Coccidioidomycosis is an infection caused by the geographically restricted dimorphic fungus, Coccidioides. Coccidioidomycosis occurs endemically in the southwestern and western United States, mainly in focused regions of Arizona and California where the incidence is highest, and in Central and South America. Patients with impaired immunity, especially those with impaired cellular immunity, are at higher risk of severe and disseminated disease. In this review, we describe the fungal ecology and mycology, epidemiology, pathophysiology, and normal immune defenses to Coccidioides as well as address current concepts in diagnosis, treatment, and continued care of patients with pulmonary coccidioidomycosis. We also present and answer our most frequently asked questions regarding patients with primary pulmonary coccidioidomycosis.
We report a case of progressive, severe mpox virus (MPXV) infection in a patient with acquired immune deficiency syndrome (AIDS) despite a standard course of tecovirimat. He significantly improved after administration of intravenous vaccinia immune globulin (VIGIV) highlighting its use as an adjunct for severe disease in immunocompromised hosts.
Background: Literature on the natural course of neuroinvasive West Nile virus (WNV) infection in solid organ transplant (SOT) recipients is sparse. In the setting of a 2021 WNV outbreak in Arizona, we reviewed our institution's experience with neuroinvasive WNV infection in patients with SOT. Methods: We retrospectively identified SOT recipients treated for neuroinvasive WNV at Mayo Clinic in Arizona from 2007 through 2021. Clinical manifestations, disease course, and outcomes were analyzed. Results: Among 24 SOT recipients with WNV infection identified during the study period, 13 infections occurred in 2021. Most patients had gastrointestinal tract symptoms and fever at disease presentation. Five patients had cognitive impairment, and 14 initially or eventually had acute flaccid paralysis. Clinically significant deterioration occurred at a median of 4 (range, 1-11) days after hospital admission. Seventeen patients (71%) were transferred to the intensive care unit, with 15 requiring mechanical ventilation. Initial cerebrospinal fluid analysis mainly demonstrated a neutrophil-predominant pleocytosis. Almost all patients (n = 23) were treated with intravenous immunoglobulin alone or in combination with interferon alfa-2b. Sixteen patients had clinical improvement, 4 of whom recovered completely. Six patients died during hospitalization due to complications of neuroinvasive WNV infection. Two patients were discharged to hospice without clinical recovery. The overall 30-day mortality rate was 36%. Conclusion: Despite advances in supportive care, neuroinvasive WNV infection is associated with substantial morbidity and mortality in SOT recipients. Flaccid paralysis is an indicator of poor prognosis.
Objectives:To study the knowledge, attitudes, and practices with regard to human immunodeficiency virus infection / acquired immune deficiency syndrome (HIV/AIDS) in illegal residents, in the Kingdom of Saudi Arabia (KSA).Materials and Methods:A questionnaire study was conducted among the illegal residents from four regions in Saudi Arabia: Jeddah, Makkah, Riyadh, and Jazan.Results:The survey enrolled 5,000 participants, 79%male (39.6% from Jeddah; 20% from Riyadh; and 20% from Jazan), aged between 15 and 45 years. Of the total, 1288 (25.8%) had not heard about HIV/AIDS. Knowledge of HIV transmission was poor in 90% of the respondents. Of the total, 737 had read about HIV/AIDS materials and 649 participants had been previously tested for HIV. The majority of participants (85%) held a negative attitude toward people living with HIV/AIDS. Those who were knowledgeable about HIV/AIDS expressed more a positive attitude. One-fifth (968, majority were men; single 55%, married 45%) had engaged in non-marital sexual activity. The largest proportion of the individuals who had engaged in non-marital sex were single (54.9%) followed by the married ones (40.4%). Men cited pleasure as the main reason for such activity (84.6%), whereas women (73.4%) cited financial gain. Of the respondents, 53.9 and 32.1% believed that TV and schools were the best media through which information with regard to HIV/AIDS could be imparted.Conclusions:Knowledge of HIV/AIDS, its mode of transmission, and prevention measures was poor. Educational programs specifically targeted toward this group were required.
BackgroundThere is growing interest in the use of rapid blood culture identification (BCID) in antimicrobial stewardship programs (ASPs). Although many studies have looked at its clinical and economic utility, its comparative utility in gram-positive and gram-negative blood stream infections (BSIs) has not been as well characterized.MethodsThe study was a quasi-experimental retrospective study at the Mayo Clinic in Phoenix, Arizona. All adult patients with positive blood cultures before BCID implementation (June 2015 to December 2015) and after BCID implementation (June 2016 to December 2016) were included. The outcomes of interest included time to first appropriate antibiotic escalation, time to first appropriate antibiotic de-escalation, time to organism identification, length of stay, infectious diseases consultation, discharge disposition, and in-hospital mortality.ResultsIn total, 203 patients were included in this study. There was a significant difference in the time to organism identification between the pre- and post-BCID cohorts (27.1 hours vs 3.3 hours, P < .0001). BCID did not significantly reduce the time to first appropriate antimicrobial escalation or de-escalation for either gram-positive BSIs (GP-BSIs) or gram-negative BSIs (GN-BSIs). Providers were more likely to escalate antimicrobial therapy in GP-BSIs after gram stain and more likely to de-escalate therapy in GN-BSIs after susceptibilities. Although there were no significant differences in changes in antimicrobial therapy for organism identification by BCID vs traditional methods, more than one-quarter of providers (28.1%) made changes after organism identification. There were no differences in hospital length of stay or in-hospital mortality comparing pre- vs post-BCID.ConclusionsAlthough BCID significantly reduced the time to identification for both GP-BSIs and GN-BSIs, BCID did not reduce the time to first appropriate antimicrobial escalation and de-escalation.
27Background: There is growing interest in the use of rapid blood culture identification (BCID)
Background More accounts of opportunistic infection in COVID-19 patients are emerging. At our institution, we identified 2 COVID-19 patients with Pneumocystis jiroveci pneumonia (PJP) opportunistic infection. This prompted a review of the literature to identify trends in patient characteristics, risk factors, and outcomes in this population. Methods A literature review was conducted using PubMed that identified 13 other patients with both COVID-19 and PJP infection. Age, gender, human immunodeficiency virus (HIV) status, other immunocompromised states, time between COVID-19 and PJP diagnosis, and clinical outcomes were captured for analysis. Results Eleven patients were male. The average age was 56 years. All but 2 patients were immunocompromised. At time of PJP diagnosis, seven patients had newly diagnosed HIV and one had known, well-controlled HIV. One patient had rheumatoid arthritis receiving leflunomide, 1 had ulcerative colitis receiving budesonide and sulfasalazine, 2 patients had multiple myeloma whereby both were on lenalidomide, 1 patient was a renal transplant recipient immunosuppressed on tacrolimus, mycophenolate, and methylprednisolone, and 1 patient had chronic lymphocytic leukemia getting fludarabine, cyclophosphamide, and rituximab. Nine patients had positive COVID-19 and PJP tests performed within 7 days of one another. One patient tested positive for PJP 54 days into admission for COVID-19. This patient received high dose steroids and tocilizumab for initial COVID-19 infection. Three patients were re-hospitalized with PJP after a recent admission for COVID-19 pneumonia, with a mean time to readmission of 25 days. One of these 3 patients had no treatment for COVID-19, while 2 received steroids. Five of the total 15 patients (33%) died. Conclusion COVID-19 treatments with high dose steroids and tocilizumab can make patients vulnerable for opportunistic infection with PJP. Furthermore, COVID-19 is known to cause lymphopenia which may further increase this risk. A diagnosis of concomitant PJP can be especially challenging due to nearly identical radiographical findings. Serum beta-D glucan and HIV testing can be especially helpful in this situation, and there should be a low threshold for performing bronchoalveolar lavage. Disclosures All Authors: No reported disclosures
Melioidosis, an infection caused by Burkholderia pseudomallei, has a very high risk of mortality when treated, with an even higher risk of fatality if undiagnosed or not treated appropriately. It is endemic to Asia, Australia, South America, and the Caribbean; however, the number of melioidosis cases reported in the United States has been increasing. Therefore, physicians should be aware of this clinical entity and its possible presentations. Mycotic aneurysms due to B. pseudomallei are extremely rare, accounting for ~1%–2% of cases. Here we describe a rare case of melioidosis presenting as a mycotic aneurysm in the United States, highlight the potential for diagnostic challenges and epidemiologic concerns, and provide a review of mycotic aneurysm cases due to B. pseudomallei published to date.
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