Histoplasmosis is usually a benign, self-limited disease with lungs predilection. However, it might manifest as a disseminated disease in immunocompromised individuals. The involvement of the central nervous system (CNS) accounts for about 5–10% of cases with disseminated disease. Isolated histoplasmosis of the CNS is rare, and the literature shows only a few reported cases. By imaging studies, it usually presents as an isolated ring-enhancing lesion. Its spectrum of symptoms ranges from acute severe infection to progressive chronic meningitis, which delays the initial diagnosis, correct work-up and initiation of appropriate therapy. We present a case of a 57-year-old man from the Midwest of the United States who misdiagnosed with Gliosarcoma in 2019, for which he underwent appropriate management for Gliosarcoma. Presented for follow-up after new neurological symptoms; worsening in ring-enhancing brain lesions was found on magnetic resonance image MRI. After a re-examination of surgical pathological cases, histoplasmosis of the CNS was diagnosed. Failure of diagnosis CNS histoplasmosis early can lead to poor outcome and decrease chances of recovery.
A formal high value, cost-conscious care (HVCCC) curriculum was implemented at a community hospital-based university-affiliated residency program starting January 1, 2014, based on the recommendations of the American Board of Internal Medicine's (ABIM) Choosing Wisely campaign. The program included a competition requiring each resident to write a HVCCC case based on an actual patient experience. Residents completed a questionnaire assessing their understanding of HVCCC near the end of the program. Residents subsequently reviewed two actual cases that had vividly described unexpected adverse outcomes (‘anecdotal’ cases). Postexposure data were collected and the results were analyzed.
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
Background Introduction: Leprosy (Hansen’s disease) is a chronic granulomatous infection of the skin/peripheral nerves caused by Mycobacterium leprae. Of 216 new cases reported in the US in 2019, 70% were in FL, LA, TX, HI, CA, GA and NY. Leprosy is considered a zoonosis in the southern US with the nine-banded armadillo as a reservoir. There have been no reported autochthonous leprosy cases in Missouri. Methods Case: 55 y/o previously healthy male noted a new rash on his arm 2 years ago. Over time it spread to his extremities/torso. Skin biopsy showed a granulomatous infiltrate, suspected granuloma annulare, but it progressed despite appropriate therapy. He noted progressive numbness of the affected areas of skin and several regional nerve distributions. In the weeks prior to his initial visit he noted facial swelling, eyelid and ear induration, worsening fatigue, diffuse arthralgia, and some vision changes. His travel history is limited to Canada, Colorado and a brief vacation to the Texas/Mexico border (no notable outdoor exposure during the latter trip; no travel outside the country). He lives in rural Missouri where he is exposed to armadillos. His dogs frequently kill them and often bring them into the yard, rolling around on/in the dead carcasses which he disposes of. He typically wears gloves when handling them and has never consumed them. On exam he had diffuse purplish-red nummular infiltrated anesthetic papules and plaques diffusely distributed over the trunk and extremities. Distinct left ulnar neuropathy was noted. He exhibited leonine facies and infiltration of the bilateral helices. Repeat biopsy showed a granulomatous infiltrate with abundant acid-fast bacilli. DNA sequencing confirmed M. leprae. He was preventatively treated with prednisone and methotrexate to minimize immune reaction, and two weeks later began a regimen of monthly rifampin, minocycline, and moxifloxacin with an anticipated duration of 24 months. Results Diagnosis lepromatous leprosy with pre-treatment immune reaction. This is potentially the first case of autochthonous leprosy in Missouri. Providers should include Hansen’s disease in the differential diagnosis of patients with dermal eruption and cutaneous neurological symptoms to avoid delays in diagnosis/care. Disclosures All Authors: No reported disclosures
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