Patient on her 30th post-transplant day of hematopoietic precursor transplantation, in severe neutropenia who presents with cough with hemoptotic expectoration. This picture is usually seen in infection by Aspergillus spp. We can rule out infection by Staphylococcus aureus because of previous treatment, although we do not know if it raises the response also a possible MRSA.

A 65-year-old woman who underwent hematopoietic precursor transplantation 30 days ago and has severe neutropenia. She starts with cough and hemoptotic expectoration in addition to fever and moderate exertional dyspnea that does not improve despite five days of treatment with amoxicillin-clavulanic acid (875/125 mg/8 h) and levofloxacin (500 mg/12 h). Chest X-ray shows multiple ill-defined pulmonary nodules, some of them cavitated. Among the following, which is the most probable diagnosis of suspicion?

Septic pulmonary embolism: three case reports.

We present three cases of septic pulmonary embolism which occurred as a result of three different causes. The first case, was a 23 year old woman suffering from cough, sputum, hemopthisis and pleuritic chest pain. She had a right subclavian port. On her thorax computed tomography (CT) scans there were widespread bilateral, irregular parenchymal nodular infiltrates and some of them beginning to cavitate. Meticilin resistant stafilococus aureus (MRSA) was isolated from the blood culture and septic embolism was diagnosed. A month after antibiotic theraphy her parenchymal nodules have considerably decreased in size. The second case was a 40 year old woman admitted to our hospital with the same complaints. Her radiological findings were similar. Meticilin sensitive stafilococus aureus (MSSA) was isolated from the blood cultures and antibiotic theraphy was initiated. To investigate the etiology of the nodules due to septic embolism, echocardiography was performed and infective endocarditis was diagnosed. After the antibiotic theraphy and a tricuspid valve operation her parenchymal nodules disappeared. The final case involved a 51 year old man suffering from fever, fatigue, cough and pain in the left arm for one week. His general status was bad. His radiological findings were also similar to the others. Staphillococcus aureus was isolated from blood and wound culture. Following clinical and radiological findings we thought it was a case of septic pulmonary embolism and antibiotic theraphy was started. Despite the therapy we did not take fever response and he died five days after antibiotic therapy. In conclusion, septic pulmonary embolism should be considered in bilateral cavitary nodular infiltrates and must be managed fast.

Fusariosis: An Invasive Fungal Disease in a Neutropenic Patient With Acute Myeloid Leukemia.

Although rare in the U.S invasive Fusariosis (IF) is increasingly being recognized as a cause of severe invasive fungal disease in patients with neutropenia in the setting of hematologic malignancy and hematopoietic stem cell transplants (HSCT). IF in these patients is associated with high mortality, moreover there are no guidelines on effective therapy, thus early diagnosis and involvement of an expert with experience in treating Fusariosis are imperative. We present a case of IF in a patient with profound prolonged neutropenia in the setting of chemotherapy for relapsed, refractory acute myeloid leukemia. A 33-year-old woman with relapsed acute myeloid leukemia (AML) was hospitalized for re-induction chemotherapy. Five days post cycle 1 she became neutropenic. She was treated with prophylactic antimicrobials that included acyclovir, levofloxacin, and Posaconazole. On day sixty she began to run a high-grade fever. The physical exam was remarkable for a temperature of 102 degrees Fahrenheit and a heart rate of 116 beats per minute. Complete blood count was remarkable for 130 WBC/ml, Hb 6.5 g/dl, hematocrit (HCT) 18.7%, 13000 platelets/ml, absolute neutrophils counts (ANC) of 0. Her CT chest showed new bilateral lung nodules. Antibiotics were changed to cefepime, vancomycin, and metronidazole on day sixty-two without response. On day sixty-five meropenem was started and cefepime stopped. On day sixty-eight posaconazole was stopped and amphotericin B was started and two days later fever became low grade. She developed hyperpigmented skin lesions with necrotic centers on extremities that were biopsied. Histopathology staining favored the presence of rare fungal hyphae. The culture of the biopsy sample grew <iFusarium spp</i that was identified by DNA sequencing as <iFusarium falciforme</i. Voriconazole and terbinafine were added. Her fevers resolved within the next 24 hours and she remained afebrile. <iFusarium</i is a hyaline mold present in the environment. Infection is acquired by inoculation into the skin, intravascular devices, or inhalation. IF incidence is low in the United States. <iF. solani</i and <iF. oxysporum</i are the most predominant disease-causing species complexes. Invasive Fusariosis (IF) is a rare disease seen in patients with hematologic malignancy and hematopoietic stem cell transplants (HSCT) with profound neutropenia. Immunocompromised patients suffer disseminated disease to multiple sites as in this case, with mortality rates of between sixty to eighty percent in this patient population. Blood and skin lesions biopsy cultures are diagnostic. Blood cultures are positive in up to sixty percent of cases in about four days. Polymerase chain reaction (PCR) can identify <iFusarium</i but species identification by PCR is difficult. Newer molecular methods are better for species identification. Histopathology can be helpful. Differential diagnoses include invasive aspergillosis (IA), mucormycosis, mycobacterial and dimorphic fungal infections. There are no guidelines for standard therapy. Amphotericin B or voriconazole are preferred. Combination therapy may be indicated. Neutrophil recovery is crucial. Adjunctive and preventive measures have roles.

[Management of hemoptysis in invasive pulmonary aspergillosis].

Invasive pulmonary aspergillosis is an opportunistic infection occurring in a background of severe immune depression. The majority of cases occur in patients who have malignant hematologic disease, particularly during chemotherapy induction or consolidations phases for acute non-lymphocytic leukemia. The principal risk factors are profound (PN < 500 per mm3) and prolonged (very high risk beyond 20 days) neutropenia, perturbed phagocyte function and cellular immune deficiency (AIDS, immunosuppressive treatment in organ and bone marrow recipients). Clinically, invasive pulmonary aspergillosis presents as acute non-specific pneumonia with cough, chest pain and fever. The severe infection rapidly becomes life-threatening. The development of massive hemoptysis is a major risk. We report four cases of invasive pulmonary aspergillosis in patients who had hemoptysis. All four patients developed non-specific pneumonia resistant to broad-spectrum antibiotics during post-chemotherapy aplasia. Computed tomography of the thorax and bronchoscopy with bronchoalveolar lavage was performed due to the occurrence of hemoptysis. In the first two cases, the patients were recovering from aplasia. The thoracic CT scan showed evidence of a cavitating mass with peripheral vessels. Bronchoscopy findings suggested mucosal lesions. The patients were managed surgically. Pathology confirmed the diagnosis of invasive pulmonary aspergillosis with the presence of ischemic necrosis of the pulmonary parenchyma harboring numerous aspergillus filaments. Outcome was favorable and chemotherapy was re-initiated in one case. These two patient died from their hematological disease a few months later. The other two patients remained in aplasia. A CT of the thorax showed multifocal infiltration with vascular contact. Bronchoscopy was again suggestive. One patient developed massive hemoptysis with respiratory distress. Embolization was performed but the patient died two days after onset of hemoptysis. In the last case, embolization was successful and outcome was favorable enabling a bone marrow allograft; the patient died a few months later from the hematological disease. The potential gravity of hemoptysis in the course of invasive pulmonary aspergillosis should lead to early treatment with emergency CT scan and, if possible, bronchoscopy with bronchoalveolar lavage to establish the therapeutic strategy based on surgical excision or embolization of the pulmonary or bronchial arteries.

Twenty-nine cases of invasive aspergillosis in neutropenic patients.

Invasive aspergillosis is a life-threatening infectious complication in hematological patients undergoing immunosuppressive chemotherapy. We report 29 cases of invasive aspergillosis diagnosed in the Sousse Farhat Hached hospital Hematology unit, Tunisia, between 2002 and 2010. The most frequent disease (65.5%) was acute myeloid leukemia. All patients were severely neutropenic (<500/mm(3), mean duration=27 days). Pulmonary invasive aspergillosis was suggested in 28 (96.5%) cases. The most frequent respiratory signs were cough (64.3%), chest pain (53.6%), and hemoptysis (50%). The chest X-ray showed suggestive lesions in 60.7% of cases. CT scans revealed nodules with cavitation in 65% of cases, a halo sign in 20% of cases, and nodules in 15% of cases. Galactomannan antigenemia was positive in 88%, mycological examination positive in 51.6%, and seroconversion was noted in 35.7% of the cases. Invasive pulmonary aspergillosis was classified, according to EORTC/MSG criteria, as probable in 26 cases, possible in one case, and proven in one case. Aspergillus flavus was the dominant species in pulmonary invasive aspergillosis accounting for 73.7% of isolates. Extrapulmonary involvement was suggested in 39.3% of cases, the most frequent were sinusitis and brain abscess. Primary cutaneous aspergillosis was observed in one case. The overall mortality rate was 64.2%; the 12-week survival rate was 71.4%. Our results are correlated to published data. A. flavus was the most frequent species in our region.

[Pneumonia caused by Fusobacterium necrophorum: is Lemierre syndrome still current?].

Fusobacterium necrophorum is a non-spore-forming gram-negative anaerobic bacillus that may be the causative agent of localized or severe systemic infections. Systemic infections due to F.necrophorum are known as Lemierre's syndrome, postanginal sepsis or necrobacillosis. The most common clinical course of severe infections in humans is a progressive illness from tonsillitis to septicemia in previously healthy young adults. A septic thrombophlebitis arising from the tonsillar veins and extending into the internal jugular vein leads to septicemia and septic emboli contributing to the development of necrotic abscesses especially in lungs and other tissues such as liver, bone and joints. In this case report, a previously healthy man with pneumonia and empyema due to F.necrophorum has been presented. A 22 year-old man suffering from sore throat for seven days was admitted to emergency department with ongoing fever and dysphagia for three days. On admission he was already taking amoxicillin-clavulanic acid and his complaints were relieved with continuation of therapy to a total of 10 days. However, five days after the cessation of treatment he developed productive cough, fever and generalized myalgia. On physical examination, there were crackles on right lower lung, and chest X-ray revealed pulmonary consolidation on the right middle lobe. Levofloxacin therapy was started based on the diagnosis of pneumonia. While polymorphonuclear leucocytes and intracellular gram-negative bacilli were seen in Gram stained sputum smear, sputum culture was reported as normal flora. Although the patient's status had started to improve with treatment, his condition deteriorated with development of fever and dyspnea. Chest X-ray revealed consolidation, pulmonary infiltrates, pleural effusion and air-fluid level on the right. Meropenem, clarithromycin and linezolid were initiated and a chest tube was inserted with the preliminary diagnosis of necrotizing pneumonia, empyema and type-1 respiratory failure. While there was no growth on bronchoalveolar lavage fluid culture, thoracentesis material inoculated into thioglycolate broth revealed turbidity. Further inoculation onto Schaedler agar which was incubated under anaerobic conditions, yielded growth of catalase negative, indol positive, gram-negative anaerobic bacilli identified as F.necrophorum by BBL Crystal system (Becton Dickinson, USA). The detailed history of the patient revealed that fish bone had stuck in his throat a week ago. Clarithromycin and linezolid were discontinued and he was recovered within six weeks of meropenem treatment. F.necrophorum infection should be considered in the differential diagnosis of persistent head and neck infections with rapidly progressive metastatic necrotic lesions especially in healthy young adults and clindamycin or metranidazol should be added to the treatment protocols.

[A case report of acute pulmonary valve endocarditis caused by fungi].

A 42 years old female was admitted for evaluation of unrelenting fever and dyspnea on exertion in March, 1991. The patient had a VSD closure in 1968. After admission, serial blood cultures were found to be positive for Candida Parapsilosis and a massive vegetation on the pulmonary valve was demonstrated by echocardiography. Chest X-ray disclosed a wedge-shaped density in the right middle lung lobe that was a compatible finding with pulmonary infarction. At surgery, performed 3 days later the admission, pulmonary valve was entirely resected without replacing it with prosthesis. Antifungal treatment was intensively given afterwards. Her postoperative course was without event and she was sent home on the 51st postoperative day. Right heart catheterization done two years surgery, revealed the pulmonary vascular resistance was 216 dynes sec cm-5. We anticipate that this degree of pulmonary vascular resistance will allow the patient enough to do well without needing valve prosthesis in the near future.

A case of Legionella pneumophila evaluated with CT and ultrasound.

A 36-year-old man was admitted to the emergency department of "SS Annunziata" hospital in Chieti complaining of a sharp chest pain arisen some hours before admission. On examination, the patient looked sweaty; his vital signs showed tachycardia and augmented breath rate; sinus tachycardia and normal ventricular repolarization were observed on ECG, and no abnormalities were observed in the echoscan of the hearth. According to the clinical and electrocardiographic findings, and to previous episode of DVT in anamnesis, a thorax CT scan was performed in order to rule out pulmonary embolism. It showed an "area of parenchymal consolidation involving almost all the left lower lobe with patent bronchial structures"; given the patient's CURB 65 score, he was then admitted to the pneumology ward where empiric treatment with levofloxacin (750 mg PO once daily) was initiated. Thoracic ultrasound was performed using a multifrequency convex transducer, and the posterior left area was examined through intercostal approach, placing the patient in a sitting position. A subpleural patchy hypoechoic lesion with irregular boundaries was detected; the maximum diameter was 11 cm, and the multiple hyperechoic spots inside it (elsewhere defined as "air bronchogram") showed no Doppler signal. Given the positive result of the Legionella urinary antigen test, antibiotic treatment was switched to Levofloxacin 1000 mg PO once daily and Claritromicin 500 mg PO twice daily. After 3 days, his clinical conditions improved dramatically. Ultrasound performed after 5 days from the diagnosis showed decreased dimensions of the lesion previously identified (maximum diameter 8.25 cm) and a marked reduction of the hyperechoic spots in it. The patient was discharged in good clinical conditions, and both thorax CT scan obtained after 1 and 4 months from the diagnosis showed radiological resolution of the parenchymal consolidation. The key to ultrasound visualization of pneumonia is its contact with the pleural surface (86-98% in cases of CAP) and the relative loss of aeration of the portion involved by the infection and a concomitant increase in the fluid content. A paradigmatic US image for parenchymal inflammatory infiltrate has not been established yet; anyway, some typical findings, when combined with the clinical features, can confirm the diagnostic hypothesis.

Comparative bacteriological efficacy of pharmacokinetically enhanced amoxicillin-clavulanate against Streptococcus pneumoniae with elevated amoxicillin MICs and Haemophilus influenzae.

A new pharmacokinetically enhanced formulation of amoxicillin-clavulanate (2,000 mg of amoxicillin/125 mg of clavulanate twice a day; ratio 16:1) has been designed, with sustained-release technology, to allow coverage of bacterial strains with amoxicillin-clavulanic acid MICs of at least 4/2 mug/ml. The bacteriological efficacy of amoxicillin-clavulanate, 2,000/125 mg twice a day, ratio 16:1, was compared in a rat model of respiratory tract infection versus four other amoxicillin-clavulanate formulations: 8:1 three times a day (1,000/125 mg), 7:1 three times a day (875/125 mg), 7:1 twice a day (875/125 mg), and 4:1 three times a day (500/125 mg); levofloxacin (500 mg once a day); and azithromycin (1,000 mg on day 1 followed thereafter by 500 mg once a day). Bacterial strains included Streptococcus pneumoniae, with amoxicillin-clavulanic acid MICs of 2/1 (one strain), 4/2, or 8/4 microg/ml (three strains each), and Haemophilus influenzae, one beta-lactamase-positive strain and one beta-lactamase-negative, ampicillin-resistant strain. Animals were infected by intrabronchial instillation. Antibacterial treatment commenced 24 h postinfection, with doses delivered by computer-controlled intravenous infusion to approximate the concentrations achieved in human plasma following oral administration. Plasma concentrations in the rat corresponded closely with target human concentrations for all antimicrobials tested. Amoxicillin-clavulanate, 2,000/125 mg twice a day, ratio 16:1, was effective against all S. pneumoniae strains tested, including those with amoxicillin-clavulanic acid MICs of up to 8/4 microg/ml and against beta-lactamase-producing and beta-lactamase-negative ampicillin-resistant H. influenzae. These results demonstrate the bacteriological efficacy of pharmacokinetically enhanced amoxicillin-clavulanate 2,000/125 mg twice a day (ratio 16:1) against S. pneumoniae with amoxicillin-clavulanic acid MICs of at least 4/2 microg/ml and support clavulanate 125 mg twice a day as sufficient to protect against beta-lactamase in this rat model.

Saprochaete Capitata Infection in an 80-Year Old Chronic Obstructive Pulmonary Disease (COPD) Patient: A Case Report.

The fungal disease caused by invasive fungus Saprochaete capitata is becoming an increasingly popular infection. Fungal pathogens mainly occur in patients with immunocompromised disorders such as hematologic malignancies, acute myeloid leukemia, transplant patients. In this study, we presented a COPD patient infected with S. capitata. At the first check, the patient showed cough, dyspnea, chest pain on both sides. The clinical laboratory test result was characterized with high White blood cell (12.8 G/L), HIV negative. The X ray showed bronchitis and emphysema. Bronchoscopy illustrated bronchial mucositis. CT scanner demonstrated pneumonia with fuzzy nodular lesions and thick interstitial organization in both lungs. The patient was treated with ciprofloxacin 800 mg/day; cefuroxime 2250 mmg/day. However, the fever appeared 2 weeks thereafter. The S. capitata was discovered in the bronchial fluid. The patient was then treated with fluconazole 400 mg/day for 14 days. At the end of treatment, all signs and symptoms of S. capitata infection disappeared and the patient recovered. This case study showed that S. capitata infection can occur in the COPD patients and fluconazole is a pertinent drug for treatment of the infection.

A 46-Year-Old Woman Who Presented with Diabetic Ketoacidosis and COVID-19 Pneumonia with Multiple Pulmonary Thromboemboli: A Case Report.

BACKGROUND Coronavirus disease 2019 (COVID-19) occurs because of a novel enveloped ribonucleic acid coronavirus called severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2). One of the major reported complications of COVID-19 includes both arterial and venous thromboembolism (VTE). Here we describe a case of COVID-19 provoked pulmonary embolism in a young patient already receiving prophylactic treatment for VTE. CASE REPORT A 46-year-old female with past medical history of diabetes mellites, hypertension, and asthma presented in the emergency department (ED) with dyspnea requiring 6 liters per minute of oxygen on presentation. Her main complaints were cough and vomiting. In the ED, hypoxemia worsened, and she ultimately required endotracheal intubation. Labs were suggestive of diabetic ketoacidosis (DKA) and showed increase in all inflammatory markers and absolute lymphocytopenia. Chest X-ray showed bilateral diffuse patchy airspace opacities. Standard DKA management was started. She was also started on ceftriaxone, azithromycin, hydroxychloroquine, and subcutaneous heparin (5000 U every 8 h) for VTE prophylaxis. SARS-Cov2 reverse transcription-polymerase chain reaction returned positive. Ceftriaxone and azithromycin were discontinued the very next day because of low suspicion of bacterial infection while hydroxychloroquine was completed for 5 days. On the third day of admission, the patient self-extubated and was immediately placed on nonrebreather with spO₂ in low 90s. On the fourth day of admission, D-dimer came back 4.74 mg/L, which was elevated from a prior value, so computed tomography angiography of the lungs was done, which disclosed multiple emboli in the lungs. She was started on therapeutic doses of enoxaparin sodium, which was continued through her admission. She was switched to Apixaban on discharge. CONCLUSIONS The finding of the case suggested that low-molecular-weight heparin prophylaxis may not be sufficient to prevent VTE in COVID-19 pneumonia. Some of these patients may benefit from receiving prophylactic half doses or full doses of anticoagulants.

[Staphylococcus pneumonia--complications].

The paper presents the case of a 4-year-old child who was admitted with the diagnosis Dg: Pleuropneumonia lat. sin, while in the further course as a suspicion due to progressive flow as staphylococcus pneumonia. The illness is complex in terms of treatment. The diagnosis was set based on the history of illness, its clinical course, laboratory findings, radiology tests. The boy was hospitalized in January in current year with symptoms (coughing, vomiting and fever) that have been lingering for the past two days. The boy has been treated with a ternary antibiotic therapy (cephalosporin of third generation parenterally with aminoglycosides, plus anti-staphylococcus therapy). In laboratory findings Sedimentation rate increased 88/134 WBC 75 thousands. Radiologically extended pleuropneumonia on the left side. In sputum staphylococcus aureus was isolated. In the further course of hospitalization, due to the development of progressive form of staphylococcus pneumoniae with a fever of up to 39 degrees, pale aspect and dyspnoic patient with anemia and with complications in the form of cysts, ruptures and pneumothorax, with a thoracic drainage performed. In the further course, the cysts were gradually absorbed, while the thoracic drain was grafted. Clinically, the child was looking better. We continued the anti-staphylococcus therapy (stanicide), to which the child reacted well clinically and radiologically. Auscultatory breathing on the left side was audible. The last follow-up and the last rtg pulmo et cor 6 months after the outbreak of illness with a complete regression of the foregoing changes.

[The use of rifampin in the treatment of infection due to Staphylococcus aureus].

Infection due to Staphylococcus aureus continues to be a source of significant morbidity and mortality. However, its treatment is increasingly complicated by the rising prevalence of resistance to antibiotics. Apart from the two recognized modes of staphylococcal resistance, namely, penicillinase production and intrinsic resistance, Sabath and associates have described a third type in which resistance is manifested by susceptibility to growth inhibition but tolerance to the lethal action of bactericidal agents. The mechanism of tolerance is attributed to a deficiency of autolytic enzyme activity in the part of bacteria, possibly secondary to an inhibition of autolysins in the tolerant staphylococcal strains. These strains are found in patients with infections responding poorly to treatment with cell-wall active antibiotics including vancomycin. Because of its unique mechanism of action and pharmacokinetic properties, rifampin has been reported to be the most active among 65 antistaphylococcal agents tested and have the capacity to kill intraleukocytic staphylococci. We present 2 cases who were cured following the addition of rifampin to previously established regimens. Case 1 was a 40-year-old male who had fever, cough, dyspnea, a right elbow abscess and left leg swelling for 2 weeks prior to admission. Culture of purulent material from the elbow abscess grew staphylococcus aureus. Chest X-ray showed bilateral septic embolism and phleborheography showed partial deep vein occlusion of the left ileofemoral vein. Case 2 was 22-year-old female with fever, chills and cough for 3 weeks. Blood culture grew staphylococcus aureus, and Chest X-ray revealed bilateral septic embolism with pneumonia. Neither of them responded to standard antibiotics which were judged adequate by in vitro sensitivity tests. Clinical cure was later obtained after rifampin was added to the regimens. These results suggest that rifampin may be a useful adjunct in the therapy of staphylococcal infections.

Disseminated Pulmonary Mycosis Caused by <i>Candida tropicalis</i> in an 11-Year-Old Male Patient with Chronic Granulomatous Disease.

Invasive fungal infection is a major threat to chronic granulomatous disease (CGD) patients. We present a rare case of invasive mycosis in a CGD boy. An 11-year-old preadolescent boy presented with fever, hypoxia, and dyspnea. Physical examination revealed left neck enlarged lymph nodes with healed scars. The chest revealed bilateral diminished air entry with bilateral coarse crackles. Peripheral blood leukocyte count was 28.260/<iμ</iL with 84% neutrophil, 11% lymphocyte, and 4.4% monocyte. The patient's condition deteriorated regardless of the empirical antibacterial against MRSA and suspected tuberculosis. A sputum sample was submitted for mycological investigation, and budding yeasts with pseudohyphae were detected in the direct smear and were isolated in pure culture using Sabouraud agar. <iCandida tropicalis</i was identified from cultural and microscopic features and confirmed by the Vitek 2 automated system. This result confirmed the invasive mycosis, obviously due to the underlying primary immunodeficiency, chronic granulomatous disease (CGD). Amphotericin was added, and he also received IV methylprednisolone for seven days. The patient improved and was weaned off oxygen with no fever. However, the patient was referred to a higher center for further workup, which confirmed CGD's diagnosis. He is on the list for HLA-identical bone marrow transplantation (BMT).

[A case of pneumothorax secondary to septic pulmonary embolism due to central venous catheter infection caused by methicillin-resistant Staphylococcus aureus].

A 72-year-old woman with deteriorated renal function underwent hemodialysis with a central venous double lumen catheter and was treated with predonisolone when diagnosed with MPO-ANCA associated rapidly progressive glomerulonephritis. She developed a high fever. On hospital day 64, the central venous catheter was removed immediately, and VCM and RFP were started. On hospital day 70, chest CT showed multiple nodular cavitated lesions, and she was diagnosed as septic pulmonary embolism (SPE). Six days later, chest radiography showed asymptomatic right hydropneumothorax. An intercostal tube was inserted and purulent fluid drained. Methicillin-resistant Staphylococcus aureus was isolated from blood culture, the central venous catheter, and pleural effusion. Her condition improved slowly, and she was discharged mobile on hospital day 129. Pneumothorax is reported to be a rare but possibly lethal complication of SPE in intravenous drug abusers. To our knowledge, this is the first case report of pneumothorax secondary to SPE due to central venous catheter infection. SPE related to intravascular devices or catheters has been increasing, and the significance of this SPE complication in the critically ill should be recognized.

[A clinical analysis of 9 cases of pulmonary alveolar proteinosis with secondary infection].

To describe the clinical characteristics of 9 cases of idiopathic pulmonary alveolar proteinosis (iPAP) with secondary infections. The clinical and radiological data of 9 patients with iPAP and secondary infections admitted into Peking Union Medical College Hospital from 1st January 1990 to 1st January 2010 were retrospectively analyzed. In that period, there were 97 patients of iPAP were admitted in our hospital. There were 9 patients of iPAP with secondary infections, aged (46.4 ± 14.6) y. There were 5 males and 4 females. Among them, 6 patients were misdiagnosed as interstitial pneumonia and corticosteroids were given to them. When the infection appeared, corticosteroids were still given to 3 patients, and the other 3 patients had stopped corticosteroids for 3 to 15 and a half months. Five patients had accepted mono-lung or whole lung lavage before 1, 2, 9, 14, 24 months. The clinical manifestations were fever (8 cases), cough (9 cases), expectoration (8 cases), hemoptysis (2 cases), chest pain (1 case) and moist rales (1 case). Glass-ground opacities (9 cases) and cavitations (4 case) were the main manifestations of chest radiology. Pleural effusions (1 case) was not common. The locations of infection was limited in chest: 9 cases had pulmonary infection and one case was associated with pleurisy. The infectious pathogens were the acid-fast tubercle bacillus (4 cases), fungus (3 cases, candida albicans, penicillium and aspergillus fumigatus for each one) and nocardia (2 cases, one case was associated with cytomegalovirus infection). 6 patients were cured, 1 patient was improved and 2 patients were died. For patients with iPAP, especially when they had been receiving corticosteroids, if they had fever and/or recently exaggerated dyspnea, especially whose chest radiology showed nodules and cavitations, the clinicians should be aware of infections diseases for them. Further specific microbiological studies and sufficient therapy should be obtained as quickly as possible.

Management of recurrent cutaneous abscesses during therapy with infliximab.

Infliximab is a chimeric monoclonal antibody, belonging to the class of anti-tumor necrosis factor-α (TNF-α) agents, approved for the treatment of psoriasis and psoriatic arthritis. Drugs of this class are known to be associated with an infective risk, probably because they interfere with inflammatory and immune response at different levels. Although cutaneous Staphylococcus aureus infections seem to be more frequent than any other infection in the course of anti-TNF-α treatment, only a few case reports in the literature deal with this side effect, and, in particular, with its management. Our aim was to report a case of recurrent methicillin-sensitive S aureus (MSSA) cutaneous abscesses during therapy with infliximab and successful management. In July 2009, a 53-year-old white woman (weighing 85 kg) affected by psoriasis and psoriatic arthritis was administered infliximab (5 mg/kg IV), based upon clinical appearance and previous unsuccessful treatment with cyclosporine, methotrexate, etanercept, and adalimumab. Three days after the first 3 infusions (at weeks 0, 2, and 6) she complained about the recurrent onset of painful, erythematous, indurated, and pus-draining cutaneous nodules located on her abdomen. The swab always revealed the presence of MSSA, and antibiotic oral therapy with amoxicillin + clavulanic acid (875 + 125 mg BID for 7 days) was established, with complete resolution of the abscesses. Routine laboratory findings were in normal ranges, with the exception of an elevated erythrosedimentation rate and an increased white blood cell count (range, 13,000-15,000/mm(3)) with neutrophilia (range, 75%-80%). HIV infection was ruled out. In agreement with the infectious disease consultant, 1 day before the fourth infusion, a prophylactic antibiotic therapy with amoxicillin + clavulanic acid (875 + 125 mg BID for 5 days) was added to the therapeutic regimen. This treatment schedule was successfully repeated at each following infusion (every 8 weeks), and no recurrence of skin abscesses was observed. The patient provided signed authorization for publication of this case. This case report describes a woman with psoriasis and psoriatic arthritis who developed MSSA skin abscesses after each of the first 3 infliximab infusions, which did not recur for the next 6 infusions after amoxicillin + clavulanic acid was added to her regimen, pre- and 4 days postinfusion. Adequately designed, placebo-controlled, double-blind trials are needed to determine whether such prophylactic antibiotic treatment is well tolerated or effective for this common complication of therapy with anti-TNF-α agents, when withdrawal of the drug is not advisable, as in this case.

[Diagnostic problems in a patient with staphylococcal endocarditis].

A patient, aged 68, admitted to the Internal Medicine Ward, in connection with syncope and a persisting fever which had appeared for the third time during the last two months. The patient had an artificial aortic valve graft implanted and a heart bypass surgery (CAPG) in 1994. A urine examination, performed before his admission to hospital, showed the characteristic changes which appeared in UTI (urine tract infection). Then the patient was treated with quinolone (zanocin) and the abatement of the fever was achieved. After two weeks the recurrence of the intermittent fever appeared. The diagnosis of bacterial endocarditis was established and a broad spectrum antibiotic treatment was introduced and continued in spite of the negative blood culture. The circulatory failure and growing cachexia developed in the patient and led to his death within two weeks. From the last blood sample Staphylococcus aureus was cultured. In autopsy the phlegmonic and haemorrhagic changes were found, with foci of necrosis in the region of the implanted artificial valve graft. Some changes of the type of interstitial numerous, microfocal, phlegmonic foci were also found. The author drew the conclusion that if the treatment with broad spectrum antibiotics had been introduced, in the patient with a fever, after a heart surgery, there would have been a chance for the successful treatment.

Levofloxacin 750 mg QD for five days versus amoxicillin/clavulanate 875 mg/125 mg BID for ten days for treatment of acute bacterial exacerbation of chronic bronchitis: a post hoc analysis of data from severely ill patients.

This post hoc analysis of data from a previous randomized, blinded, multicenter, parallel, noninferiority study assessed the bacterial etiology, symptom resolution, and tolerability of severe acute bacterial exacerbation of chronic bronchitis (ABECB) patients treated with either levofloxacin 750 mg QD for 5 days or amoxicillin/clavulanate 875 mg/125 mg BID for 10 days. Severe ABECB was defined as ABECB and forced expiratory volume in 1 second (FEV(1)) <50% of the predicted value, or (FEV(1)) of 50% to 65% of the predicted value plus comorbidities, or > or =4 exacerbations per year. A total of 369 patients were included in the intent-to-treat (ITT) population (187 treated with levofloxacin and 182 treated with amoxicillin/clavulanate), and 175 patients were microbiologically assessable (MA) (86 treated with levofloxacin and 89 treated with amoxicillin/clavulanate). In the ITT population, the mean age was 58.7 years, 49.1 % were male, and 48.2% were current smokers. At the on-treatment visit, a significantly higher proportion of MA patients in the levofloxacin group resolved purulent sputum production (57.5% vs 35.6%; P < 0.006), sputum production (65.4% vs 45.3%; P < 0.013), and cough (60.0% vs 44.0%; P < 0.045), compared with the amoxicillin/clavulanate group. However, no significant between-group differences were observed at posttreatment. A total of 341 pathogens were isolated, of which 143 (41.9%) were traditional ABECB flora, 181 (53.1%) were other gram-negative organisms, and 17 (5.0%) were gram-positive organisms. Overall susceptibility of the pathogens was 97.1% for levofloxacin and 90.6% for amoxicillin/clavulanate (P < 0.001). The prevalence of treatment-emergent adverse events was 42.1 % in patients who received levofloxacin and 48.6 % in those who received amoxicillin/clavulanate (95% CI,-4.0 to 17.0).

[Clinical analysis of 20 cases with Streptococcus pneumoniae necrotizing pneumonia in China].

Streptococcus pneumoniae necrotizing pneumonia (SPNP) was reported elsewhere but not in China yet. Inappropriate treatment due to poor recognition of this disease could influence its prognosis. This paper presents the clinical characteristics, diagnosis and treatment of SPNP hoping to elevate pediatrician's recognition level for this disease. Clinical manifestations, radiological findings, treatment and prognosis of 20 patients (9 boys, 11 girls) who had been hospitalized with SPNP in Beijing Children's Hospital from 2004-2011 were retrospectively analyzed. The patients included in this study aged from 9 months to 6 years [(27.9 ± 15.8) m] and were healthy before admission. They were febrile for 8 to 50 days [(27.7 ± 13.5) d] and hospital day was 24 - 55 days [(36.5 ± 8.3) d]. The general condition of all subjects was relatively poor and they all had fever and cough. One child had moderate fever and nineteen children had high fever. Dyspnea was found in sixteen children. Fine rales were found on auscultation in 18 children, among whom diffuse wheeze appeared in 4 children, and wheezy phlegm was found in two children. Signs of pleural effusion were discovered in all cases by physical examination and chest X-ray. White blood cell (WBC) count was 16.2 - 60.95×10(9)/L and neutrophil was 70.5% - 80.2% in peripheral blood routine test. Erythrocyte sedimentation rate (ESR) was 44 - 109 mm/h [(69.6 ± 16) mm/h]and C-reactive protein (CRP) was 80 - > 160 mg/L. The pleural effusion biochemistry and routine test revealed a WBC count of 6400×10(6)/L-too much to count, polykaryocyte of 51% - 90%, glucose of 0.02 - 1.8 mmol/L, protein of 32 - 51 g/L and LDH of 5475 IU/L-or higher. Pleural effusion culture in all cases and blood culture in 2 cases was positive for Streptococcus pneumoniae. Chest X-ray or CT revealed high density and well-distributed lobar consolidation in one lung or two lungs initially. Single or multiple low density lesions in the area of lobar consolidation were found a week later, accompanied by multiple cystic shadow or cavity at the same time or afterwards. Bulla of lung appeared later. Pleural effusions were found in all patients. Seven cases complicated with hydropneumothorax, two with otitis media, one with heart failure, one with cardiac insufficiency. Seventeen patients were treated with vancomycin or teicoplanin or linezolid two with amoxicillin and clavulanate potassium. Other two patients had been treated with meropenem and cephalosporin antibiotics respectively before admission, and they had been at recovery stage when they were hospitalized. Thoracic close drainage and thoracoscopy were performed respectively in 18 cases and 3 cases, respectively. After a follow up of more than 6 months, chest CT showed that almost all lesions in lungs recovered during 4-6 months. No one received pneumonectomy. SPNP has special manifestations. The incidence in infants is higher. Patients' general condition is poor and febrile course is relatively long. All patients manifested fever and cough, with a presence of dyspnea in most of them. WBC, neutrophil and CRP elevated apparently. The characteristic of pleural effusion indicates empyema. In early stage, the chest X-ray and CT showed high-density lobar lesions, followed by low-density lesions and cyst gradually. Bulla of lung and/or hydropneumothorax may appear at the late stage. But if diagnosed and treated promptly, the prognosis of SPNP was relatively good.

InternalMed_Harrison

raises a distinct set of potential pathogens, including Legionella, Pneumocystis, and fungal agents that may require further diagnostic evaluations, such as bronchoscopy with bronchoalveolar lavage. Febrile neutropenic patients can be stratified broadly into two prognostic groups. The first, with expected short duration of neutropenia and no evidence of hypotension or abdominal or other localizing symptoms, may be expected to do well even with oral regimens, e.g., ciprofloxacin or moxifloxacin, or amoxicillin plus clavulanic acid. A less favorable prognostic group is patients with expected prolonged neutropenia, evidence of sepsis, and end organ compromise, particularly pneumonia. These patients require tailoring of their antibiotic regimen to their underlying presentation, with frequent empirical addition of antifungal agents if fever and neutropenia persists for 7 days without identification of an adequately treated organism or site.

Performance in practice: bacteriological efficacy in patients with drug-resistant S. pneumoniae.

Using pharmacokinetic/pharmacodynamic principles, pharmacokinetically enhanced amoxicillin/clavulanate 2000/125 mg twice daily was designed to provide adequate levels of amoxicillin over the 12-h dosing interval to eradicate penicillin-resistant Streptococcus pneumoniae (PRSP, penicillin MICs > or = 2 mg/L) with amoxicillin MICs of at least 4 mg/L. The clinical efficacy of amoxicillin/clavulanate 2000/125 mg was evaluated in patients with respiratory tract infections caused by S. pneumoniae, including isolates with elevated penicillin (2-8 mg/L) MICs. Data from 10 clinical studies were combined: seven randomised (1:1), double-blind, controlled trials (efficacy intent-to-treat [ITT]N = 3376): amoxicillin/clavulanate 2000/125 mg twice daily vs. levofloxacin 500 mg once daily in acute bacterial sinusitis (ABS); levofloxacin 500 mg once daily in acute exacerbations of chronic bronchitis (AECB); clarithromycin 500 mg twice daily in AECB; amoxicillin/clavulanate 875/125 mg twice daily/three times daily and 1000/125 mg three times daily in community-acquired pneumonia (CAP) and three noncomparative studies (efficacy ITT N = 3024): two in ABS, one in CAP. The bacteriological per-protocol (PP) population at follow up (days 14-39) comprised 1295 patients for amoxicillin/clavulanate 2000/125 mg and 241 for comparators. With amoxicillin/clavulanate 2000/125 mg at follow-up, outcome was successful (clinical success and eradication/presumed eradication) in 85/90 (94.4%) patients with S. pneumoniae in comparative studies and 421/445 (94.6%) in noncomparative studies, and with comparators 58/70 (82.9%) were successes. In the amoxicillin/clavulanate 2000/125 mg group at follow up, 52/552 S. pneumoniae isolates were resistant to penicillin. At follow up, 50/52 (96.2%) patients with PRSP were successes, including 6/7 with amoxicillin MICs of 4 mg/L and 7/8 with amoxicillin MICs of 8 mg/L. Success rates for amoxicillin/clavulanate 2000/125 mg against PRSP were similar for CAP (96.0%[24/25]), AECB (100%[3/3]) and ABS (95.8%[23/24]). There were six PRSP isolates in the comparator group (two isolates were from one patient), and three of five patients in this group were successes. In conclusion, amoxicillin/clavulanate 2000/125 mg demonstrated combined clinical/bacteriological success against 50/52 patients with PRSP, including 13/15 strains with amoxicillin MICs of 4-8 mg/L. These results for the pharmacokinetic-enhanced formulation of amoxicillin/clavulanate 2000/125 mg are in line with the high efficacy against PRSP predicted using pharmacokinetic/pharmacodynamic parameters.

[Septicemia due to Streptococcus milleri with pulmonary complications].

Streptococcus milleri can occasionally cause serious septicemia, that is often complicated by abscesses, particularly pulmonary. A 12.5 year-old boy was admitted because he had suffered from fever for 6 days. He also had headache, diffuse abdominal pain, chills and a cough. Laboratory investigations showed leukocytes: 9,300/mm3 (PMN: 6,700/mm3; lymphocytes: 1,400/mm3; monocytes: 1,200/mm3); hemoglobin: 12.5 g/dl; platelets: 106,000/mm3; sedimentation rate: 120 mm at 1 hour; blood fibrinogen: 5.6 g/l and C-reactive protein: 193 mg/l. His chest X-rays was normal. Four blood cultures showed Streptococcus milleri. The patient was given amoxicillin (150 mg/kg/d) plus gentamicin (3 mg/kg/d). Two foci of dental infection were found and treated by tooth extraction. Blood cultures remained positive 2, 3 and 6 days after onset of treatment and a second chest X-rays and CT scan showed several bilateral pulmonary abscesses. Cardiac ultrasonographs showed no valvular vegetations. The patient was then given ceftriaxone (100 mg/kg/d) plus rifampicin (20 mg/kg/d) and netilmicin (6 mg/kg/d). Blood culture was negative two days later, but the fever persisted and ceftriaxone was then successfully replaced by vancomycin (40 mg/kg/d) for three weeks. There are several reasons for the apparent resistance to treatment of this potentially severe infection; they are discussed by the authors.

COVID-19 Infection and Late Manifestation of Pulmonary Aspergillosis.

We present the case of a 56-year-old woman who was diagnosed with severe coronavirus disease 2019 (COVID-19) pneumonia complicated by severe acute respiratory distress syndrome who was intubated for 19 days. She recovered from COVID-19 after a month. A computed tomography (CT) scan of the chest, after a month, showed improved infiltrates with a small residual cavity within the lingula. A CT angiogram showed a more confluent density in the lingular portion on follow-up 2 months later. She developed intermittent hemoptysis after 3 months in December 2020, which persisted for almost 6 months, and CT of the chest showed the lingular nodular with resolution of the cavitation. She underwent bronchoscopy with bronchoalveolar lavage, confirming <iAspergillus fumigatus</i by galactomannan assay and histology showing branching hyphae. Once she started treatment with itraconazole, her hemoptysis resolved. The follow-up CT of the chest after 2 months of treatment did not show a cavity or a nodule in the lingula. Our patient developed invasive pulmonary aspergillosis (IPA) as a sequela of severe COVID-19 infection. COVID-19-associated invasive pulmonary aspergillosis (CAPA) is an underrecognized complication that needs to be investigated on whether prophylactic treatment is required. Our case also demonstrates that the diagnosis of IPA needs to be considered months after COVID-19 infection when a superimposed fungal infection can occur after a viral infection if the patient continues to have persistent symptoms.

Successful voriconazole treatment of invasive pulmonary aspergillosis in a patient with acute biphenotypic leukemia.

A 23-year old woman with acute biphenotypic leukemia (ABL) complained of chest pain with cough, high fever and hemoptysis during induction chemotherapy, although she had been treated with anti-biotics and micafungin. We made a clinical diagnosis of invasive pulmonary aspergillosis (IPA) based on a consolidation in the right upper lung field on a chest radiograph as well as a high level of serum beta-D-glucan (with no evidence of tuberculosis and candidiasis). We changed her treatment from micafungin to voriconazole. Later, we discovered an air-crescent sign by CT scan that supported the diagnosis of IPA. Following voriconazole treatment, clinical symptoms ceased and abnormal chest shadows improved gradually and concurrently with a recovery of neutrophils. IPA must be considered in immunocompromised patients with pulmonary infiltrates who do not respond to broad-spectrum antibiotics. Serological tests and CT findings can aid in early diagnosis of IPA, which, along with treatment for IPA, will improve clinical outcomes.

[A case of hypoxemic acute bronchiolitis presenting with diffuse nodular shadows caused by Mycoplasma pneumoniae].

A fifty year-old female who had previously been well presented with a productive cough and a high fever. Her initial chest X-ray film showed no abnormal lung shadows. Despite partial improvement of the fever and the serum level of acute phase reactant (CRP) in response to intravenous administration of piperacillin, she complained of increasing severity of cough and dyspnea. Follow-up chest X-ray films taken five days after therapy with piperacillin showed diffuse nodular shadows in the mid-to-lower lung fields bilaterally. Chest CT scan disclosed diffuse miliary nodules at the lung periphery and thickening of bronchovascular markings. Chest auscultation revealed late inspiratory coarse crackles and expiratory wheezing, and the patient's arterial oxygen tension was 61 mmHg. Suspected of suffering from primary atypical pneumonia, she was started on therapy with intravenous minocyclin (200 mg/day), two days after treatment her symptoms began improving significantly. Anti-mycoplasma antibody was found to be x 1280, and cold hemoagglutinin x 1024, establishing the diagnosis of Mycoplasma pneumoniae infection. The patient's condition completely recovered following a one week treatment with minocyclin. We concluded that her respiratory infection was caused by piperacillin-sensitive mico-organism, and also Mycoplasma pneumoniae which brought about hypoxic acute bronchiolitis to the patient.

Evaluation of pulmonary infections in solid organ transplant patients: 12 years of experience.

Recipients of solid organ transplants (SOTs) are at higher risk to develop pulmonary infections (PIs) owing to their immunocompromised state. Flexible bronchoscopy (FB) is frequently performed to diagnose nature of these infections. The aim of 12-year review was to evaluate the demographic characteristics of SOT recipients with PIs and to study diagnostic utility of FB in this group of patients. Medical records of patients who underwent SOT as well as FB between 2000 and 2012 were retrospectively reviewed. Patients' demographics, type of transplantation, primary diagnoses, thoracic computed tomography (CT) findings, total blood count and chemistry, indication for FB, FB results, specimen culture results, and suspected and final diagnoses were all recorded. If the bronchoscopy findings altered medical management and produced improvement in PI, the procedure was considered diagnostic. Ninety of 998 liver, heart, or kidney transplant recipients underwent FB (73 renal, 16 liver, and 1 heart; mean age, 42.3 ± 12.1 years) during the study period. CT findings were as follows: Consolidation (49.4%), lymphadenopathy (3.4%), nodular infiltrates (5.6%), and cavitary lesion (1.1%). FB was unremarkable in 29, but showed increased secretions in 33 patients (36.7%), chronic mucosal changes in 9 (10%), edema in 7 (7.8%), mucosal plaque in 7 (7.8%), friable mucosa in 3 (3.3%), and endobronchial lesion in 2 (2.2%). A total of 29 bronchial washings (BW; 32.6%) and 10 bronchoalveolar lavages (BAL; 11.2%) were performed. PI was diagnosed in 82% of the patients (n = 73). In 32 patients (36%), micro-organism growth was observed on either BW or BAL. Mycobacterium tuberculosis was detected in 6 (6.7%), Staphylococcus aureus in 4 (4.4%), Moraxella catharralis in 4 (4.4%), Candida albicans in 6 (6.7%), Klebsiella pneumonia in 2 (2.2%), Escherichia coli in 2 (2.2%), Streptococcus pneumoni in 2 (2.2%), Stenotrofomonas maltofilia in 1 (1.1%), Aspergillus fumigatus in 4 (4.5%), and Pseudomonas aeruginosa in 1 (1.1%). Final diagnosis was established by FB (n = 33) with a diagnostic yield of 36%. No significant finding was observed between the type of the transplant and the culture results (P > .05). Suspected PI is the most common indication for FB in SOT recipients. It may identify the causative organism in >30% of patients. Tuberculosis was found to be the most frequent agent, which is not surprising from such an endemic area. Bacteria were more common than fungal or viral micro-organisms. FB should be considered in SOT recipients presenting with lung infiltrates and suspected to have PI.

[Fulminant Mycoplasma pneumoniae pneumonia resulting in respiratory failure and a prolonged pulmonary lesion].

A previously healthy 26-year-old woman presented with a fever and coughing on October 1, 1995. Despite treatment with beta-lactam antibiotics at another hospital, she had a high fever, coughing, and dyspnea. A chest roentgenogram showed diffuse infiltrates in both lung fields. On October 9, she was transferred to our hospital. On admission, a chest X-ray film showed marked diffusely infiltrates in both lung fields and a effusion in the left lung. Arterial blood gas analysis after inhalation of 4 liters per minute of oxygen via a nasal cannula revealed a PaO2 of 39.0 torr. Despite treatment with various antibiotics, including minocyclin and gamma-globulin, her respiratory condition rapidly deteriorated. She was mechanically ventilated by with intermittent mandatory ventilation and positive end-experiatory pressure, and received antibiotics and methylprednisolone pulse therapy. He chest X-ray and arterial blood gase findings, gradually improved. The passive hemagglutination titer for Mycoplasma rose from 1:4 on October 9, to 1:2,560 on the 14th hospital day. Acute respiratory failure due to Mycoplasma pneumoniae pneumonia was diagnosed. A chest X-ray film obtained 2 months after admission showed linear-reticular shadows in both lung fields and pulmonary-function tests revealed abnormally low vital capacity and diffusing capacity. Examination of a specimen obtained by transbronchial lung biopsy revealed focal intraalveolar exudate with fibrin and macrophages. Very mild interstitial thickening was also noted. The lymphocyte stimulation responses to PPD, PHA, and Con A were low early in the illness and became normal after recovery. Several reports have said that an enhanced pulmonary cellular immune response may be responsible for the development of severe Mycoplasma pneumoniae, resulting in a temporary decrease in the cell-mediated immune response. This case supports that hypothesis. We believe that in severe cases, steroid therapy including pulse therapy should be started as soon as possible.

[Pulmonary nocardiosis with a large solitary cavitary nodule caused by Nocardia cyriacigeorgica in a patient receiving corticosteroid therapy].

Nocardiosis is a rare disease generally caused by members of Nocardia asteroides complex, particularly in immunosupressed patients. Nocardia cyriacigeorgica is a newly described member of this complex. In this article, a case of pulmonary nocardiosis with a large solitary cavitary nodule caused by N. cyriacigeorgica, in a patient receiving corticosteroid therapy was presented. A 29 years old male patient receiving prednisolone for 5 months was admitted to our hospital with fever, cough, right thoracic pain and night sweats. Computed tomography scan of chest demonstrated a large solitary cavitary nodule in the right lower lobe. Gram stained smear of the sputum revealed gram-positive, beaded, branched filamentous bacilli. On the third day of his admission, a catalase positive, oxidase negative and immotile bacilli, compatible with Nocardia spp., were isolated from the sputum sample taken at the day of admission. The isolated bacterium was identified as N. cyriacigeorgica by reference laboratory (Lyon, France). Oral trimethoprim (320 mg/day) and sulfamethoxazole (1600 mg/day) therapy given for three months, resulted in complete cure of the lesion without any sequela. This was the fourth case of pulmonary nocardiosis caused by N. cyriacigeorgica reported from Turkey. Microbiological examination of sputum is the most important tool for the diagnosis. Treatment with appropriate antibiotics may achieve complete cure even in large cavitary lesions. In conclusion, pulmonary nocardiosis should be considered in differential diagnosis of solitary cavitary nodules, especially in immunocompromised patients.

Temsirolimus

Lung toxicity Temsirolimus is associated with lung toxicity, and the risk of developing this complication may be increased among subjects with abnormal pre-treatment pulmonary functions or history of lung disease. The risk of interstitial lung disease is increased with temsirolimus doses greater than 25 mg, symptoms of which may include dry cough, fever, eosinophilia, chest pain, and dyspnea on exertion. Toxicity usually occurred early (within days to weeks) or late (months to years) after treatment. Dosing Although infusion reactions can occur while temsirolimus is being administered, most hypersensitivity reactions occurring on the same day as temsirolimus administration were not severe. Antihistamine pretreatment (e.g. 25–50 mg diphenhydramine, 30 minutes prior to administration) is recommended to minimize the risk of an allergic reaction. See also Discovery and development of mTOR inhibitors References External links

Disseminated cutaneous Fusarium moniliforme infections in a leukemic child.

A 5-year-old boy had a 10-month remission of acute lymphocytic leukemia (ALL) after chemotherapy. Re-induction chemotherapy was performed for relapse of ALL. Thereafter, he suffered from an episode of neutropenic fever with pneumonia. One week following control of the condition with antibiotics, a 1 x 1-cm, red, painful nodule appeared on the left thigh, which was initially suspected to be Pseudomonas infection. Parenteral ceftazidime and amikacin were administered, but persistent high fever, mild cough, and a few painful erythematous papulonodules on the face and lower extremities appeared several days later (Fig. 1). These lesions increased insidiously in diameter up to 2-5 cm with central necrosis. Hemogram showed neutropenia with a shift to the left [white blood cell (WBC) count, 2.1 x 10(9)/L; neutrophil count, 0.21 x 10(9)/L]. A skin biopsy showed heavy growth of hyaline branching septate hyphae in the deep dermis and subcutis, together with fat necrosis (Fig. 2). Invasion of molds into vessels and sweat glands was also seen. A culture from a lesion yielded Fusarium moniliforme, but no fungi were isolated from blood specimens. Only mild infiltrations on bilateral lower lung fields were detected by chest roentgenography. The skin lesions gradually healed and the fever subsided 2 weeks after the initiation of therapy with amphotericin B 30 mg and itraconazole 200 mg daily. Meanwhile, relapse of leukemia was detected by hemogram showing atypical leukocytosis (WBC count of 24,400 x 10(9)/L, with blast cells representing 78%). A course of chemotherapy with cytarabine, mitoxantrone, and VP-16 was prescribed, subsequently resulting in neutropenia (WBC count, < 0.1 x 10(9)/L; neutrophil count, 0/L) and spiking fever. Although the aforementioned antifungal therapy was continued, the centers of the originally healed lesions turned dusky red, swollen, necrotic, and ulcerative. There were more than 10 such ecthymiform lesions. After administration for 22 days, itraconazole was discontinued because of no appreciable effects. Granulocyte colony-stimulating factor (G-CSF) salvage was used, and the neutropenia gradually subsided 20 days later. In addition, the ecthymiform lesions gradually resolved. Amphotericin B was discontinued 1 week following neutrophil recovery. The patient died of Acinetobacter baumannii and Stenotrophomonas maltophilia sepsis 8 months later.

Fentanyl-Induced Chest Wall Rigidity as a Cause of Acute Respiratory Failure in the Intensive Care Unit.

We aim to report a case of chest wall rigidity induced by high-dose fentanyl infusion sedation and analgesia in the intensive care unit (ICU) for management of pneumonia and asthma. The patient is an 80-year-old woman, who presented to the hospital with complaints of fever and productive cough with yellowish expectoration of 2 days duration. She also had lethargy over the same time period and had sick contacts in the form of two daughters who both had recently recovered from a "flu-like" illness. She was known to have bronchial asthma treated with seretide 25/250 two puffs ON + PO monteleukast 10 mg ON, hypertension treated with PO losartan 50 mg BD, type 2 diabetes mellitus controlled with PO linagliptin 5 mg OM and a previous right thalamic ischemic stroke 5 years ago for which she was on PO clopidogrel 75 mg OM and PO simvastatin. She developed severe ventilator desynchrony characterized by dramatic sudden onset of severe hypercarbia, severely decreased pulmonary compliance and episodic breath holding. She was empirically treated for asthma exacerbation and treated with steroids, bronchodilators and manual ventilation but despite doing so during this episode the patient failed to respond. The patient was clinically evaluated and dynamic hyperinflation was excluded as a cause of the respiratory failure. There was no evidence of pneumothorax and worsening pneumonia. Considerations of insufficient sedation and analgesia led to deepening sedation and analgesia without good response. Ventilation was dramatically improved after small doses of neuromuscular relaxation. This cycle was repeated many times. The patient was kept on high-dose propofol and fentanyl, but there were repeated cycles of sudden persistent severe hypercarbia, severely decreased pulmonary compliance and episodic breath holding. Eventually a suspicion of fentanyl-induced chest wall rigidity was made after excluding causes of airway resistance and reduction in pulmonary compliance. Gradual reduction in fentanyl infusion was associated with a reduction of episodes of reduced lung compliance and improvement in ventilation. Fentanyl is often used for analgesia and sedation in the ICU. It has a good side effect profile but it is not without harm. High doses of fentanyl can lead to dramatic worsening of respiratory mechanics that may be life threatening. Fentanyl-induced chest wall rigidity is an important side effect that needs to be considered in the differential diagnosis of respiratory failure in the ICU.

[A case of coccidioidomycosis in Turkey imported from the United States of America].

Coccidioidomycosis caused by Coccidioides immitis or Coccidioides posadasii is a rare infectious disease except in endemic regions. In this report the third documented imported case of coccidioidomycosis in Turkey was presented. A thirty-year-old male patient was admitted to our hospital with fever and purulent drainage from his chest tube. He had worked in Arizona, USA, until 4 months before this presentation. While in Arizona, he experienced cough and hemoptysis and was diagnosed as pulmonary coccidioidomycosis. He was treated with itraconazole for two months and he had no symptoms for 3 years. He then returned to Turkey and 2 months after his return to Turkey, he was admitted to another hospital in Istanbul with dyspnea and diagnosed as hydro-pneumothorax, and pleural fluid obtained from the inserted chest tube was found to be purulent. One gram of BID amoxicillin-clavulanate was given. Physical examination on admission revealed a purulent drainage on the right side chest tube, a temperature of 38.5°C and decreased breath sounds on the right lung. Piperacillin-tazobactam 3 x 4.5 g intravenous and fluconazole 400 mg intravenous once daily were started. Human immunodeficiency virus test was negative. Gram-negative diplococci and rods, gram-positive cocci and septate hyphae were seen in the Gram stain of his pleural fluid. Pleural fluid culture revealed Moraxella catarrhalis after 24 hours incubation and a mold after 72 hours of incubation. Anti-coccidioidal antibodies were found positive in a titer of 1/2. Hydro-pneumothorax, atelectasis and a 3 mm nodules in the right lung were seen in his thorax CT. The patient's pleural fluid and the culture plates were sent to the Public Health Institute of Turkey, Mycology Reference Laboratory (PHIT-MRL), with a clinical suspicion of coccidioidomycosis. The specimen and plates were submitted to the PHIT-MRL Bio Safety Level-3 laboratory for mycological evaluation. The microscopic examination of 15% KOH preparations of pleural fluid specimens revealed septate hyphae which appear to be in the early stages of forming arthroconidia. The pleural fluid culture grew buff-white coloured colonies with aerial hyphae, which were suspected of being a Coccidioides spp. The strain was identified as C.immitis/posadasii by direct microscopy and culture, and subsequently confirmed by the FDA-approved DNA probe. DNA sequence analysis of the ITS and D1/D2 rDNA regions confirmed the isolate to be C.posadasii species [ITS 100% match to GenBank Accession No. AB232901 (630/630 base pair match), and D1/D2 100% match to GenBank Accession No. AB232884 (617/617 base pair match)]. ITS1 and ITS2 barcode analysis also confirmed the species to be C.posadasii, which is the species endemic in Arizona. Susceptibility testing was performed according to Clinical and Laboratory Standards Institute M38-A2 guidelines in the Fungus Testing Laboratory of the University of Texas Health Science Center at San Antonio and minimal inhibitory concentration values were; 0.125 µg/ml for amphotericin B, posaconazole and voriconazole, 0.5 µg/ml for itraconazole and 8 µg/ml for fluconazole. He had decortication of the pleura and was discharged from hospital after six weeks treatment with intravenous fluconazole which was continued orally for one year. Anti-coccidioidal antibodies were negative after two months of treatment. The patient is currently asymptomatic. The presented case is the third case reported from Turkey and provides additional contribution to the existing literature with regard to the appearance of arthroconidium, which is the unusual hyphal form, instead of the expected spherules in the infected tissue.