Primary Cytomegalovirus (CMV) infection is often not suspected as a cause of fever of unknown origin (FUO) in immune-competent adults. We present a case-series of symptomatic primary CMV infection in immunocompetent adults presenting as fever of unknown origin (FUO). All patients with CMV serology tested between November 2008 and June 2016 underwent chart review. Cases were defined as those between 18 and 65 years of age with documented fever and elevated serum anti-CMV IgM. Exclusion criteria were organ specific CMV disease, positive serum anti-EBV IgM, or presence of any immunocompromising condition. Sixteen patients (69% male, mean age 42.2 ± 11.7 years) met criteria. Mean duration of illness was 4.6 ± 3.3 weeks. Common symptoms other than fever included fatigue (94%), night sweats (81%), malaise (75%), myalgias (63%), and headache (56%). Eleven patients (68.8%) had contact with young children; six (35.3%) patients had children in daycare. Twelve (75%) patients had extensive testing and multiple visits or hospitalizations prior to consulting with an infectious disease specialist. Peripheral smear was done in twelve (75%) patients and all had atypical lymphocytes. Five patients (31.3%) had a leukocytosis. Peak serum transaminases were: AST 115.25 ± 50.5 IU/L and ALT 168.38 ± 92.0 IU/L. One patient had splenic infarcts. In addition, two cases of hydrops fetalis were attributed to primary CMV infection. In summary, primary CMV infection can present as FUO in immunocompetent adults. Contact with young children in daycare may be a risk factor. Heightened clinical suspicion will promote earlier diagnosis and avoid unnecessary testing.
Contaminated multiple-dose medication vials (MDV) have been implicated in transmission of bacterial infections. It has been suggested that MDV be discarded after 24 hours or even after a single use. At our hospital, we cultured 1,223 weekly samples from 864 MDV in-use over a three-month period. Medications included xylocaine, insulin, heparin, immunizations, and miscellaneous agents. None of the samples was culture-positive. The duration of use was 9.5d (median), 18d (mean), and 1-402d (range) with 13% of vials in-use for more than 30 days. The mean duration of use was significantly shorter for medicine wards, emergency room, and outpatient clinics than for surgery and obgyn wards (p<0.05). Heparin and insulin MDV were in-use for significantly less time than xylocaine and miscellaneous agents (p<0.05), and insulin MDV were more regularly dated (p=0.001). The percentage of undated MDV declined significantly by month during die study (p=0.003). These results lend support to our current guideline that MDV should be dated upon opening and that, unless visible or suspected contamination occurs, vials are discarded either when empty or at the manufacturer's expiration date.
cHerbaspirillum spp. are Gram-negative bacteria that inhabit soil and water. Infections caused by these organisms have been reported in immunocompromised hosts. We describe severe community-acquired pneumonia and bacteremia caused by Herbaspirillum aquaticum or H. huttiense in an immunocompetent adult male. CASE REPORT In early September 2014, a 46-year-old white male presented to a referring facility with fever, fatigue, and shortness of breath. His illness began 5 days prior to admission to our facility after he was drenched in rain during a fishing trip. He had a fever of 40°C, despite use of antipyretics, with chills, night sweats, anorexia, myalgia, and headache. Three days prior to admission, he had a transient period of dry cough for half a day that resolved spontaneously. The next day he developed sharp right-sided pleuritic chest pain, worsening dyspnea, and severe fatigue. When he presented to the referring facility, clinical findings were remarkable for a respiratory rate (RR) of 28/min with an oxygen saturation (SpO 2 ) level of 77% on room air which improved to 91% on 4 liters/min of oxygen via nasal cannula. His white blood cell (WBC) count was 7.7 ϫ 10 Ϫ3 /l with 55% bands, and bilateral alveolar infiltrates were noted on a chest X-ray. Analysis of his arterial blood gas revealed a pH level of 7.46, partial pressure of CO 2 (pCO 2 ) of 34 mm Hg, pO 2 of 53 mm Hg, SpO 2 of 89% on 4 liters/min of oxygen via nasal cannula, and HCO 3 of 24 meq/liter. Blood cultures were drawn, and he was treated with intravenous vancomycin, ceftriaxone, and azithromycin. His condition worsened and he was transferred to our university teaching hospital.The patient's past medical history was unremarkable, except for childhood asthma, atypical pneumonia as a teenager, and tonsillectomy. He was on no home medications. He lived on a farm in rural Missouri with his wife and had close contact with cattle and turkeys (he had birthed calves 6 months earlier and handled 15,000 baby turkeys 3 weeks prior to the onset of illness). A few weeks prior to admission, the patient returned from work with about 20 loosely attached ticks. He also cleaned a grain bin in his barn (contained mold and possible rat excreta) a week prior to presentation. He smoked cigarettes for 30 years and also consumed alcohol regularly. He denied sick contacts, animal bites or scratches, and recent travel.The results of a physical examination conducted on presentation to our facility were remarkable for temperature (38°C), heart rate (HR) (98 beats/min), blood pressure (BP) (141/88 mm Hg), and RR (30/min with use of accessory muscles). There was bilateral lower chest wall tenderness, coarse inspiratory crepitations were heard in left axilla and left lower chest, and diminished breath sounds were noted in the right axilla and right lower chest.The rest of the exam was unremarkable. Laboratory measurements on admission revealed a WBC count of 9.0 ϫ 10 Ϫ3 /l, granulocytes at 89.6% and no bands on automated differential determinations, hemoglobin at 13.4 g/dl, ...
Most physicians recognize the false-positive blood cultures (generally due to contamination) are common. Bacteria such as pneumococci, however, may rapidly die in broth cultures, and viable bacteria may not be identified. Several patients were observed with pneumococcal infections that had false-negative blood cultures 24 hours after inoculation. Hemolysis and methemoglobin formation in the bottle suggested bacterial growth within 12 hours after incubation, and blind subcultures at that time yielded pneumococci. Pneumococcal antigen could be detected in the blood culture bottles using counter-immunoelectrophoresis, even though subculture at 24 hours yielded no growth. Physicians and laboratory personnel should be aware that false-negative blood cultures may occur, particularly with certain bacteria such as Streptococcus pneumoniae, and that the blood culture bottles should be observed visually for the presence of brown sediment or hemolysis.
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