INTRODUCTION: Rhinocerebral mucormycosis is a fatal infection in poorly controlled diabetic patients with a history of diabetic ketoacidosis (DKA). DKA blunts neutrophil chemotaxis, phagocytosis and boosts serum iron, a mucor nutrient. It spreads to the brain via the hematogenous or contiguous spread [1]. We present a case of disseminated rhinocerebral mucormycosis in a diabetic patient on treatment with a combination antifungal regimen CASE PRESENTATION: A 22-year-old poorly controlled diabetic with a hemoglobin A1c of 14.1% was admitted to an outside hospital for a week of chest pain, dyspnea, fever, and dry cough with recently diagnosed coronavirus disease 2019. She was treated for DKA. Four days later, she developed a new-onset right-sided vision loss, ptosis, areflexic pupil, eye abduction loss, and bloody nasal mucus drainage. Computed tomography (CT) of the chest was normal. CT angiogram (CTA) of the head and neck showed occlusion of the right ophthalmic artery and the superior ophthalmic vein. Magnetic resonance imaging (MRI) showed subacute right frontal infarct and chronic sinusitis. An oral exam disclosed a large hard palate necrotic area, which on biopsy culture grew Rhizopus oryzae (Figure A-B). She was transferred to our facility for further surgical debridement. On arrival, she was placed on high-dose liposomal amphotericin (LAmB) and euglycemic control. A cerebral angiogram revealed right internal carotid artery occlusion. MRI showed right cavernous sinus thrombosis, right ophthalmic artery mycotic aneurysm, paranasal sinusitis with right sphenoid fungal sinusitis extending into gyri rectus, and watershed infarcts in the right middle and anterior cerebral artery territories (Figure C1). Neurosurgery deferred surgical debridement. Later caspofungin and deferasirox were added adjunctively for two weeks with surgical debridements and a week of hyperbaric oxygen, after which MRI findings improved (Figure C2). She is clinically improving on LAmB and caspofungin DISCUSSION: Combination regimens are ineffective in neutropenic or cancer patients [2,3]. LAmB and deferasirox with or without an echinocandin/posaconazole have been effective in diabetics with intracranial lesions [2]. Combination regimen efficacy has been observed in diabetic mice and anecdotal case reports [3,4]. This is due to prompt recovery of neutrophil function and loss of glucose-regulated protein78 mediated Rhizopus angioinvasion once acidosis and hyperglycemia are corrected [5] CONCLUSIONS: To improve diabetic patient outcomes, a timely diagnosis, prompt reversal of DKA and hyperglycemia, along with surgical debridement and antifungal therapy, are of immense importance. Combination antifungal therapy may benefit cases where complete surgical debridement is not achievable
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INTRODUCTION:Empyema is an infection of the pleural space. Inadequate drainage or antimicrobial therapy results in increased morbidity and mortality and a 20%-30% fatality rate [1][2][3]. Streptococcal and Staphylococcal species are the frequent cause of community-acquired empyema. In comparison, Enterobacteriaceae and Staphylococcus Aureus have been implicated in healthcare-associated empyema CASE PRESENTATION: A 58-year-old female came in with right-sided chest discomfort and acute onset hypoxic respiratory failure with a history of diabetes mellitus, chronic obstructive pulmonary disease, and Roux-en Y surgery (requiring multiple revisions). Examination revealed acute respiratory distress and diminished right-sided breath sounds, and she underwent emergent intubation. Chest x-ray showed right pleural effusion and pneumomediastinum (Figure A). A complex right pleural effusion with a extensive pneumomediastinum surrounding the distal esophagus was displayed by chest computed tomography (CT) (Figure B). CT chest with oral contrast revealed no esophageal perforation (Figure C). A 20 French chest tube insertion returned feculent fluid. Pleural fluid analysis revealed: pH 6.88, protein: 3.9 g/dL, LDH >2500 U/L, amylase 655 U/L. Pleural fluid stain was positive for gram-positive cocci and culture grew vancomycin-resistant Enterococcus faecium (VRE) sensitive to daptomycin and linezolid. She was treated with daptomycin and meropenem. Pan-endoscopy was performed to evaluate the pneumomediastinum, and esophagogastroduodenoscopy revealed gastro-pleural fistula. She was diagnosed with VRE empyema due to a gastro-pleural fistula from gastric limb perforation. Unfortunately, her clinical course worsened, and she was transitioned to comfort care DISCUSSION: Among the infrequent enterococcal empyema's, VRE is rare. A literature review revealed only two VRE empyema cases. Both cases occurred in immunocompromised hosts (Asplenia and HIV) [4][5]. The presented patient's empyema was due to the perforation of her residual gastric limb with bile reflux, resulting in her pleural cavity VRE seeding. Enterococci are commensals in the gastrointestinal tract (GI) but typically only represent a small portion of the gut microbiome [6]. As with the above patient, in individuals with multiple hospitalizations and courses of antibiotics, VRE can flourish due to significant shifts in the gut microbiota [7] CONCLUSIONS: Enterococcus infections are a rare cause of empyema and correlates with increased mortality and morbidity without prompt identification and treatment. When VRE is identified in the pleural space, a GI source should be considered and evaluated with pan-endoscopy. It should be preceded promptly with thoracic drainage and broad antimicrobial coverage
INTRODUCTION: Pasteurella is commonly found in the oral cavities and digestive tracts in many household pets and farm animals [1]. P. multocida most commonly causes soft tissue infections from dog and cat bites, or scratches. We report an unusual case of bacteremia and empyema caused by P. multocida in a turkey farmer. CASE PRESENTATION:A 61-year-old male with a 50 pack year smoking history presented with a left anterior chest wall pleuritic pain and a productive cough. He denied fevers, night sweats, chills, or weight changes. In the ER, the patient was hypoxic requiring 6 Liters per minute oxygen via nasal cannula. Labs were significant for white blood cell (WBC) of 13.37 x10(9), troponin <0.01 ng/dL, and blood pressure 184/76 mmHg. CT chest revealed a left pleural effusion. Blood cultures were obtained and IV antibiotics were started. The patient was admitted to the general medical ward.Patient underwent a thoracentesis in which 450ml of straw-colored pleural fluid was obtained. Analysis of pleural fluid was significant for pH 7.09, glucose <2 mg/dL, LDH 524 units/L, total protein 4.5 g/dL and WBC count 62,725/mcl. Pulmonary was consulted and placed a 12 French chest tube. Thoracic surgery was consulted and advised continued chest tube drainage. Intrapleural alteplase and dornase were administered to help resolve the empyema.On day three of hospitalization, P. multocida grew in blood culture and pleural fluid that was obtained. Further patient history revealed the patient was currently employed at a turkey farm that was experiencing a fowl cholera outbreak. He endorsed frequently being bit and scratched by turkeys. On day nine the chest tube was removed with subsequent discharge on day ten with levofloxacin for a total of 28 days of antibiotics.DISCUSSION: P. multocida can be found in oral, nasopharyngeal, and upper respiratory tract in 70-90% of cats and 50-66% of dogs; and in many other common animals including turkeys. Even though genus Pasteurella was first isolated as the causative agent of fowl cholera by Louis Pasteur, fowl to human transmission is less common [1]. Literature review revealed empyema cases of P. multocida were typically characterized as grossly purulent (87%) with a low pleural fluid pH (mean 6.8), high protein (mean 4.8 g/dl), high LDH (mean 1911 U/L) and low glucose (mean 28.6 mg/dl). Pleural fluid drainage with tube thoracostomy was required in the majority (62%) of cases [2]. Fortunately, the bacterium generally responds favorably to antibiotic treatment. It is susceptible to antibiotics including penicillins, doxycycline, fluoroquinolones, third generation cephalosporins and carbapenems [3]. CONCLUSIONS:In conclusion, P. multocida is a rare cause of empyema [2]. Health care providers need to have a high clinical suspicion of P. multocida infection in patients that handle fowl.
Bronchiectasis is an obstructive lung disease characterized as irreversible bronchial wall thickening and dilatation, this can be localized or diffuse. In the United States, among those over 75, the incidence of bronchiectasis is estimated to be 272 per 100,000 [1]. A myriad of causes, including aspiration, can result in bronchiectasis. This case illustrates how lower lobe predominant bronchiectasis (LLPB) resulting from aspiration predisposed a patient to recurrent pneumonia. CASE PRESENTATION:A 74-year-old female with a medical history of coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease, and non-resolving recurrent pneumonia presented with a four-month history of worsening exertional dyspnea and productive cough. Physical examination revealed a thin female, with rhonchi present in the left thorax, and diminished breath sounds diffusely. Routine laboratory analysis was unremarkable. A computed tomography (CT) scan of her chest demonstrated a chronic appearing left upper lobe consolidation, and lower lobe predominant bronchiectasis [Figure 1A-B]. She underwent bronchoscopy for evaluation of her recurrent pneumonia. During bronchoscopy, a foreign body surrounded by thick secretions was identified and removed from the left main bronchus [Figure 2A]. Further inspection revealed copious thick secretions within the left lower lobe. After suctioning, the left lower lobe was found to be grossly normal, and bronchoalveolar lavage was performed. Biopsies and cultures from bronchoscopy were negative. Furthermore, the patient's foreign body was determined to be a kernel of corn [Figure 2B-C]. The diagnosis of LLPB resulting from aspiration was made. She subsequently underwent formal swallow evaluation. Upon follow-up, the patient had no further pneumonia and improved cough with strict aspiration precautions and airway clearance therapy. DISCUSSION: Bronchiectasis is typically a clinical diagnosis which can then be radiographically confirmed by chest CT. Hallmark imaging findings of bronchiectasis include tram tracking (parallel line opacities) and an increased bronchoarterial ratio (signet-ring sign) [1]. Bronchiectasis can be divided based on lobar predominance (upper, middle, and lower), with LLPB being the most common. Etiologies of LLPB include post-infectious, idiopathic, fibrotic lung disease, and recurrent aspiration [1]. As in the above case, aspiration can present with the classic triad of cough, rhonchi, and decreased air entry [2]. Whenever aspiration is suspected to be the etiology of LLPB patients should undergo foreign body evaluation by bronchoscopy, a formal swallow assessment, and a trial of acid suppression [3].CONCLUSIONS: Clinicians should be cognizant that aspiration, especially in the elderly, may masquerade as recurrent pneumonia and can present radiographically as LLPB. Appropriate additional work-up should be conducted if clinically warranted.
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