had a hematologic malignancy consisting of multiple myeloma, acute and chronic leukemia, myelodysplastic syndrome, and lymphoma. We collected data from 10 patients (22.2%) who had breast cancer and five (11.1%) with lung cancer. Eight of the patients (17.8%) had other forms of malignancy consisting of ovarian, thyroid, skin, sinuses, scalp, and gastrointestinal malignancies. Of the 45 cases analyzed, 4 species of RGM were identified including 26 cases (57.8%) of Mycobacterium abscessus, 13 (28.9%) with Mycobacterium fortuitum, two (4.4%) with Mycobacterium chelonae, and two (4.4%) with Mycobacterium mucogenicum. Two patients (4.4%) were diagnosed with Mycobacterium abscessus/chelonae complex. Conclusions: Our study demonstrates the diversity of malignancies associated with RGM infections. We add 45 more documented cases to the current collection of data correlating malignancies and RGM infections. Future research regarding treatment options for RGM infections is much needed due to high levels of resistance and limited treatment options.
We report a case of advanced basal cell carcinoma and cra-nial osteomyelitis. His skull bone seem... more We report a case of advanced basal cell carcinoma and cra-nial osteomyelitis. His skull bone seemed to be destroyed due to osteo-myelitis, and the underlying dura was exposed with a unique color of the wound surface due to pigment-producing bacteria.
Propionibacterium acnes is a pleomorphic, gram-positive organism that is part of the normal skin ... more Propionibacterium acnes is a pleomorphic, gram-positive organism that is part of the normal skin microbiota and lies deeply seated in the pilosebaceous glands, especially those of the scalp and face. After Staphylococcus aureus and Staphylococcus epidermidis, P. acnes is the organism most commonly isolated from wounds following craniotomies. We present the case of a delayed P. acnes brain abscess that mimicked an accompanying recurrent glioblastoma multiforme and that was successfully treated with meropenem. Late onset of P. acnes brain abscess following neurosurgery should be considered in the differential diagnosis of recurrent brain tumors. Magnetic resonance imaging is helpful in distinguishing brain abscess from tumor recurrence. If drainage and high-dose intravenous penicillin or ampicillin treatment prove unsatisfactory, meropenem offers an attractive alternative, providing a good penetration into the cere-brospinal fluid, ready entry into brain abscesses, and a very wide spectrum of antimicrobial activity.
This article on prophylaxis in hematopoietic stem cell transplantation (HSCT) patients is written... more This article on prophylaxis in hematopoietic stem cell transplantation (HSCT) patients is written with the following goals in mind. First of all it is to provide data on the current guidelines for the prophylactic therapy with the evidence-based approach in mind. Secondly, it is to serve as a reference and guide for the health care providers who care for HSCT patients and a reference for the HSCT recipients and their family members. Prophylaxis for the various infections, which are commonly encountered in the HSCT patients, is discussed in this article.
Background. Nutritionally variant Streptococci (NVS), Abiotrophia and Granulicatella are implicat... more Background. Nutritionally variant Streptococci (NVS), Abiotrophia and Granulicatella are implicated in causing endocarditis and blood stream infections more frequently than other sites of infection. Neutropenia and mucositis are the most common predisposing factors for infection with other pathogens in cancer patients. In this study, we investigated the clinical characteristics of NVS bacteremia in cancer patients and identified risk factors and outcomes associated with these infections. Materials and Methods. We retrospectively reviewed all cases of NVS bacteremia occurring from June 1999 to April 2014 at H. Lee Moffitt Cancer Center and Research Institute. The computerized epidemiology report provided by the microbiology laboratory identified thirteen cancer patients with NVS bacteremia. We collected data regarding baseline demographics and clinical characteristics such as age, sex, underlying malignancy, neutropenic status, duration of neutropenia, treatment, and outcome. Results. Thirteen patients were identified with positive NVS blood stream infection. Ten patients (77%) had hematologic malignancies, including chronic lymphocytic leukemia (CLL)(1), multiple myeloma (MM)(1), acute myelogenous leukemia (AML)(4), and non-Hodgkin's lymphoma (NHL)(4). The non-hematologic malignancies included esophageal cancer(2) and bladder cancer (1). Conclusion. NVS should be considered as a possible agent of bacteremia in cancer patients with neutropenia and a breach in oral, gastrointestinal and genitourinary mucosa (gingivitis/mucositis).
The incidence of nontyphoidal Salmonella (NTS) infection is increasing worldwide. It has been wel... more The incidence of nontyphoidal Salmonella (NTS) infection is increasing worldwide. It has been well documented that immunosuppressed patients are vulnerable to severe and invasive NTS infection. T-cell immu-nodeficiency is commonly observed in cancer patients, and cell-mediated immunity is essential in clearing NTS infection and prevention. In this study, we retrospectively reviewed 10 cases at our institution during a 2-year period.
Background: This study examined the characteristics and risk factors associated with non-Candida ... more Background: This study examined the characteristics and risk factors associated with non-Candida fungemia. It is important to diagnose early and distinguish from Candida species because of the high mortality rate in non-Candida yeast fungemia. Materials and Methods: We performed a retrospective analysis of patients with cancer from 1999 to 2014 at Moffitt Cancer Center in Tampa, Florida with a positive blood cultures for non-Candida yeast.Nine patients were identified. Types of malignancy included both hematological and solid tumors. All patients received cytotoxic chemotherapy and were on prophylactic antifungal therapy. Five patients were diagnosed with Trichosporon species. Risk factors included prolonged neutropenia, hematological malignancy, hematopoietic stem cell transplantation (HSCT), chemotherapy and immunosuppressive therapy. We found a very high mortality rate in patients with non-Candida yeast fungemia with refractory and end-stage cancer. This demonstrated the need for early identification of non-Candida fungemia. In addition, many of these patients had prolonged neutropenia and a refractory malignancy as significant risk factors. Results: There were 9 patients with positive blood cultures for non-Candida yeasts in our study. The most common non-Candida yeasts were Trichosporon species. The majority of the patients had a hematological malignancy. All patients received cytotoxic chemotherapy, and most of them were refractory to treatment with end-stage hematological malignancy. Prolonged neutropenia was found in the majority of the patients receiving chemotherapy. All patients were receiving potent antifungal therapy, such as liposomal amphotericin B, micafungin, posaconazole, or voriconazole, either alone or in combination, when breakthrough infection occurred. The central venous catheter was removed in all patients. However, prolonged fungemia persisted in all patients despite removal. We found a very high mortality rate in patients with non-Candida yeast fungemia with refractory malignancy. Yeast-related sepsis was the cause of death in most of the patients. Ongoing neutropenia was found at the time of death in most of the patients with yeast-related death. Conclusions: Non-Candida yeast fungemia is rare but associated with significant mortality. They usually occurred as breakthrough fungemia while on antifungal prophylaxis. Thus, in vitro susceptibility testing should be performed on all isolates, and antifungal therapy should be modified or broadened pending identification and susceptibly results. Without resolution of neutropenia and oncologic control of the malignancy, outcomes are poor.
NF-κB essential modulator (NEMO) is a kinase integral to the macrophage TNF-α pathway, which lead... more NF-κB essential modulator (NEMO) is a kinase integral to the macrophage TNF-α pathway, which leads to the intracellular destruction of Mycobacteria species. Defects in the NEMO pathway result in spectrum of diseases, including but not limited to ectodermal dysplasia, Mendelian susceptibility to mycobacterial diseases, and incontinentia pigmenti. In addition, paucity of NEMO can lead to the inability to mount a proper immune response against opportunistic pyogenic and mycobacterial infections, leading to dissemination to various organ systems. This manuscript will discuss the numerous clinical manifestations of NEMO deficiency, the differential diagnosis of atypical mycobacterial infections in immunocompetent adults, and feature a case report of rare isolated susceptibility to disseminated atypical mycobacteria due to a mutation in the first exon of the NEMO gene.
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Thus, the preemptive administration of corticosteroid to patients diagnosed with VGS bacteremia with early onset of respiratory failure has been employed to prevent ARDS. While this management strategy has been suggested in the literature, little published data are available to validate this practice. In this study, we sought to review the benefit of early administration of corticosteroid to patients who developed symptom or early signs of respiratory failure while being neutropenic with VGS bacteremia.
Materials and Methods: We performed a retrospective analysis of patients with hematologic malignancy at the Moffitt Cancer Center in Tampa, Fla, with a positive nasopharyngeal swab polymerase chain reaction for RV with symptomatic infection. The patients were identified based on the presence of hematologic malignancy, with or without a history of stem cell transplantation (SCT). The patient's clinical notes including age, SCT transplant date, symptoms, chest x-ray, chest computed tomography scan, cancer type, medications, and laboratory values were collected. Results: Among patients with RV infection, 97.5% (78/80) had a mild illness. Of those patients, all had resolution of symptoms by 30 days after the onset of symptoms. A total of 16.25% (13/80) had evidence of pneumonia on imaging studies, and a total of 56.25% (45/80) had evidence of lymphopenia versus only 28.75% (23/80) with evidence of neutropenia. The overall mortality was 2.5% (2/80) with both patients having evidence of coinfection with another pathogen at the time. Conclusions: Our study found that the overall mortality associated with RV was low but that coinfection was rarely associated with mortality. Rhinovirus infection is benign, and patients can proceed to transplant before they clear the virus. Cryptogenic organizing pneumonia may be a rare but serious complication after RV infection, especially after SCT. However, the main cause of morbidity and possible mortality is secondary infections with other viruses, bacteria, or molds.
The computerized epidemiology report provided by the microbiology laboratory identified patients who had been diagnosed with an RGM infection from January 1990 to October 2008. Results: Of the 45 patients included, 24 were women and 21 were men. The median age of these patients was 58 years. Twenty-one (46.7%) of the 45 patients had a hematologic malignancy consisting of multiple myeloma, acute and chronic leukemia, myelodysplastic syndrome, and lymphoma. We collected data from 10 patients (22.2%) who had breast cancer and five (11.1%) with lung cancer. Eight of the patients (17.8%) had other forms of malignancy consisting of ovarian, thyroid, skin, sinuses, scalp, and gastrointestinal malignancies. Of the 45 cases analyzed, 4 species of RGM were identified including 26 cases (57.8%) of Mycobacterium abscessus, 13 (28.9%) with Mycobacterium fortuitum, two (4.4%) with Mycobacterium chelonae, and two (4.4%) with Mycobacterium mucogenicum. Two patients (4.4%) were diagnosed with Mycobacterium abscessus/chelonae complex. Conclusions: Our study demonstrates the diversity of malignancies associated with RGM infections. We add 45 more documented cases to the current collection of data correlating malignancies and RGM infections. Future research regarding treatment options for RGM infections is much needed due to high levels of resistance and limited treatment options.
Prophylaxis for the various infections, which are commonly encountered in the HSCT patients, is discussed in this article.
Thus, the preemptive administration of corticosteroid to patients diagnosed with VGS bacteremia with early onset of respiratory failure has been employed to prevent ARDS. While this management strategy has been suggested in the literature, little published data are available to validate this practice. In this study, we sought to review the benefit of early administration of corticosteroid to patients who developed symptom or early signs of respiratory failure while being neutropenic with VGS bacteremia.
Materials and Methods: We performed a retrospective analysis of patients with hematologic malignancy at the Moffitt Cancer Center in Tampa, Fla, with a positive nasopharyngeal swab polymerase chain reaction for RV with symptomatic infection. The patients were identified based on the presence of hematologic malignancy, with or without a history of stem cell transplantation (SCT). The patient's clinical notes including age, SCT transplant date, symptoms, chest x-ray, chest computed tomography scan, cancer type, medications, and laboratory values were collected. Results: Among patients with RV infection, 97.5% (78/80) had a mild illness. Of those patients, all had resolution of symptoms by 30 days after the onset of symptoms. A total of 16.25% (13/80) had evidence of pneumonia on imaging studies, and a total of 56.25% (45/80) had evidence of lymphopenia versus only 28.75% (23/80) with evidence of neutropenia. The overall mortality was 2.5% (2/80) with both patients having evidence of coinfection with another pathogen at the time. Conclusions: Our study found that the overall mortality associated with RV was low but that coinfection was rarely associated with mortality. Rhinovirus infection is benign, and patients can proceed to transplant before they clear the virus. Cryptogenic organizing pneumonia may be a rare but serious complication after RV infection, especially after SCT. However, the main cause of morbidity and possible mortality is secondary infections with other viruses, bacteria, or molds.
The computerized epidemiology report provided by the microbiology laboratory identified patients who had been diagnosed with an RGM infection from January 1990 to October 2008. Results: Of the 45 patients included, 24 were women and 21 were men. The median age of these patients was 58 years. Twenty-one (46.7%) of the 45 patients had a hematologic malignancy consisting of multiple myeloma, acute and chronic leukemia, myelodysplastic syndrome, and lymphoma. We collected data from 10 patients (22.2%) who had breast cancer and five (11.1%) with lung cancer. Eight of the patients (17.8%) had other forms of malignancy consisting of ovarian, thyroid, skin, sinuses, scalp, and gastrointestinal malignancies. Of the 45 cases analyzed, 4 species of RGM were identified including 26 cases (57.8%) of Mycobacterium abscessus, 13 (28.9%) with Mycobacterium fortuitum, two (4.4%) with Mycobacterium chelonae, and two (4.4%) with Mycobacterium mucogenicum. Two patients (4.4%) were diagnosed with Mycobacterium abscessus/chelonae complex. Conclusions: Our study demonstrates the diversity of malignancies associated with RGM infections. We add 45 more documented cases to the current collection of data correlating malignancies and RGM infections. Future research regarding treatment options for RGM infections is much needed due to high levels of resistance and limited treatment options.
Prophylaxis for the various infections, which are commonly encountered in the HSCT patients, is discussed in this article.