We present a case of disseminated Pneumocystis jirovecii pneumonia in a patient with a medical history of glioblastoma multiforme associated with acute deep-vein thrombosis. The patient presented to the emergency department with clinical features of pulmonary infection, and the chest images showed pneumonia. Antibiotics were initiated (azithromycin, cefepime, and vancomycin) and the patient was transferred to the ward for further management, where the condition of the patient continued to worsen over the second day. The patient developed bilateral lower extremity swelling and the doppler ultrasound revealed bilateral lower extremity acute deep vein thrombosis. Laboratory results showed pancytopenia and transaminitis. However, a repeated chest X-ray showed groundglass changes and interstitial infiltrates, suggestive of atypical infection. We indeed identified D-glucan which hints to a disseminated form of Pneumocystis jirovecii pneumonia infection in this patient. We further confirmed the Pneumocystis jirovecii pneumonia by polymerase chain reaction test from the fluid obtained via bronchoalveolar lavage. We, therefore, initiated intravenous trimethoprim/sulfamethoxazole treatment with an anticoagulant, and the patient’s condition improved. Our findings strongly suggest a possible link between Pneumocystis jirovecii pneumonia infection and thrombogenesis, with impact in medical practice.
Background Epididymitis has several etiologies that can be related to infectious and non-infectious causes, autoimmune conditions, aseptic causes, and even certain pharmaceutical medications (amiodarone and chemotherapeutic agents). Some cases of epididymitis are complicated with pyocele formation that requires emergent surgical intervention to prevent testicular gangrene. This report describes the case of a 66-year-old male who developed severe bilateral epididymitis complicated by bilateral pyocele and ensuing sepsis. Astonishingly, the condition resolved completely without surgical intervention. Case presentation We are presenting a case of a non-sexually active male who developed bilateral severe epididymitis complicated by pyocele that led to the development of septic shock. Further history revealed that the patient was not sexually active with male or female partners and denied any form of trauma. Physical examination demonstrated scrotal swelling and erythema on inspection and severe tenderness on palpation. Digital rectal examination as well as abdominal examinations was unremarkable. Laboratory investigations disclosed severe leukocytosis with a neutrophil predominance (39,000 K/UL, normal range 4500–11,000 K/UL), as well as an elevation of systemic inflammatory markers such as erythrocyte sedimentation rate and C-reactive protein. Urine culture was positive for Escherichia coli. Ultrasound revealed bilateral epididymitis and pyocele. This patient was managed with a course of meropenem, resolving the epididymitis and pyocele without the need of surgical intervention. Conclusions Surgical intervention is considered the standard of care and the approved management for pyocele to avoid further complications such as Fournier’s gangrene. However, this patient was treated solely with antibiotics, and his condition was stabilized without the need of surgical intervention that would result in additional cost and length of stay for the patient. This case raises further questions regarding the potentially better bioavailability of this antibiotic in the scrotum compared to elsewhere in the body and the potential for a non-surgical alternative approach in the management of patients with pyocele and requires further research.
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