Mycobacterium chelonae is a rapidly growing mycobacterium found in water and soil that can cause local cutaneous infections in immunocompetent hosts but more frequently affects immunocompromised patients. Typically, patients will present with painful subcutaneous nodules of the joints or soft tissues from traumatic inoculation. However, exhibiting a sporotrichoid-like pattern of these nodules is uncommon. Herein, we report a case of sporotrichoid-like distribution of cutaneous Mycobacterium chelonae in a patient with systemic lupus erythematosus on significant immunosuppressive medications. Clinicians treating immunocompromised patients should be cognizant of their propensity to develop unusual infections and atypical presentations.

Majocchi's granuloma is a rare condition in which a dermatophyte invades the deeper layers of the dermis and subcutaneous tissue and can often be misidentified and treated as eczema. It has a variable presentation ranging from cutaneous lesions to deeper infections in immunocompromised patients. No prior cases have described the formation of Majocchi's granuloma with the deuteromycetes, Malabranchea.

Infective endocarditis due to Gram-negative, non-HACEK bacteria is a rare clinical entity. Even moreso, isolated pulmonic valve endocarditis accounts for less than 1.5–2% of all cases of infective endocarditis. These disease pathologies commonly occur in the setting of intravenous drug abuse, indwelling catheters or cardiac devices, or underlying structural heart disease. We present a unique case of pulmonic valve endocarditis in the setting of persistent polymicrobial bacteremia with Klebsiella pneumoniae and Citrobacter koseri with recent gastrointestinal instrumentation evolving into isolated pulmonic valve endocarditis.

We report a 63-year-old woman who presented with 1 month of non-productive cough and non-bloody diarrhea. She was on maintenance therapy for a 15-year history of Crohn's disease. Treatment with systemic corticosteroids resulted in rapid improvement of both her diarrhea and respiratory symptoms. Our patient is unique in that she presented with tracheobronchitis during an acute flare of her Crohn's without obvious lung pathology on chest imaging. Tracheobronchitis is a rare manifestation of inflammatory bowel disease that should be considered in Crohn's disease patients presenting with persistent non-infectious cough.

BackgroundHepatitis B virus (HBV) reactivation is a common complication in the treatment of oncology patients when using anti-CD20 monoclonal antibodies (MABs) such as rituximab, obinituzumab, and ofatumumab. In such patients, the reaction of HBV is seen in up to 70% who are HBV DNA positive. Antiviral therapy in high-risk patients has been shown to improve outcomes.MethodsThis retrospective review evaluated patients at Thomas Jefferson University Hospital who received rituximab, obinituzumab, or ofatumumab as a component of hematologic malignancy therapy between 2013 and 2016. We determined the number of patients who had appropriate HBV testing prior to therapy, the number who received appropriate antiviral therapy, and the number who developed reactivation of HBV and their outcomes.Results402 patients received one of the above anti-CD20 MABs between November 2013 and December 2016. Of these 402 patients, 52 (13.4%) did not have either HBsAg or HBcAb performed prior to anti-CD20 therapy. 39 (9.7%) patients had positive HBsAg or HBcAb prior to therapy. Of these 39 highrisk patients, only 16/39 (41.3%) were placed on appropriate antiviral therapy. Two of the 39 high-risk patients (5.1%), who were not started on antiviral therapy, developed HBV reactivation as a complication of anti-CD20 MAB therapy.ConclusionA significant number of patients were not appropriately screened with HBV markers prior to anti-CD20 therapy for hematologic malignancies at our institution. In addition, less than half of highrisk HBV patients received appropriate antiviral therapy. System-wide changes are anticipated to improve this process at our institution.Disclosures All authors: No reported disclosures.

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A 59-year-old woman with a status of post–renal transplant 7 years prior for autosomal dominant polycystic kidney disease on tacrolimus and mycophenolate mofetil presented with subacute left knee and right wrist pain. She received local steroid injections to both areas as an outpatient without improvement in her symptoms. She had recently traveled to India, her home country, to visit relatives. Aspiration of the knee revealed 4+ acid fast bacilli on smear, and she was taken for surgical debridement. She was started on empiric antibiotics for presumed infection with rapidly growing mycobacteria. Her course was complicated by acute onset abdominal pain with pneumoperitoneum and mesenteric abscess on imaging, requiring exploratory laparotomy. Surgical cultures from all sites were positive for Mycobacterium tuberculosis. Her medications were adjusted to rifabutin, isoniazid, pyrazinamide, and ethambutol. Pretransplant screening results were unknown. She was discharged in stable condition and completed 12 months of medical therapy.

This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in The Medicine Forum by an authorized administrator of the Jefferson Digital Commons.