This report documenting the transmission of rabies virus from an organ donor to multiple recipients underscores the challenges of preventing and detecting transmission of unusual pathogens through transplantation.
Although persistent infection of animals by members of the genus Ehrlichia is well known and may be associated with subsequent severe or fatal illness, persistent infection of humans with Ehrlichia chaffeensis has not been reported. Herein we report a typical case of serologically documented acute ehrlichiosis; despite therapy with tetracycline and chloramphenicol, the patient's condition progressively worsened and he suffered multiple secondary infections and gastrointestinal hemorrhage. He died 68 days after his initial hospitalization. Retrospective immunohistologic examination of both acute-phase bone marrow specimens (obtained day 12 of illness) and postmortem liver tissue specimens (obtained day 68 after onset of disease) revealed E. chaffeensis morulae in mononuclear cells, presumably macrophages and monocytes. Findings of this case provide the first definitive evidence that E. chaffeensis is capable of establishing persistent human infection and suggest a role for this obligate intracellular bacterium in the induction of immune compromise associated with a fatal outcome.
Intravesical BCG (bacillus Calmette-Guérin) instillation is a first-line treatment for superficial transitional cell carcinoma of the bladder. A rare but severe complication of BCG immunotherapy is the development of disseminated BCG disease, which can result in miliary pneumonitis, granulomatous hepatitis, soft tissue infections, bone marrow involvement, and sepsis. Symptoms can present as early as a few hours or as late as several months following the BCG therapy. The key finding in disseminated BCG disease is the formation of caseating granulomas in distant organs; detection of BCG organisms from tissue samples can be difficult. Recommended treatment for disseminated BCG disease includes a combination of antituberculous medications (with the exception of pyrazinamide, to which BCG is typically resistant) and a tapering course of steroids. We present the cases of four patients who developed granulomatous infection consistent with disseminated disease after intravesical BCG treatment and provide a summary of current clinical management recommendations.
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