Once a Known Veterinary Pathogen, Now a Forgotten Zoonosis. Case Report of An Invasive Staphylococcus intermedius Group Infection

We describe the case of a 66-year-old man who was admitted to the Emergency Department with high fever, urinary incontinence, asthenia, and altered mental status characterized by drowsiness and lethargy from the previous night. The head CT scan was negative, while the chest X-ray showed a right basal reduced transparency and solitary pulmonary nodules already known and considered as expression of asbestosis. No acute neurological signs were observed by the consultant neurologist. A diagnosis of right basal pneumonia complicated by delirium was made and an empiric antibiotic therapy with ceftriaxone plus azithromycin was started. As patient’s conditions did not improve in the following 48 hours, a lumbar puncture was performed, with the microbiological isolation of L. monocytogenes. According to the indications of the infectious disease consultant, a new antibiotic regimen with ampicillin/sulbactam plus gentamicin was introduced. The chest CT scan performed as further examination revealed right pleural thickening highly suspicious for mesothelioma. The patient was discharged after 4 weeks with no neurological deficits.

Context.Polyacrylamide hydrogel (PAAG) has gained importance as a synthetic soft tissue filling agent. It has been commonly employed by physicians in Europe for facial contouring and soft tissue augmentation. Previously, PAAG is considered nontoxic and well tolerated with a few mild procedural complications.Case Presentation.A 26-year-old female was hospitalized for dry cough, worsening dyspnea, and chest discomfort after 3 hours of multiple PAAG injections in buttocks. The patient’s condition deteriorated and rapidly advanced to acute respiratory failure. Therein, the diagnosis of nonthrombotic pulmonary embolism (NTPE) was established on standard set of investigations. She was intubated; corticosteroid and empiric antibiotic therapy was initiated resulting in improvement of her condition. Subsequently, extubation was done, and she was discharged from the hospital after an uneventful recovery. On 1-month follow-up, the patient had no previous symptoms.Conclusion.This report implicates clinicians to maintain a high index of suspicion for NTPE in patients presenting with respiratory symptoms following PAAG usage.

Staphylococcuspseudintermediusis a coagulase-positive species that colonizes the nares and anal mucosa of healthy dogs and cats. Human infections withS. pseudintermediusrange in severity from bite wounds and rhinosinusitis to endocarditis; historically, these infections were thought to be uncommon, but new laboratory methods suggest that their true incidence is underreported. Oxacillin and cefoxitin disk and MIC tests were evaluated for the detection ofmecA- ormecC-mediated methicillin resistance in 115 human and animal isolates of theStaphylococcus intermediusgroup (SIG), including 111Staphylococcuspseudintermediusand 4Staphylococcusdelphiniisolates, 37 of which weremecApositive. The disk and MIC breakpoints evaluated included the Clinical and Laboratory Standards Institute (CLSI) M100-S25Staphylococcus aureus/Staphylococcuslugdunensisoxacillin MIC breakpoints and cefoxitin disk and MIC breakpoints, the CLSI M100-S25 coagulase-negativeStaphylococcus(CoNS) oxacillin MIC breakpoint and cefoxitin disk breakpoint, the CLSI VET01-S2S. pseudintermediusoxacillin MIC and disk breakpoints, and the European Committee on Antimicrobial Susceptibility Testing (EUCAST)S. pseudintermediuscefoxitin disk breakpoint. The oxacillin results interpreted by the VET01-S2 (disk and MIC) and M100-S25 CoNS (MIC) breakpoints agreed with the results ofmecA/mecCPCR for all isolates, with the exception of one false-resistant result (1.3% ofmecA/mecCPCR-negative isolates). In contrast, cefoxitin tests performed poorly, ranging from 3 to 89% false susceptibility (very major errors) and 0 to 48% false resistance (major errors). BD Phoenix, bioMérieux Vitek 2, and Beckman Coulter MicroScan commercial automated susceptibility test panel oxacillin MIC results were also evaluated and demonstrated >95% categorical agreement withmecA/mecCPCR results if interpreted by using the M100-S25 CoNS breakpoint. The Alere penicillin-binding protein 2a test accurately detected allmecA-positive isolates, although for four isolates, cefoxitin induction was required prior to testing. These data demonstrate that the cefoxitin surrogate test does not reliably detect the presence ofmecAinS. pseudintermediusisolates and that laboratories should perform oxacillin disk or MIC tests of these isolates when they are encountered.

Disseminated toxoplasmosis is an uncommon but highly lethal cause of hyperferritinemic sepsis after hematopoietic cell transplantation (HCT). We report two cases of disseminated toxoplasmosis from two centers in critically ill adolescents after HCT: a 19-year-old who developed fever and altered mental status on day +19 after HCT and a 20-year-old who developed fever and diarrhea on day +52 after HCT. Both patients developed hyperferritinemia with multiple organ dysfunction syndrome and profound immune dysregulation, which progressed to death despite maximal medical therapies. Because disseminated toxoplasmosis is both treatable and challenging to diagnose, it is imperative that intensivists maintain a high index of suspicion for Toxoplasma gondii infection when managing immunocompromised children, particularly in those with known positive T. gondii serologies.

Prevalence of haemoglobin sickle-β+ thalassaemia (Hb S/β+thal) is variable with geography ranging from 0.2% to 10% among sickle cell patients. Clinical presentation of Hb S/β+thal patients depends on HbA level, with milder disease often going undiagnosed. However, rarely these patients can present with a fulminant vaso-occlusive crisis (VOC). Given VOC can present with non-specific symptoms, the diagnosis and treatment is often delayed. Here, we present a patient who initially developed altered mental status, pancytopenia and multiorgan failure due a critical VOC resulting in bone marrow necrosis and fat embolism. Subsequent workup confirmed that our patient had Sickle-β+ thalassaemia, which had gone undiagnosed, despite subclinical evidence of haemolysis on routine lab work for years. Following diagnosis and initiation of RBC exchange, he improved significantly and was discharged home. High index of suspicion and bone marrow biopsy is vital for early diagnosis and management of this rare condition.

Abstract Background Hypoglycemia usually includes various neurological symptoms, which are the consequence of neuroglycopenia. When it is severe, it is associated with altered mental status, even coma. Case presentation We report the case of a patient with severe hypoglycemia, completely asymptomatic, due to the increase of lactate production in response to tissue hypoperfusion following a hemorrhagic shock. This illustrates that lactate can substitute glucose as an energy substrate for the brain. It is also a reminder that this metabolite, despite its bad reputation maintained by its role as a marker of severity in critical care patients, has a fundamental role in our metabolism. Conclusions Following the example of the “happy hypoxemia” recently reported in the literature describing asymptomatic hypoxemia in COVID-19 patients, we describe a case of “happy hypoglycemia.”

Abstract Background Coronavirus disease (COVID-19) presents in children usually with less severe manifestations than in adults. Although fever and cough were reported as the most common symptoms, children can have non-specific symptoms. We describe an infant with aplastic anemia as the main manifestation. Case presentation We describe a case of SARS-CoV-2 infection in an infant without any respiratory symptoms or signs while manifesting principally with pallor and purpura. Pancytopenia with reticulocytopenia was the predominant feature in the initial laboratory investigations, pointing to aplastic anemia. Chest computed tomography surprisingly showed typical findings suggestive of SARS-CoV-2 infection. Infection was later confirmed by positive real-time reverse transcription polymerase chain reaction assay (RT-PCR) for SARS-CoV-2. Conclusions Infants with COVID-19 can have non-specific manifestations and a high index of suspicion should be kept in mind especially in regions with a high incidence of the disease. Chest computed tomography (CT) and testing for SARS-CoV-2 infection by RT-PCR may be considered even in the absence of respiratory manifestations.