Cryptococcosis is a life-threatening opportunistic infection caused by Cryptococcus gattii and Cryptococcus neoformans. It affects both immunocompetent and immunosuppressed hosts. Disseminated cryptococcal infection is rare in immunocompetent patients, but the cryptococcal disease's neurological sequelae may be more prominent in this group. We present a case of a 58-year-old male patient with medical comorbidities of monoclonal gammopathy of undetermined significance (MGUS) and polycythemia vera. The patient presented with gradual worsening of mental status over one week. He was found to have Cryptococcus neoformans meningoencephalitis and fungemia. The patient received two weeks of liposomal amphotericin B (LAmB) and flucytosine with excellent clinical response. He was discharged on high dose fluconazole, and he returned to the hospital in one week with new-onset hemiplegia and cryptococcomas on imaging. Prolonged intravenous (IV) treatment of six weeks duration resulted in significant clinical improvement and disease-free state at two years follow-up. This article aims to stress the importance of individualized prolonged IV treatment with liposomal amphotericin B and flucytosine despite good initial response in patients with polycythemia vera and MGUS. This is the first reported case of cryptococcal disease, to the best of our knowledge, in a patient with MGUS and the third case of cryptococcal infection in patients with polycythemia vera in a non-HIV non-transplant state. Prolonged individualized IV treatment should be considered in immunocompetent patients with the above conditions, as this condition, if not adequately treated and relapses, lead to high morbidity and mortality.

Background Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are two forms of thrombotic microangiopathies. They are characterized by severe thrombocytopenia, microangiopathic hemolysis, and thrombosis, leading to a systemic inflammatory response and organ failure. Plasmapheresis is used to treat thrombotic microangiopathies. A different entity known as atypical hemolytic uremic syndrome has garnered more clinical recognition because reported cases have described that it does not respond to standard plasmapheresis. Diclofenac potassium is a non-steroidal anti-inflammatory drug that is used to treat pain. Case report A 35-year-old Hispanic man presented to our emergency department with complaints of generalized malaise, fever, and an evanescent skin rash. During admission, he reported the use of diclofenac potassium for back pain on a daily basis for 1 week. He was noted to have peripheral eosinophilia, so he was admitted for suspected drug reaction involving eosinophilia and systemic symptoms. His initial laboratory work-up showed microangiopathic hemolytic anemia and thrombocytopenia. He also experienced a seizure, encephalopathy, and had a PLASMIC score of 7, thus raising concerns for thrombotic thrombocytopenic purpura. He underwent emergent plasmapheresis, which improved his clinical condition. The diagnosis was confirmed by assessing the levels of disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13, which was less than 3%. In addition, his skin biopsy was positive for patchy complement deposition, demonstrating complement dysregulation. Conclusion Thrombotic thrombocytopenic purpura is a rare condition that can be acquired. Our case is rare because it represents the first report of diclofenac potassium-induced thrombotic thrombocytopenic purpura with subjacent complement activation and dysregulation. Early recognition and aggressive management led to a favorable outcome.

Background Adult onset Still’s disease (ASD) is a rare systemic auto-inflammatory condition that often poses a diagnostic dilemma due to nonspecific clinical signs and symptoms. We report a case of ASD that dramatically improved after a short course of steroids. Case presentation A 23-year-old women from Ghana presented with a two-week history of fever, sore throat, right-sided neck swelling and an evanescent, pruritic rash on her extremities. On exam she was febrile to 103 F, tachycardic, tachypneic, had tender, right-sided cervical lymphadenopathy, and diffuse joint tenderness with decreased range of motion. She was admitted to the ICU for possible sepsis and started on broad-spectrum antibiotics. Extensive work-up for possible infectious and auto-immune etiologies, including a bone marrow biopsy was negative. The diagnosis of Still’s disease was made based on the Yamaguchi criteria. The patient was started on methyl-prednisolone and significantly improved within 24 hours. Conclusion Patients presenting with ASD often represent a diagnostic challenge. Clinicians should be aware of this rare disorder, exclude other more frequent diseases and start early anti-inflammatory therapy to avoid poor outcomes.

Background: Severe acute uncomplicated pyelonephritis is an infection of the kidneys that usually have an ascending route and occur in presumably healthy urinary tract. The most common pathogen involved is E. coli. The Infectious Diseases Society of America (IDSA) has issued an updated guideline in 2010 suggesting IV quinolones to be considered in the initial empiric antimicrobial therapy giving known resistance of less than 10%. However, E. coli resistance to quinolones has been increasing, the recent data of E. coli, causing pyelonephritis, resistance is not known in the Midwest. Local hospital antibiogram for two years showed up to 22% resistance to ciprofloxacin among E. coli isolates. Methods: We conduct a retrospective non-concurrent cohort study in one teaching hospital in the Midwest, females who were admitted with severe acute uncomplicated pyelonephritis in a three years period were included. Patients with urinary tract obstruction, pregnancy, immuno-suppression, males, and indwelling Foley's catheters were excluded. Data collected include causative pathogens and resistance to antibiotics were collected. Percentages, frequencies, and measures of central tendency and dispersion were calculated to describe the study sample Results: 73 patients were included in the final analysis. E. coli was the most common isolated pathogen (81%), followed by other enteric gram negative. E. coli resistance to ciprofloxacin was 13.5%, 37% to trimethoprim-sulfamethoxazole, and 5% to ceftriaxone. Conclusion: Ciprofloxacin should be avoided initially in treating severe acute uncomplicated pyelonephritis until culture results and sensitivity is available.