The history of contact with fresh water in an endemic area points to leptospirosis, and in the clinical picture we also find jaundice and conjunctival injection which also points to leptospirosis and is not so characteristically related to the other three pathogens.

A 25-year-old man with no past history of interest presents to the emergency department with fever, headache, myalgia, nausea, vomiting, abdominal pain, jaundice and conjunctival injection, 2 weeks after traveling to Thailand to participate in a freshwater regatta. What is the most likely diagnosis?

Etiologies of acute undifferentiated febrile illness in Thailand.

Acute pyrexia of unknown origin (Acute PUO) was reported to affect approximately 200,000-400,000 patients each year reported by the national Annual Epidemiological Surveillance Report. The patients usually present with fever of less than two-week duration and non-specific symptoms such as malaise, myalgia, headache and loss of appetite. Its mortality rate is less than 0.02 percent. It would be interesting to find the etiologies and propose a management plan if the etiologies are discovered. This prospective epidemiologic study aimed to discover the etiologies of acute undifferentiated febrile illness in a tropical region like Thailand. Ten community-based hospitals were chosen as representatives in each part of Thailand to enroll patients into the study. Patients aged over two years old who presented with fever at the participating hospitals during year 1991-1993 were eligible for the study. Entry criteria of acute undifferentiated febrile illnesses (AUFI) included oral temperature over 38.3 degrees C within the last 24 hours, duration of fever ranging from 3-14 days, no specific single organ involvement by history taking and physical examination, normal or non-specific results of the following investigations: complete blood count, thick film for malaria, urinalysis and chest roentgenogram. The patients were hospitalized and a preset diagnostic protocol was performed. Other diagnostic procedures deemed necessary by attending physicians were perform. Patients were followed up within one month after hospital discharge. 1,240 patients were enrolled but only 1,137 case records and results of the serological tests were available for analysis. Etiologies could be found in 471 cases (38.7%). Primary bacteremia was detected in 36 cases (3.2%). E. coli, streptococci, salmonella, Enterobacter spp. and S. aureus were the five most common blood isolates. Serological studies revealed positive results for scrub typhus (7.5%), influenza (6.0%), dengue fever (5.7%), murine typhus (5.3%), enteric fever (1.9%), chikunkunya infection (1.1%), leptospirosis (1.1%) and melioidosis (0.9%). Thirteen cases succumbed (1.1%) in this study. The etiologies in the majority (61.3%) of AUFI remained unknown. Rickettsial infection, influenza and dengue fever are the most common identifiable diseases in a tropical country like Thailand especially during the rainy season. A management guideline for diagnosis and treatment of the AUFI with emphasis on primary bacteremia and antimicrobial-treatable AUFI was proposed.

Assessment of the clinical presentation and treatment of 353 cases of laboratory-confirmed leptospirosis in Hawaii, 1974-1998.

Leptospirosis is frequently misdiagnosed as a result of its protean and nonspecific presentation. Leptospirosis, a zoonosis with global distribution, commonly occurs in tropical and subtropical regions; most reported cases in the United States occur in Hawaii. All laboratory-confirmed leptospirosis cases in the State of Hawaii from 1974 through 1998 (n=353) were clinically evaluated. The most common presentation involved nonspecific signs or symptoms, including fever, myalgia, and headache. Jaundice occurred in 39% of cases; conjunctival suffusion was described in 28% of these cases. Initiation of antibiotics before the seventh day of symptoms was associated with a significantly shortened duration of illness. Because early recognition and initiation of antibiotic therapy are important, clinicians should familiarize themselves with the clinical presentation of leptospirosis, and when evaluating a patient with a febrile illness, they should obtain exposure and travel histories and entertain the possibility of leptospirosis in the differential diagnosis.

Leptospirosis in the Tohoku region: re-emerging infectious disease.

Leptospirosis is a zoonotic and disaster-related infectious disease. It is mainly endemic in subtropical or tropical countries and has not been reported since 2009 in the Tohoku region (northern Japan), including the Yamagata and Miyagi Prefectures. However, we experienced four patients with leptospirosis in the Tohoku region from 2012 to 2014; three patients (#1-3) live in the agricultural areas of the Yamagata Prefecture and one patient (#4) was a visitor to the Miyagi Prefecture. Patient 1 (81-year-old female) is a villager, with a rat bite, while Patient 2 (77-year-old male) and Patient 3 (84-year-old female) are farmers and were infected probably during agriculture work. Patient 4 (40-year-old male US citizen) was infected while traveling in Thailand. They had chief complaint of fever, headache, and myalgia and showed manifestations of hyperbilirubinemia (mean, 4.35 mg/dL), thrombocytopenia and acute kidney injury (AKI). All patients were diagnosed by polymerase chain reaction using blood and/or urine samples and a microscopic agglutination test for the anti-Leptospira antibody. All the patients were treated with infused antibiotics, including minocycline. The patients underwent hemodialysis due to severe AKI (mean serum creatinine, 4.44 mg/dL), except for Patient 2 with the normal serum creatinine level (1.12 mg/dL). All the patients recovered and were discharged. The presence of the three patients in the Yamagata Prefecture implies that leptospirosis does re-emerge in the Tohoku region. Therefore, careful survey of the pathogen is necessary for febrile patients with AKI who engage in agriculture or have a recent history of travelling in subtropical or tropical countries.

A Tale of Black Eschar in a Returning Traveller.

African tick-bite fever is an increasingly common cause for fever in the returning traveller. It needs to be considered in the febrile returning traveller with a characteristic rash: a black eschar. We describe a 51-year-old man returning from South Africa who presented to our emergency department with fever, headache, myalgia, and chills. On careful history and skin examination, a black eschar was found on the patient's left lateral shoulder, pointing toward a diagnosis of African tick-bite fever. The patient was treated with doxycycline and rapidly improved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In the emergency department, the diagnosis of African tick-bite fever is often overlooked in the pursuit of ruling out other travel-related illnesses, such as malaria. A thorough history, a complete physical examination, and a high level of suspicion are essential to the timely diagnosis and treatment of African tick-bite fever in the returning traveller.

Leptospirosis presenting as honeymoon fever.

An increasing number of travelers from western countries visit tropical regions, questioning western physicians on the prophylaxis, the diagnosis and the therapeutic management of patients with travel-associated infection. In July 2014, a French couple stayed for an adventure-travel in Columbia without malaria prophylaxis. A week after their return the woman presented with fever, myalgia, and retro-orbital pain. Three days later, her husband presented similar symptoms. In both patients, testing for malaria, arboviruses and blood cultures remained negative. An empirical treatment with doxycycline and ceftriaxone was initiated for both patients. Serum collected from the female patient yielded positive IgM for leptospirosis but was negative for her husband. Positive Real-Time PCR were observed in blood and urine from both patients, confirming leptospirosis. Three lessons are noteworthy from this case report. First, after exclusion of malaria, as enteric fever, leptospirosis and rickettsial infection are the most prevalent travel-associated infections, empirical treatment with doxycycline and third generation cephalosporin should be considered. In addition, the diagnosis of leptospirosis requires both serology and PCR performed in both urine and blood samples. Finally, prophylaxis using doxycycline, also effective against leptospirosis, rickettsial infections or travellers' diarrhea should be recommended for adventure travelers in malaria endemic areas.

Leptospiral pneumonia.

Severe leptospirosis rarely presents with primary pulmonary manifestations, without any associated jaundice or renal dysfunction. The authors report a nine-year-old boy who presented with complaints of abrupt onset of high fever; with myalgia, headache, and pain in right chest region, productive cough with hemoptysis and vomiting developing over the past 72 hours. Chest radiograph showed consolidation in the right upper lobe with air bronchogram. A history of contact with sewage water and presence of conjunctival suffusion in a child with pneumonia made us suspect leptospirosis. Following prompt initiation of parenteral penicillin therapy the child's complaints resolved over the next five days. Dri-Dot test to detect anti-Leptospira antibodies was positive. The diagnosis of leptospirosis was confirmed by a positive microagglutination test to Leptospira interrogans serovar Australis by a fourfold rise in antibody titer in paired sera collected during convalescence. Leptospirosis presenting with pulmonary hemorrhage has been associated with significant mortality but it can be successfully treated with early clinical suspicion of alveolar hemorrhage and prompt therapy.

Malaria: an important emergency room diagnosis.

Fever in a traveller returning from an area endemic with malaria is a medical emergency. Although malaria is rare in Canada, it is one of the commonest communicable diseases in the world. A history of prophylaxis is no guarantee that malaria has not been contracted. This case history details an example of failed prophylaxis, emergency room presentation, and emergency treatment for Plasmodium falciparum. Clinical manifestations of the disease can occur up to six months after return from a malarial region, especially if chemoprophylaxis delays initial presentation. Symptoms include the sudden onset of chills, rigor, fever, profuse sweating, prostration, malaise, myalgia, headache, anorexia, nausea, vomiting and diarrhea. A single negative blood film does not exclude the diagnosis.

InternalMed_Harrison

Physicians in areas not endemic for schistosomiasis face considerable diagnostic challenges. In the most common clinical presentation, a traveler returns with symptoms and signs of acute syndromes of schistosomiasis—namely, cercarial dermatitis or Katayama syndrome. Central to a correct diagnosis is a thorough inquiry into the patient’s history of travel and exposure to freshwater bodies—whether slowor fast-running—in an endemic area. Differential diagnosis of fever in returned travelers includes a spectrum of infections whose etiologies are viral (e.g., dengue fever), bacterial (e.g., enteric fever, leptospirosis), rickettsial, or protozoal (e.g., malaria). In cases of Katayama syndrome, prompt diagnosis is essential and is based on clinical presentation, high-level peripheral-blood eosinophilia, and a positive serologic assay for schistosomal antibodies. Two tests are available at the CDC: the Falcon assay screening test/enzyme-linked immunosorbent assay (FAST-ELISA) and the

Leptospirosis -- History and Physical

The differential diagnosis for Leptospirosis is extremely large and varies from benign processes like viral upper respiratory tract infections, other viral flu-like illnesses, to severe infections from rarer "travel" conditions including Dengue Fever, malaria, Hantavirus, hemorrhagic fevers, and typhoid fever. Also consider other more common conditions (which one would be likely to consider unless specific exposure history is known) like cholecystitis, mononucleosis, primary HIV, or if unvaccinated measles or rubella.

The spotted traveller.

A 23 year old university student comes to see you with a febrile illness and a rash. She has just returned from a 6 week holiday in South East Asia having visited Thailand, Vietnam, Hong Kong and the Philippines. Prior to going away she went to a travel clinic, was appropriately immunised and given malaria prophylaxis which she has taken assiduously. Her symptoms have been present for about 3 days and consist of severe retro-orbital headache, diffuse myalgias, fevers and chills, and anorexia. The rash appeared the day before on her trunk and is now beginning to involve her arms with a slight papular element. She also has conjunctival haemorrhages and is febrile with a temperature of 38.9 degrees C. A full blood count done urgently does not show any malaria parasites but does reveal a low platelet count of 85,000 x 10(6)/L.

InternalMed_Harrison

Mild Leptospirosis Most patients are asymptomatic or only mildly ill and do not seek medical attention. Serologic evidence of past inapparent infection is frequently found in persons who have been exposed but have not become ill. Mild symptomatic leptospirosis usually presents as a flu-like illness of sudden onset, with fever, chills, headache, nausea, vomiting, abdominal pain, conjunctival suffusion (redness without exudate), and myalgia. Muscle pain is intense and especially affects the calves, back, and abdomen. The headache is intense, localized to the frontal or retroorbital region (resembling that occurring in dengue), and sometimes accompanied by photophobia. Aseptic meningitis may be present and is more common among children than among adults. Although Leptospira can be cultured from the cerebrospinal fluid (CSF) in the early phase, the majority of cases follow a benign course with regard to the central nervous system; symptoms disappear within a few days but may persist for

2017 Puerto Rico Leptospirosis outbreak

The delayed onset of symptoms of leptospirosis can make it difficult to detect and distinguish. After an incubation period of typically 5 to 10 days, but potentially as early as 2 days and up to 30 days after infection, people infected with leptospira bacteria can develop flu-like symptoms including fever, chills, headache, myalgia (muscle pain), cough, vomiting, and diarrhea. The early signs are vague and often too general to be able to make a confident presumptive diagnosis of leptospirosis. In some cases, patients may present with only febrile illness with other differentials considered including meningitis, influenza, sepsis and many others. Other patients will present with the fulminant infection exhibiting signs of end stage liver failure, acute renal failure or severe pulmonary hemorrhage syndrome (SPHS). The test considered to be the gold standard for leptospirosis diagnosis by the WHO is one that is not very sensitive in the early stages of the disease, before the body

InternalMed_Harrison

The differential diagnosis of leptospirosis is broad, reflecting the diverse clinical presentations of the disease. Although leptospirosis transmission is more common in tropical and subtropical regions, the absence of a travel history does not exclude the diagnosis. When fever, headache, and myalgia predominate, influenza and other common and less common (e.g., dengue and chikungunya) viral infections should be considered. Malaria, typhoid fever, ehrlichiosis, viral hepatitis, and acute HIV infection may mimic the early stages of leptospirosis and are important to recognize. Rickettsial diseases, hantavirus infections (hemorrhagic fever with renal syndrome or hantavirus cardiopulmonary syndrome), and dengue share epidemiologic and clinical features with leptospirosis. Dual infections have been reported. In this light, it is advisable to conduct serologic testing for hantavirus, rickettsiae, and dengue virus when leptospirosis is suspected. When bleeding is detected, dengue

InternalMed_Harrison

Malaria is a very common cause of fever in tropical countries. The first symptoms of malaria are nonspecific; the lack of a sense of wellbeing, headache, fatigue, abdominal discomfort, and muscle aches followed by fever are all similar to the symptoms of a minor viral illness. In some instances, a prominence of headache, chest pain, abdominal pain, cough, arthralgia, myalgia, or diarrhea may suggest another diagnosis. Although headache may be severe in malaria, the neck stiffness and photophobia seen in meningitis do not occur. While myalgia may be prominent, it is not usually as severe as in dengue fever, and the muscles are not tender as in leptospirosis or typhus. Nausea, vomiting, and orthostatic hypotension are common. The classic malarial paroxysms, in which fever spikes, chills, and rigors occur at regular intervals, are relatively unusual and suggest infection with P. vivax or P. ovale. The fever is usually irregular at first (that of falciparum malaria may never become

Serological evidence of human leptospirosis in patients with acute undifferentiated febrile illness from Uttarakhand, India: A pilot study.

To the best of our knowledge, there are no reports of serological evidence of human leptospirosis from Uttarakhand state in India. The aim of this study was to screen for serological evidence of leptospirosis in patients with acute undifferentiated febrile illness at a tertiary care teaching hospital in Uttarakhand. A pilot study was conducted from March to November 2017. Fifty-three adult patients who presented in Medicine outpatient Department with a history of fever of ≥7 up to 14 days duration with or without other associated symptoms such as a headache, rashes, myalgia, arthralgia, and conjunctival suffusion were enrolled in the study using convenience sampling technique. Blood samples of these patients were collected and subjected to peripheral smear examination for malaria parasites, dengue immunoglobulin M (IgM) immunochromatographic card test, IgM Typhidot, Leptospira and Scrub typhus IgM ELISA, respectively. Aerobic blood culture was performed in 24 cases. Relevant clinico-epidemiological details were obtained as per the pro forma formulated in accordance with the modified Faine's criteria. Descriptive statistics. The study population consisted of 50.94% of males and 49.06% of females with a mean age ± standard deviation of 34.2 ± 15.2 years. Fifty febrile patients had additional symptoms of which myalgia was the most common (81.1%) followed by arthralgia (22.6%). Peripheral smears of all patients were negative for malaria parasites. Dengue and Typhidot IgM positivity was observed in two and eight patients, respectively. Six and five patients were tested positive by leptospira and scrub typhus IgM ELISA, respectively. <iSalmonella</i Typhi was isolated from blood sample of only one patient. Serum samples of two patients showed dual positivity. All six leptospira seropositive patients satisfied modified Faine's criteria. Leptospirosis is a seemingly unexplored infection in Uttarakhand and should be considered as a differential diagnosis in patients with acute undifferentiated febrile illness.

Weil's Disease from a Local New Orleans Bar.

Leptospirosis is a zoonotic infection that typically presents with fever, myalgias, nausea, and vomiting after contact with contaminated waters or infected animals (typically rodents); and their excrements. Conditions favorable to the transmission of leptospirosis are common in LA and, without treatment, leptospirosis can lead to both liver and renal failure, meningitis, pulmonary hemorrhage and ultimately death. A 56 year old woman with no past medical history presented to the Emergency Department with weakness, myalgias, jaundice and decreased urine output for one week. On arrival, she appeared septic with a heart rate of 130 and fever. Her exam was significant for significant jaundice and diffuse abdominal pain. Laboratory studies were notable for WBC 14, hemoglobin of 12 and platelet count of 63. Creatinine was 8.5mg/dL with a blood-urea nitrogen of 96mg/dl. Total bilirubin was 19.4mg/dL and direct bilirubin was 13.7mg/dL. AST/ALT were 69/38 U/L, respectively and the alkaline phosphate was 160U/L. The patient was admitted to the hospital medicine wards for sepsis and multi-organ failure. She was started on broad spectrum antibiotics but her clinical condition continued to worsen with progressive decline in her hemoglobin and thrombocytopenia and worsening liver failure. She quickly became anuric necessitating dialysis and developed respiratory distress with bilateral pulmonary infiltrates and hemoptysis. Additional history was obtained from her employer that she works at a local New Orleans bar and had been cleaning out rats from the kitchen. Leptospirosis antibody was sent, which returned as positive. Her antibiotics were de-escalated to IV Ceftriaxone. She made a slow recovery over the next two-week period. Since 1987, there has been an average of 3 cases of Leptospirosis diagnosed per year, most of which have been from southeast LA. This case illustrates the importance of considering the diagnosis of Leptospirosis and Weil's Disease in patients in the southeast region of LA who present with multi-organ failure. In addition, our patient's occupational exposure was key to her diagnosis which emphasizes the importance of a detailed history in clinical decision making and patient outcomes.

Orientia tsutsugamushi

The main symptom of O. tsutsugamushi infection is high (febrile) fever; however, the symptom is similar to other vector-borne tropical diseases such as malaria, leptospirosis, typhoid, murine typhus, chikungunya, and dengue fever. This makes precise clinical diagnosis difficult, which often leads to misdiagnosis. The initial indications are fever with chills, associated with headache, muscle pain (myalgia), sweating and vomiting. The appearance of symptoms (the incubation period) takes between 6 and 21 days. A simple visual diagnosis is the presence of an inflamed scar-like scab called eschar, which is regarded as "the most useful diagnostic clue in patients with acute febrile illness". Eschar is formed on the skin where an infected mite bit, usually seen in the armpit, groin or any abdominal area (Figure 7). In rare cases, it can be seen on the cheek, ear lobe and dorsum of the feet. But, the problem is that eschar is not always present; at the highest record, only 55% of scrub

InternalMed_Harrison

FIGuRE 211-2 Eschar at the site of the mite bite in a patient with rickettsialpox. (Reprinted from A Krusell et al: Emerg Infect Dis 8:727, 2002. Photo obtained by Dr. Kenneth Kaye.) FIGuRE 211-3 Top: Papulovesicular lesions on the trunk of the patient with rickettsialpox shown in Fig. 211-2. Bottom: Close-up of lesions from the same patient. (Reprinted from A Krusell et al: Emerg Infect Dis 8:727, 2002. Photos obtained by Dr. Kenneth Kaye.) 10–17 days, during which the eschar and regional lymphadenopathy frequently go unnoticed, disease onset is marked by malaise, chills, fever, headache, and myalgia. A macular rash appears 2–6 days after onset and usually evolves sequentially into papules, vesicles, and crusts that heal without scarring (Fig. 211-3); in some cases, the rash remains macular or maculopapular. Some patients develop nausea, vomiting, abdominal pain, cough, conjunctivitis, or photophobia. Without treatment, fever lasts 6–10 days.

Plasmodium knowlesi in travellers, update 2014.

Since the initial discovery of Plasmodium knowlesi in Malaysia, cases have been reported from several neighbouring countries. Tourism has also resulted in an increasing number of cases diagnosed in Europe, America, and Oceania. In this review we focus on the risk of the travel-associated acquisition of P. knowlesi malaria. A search of the literature in PubMed was carried out to identify articles and literature on the distribution of P. knowlesi infections in Southeast Asia and details of its acquisition and importation by travellers to other continents. The cut-off date for the search was December 1, 2013. Search words used were: "Plasmodium knowlesi", "Plasmodium knowlesi infections", "Plasmodium knowlesi travellers", "Plasmodium knowlesi prevalence", "Plasmodium knowlesi host", "Plasmodium knowlesi vector" "Plasmodium knowlesi RDT", and "Plasmodium knowlesi Malaysia". Traveller numbers to Malaysia were obtained from the Tourism Malaysia website. A total of 103 articles were found. Using a selection of these and others identified from the reference lists of the papers, we based our review on a total of 66 articles. P. knowlesi malaria appears to be the most common malaria species in Malaysian Borneo and is also widely distributed on the Malaysian mainland. Furthermore, locally transmitted cases of P. knowlesi malaria have been reported in Thailand, the Philippines, Vietnam, Singapore, Myanmar, Indonesian Borneo, and Cambodia. Two cases have been reported from non-endemic countries in Asia (Japan and Taiwan) in people with a history of travel to Malaysia and the Philippines. Twelve cases were imported to their home countries by travellers from other continents: two from the USA, two from the Netherlands, two from Germany, and one each from Spain, France, Sweden, Finland, Australia, and New Zealand. In most cases, the infection was associated with a trip to or near forested areas. The symptoms were fever (n=12), headache (n=6), chills (n=6), nausea (n=4), myalgia (n=3), back pain (n=3), abdominal problems (n=1), anorexia (n=2), fatigue (n=2), malaise (n=1), arthralgia (n=1), sore throat (n=1) vomiting (n=2), and jaundice (n=1). All patients were treated successfully with currently available antimalaria treatments. The identification of the pathogen by microscopy can be problematic due to the morphological similarity of P. knowlesi to Plasmodium malariae. P. knowlesi appears to be a threat not only to the local population in Malaysia, but also to the estimated 25 million annual tourists and occupational travellers to Malaysia, especially those who visit rural, forested areas of the country. The P. knowlesi risk is not limited to Malaysia, and travellers from Southeast Asia presenting with possible malaria should be considered for a diagnostic work-up that includes P. knowlesi.

Acute schistosomiasis in travelers: 14 years' experience at the Hospital for Tropical Diseases, London.

We report 79 cases of acute schistosomiasis. Most of these cases were young, male travelers who acquired their infection in Lake Malawi. Twelve had a normal eosinophil count at presentation and 11 had negative serology, although two had neither eosinophilia nor positive serology when first seen. Acute schistosomiasis should be considered in any febrile traveler with a history of fresh water exposure in an endemic area once malaria has been excluded.

[Leptospirosis (Weil's disease) in Augsburg].

Three unrelated patients presented within three months at the Central Hospital of Augsburg, Southern Germany, with jaundice of initially unknown etiology. Patient (Pt.) 1, a 51-year old man was admitted with a history of nausea, vomiting, diarrhea, jaundice and anuria. Pt. 2 was a 58-year-old man who had fever and shivering, and had developed jaundice after a fishing-trip to Canada. Pt. 3 was a 66-year-old woman who presented at the Emergency Unit with recently developed jaundice and pain in the right lateral epigastric area. Laboratory results showed elevated levels for bilirubin, CK, BUN, creatinine and low thrombocytes in patients 1 and 2. An elevated lipase level was found in Pt 1, while Pt 3 had an elevated bilirubin and thrombocytopenia. In Pt 1 and 2 active leptospirosis was diagnosed by serological tests. The third patient showed a subsided leptospirosis, the jaundice having been due to a histologically confirmed drug-associated hepatitis. Patients 1 and 2, who had active disease, showed the full-blown clinical picture of Weil's disease with jaundice, renal failure and thrombocytopenia. After administration of penicillin G and a third generation cephalosporin (ceftriaxone), respectively, all symptoms disappeared. The 66-year-old woman (Pt 3) developed pneumonia and died of multiple organ failure. Leptospirosis is an important differential diagnosis in patients with recent onset of jaundice and acute renal failure. A detailed history may offer the crucial hint and serological tests provide proof. The clinical outcome mainly depends on starting antimicrobial therapy with penicillin G or a third generation cephalosporin as soon as practicable.

Albert Brown (American veteran)

Following the Bataan Death March, Brown endured a three-year imprisonment in a Japanese POW camp from 1942 until he was liberated in the middle of September 1945. He ate nothing but rice while in the camp. Brown became afflicted with more than twelve diseases while in the camp, including dengue fever, malaria and dysentery. He also suffered a broken neck and back. He was released from the camp when he was 40 years old. He was nearly blind from maltreatment and had lost more than eighty pounds, then weighing less than one hundred pounds. A doctor told Brown that he would not live to be 50 years old due to the extent of his injuries. However, he lived to be 105 years old.

[Leptospirosis in children of Libreville: difficult diagnosis, apropos of 1 case].

Leptospirosis is a widespread zoonosis, which is diagnosed less frequently in children than might be expected from the level of exposure to hazards, especially in tropical areas. A 15 1/2-year-old Gabonese boy was admitted following five days of fever, headache, myalgia, abdominal pain, diarrhea, intestinal bleeding, jaundice and conjunctival suffusion. Laboratory data showed abnormal liver and renal function tests, and diagnosis of Plasmodium falciparum malaria was confirmed by thin blood smear. The patient did not clinically improve despite antimalarial treatment and then leptospirosis was suspected. Serologic tests were performed and leptospirosis was later confirmed. Antibiotic treatment (cefuroxim) was given. The outcome was good, liver and renal tests returned to normal in a few days. In tropical area, leptospirosis should be considered in children who are diagnosed with either an unexplained fever, a pseudo-influenza syndrome, or jaundice with hepatorenal involvement and gastrointestinal bleeding.

Fever in the returned traveler.

The most important cause of fever in the returned traveler is malaria. All febrile patients in which malaria is epidemiologically possible require urgent evaluation for P. falciparum malaria, which can be rapidly fatal in the nonimmune patient. Early diagnosis and therapy can prevent severe morbidity and mortality. Other less common causes of undifferentiated fever include acute schistosomiasis, the enteric fevers, rickettsial diseases, leptospirosis, and dengue fever. Early empiric therapy for suspected leptospirosis and the rickettsial infections is encouraged to decrease morbidity and mortality. About a quarter of febrile patients do not have an etiologic agent determined for their illness but recover without sequelae. Patients with fever and hemorrhagic manifestations within 3 weeks of their return need to be isolated for the remote possibility of a highly transmissible agent. Although the febrile traveler is always a challenge, the real world differential diagnosis is limited and a systematic approach via the history, physical examination, and selected laboratory tests is usually sufficient to confirm the diagnosis or eliminate potentially serious infections.

InternalMed_Harrison

Physical examination may include any of the following findings, none of which is pathognomonic for leptospirosis: fever, conjunctival suffusion, pharyngeal injection, muscle tenderness, lymphadenopathy, rash, meningismus, hepatomegaly, and splenomegaly. If present, the rash is often transient; may be macular, maculopapular, erythematous, or hemorrhagic (petechial or ecchymotic); and may be misdiagnosed as due to scrub typhus or viral infection. Lung auscultation may reveal crackles, and mild jaundice may be present. The natural course of mild leptospirosis usually involves spontaneous resolution within 7–10 days, but persistent symptoms have been documented. In the absence of a clinical diagnosis and antimicrobial therapy, the mortality rate in mild leptospirosis is low.

Severe leptospirosis: treatment with intravenous corticosteroids and supportive care.

Leptospirosis is a common zoonotic infection worldwide and is recognized as an emerging public health problem. Although commonly thought of as a tropical disease, incidence in temperate climates is increasing, with recent outbreaks in the United States and Germany, among other countries. The disease presents with symptoms ranging from fever, headache, nausea, and vomiting to life-threatening multiorgan failure characterized by acute liver failure, nephritis, pulmonary hemorrhage, meningitis, and cardiac arrhythmia. We describe a case of an otherwise healthy 28-year-old man who had just returned from a 2-month trip to Southeast Asia. He presented to our emergency department twice after his return with the complaint of fever and malaise. Initially, he was treated with symptomatic measures and discharged home with malaria smears and blood cultures pending. On his final presentation before admission, he presented with severe fatigue, myalgia, acute renal failure, and marked thrombocytopenia. After several days, inpatient testing revealed the patient's leptospira antibody titer was markedly positive. Given the nonspecificity of patient symptoms, early diagnosis of leptospirosis can be challenging. Diagnostic uncertainty may lead to delay in recommended intravenous antibiotic treatment. We present a case of severe leptospirosis treated exclusively with supportive measures and intravenous corticosteroids.

The importance of "His" story.

A 73-year-old previously healthy man presented with a 3-day history of rigours, abdominal pain, diarrhoea, haemoptysis and myalgia. He had not been abroad recently, but reported being a farmer and having had a recent rat infestation. Laboratory investigations revealed acute kidney failure, deranged liver function tests, raised C reactive protein and a chest CT revealed bilateral ground-glass opacities. This presentation was consistent with icteric leptospirosis which was confirmed by serological testing. Following haemofiltration and the administration of antibiotics the patient made an excellent recovery from his leptospirosis.

Childhood immunizations in the United States

Vaccine There are two types of vaccines, Cervarix and Gardasil. They are both a three-dose series of injections that are recommended at 11 to 12 years of age, but is commonly given to persons older than 12. Cervarix is used around the world and is considered very safe. Some side effects that may arise are pain at injection site (9 in 10) redness or swelling at injection site (1 in 2) fever of 99.5 degrees Fahrenheit or higher (1 in 8) headache or fatigue (1 in 2) nausea, vomiting, diarrhea, or abdominal pain (1 in 4) brief fainting Gardasil is used more commonly in the United States but it also used around the world and is also considered very safe. Some side effects that may arise are pain at injection site (8 in 10) redness or swelling at injection site (1 in 4) fever mild (100 degrees Fahrenheit) (1 in 10) moderate (102 degrees Fahrenheit) (1 in 65) headache (1 in 3) brief fainting

[Febrile episodes, headache and limb pain as well as generalized myalgia in a 27-year-old returning male traveller].

Unspecific flu-like symptoms, such as fever, headache and limb pain are encountered very often by general practitioners and in emergency departments. In patients with sepsis and a history of travelling to warmer climates, the differential diagnosis needs to be broader than just commonly encountered viral infections. A 27-year-old Swiss man presented with the symptoms mentioned above after a holiday in the south of France. The pulmonary, hepatic and renal status rapidly deteriorated and the patient required intensive care. The initially suspected diagnosis of leptospirosis could be confirmed serologically during the course of the disease.

A twelve-year study of leptospirosis on Barbados.

Between November 1979 and December 1991, 398 cases of severe leptospirosis were confirmed on Barbados (range for 1980-1991 23-56; mean 32.7; incidence 13.3/100,000/year). For the six-year periods 1980-1985 and 1986-1991 there was no significant change in incidence with time. Incidence is unlikely to change significantly in the next decade. Monthly average case numbers ranged from 1.4 (July) to 4.3 (November). The average (2.8) for June to December (the 7 wetter months) was not significantly higher than that (2.5) for January to May (the 5 drier months). The age range was 7-86. There were three times as many male cases (302) as female (96), and nearly 10 times as many in those < 35. Although the highest number of cases (69) was in males aged 15-24, the highest incidence was in the older age groups, particularly the male 65-74 year-olds, and the female 55-64 year-olds. Leptospirosis was the proven cause of death in 55 (13.8%) hospital patients (annual range 0-13, mean 4.5). Some of a further 39 fatalities might have been cases. Death from leptospirosis was nearly twice as common among the women as among the men. Only one patient under 20 years of age died. Leptospira were isolated and identified from 117 (29.4%) of the 398 sick patients. The infecting organisms were bim (serogroup Autumnalis--75), copenhageni (Icterohaemorrhagiae-26), arborea (Ballum-14) and bajan (Australis-2). These infecting serovars could not be distinguished clinically, but infection was milder in children than in adults. Despite its predominance in surveyed children, serogroup Panama was virtually absent in this study. Rainfall is the major factor affecting the distribution of cases; not surprisingly, sanitation workers and agricultural workers appear to be the groups at highest risk. The general lack of clear-cut risk factors reflects the ubiquity of leptospires in the environment and the fact that the disease is not entirely occupational.

Abscess of urachal remnants presenting with acute abdomen: a case series.

Urachal diseases are rare and may develop from a congenital anomaly in which a persistent or partial reopening of the fetal communication between the bladder and the umbilicus persists. The most frequently reported urachal anomalies in adults are infected urachal cyst and urachal carcinoma. The diagnosis of this entity is not always easy because of the rarity of these diseases and the atypical symptoms at presentation. Imaging techniques, such as ultrasonography and computed tomography have a significant role in recognizing the presence of urachus-derived lesions. Case presentation 1: A 25-year-old Arab-Berber man presented with a 10-day history of progressive lower abdominal pain accompanied by fever, vomiting, and low urinary tract symptoms to our emergency department. Laboratory data revealed leucocytosis. The diagnosis of an acute peritonitis was made initially. Abdominal ultrasonography revealed a hypoechoic tract from the umbilicus to the abdominal wall, and the diagnosis was rectified (infected urachal remnants). The patient was initially treated with intravenous antibiotics in combination with a percutaneous drainage. Afterwards an extraperitoneal excision of the urachal remnant including a cuff of bladder was performed. The histological analysis did not reveal a tumor of the urachal remnant. Follow-up examinations a few months later showed no abnormality.Case presentation 2: A 35-year-old Arab-Berber man, without prior medical history with one week of abdominal pain, nausea and vomiting, associated with fever but without lower urinary tract symptoms visited our emergency department. Laboratory data revealed leucocytosis. Abdominal ultrasonography was not conclusive. Computed tomography of the abdomen was the key to the investigation and the diagnosis of an abscess of urachal remnants was made. The patient underwent the same choice of medical-surgical treatment as previously described for case one, with a good follow-up result.Case presentation 3: A 22-year-old Arab-Berber man, with no relevant past medical history, presented to our emergency department because of suspected acute surgical abdomen. Physical examination revealed umbilical discharge with erythema and a tender umbilical mass. Abdominal ultrasonography and computed tomography scan confirmed the diagnosis of infected urachal sinus. Initial management was intravenous antibiotics associated with a percutaneous drainage with a good post-operative result, but a few days later, he was readmitted with the same complaint and the decision was made for surgical treatment consisting of excision of the infected urachal sinus. The clinical course was uneventful. Histological examination did not reveal any signs of malignancy. We describe our clinical observations and an analysis of the existing literature to present the various clinical, radiological, pathological and therapeutic aspects of an abscess of urachal remnants. To the best of our knowledge, this manuscript is an original case report because this atypical presentation is rarely reported in the literature and only a few cases have been described.

Early Indicators of Fatal Leptospirosis during the 2010 Epidemic in Puerto Rico.

Leptospirosis is a potentially fatal bacterial zoonosis that is endemic throughout the tropics and may be misdiagnosed as dengue. Delayed hospital admission of leptospirosis patients is associated with increased mortality. During a concurrent dengue/leptospirosis epidemic in Puerto Rico in 2010, suspected dengue patients that tested dengue-negative were tested for leptospirosis. Fatal and non-fatal hospitalized leptospirosis patients were matched 1:1-3 by age. Records from all medical visits were evaluated for factors associated with fatal outcome. Among 175 leptospirosis patients identified (4.7 per 100,000 residents), 26 (15%) were fatal. Most patients were older males and had illness onset during the rainy season. Fatal case patients first sought medical care earlier than non-fatal control patients (2.5 vs. 5 days post-illness onset [DPO], p < 0.01), but less frequently first sought care at a hospital (52.4% vs. 92.2%, p < 0.01). Although fatal cases were more often diagnosed with leptospirosis at first medical visit (43.9% vs. 9.6%, p = 0.01), they were admitted to the hospital no earlier than non-fatal controls (4.5 vs. 6 DPO, p = 0.31). Cases less often developed fever (p = 0.03), but more often developed jaundice, edema, leg pain, hemoptysis, and had a seizure (p ≤ 0.03). Multivariable analysis of laboratory values from first medical visit associated with fatal outcome included increased white blood cell (WBC) count with increased creatinine (p = 0.001), and decreased bicarbonate with either increased WBC count, increased creatinine, or decreased platelet count (p < 0.001). Patients with fatal leptospirosis sought care earlier, but were not admitted for care any earlier than non-fatal patients. Combinations of routine laboratory values predictive of fatal outcome should be considered in admission decision-making for patients with suspected leptospirosis.


Nocardia can typically affect immunosuppressed patients, especially those with impaired cell-mediated immunity such as that produced by steroids, and can present with pulmonary involvement, brain abscesses and skin abscesses. Tuberculosis can affect lung and brain but not cutaneous abscesses. Aspergillus also does not affect the skin.

A 64-year-old patient, farmer, former smoker (5 years), COPD and afflicted with rheumatoid arthritis on corticosteroid therapy. He consults the emergency department for presenting intense headache of 2 days of evolution with deviation of the oral commissure. As background, he reports that after a month of influenza, he persists with cough, purulent and occasionally hemoptotic expectoration, febrile fever, anorexia, asthenia and weight loss. On arrival, the patient had a fever of 38.2ºC, multiple skin abscesses on the hands, back and buttocks (some with fistulous tracts) and right central facial paralysis, apical infiltrates with small associated pleural effusion on chest X-ray and leukocytosis with neutrophilia. Among the following suspected diagnoses I would consider MOST likely:

[Two cases of invasive pulmonary aspergillosis in non-immunocompromised hosts].

Invasive pulmonary aspergillosis generally occurs in immunocompromised hosts such as patients with leukemia, and other malignancies, who are receiving anti-cancer chemotherapy. In this report, two non-immunocompromised patients who developed invasive pulmonary aspergillosis are presented. Case 1: A 63-year-old man complained of productive cough and fever. He received antibiotic therapy from his personal physician. This symptoms did not respond, however, and dyspnea developed. He was then transferred to our hospital, about one month after the onset. The chest X-ray showed a meniscus shadow suggesting an aspergilloma in the right upper lung field and an infiltrative shadow in the remaining right lung field. Case 2: A 78-year-old man was admitted because of dyspnea, productive cough and appetite loss over the previous three months. The chest X-ray showed a meniscus shadow in the left upper field, an infiltrative shadow in the left lower field and a right pleural effusion sign was also observed. Both cases were diagnosed as having aspergillosis, early in their illness, by the detection of aspergillus antigen in their sera and histopathological and cultural studies of specimens obtained by TBLB. Both improved with intravenous amphotericin B (30 mg/day) and intravenous ulinastatin (200000 IU/day) administration. On the examinations conducted during hospitalization, there was no evidence of any immunosuppressive diseases or immunoincompetent conditions such as leukemia, and other malignancies human immunodeficiency virus infection, diabetes or alcoholism.

Body aches, tender bones and rapid loss of weight: a case report.

Bone metastases presenting with pain and body-ache may be the first presentation of carcinoma in about a fourth of patients with cancer. Radiologically majority of the metastases are osteolytic and multiple. Sometimes these may be confused with infective or inflammatory conditions, particularly in young individuals, and degenerative conditions of the spine and hip in elderly, which may delay the diagnosis and treatment leading to poor outcomes. A 30 year old non-smoking male teetotaller presented with intermittent, high-grade nocturnal fever with night sweats of one year. He also had low back ache over his right hip. We found him febrile, pale and his long bones, ribs and pelvis were tender. He had a 3 x 4 cm tender and hard swelling over the upper part of his sternum. Another firm, non-tender swelling about 4 x 5 cm was seen in the right iliac region. Radiographs of the skull, spine and pelvis revealed multiple variable sized lytic lesions. A metastatic malignancy or disseminated tuberculosis was considered. His anti-tubercular therapy was intensified Fine needle aspiration from sternal lesion showed inflammatory cells. A bone marrow biopsy showed infiltration by tumor cells suggestive of metastatic adenocarcinoma. Patient's condition continued to deteriorate and he died within a fortnight of his hospitalization. Although masquerading as tuberculosis lytic lesions might be an evidence of malignant metastatic. Although, treatment is ineffective in this stage palliative efforts to improve quality of life should be made.

Coccidioidomycosis where you least expect it.

An elderly man without history of travel presented with complaints of intermittent fever for 2 months, cough with scanty expectoration for 15 days and history of weight loss of 5 kg in 1 year. The chest X-ray and CT scan of the thorax showed dispersed centrilobular nodules and patchy subpleural consolidation in both lungs with mediastinal lymphadenopathy. He underwent bronchoscopy and bronchoalveolar lavage culture grew <iPseudomonas aeruginosa</i He was prescribed antibiotics based on culture sensitivity; however, patient continued to have symptoms. All relevant blood investigations were within normal limits. He underwent CT-guided biopsy of the right lung lesion during which clearing of the radio-opacities present in the initial CT scan and appearance of fresh lesions in different locations were observed. Migratory shadows were suspected. Fine-needle aspiration cytology showed features suggestive of coccidioidomycosis for which antifungals were started. After 1 month, he improved symptomatically and chest X-ray showed clearance of shadows.

InternalMed_Harrison

CLINICAL MANIFESTATIONS Respiratory Tract Disease Pneumonia, the most common form of nocardial disease in the respiratory tract, is typically subacute; symptoms have usually been present for days or weeks at presentation. The onset is occasionally more acute in immunosuppressed patients. Cough is prominent and produces small amounts of thick, purulent sputum that is not malodorous. Fever, anorexia, weight loss, and malaise are common; dyspnea, pleuritic pain, and hemoptysis are less common. Remissions and exacerbations over several weeks are frequent. Roentgenographic patterns vary, but some are highly suggestive of nocardial pneumonia. Infiltrates vary in size and are typically dense. Single or multiple nodules are common (Figs. 199-1 and 199-2), sometimes suggesting tumors or metastases. Infiltrates and nodules tend to cavitate (Fig. 199-2). Empyema is present in one-quarter of cases. Co-infection with Nocardia and Mycobacterium tuberculosis has been reported from regions where

InternalMed_Harrison

Acute pulmonary infection is often diagnosed in association with point-source outbreaks. Typical symptoms include the abrupt onset of fever, chills, pleuritic chest pain, arthralgias, and myalgias. Cough is initially nonproductive but frequently becomes purulent as disease progresses. Chest radiographs usually reveal alveolar infiltrates with consolidation. Pleural effusions and hilar adenopathy are uncommon. Most patients diagnosed with pulmonary blastomycosis have chronic indolent pneumonia with signs and symptoms of fever, weight loss, productive cough, and hemoptysis. The most common radiologic findings are alveolar infiltrates with or without cavitation, mass lesions that mimic bronchogenic carcinoma, and fibronodular infiltrates. Hematogenous dissemination to the skin, bones, and genitourinary tract occurs most often in association with chronic pulmonary disease. Although blastomycosis is not considered an opportunistic infection, immunosuppression has been recognized as a risk

Coccidioidomycosis -- History and Physical

Symptoms appear seven to 21 days post-exposure. Fever, cough, shortness of breath (SOB), and chest pain are most frequent. The clinical presentation may be acute or sub-acute based on the inoculum size. A headache, weight loss, and rash are often seen. The rash is faint, maculopapular, transient, occurs early during disease, and is, therefore, often missed. Erythema nodosum or erythema multiforme occurs more frequently in women. Migratory arthralgias are also common. The triad of fever, erythema nodosum, and arthralgias (especially of the knees and ankles) has been termed desert rheumatism. Laboratory findings include elevated erythrocyte sedimentation rate (ESR) and eosinophilia. Chest x-ray (CXR) shows unilateral infiltrates. Hilar and peritracheal adenopathy suggests the extrathoracic spread of the disease. Lung cavities are present in only 8% of adults but are more frequent in children.

Blastomycosis

a flu-like illness with fever, chills, arthralgia (joint pain), myalgia (muscle pain), headache, and a nonproductive cough which resolves within days. an acute illness resembling bacterial pneumonia, with symptoms of high fever, chills, a productive cough, and pleuritic chest pain. a chronic illness that mimics tuberculosis or lung cancer, with symptoms of low-grade fever, a productive cough, night sweats, and weight loss. a fast, progressive, and severe disease that manifests as ARDS, with fever, shortness of breath, tachypnea, hypoxemia, and diffuse pulmonary infiltrates. skin lesions, usually asymptomatic, can be verrucous (wart-like) or ulcerated with small pustules at the margins. bone lytic lesions can cause bone or joint pain. prostatitis may be asymptomatic or may cause pain on urinating. laryngeal involvement causes hoarseness. 40% immunocompromised individuals have CNS involvement and present as brain abscess, epidural abscess or meningitis.

[Clinical analysis of the first patient with imported Middle East respiratory syndrome in China].

To report the treatment of the first imported Middle East respiratory syndrome ( MERS ) in China, and to investigate the clinical features and treatment of the patient. On May 28th, 2015, the first patient of imported MERS to China was admitted to Department of Critical Care Medicine of Huizhou Municipal Central Hospital. The clinical features and treatments of this patient were analyzed. (1) A 43 years old male of South Korean nationality was admitted with the complaint of back ache for 7 days and fever 2 days with the following characteristics: back ache 7 days ago, without fever or cough or expectoration. He had been suspected to suffer from infection of Middle East respiratory syndrome coronavirus ( MERS-CoV ) by the Disease Control Department of South Korea, but no specific treatment was given. He had fever for 2 days with maximum body temperature of 39.7 centigrade. He had no chills, cough, expectoration, short of breath, abdominal pain, diarrhea, frequent micturition, or urgency or pain of urination, and no sore throat. The patient had a history of exposure to MERS-CoV patient. He was considered to be a patient of the second batch of South Korean epidemic. (2) Auxiliary examination: 3 copies of throat swab specimens for virus nucleic acid detection were performed by the Disease Prevention Control Center of China ( China CDC ), and they were positive on May 29th, 2015, and also for serum, sputum and stool. Based on the results of whole genome sequence analysis, the virus strains were implicated to be derived from Riyahh and Jeddah regions of Saudi Arabia. On admission, the patient's blood test showed that the white blood cell count was low ( 3.22×10(9)/L ), the proportion of the neutrophils was high ( 0.73 ), and that of the platelet was low ( 81×10(9)/L ). On admission, the patient's chest X-ray showed that a small amount of infiltration in the lung. (3) TREATMENT: a high-flow nasal cannula ( HFNC ) with oxygen concentration of 0.50-0.80 was given, with a flow rate was set at 60 L/min if tolerated. It was changed to a low flow oxygen inhalation nasal cannula on the 20th day, and oxygen treatment was stopped on the 24th day. Ribavirin 2.0 g was given as the first dose, and was switched to 600 mg every 8 h ( q8h ), and it was reduced to 600 mg q12h after 10 days, and extenuated since the 13th day. Ceftriaxone was added on the 4th day with 2.0 g a day , and it was changed to meropenem 2.0 g, q8h on the 7th day for 2 weeks. Gamma globulin was given for 7 days ( 20 g, qd ). Thymosin-α1 was given on the 8th day for 2 weeks. Interferon was given once a week, but only one dose was used. At the same time symptomatic treatment such as methimazole and liver protection therapy were given. (4) Patient began to cough at admission, and it disappeared on the 18th day. There was no sputum at first, then a small amount of sputum with a little blood appeared after the admission. Then there was cough without sputum. Mild shortness of breath and diarrhea after exertion were noticed. He had no chest pain, difficulty in breathing or other symptoms. There was dullness on percussion in both sides of chest, and it disappeared gradually. Fine moist rales were detectable in scapular area and interscapular area on the 5th day, and they disappeared after 3 days. Breath sounds on both sides was weak, and it became more obvious in the right lung after 5 days, and returned to normal after 18 days. He had a sustaining fever for 1 week with the maximum temperature of 39.5 centigrade, then the body temperature returned to normal. The viral nucleic acid test as performed by the Center for Disease Control of Guangdong ( CDC, Guangdong ) showed that the pharyngeal swab cultured turned negative on the 3rd day, that of serum specimens turned negative on the 8th day, that of stool specimen after 2 weeks, and it was persistently positive for sputum culture until 5 days before discharge. The oxygenation index gradually increased, and it was over 300 mmHg ( 1 mmHg = 0.133 kPa ) after 15 days. Pleural effusion was rapidly increased during the first week as shown by chest X-ray films, and it began to be absorbed gradually in the second week, but it was not completely absorbed until discharge. The disease course of the reported patient was short, with an acute onset, with fever as the chief complaint, but there were no respiratory symptoms, though there were high fever, cough, shortness of breath, diarrhea and other clinical symptoms after admission. Virus in sputum disappeared after treatment, but pleural effusion was not completely absorbed. Negative test for virus in sputum was late, indicating that clearance of virus was slow from the lungs. It is the first case of MERS in China, therefore, the clinical manifestations and the treatment strategy need to be further explored.

[Pulmonary nocardiasis with abscesses spreading to cerebrum, cerebellum and orbits].

A 71-year-old woman presented with suspected tuberculosis. She reported having productive coughs, unwanted weight loss and subfebrile temperature in the preceding 3 months. She was known to have chronic obstructive pulmonary disease treated with corticoids given systemically and by inhalation. She was a heavy smoker. Computed tomography revealed a left apical lung abscess. In the further course of the disease magnetic resonance imaging of the head demonstrated multiple abscesses in both cerebral hemispheres and an abscess, 3.4 cm in diameter, in the right side of the cerebellum, as well as a intra-orbital tumor on the right. Needle aspirate of the eyeball grew Nocardia farcinica. Over 3 weeks antimicrobial treatment was given with imipenem and amikacin, followed by oral cotrimoxazole for 12 months. The abscesses completely regressed and after 12 months no recurrence was demonstrated either radiologically or clinically. Although nocardiasis is rare in Germany it must be included in the differential diagnosis of pneumonia with abscesses. This is especially so if acid-fast bacilli are found. As the resistance pattern of N. farcinica to antibiotics varies, early treatment is essential with antibiotics to which it is sensitive.

[Two cases of invasive pulmonary aspergillosis mimicking pneumonia in lung cancer patients].

Invasive pulmonary aspergillosis (IPA) occurs predominantly in immunocompromised hosts, however increasing numbers of cases of IPA have been reported among basically immunocompetent patients who have some pulmonary abnormalities such as lung cancer and chronic obstructive pulmonary disease (COPD). Case 1. A 67-year-old man was admitted because of hemoptysis and purpura. He had COPD and small cell lung cancer and had finished chemotherapy 5 years previously. Chest X-ray showed pneumonia-like infiltration in his right lower lung field, and marked thrombocytopenia was pointed out. We started antibiotics and corticosteroids for community-acquired pneumonia (CAP) and idiopathic thrombocytopenic purpura. During treatment, we found Aspergillus fumigatus in his sputum culture and therefore added antifungal agents to his treatment. Despite intensive care, he died due to multi-organ dysfunction. Case 2. An 80-year-old man was admitted with fever and productive cough. He had COPD and non-small cell lung cancer and finished chemotherapy 2 months previously. Chest X-ray showed pneumonia-like infiltration in his right upper lung field. We started antibiotics and corticosteroids for acute exacerbation of COPD because of CAP. Several weeks later, after we observed initial improvement of his condition, pneumonia-like infiltration re-developed and Aspergillus fumigatus was detected in his sputum. We started antifungal agents and the treatment of IPA was successful, but he died because of idiopathic perforation of the sigmoid colon. In patients without myelosuppression, IPA could develop pneumonia-like pulmonary infiltrations.

Pulmonary nocardiosis: clinical experience in ten cases.

Pulmonary nocardiosis is an infrequent infection whose incidence seems to be increasing due to a higher degree of clinical suspicion and the increasing number of immunosuppressive factors. To study the predisposing factors, clinical characteristics, diagnostic procedures, treatment and progress of pulmonary nocardiosis (PN). Review of 10 patients (9 male, 1 female, mean age 61) with PN in a 600-bed teaching hospital, diagnosed from 1992 to 1999. Associated diseases observed were chronic obstructive pulmonary disease (COPD) in 6 patients, human immunodeficiency virus (HIV) infection in 3 and polymyalgia rheumatica in 1. Four patients had received oral corticotherapy for COPD for over a year (mean dose 13 mg/day of prednisone or equivalent). The main reason for consultation was an increase in dyspnea in the patients with COPD (6/6) and fever in those with HIV (3/3). Mean time between onset of symptoms and diagnosis was 5 weeks. In 8 patients, the infection occurred outside the hospital setting. The infection was restricted to the lung in 9/10; in the remaining case, the central nervous system (CNS) and subcutaneous tissue were affected. Lobar or multilobar consolidation was the most frequent radiographic pattern found (6/10). Sputum culture was positive when performed (8 cases). Diagnosis was made or confirmed by bronchoscopy (bronchoaspirate or protected specimen brush) in 5 patients. Germs isolated were: Nocardia asteroides (8/10), Nocardia farcinica (1/10), Nocardia otitidiscaviarum (1/10). Cotrimoxazole was the most used empirical treatment (6/10). Resolution was achieved in 5 cases. Four subjects died: 1 HIV patient with disseminated nocardiosis, and 3 COPD patients, 2 of whom had received long-term corticotherapy. Illness recurred in only 1 case, due to failure to comply with treatment. (1) In our geographical setting Nocardia presents as a subacute or chronic pulmonary infection, mainly outside the hospital. (2) It tends to affect only the lung. (3) Diagnosis requires a high clinical suspicion, and can be made on the basis of a sputum culture. (4) Nocardia tends to attack patients with underlying COPD, or immunodepressed patients treated with glucocorticoids, or patients with HIV infection. (5) Mortality is high in both COPD and HIV patients. (6) In our area, cotrimoxazole seems to be the most commonly prescribed treatment.

Use of steroids to treat anti-tumor necrosis factor α induced tuberculosis-associated immune reconstitution inflammatory syndrome: Case report and literature review.

Individuals with tuberculosis (TB) who are being treated with anti-tumor necrosis factor α (anti-TNFα) for coexisting conditions may experience unexpected exacerbations of TB after the initiation of antituberculous therapy, so-called anti-TNFα-induced TB-immune reconstitution inflammatory syndrome (anti-TNFα-induced TB-IRIS). Anti-TNFα-induced TB-IRIS is often treated empirically with corticosteroids; however, the evidence of the effectiveness of corticosteroids is lacking and the management can be a challenge. A 32-year-old man on long-term infliximab therapy for Crohn disease visited a clinic complaining of persistent fever and cough that had started 1 week previously. His most recent infliximab injection had been administered 14 days before the visit. A chest X-ray revealed a left pleural effusion, and he was admitted to a local hospital. A chest computed tomography (CT) scan revealed miliary pulmonary nodules; acid-fast bacilli were found in a sputum smear and a urine sediment sample; and polymerase chain reaction confirmed the presence of Mycobacterium tuberculosis in both his sputum and the pleural effusion. He was diagnosed with miliary TB. Antituberculous therapy was started and he was transferred to our hospital for further management. His symptoms initially improved after the initiation of antituberculous therapy, but 2 weeks later, his symptoms recurred and shadows on chest X-ray worsened. A repeat chest CT scan revealed enlarged miliary pulmonary nodules, extensive ground-glass opacities, and an increased volume of his pleural effusion. This paradoxical exacerbation was diagnosed as TB-IRIS associated with infliximab. A moderate-dose of systemic corticosteroid was initiated [prednisolone 25 mg/day (0.5 mg/kg/day)]. After starting corticosteroid treatment, his radiological findings improved immediately, and his fever and cough disappeared within a few days. After discharge, prednisolone was tapered off over the course of 10 weeks, and he completed a 9-month course of antituberculous therapy uneventfully. He had not restarted infliximab at his most recent follow-up 14 months later. We successfully managed a patient with anti-TNFα-induced TB-IRIS using moderate-dose corticosteroids. Due to the limited evidence currently available, physicians should consider the necessity, dosage, and duration of corticosteroids for each case of anti-TNFα-induced TB-IRIS on an individual patient-by-patient basis.

Clinical spectrum of pulmonary tuberculosis in older patients: comparison with younger patients.

We compared the clinical-radiographic presentations of bacteriologically proven tuberculosis in 72 elderly (mean age: 71 yr) and 73 younger patients (mean age: 39 yrs). The tuberculin test (2 TU PPD) was positive in 55% and 92%, respectively. The prevalence of cough, dyspnea, anorexia, and weight loss was higher in the elderly (p less than .05), and night sweats were more prevalent in the younger patients (p less than .01). The radiographic pattern was not different between both groups (p greater than .10): "usual" apicoposterior lesions (with or without other abnormalities) were found in more than 70% of both groups; isolated "unusual" lesions consisted in both groups mainly of anterobasal infiltrations and sometimes of pleural effusions, rounded nodules, or miliary patterns. Yet, initially a wrong diagnosis was made more often in the elderly (p = .05). Malignancy, chronic pulmonary disease, and immunosuppression were more frequently encountered in the elderly (p less than .05), whereas alcoholism and smoking were more frequent in the younger patients (p less than .001). Tuberculosis-related mortality occurred in 6 elderly and 1 younger patient.

Recurrent Empyema Thoracic Secondary to Pulmonary Nocardiosis in Immunocompetent Patients.

Pulmonary nocardiosis is a rare disorder that mainly affects immune-compromised patients. We report a 37-year-old male who presented with persistent fever associated with productive cough. During this course of therapy, he had recurrent admissions for empyema thoracic. Clinically, his vital signs were normal. Blood investigations show leukocytosis with a significantly raised erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Sputum acid-fast bacilli (AFB) was scanty 1+ and sputum mycobacterium culture was negative. Chest X-ray (CXR) showed consolidative changes with mild to moderate pleural effusion on the right side. Skin biopsy was taken and showed Paecilomyces species. A computed tomography scan (CT thorax) was performed and revealed a multiloculated collection within the right hemithorax with a split pleura sign. Decortications were performed and tissue culture and sensitivity (C+S) growth of <iNocardia</i species. And it is sensitive to sulfamethoxazole-trimethoprim and completed treatment for 4 months. This case highlights that pulmonary nocardiosis should be kept in mind in also immune-competent patients, especially in suspected cases of tuberculosis not responding to antitubercular therapy.

Case report: pulmonary nocardiosis caused by Nocardia exalbida in an immunocompetent patient.

Nocardiosis is known as an opportunistic infection in immunocompromised hosts, but it occasionally has been reported in immunocompetent patient. The Nocardia exalbida is first-reported in 2006 from Japan, and a few cases of have been reported in only immunocompromised host, and the characteristic is still unclear. We herein describe the first case of pulmonary nocardiosis caused by N. exalbida in an immunocompetent patient. A77 -year-old Japanese man was admitted to our hospital on November 2, 2018. He was a lifelong non-smoker with no childhood history of respiratory disease. He had a medical history of dyslipidemia. One month before this admission fevers, sputum, mild cough were developed and he was evaluated in a clinic near our hospital. His diagnosis was community acquired pneumonia within his right middle lobe. He was treated with ceftriaxone 1 g/day intravenously for a week, however his symptoms relapsed a few days later. So, the physician retried ceftriaxone for another 3 days, but his symptoms did not improve. He was referred to our hospital. He was treated with sitafloxacin as an outpatient for a week, however his symptoms got worse. The chest CT showed consolidation and atelectasis in his right middle lobe. Low density area was scattered in consolidation, and right pleural effusion was observed. The patient was diagnosed with pulmonary abscess and he was admitted. Administration of piperacillin/tazobactam improved his condition. We switched antibiotics to amoxicillin/clavulanate, and he was discharged. After 2 weeks, he relapsed and was admitted again. After administration of piperacillin/tazobactam for 3 weeks, we perform bronchoscopy and Nocardia species were cultured from samples of the bronchial wash. The isolates were identified as N. exalbida using 16S rRNA gene sequencing. We prescribed Trimethoprim / Sulfamethoxazole (TMP/SMX) for 4 months. Then we switched to minocycline for renal dysfunction caused from TMP-SMX for 1 more month. After 5 months therapy, Consolidation on CT disappeared, and Nocardiosis was cured. we reported the first case of pulmonary nocardiosis caused by N. exalbida in an immunocompetent patient. N. exalbida infection might be associated with a good response to treatment.

A 49-Year-Old Man Presents With Fever of Unknown Origin and Cough.

A 49-year-old man presented with 3 months of persistent fever, cough, shortness of breath, and chest tightness. He had no response to treatment with antibiotics. He had been treated with an empiric 2-week course of steroids approximately 2 months before presentation, with mild and transient improvement. He did not use tobacco and had not experienced any weight loss, hemoptysis, arthralgia, or myalgia, and was otherwise in good health. He denied contact with anyone with pulmonary TB or other respiratory illnesses.

InternalMed_Harrison

Chronic Pulmonary Aspergillosis The hallmark of chronic cavitary pulmonary aspergillosis (also called semi-invasive aspergillosis, chronic necrotizing aspergillosis, or complex aspergilloma) (Fig. 241-1) is one or more pulmonary cavities expanding over a period of months or years in association with pulmonary symptoms and systemic manifestations such as fatigue and weight loss. (Pulmonary aspergillosis developing over <3 months is better classified as subacute invasive aspergillosis.) Often mistaken initially for tuberculosis, almost all cases occur in patients with prior pulmonary disease (e.g., tuberculosis, atypical mycobacterial infection, sarcoidosis, rheumatoid lung disease, pneumothorax, bullae) or lung surgery. The onset is insidious, and systemic features may be more prominent than pulmonary symptoms. Cavities may have a fluid level or a well-formed fungal ball, but pericavitary infiltrates and multiple cavities—with or without pleural thickening—are typical. An irregular

A Clinical Challenge in the Emergency Department: A Case of Klebsiella Infective Endocarditis Presenting With Splenic Abscess.

Infective endocarditis (IE) is a serious bacterial infection of the endocardium and/or heart valves that carries considerable morbidity and mortality. Often presenting with very non-specific symptoms, this disease presents many challenges to the emergency medicine practitioner. A 47-year-old male with no pertinent medical history presented to the emergency department complaining of shortness of breath. He stated that his symptoms had been persistent for the last three weeks and were associated with malaise and fatigue. CT of the abdomen/pelvis with IV contrast revealed a 7-cm hypodensity of the spleen concerning for abscess versus infarct. He denied any trauma or IV drug use. Follow-up ultrasound was ordered, which characterized the hypodensity as a splenic abscess. An echocardiogram was recommended for possible IE, and cardiology was consulted. The transthoracic echocardiogram was performed on hospital day 2, which showed minimal mitral valve thickening with mild mitral regurgitation. The interventional radiology (IR) service was consulted for the splenic abscess in order to perform CT-guided drainage. An IR drain was successfully placed on hospital day 3. On the same day, blood cultures grew Klebsiella pneumoniae. On hospital day 5, that patient was transferred to the ICU for possible empyema formation with signs of respiratory distress. The patient underwent CT of the chest that showed the development of a left-sided effusion. The patient had also been persistently tachycardic and febrile, with high leukocytosis since admission and worsening respiratory status. Transesophageal echocardiogram (TEE) was scheduled but put on hold due to worsening respiratory status. Repeat TEE was scheduled five days later, which showed mitral regurgitation and increased size of the vegetation despite antibiotic therapy. Two days later, he was scheduled for mitral valve repair. When reviewing our case, the patient had both common and uncommon aspects of splenic abscess or IE. First, despite having respiratory symptoms for two weeks, the primary reason he came to the hospital was due to the new onset of fevers. He was febrile, tachycardic, and with significant leukocytosis. He continued to have fevers despite antibiotic therapy and IR drainage of the abscess. With no history of IV drug use history, negative transthoracic echocardiography, lack of immunocompromising condition, and blood cultures with gram-negative rods, IE became less likely of a diagnosis.  Establishing the diagnosis of IE proved to be exceptionally complicated, especially in the setting of a COVID-19 pandemic. The most notable challenge was having a high index of suspicion despite any risk factors. The patient was a previously healthy 47-year-old male with no medical problems. IE continues to be a clinical challenge for physicians, especially in the emergency department, due to the lack of diagnostic criteria such as positive blood cultures or vegetations visualized on echocardiographic studies. IE has a wide gamut of presentations with different levels of acuity. Diagnosis is more straightforward when patients present with obvious risk factors, but, in many cases, such as this one, those risk factors may be absent. A high index of suspicion is required, especially in patients with additional findings such as splenic abscess, embolic phenomenon, focal neurologic deficit, mycotic aneurysm, decompensated heart failure, new murmurs, or pleural effusions.

Pulmonary actinomycosis and marijuana vaping.

A 33-year-old man without significant medical history presented to the emergency department with a 6-month history of fatigue and 30 pounds of unintentional weight loss, with a recent cough and fever over the past week. He recalled two similar illnesses during college that did not require medical care. He denied tobacco use but reported inhaling marijuana 1-2 times daily over the past year with a vaping device. Physical exam was notable for a temperature of 100.0°F and an elevated blood pressure at 161/77 mm Hg. He was diaphoretic with clear breath sounds bilaterally. Chest imaging revealed diffuse ground glass opacities with subpleural sparing and mildly enlarged hilar lymph nodes. Bronchoscopy with transbronchial lung biopsies and needle aspirate of lymph nodes revealed organising pneumonia, and subsequent cultures grew <iActinomyces odontolyticus</i He was treated with amoxicillin and corticosteroids with subsequent resolution on repeat chest imaging.

A 44-Year-Old Woman With a 10-Year History of Dyspnea and Pulmonary Nodules.

A 44-year-old woman was referred for evaluation of dyspnea on exertion and multiple nodular opacities on a chest CT scan. She had a medical history of autoimmune encephalitis, diabetes mellitus, hypertension, migraines, and allergic rhinitis. Ten years earlier, the patient was admitted to an outside institution with symptoms of shortness of breath. She was found to have multiple pulmonary nodules and was diagnosed empirically with and treated for sarcoidosis. She was told that her pulmonary nodules had improved on follow up. However, she continued to have symptoms of dyspnea. Due to progressive symptoms of shortness of breath, she was referred to pulmonology. She reported a weight gain of 80 pounds over the last year. She denied fever, chills, hemoptysis, night sweats, joint swelling, or skin rash. She is a former cigarette smoker with a 15 pack-year smoking history, quit smoking in 2005. She denied alcohol or drug use. She resided in Arkansas and Texas over the past decade. She previously worked as a teacher and is currently unemployed. She had no other relevant exposures. She denied a family history of autoimmune diseases or malignancies.

Unusual cause of chest pain: empyema necessitans and tubercular osteomyelitis of the rib in an immunocompetent man.

A 33-year-old man, born in India but resident in the UK for 5 years, presented to the emergency department with a 4-week history of a dry cough and right-sided pleuritic chest pain. He reported systemic features, including fever and unintentional weight loss. His medical history included vitamin D deficiency. He had travelled to India 10 months previously and denied any exposure to tuberculosis (TB). He was an ex-smoker with a 20 pack history. Respiratory examination confirmed decreased air entry of the right lower lobe and stony dullness on percussion. His C reactive protein was 178 mg/L. A chest radiograph identified a moderate-sized right-sided pleural effusion and destruction of the lateral aspect of the right fifth rib, strongly suggestive of underlying malignancy. Further investigation with a CT of the thorax identified a focal lytic lesion in the right fifth rib, at its lateral aspect, with expansion of the rib observed. Ultrasound-guided pleural aspiration confirmed an exudative pleural effusion. Gram stain revealed no organisms or polymorphs. Four days post admission, the patient was transferred to the regional thoracic surgery unit and underwent video-assisted thoracic surgery, bronchoscopy and drainage of his empyema. His Mantoux tuberculin skin test and his TB Elispot were negative, suggesting that TB infection was unlikely. Culture confirmed no growth after 48 h incubation. Histology of his pleural biopsy identified multiple non-confluent necrotising granulomatous inflammation with very occasional acid-alcohol-fast bacilli-like organisms, highly suspicious for mycobacterial infection. The isolate, Mycobacterium tuberculosis, was identified by Accuprobe and HAIN tests, respectively. MPT64 erythrocyte sedimentation rate (ESR) results from the fifth rib were positive for M. tuberculosis. This case report discusses the aetiology, clinical presentation and pathophysiology of both empyema necessitans and tubercular osteomyelitis of the rib.

A 35-year old woman with productive cough and breathlessness.

A 35-year-old lady was seen in the outpatient clinic owing to fever, cough with mucopurulent expectoration, and breathlessness for the duration of 1 month. She had history of similar episodes treated with antibiotics four times during last 2 years. There was no history of recurrent sinusitis, diarrhea, and skin or soft tissue infection. She had no history of diabetes mellitus or steroid intake. She denied any history of facial trauma or dental infection in the past. There was no history of tuberculosis in her or in the family. Radiograph and CT scan of the chest revealed right upper lobe consolidation. Flexible fibreoptic bronchoscopy revealed multiple nodules at opening of right upper lobe bronchus. This clinicopathological conference describes the details of differential diagnoses, difficulties in achieving the final diagnosis and management of such patient.

[Disseminated nocardiosis presenting as retroperitoneal abscess: a case report].

A 64-year-old man presented to our emergency room with right back pain on July 10, 2009. At the emergency room, abdominal enhanced computed tomography revealed a cystic lesion in the retroperitoneum. Then he was referred to our department. We performed percutaneous drainage of the retroperitoneal lesion and aspirated white pus. The retroperitoneal cystic lesion proved to be an abscess. Microscopic examination of a Gram stained specimen of the abscess revealed gram-positive bacillary fragments ; therefore, we suspected the pathogen to be Nocardia. He had a history of chronic glomerulonephritis and had received treatment consisting of 20 mg prednisolone, and 75 mg cyclosporine per day. He was regularly visiting the department of cardiovascular for follow-up of chronic heart failure. On the day before his visit to our emergency room, his chest X-ray medicine had revealed a nodular shadow. Then he was referred to the department of respiratory medicine and was scheduled to receive a bronchoscopy later. We suspected the nodule of the lung also to be an abscess of Nocardia. Later, head computed tomography (CT) revealed a brain abscess the pathogen of which was Nocardia. Nocardia is a filamentous, gram-positive, branched bacterium and classified as an aerobic actinobacteria. Nocardia species are difficult to diagnose due to non-specific clinical and histological manifestation. We report this case of disseminated nocardiosis presenting as retroperitoneal abscess. The disseminated nocardiosis was diagnosed without delay by percutaneous drainage and appropriate treatment was provided.

[First case report of respiratory infection with Rothia aeria].

A 53-year-old woman was admitted to our hospital with dysbasia and forgetfulness. Her past history included uveitis at age 39. Medical examinations led to a diagnosis of neurosarcoidosis. Although she was treated with prednisolone, her symptoms remained, so she received steroid pulse therapy twice, and administration of azathioprine. In early January 2007, a chest X-ray film showed nodules in the right upper lung that rapidly increased in size and number. A CT scan revealed multiple nodules including cavitary lesions in both lung fields. Examination of bronchial lavage fluid and a transbronchial lung biopsy showed a mycelium-like gram-negative filament. After the treatment with benzylpenicillin for 1 month, her laboratory data and radiological abnormalities markedly ima proved. However, switching to oral administration of amoxicillin caused the regrowth of the nodules. She was retreated with intravenous benzylpenicillin for 8 weeks, followed by oral administration of amoxicillin for 5 months, and her condition completely resolved. The causative organism was identified as Rothia aeria (described in 2004) by 16S rRNA gene sequencing. This is the first report of a case of pulmonary infection with this species.

Tuberculous pleural effusion in a patient with sympathetic ophthalmia on immunosuppression: a case report.

Tuberculous pleural effusion (TPE) is paucibacillary, making its diagnosis difficult based on laboratory investigations alone. We present a case of a patient with a TPE who was initially misdiagnosed to have azathioprine-induced lung injury. The diagnosis of TPE was arrived at with the help of clinical assessment, laboratory and radiological investigations. A 25-year-old chronic smoker with sympathetic ophthalmia on long-term immunosuppression, latent tuberculosis infection and a significant family history of tuberculosis presented with a three-week history of productive cough, low-grade fever, night sweats and weight loss. Examination of the lungs showed reduced breath sounds at the right lower zone. Chest x-ray showed minimal right pleural effusion with a small area of right upper lobe consolidation. The pleural fluid was exudative with predominant mononuclear leukocytes. Direct smears of sputum and pleural fluid; polymerase chain reaction of pleural fluid; and sputum, pleural fluid and blood cultures were negative for M. tuberculosis (MTB) and other organisms. As he did not respond to a course of broad-spectrum antibiotics, he was then treated as a case of azathioprine-induced lung injury. However, his condition did not improve despite the cessation of azathioprine. A contrast-enhanced computed tomography of the thorax showed right upper lobe consolidation with tree-in-bud changes, bilateral lung atelectasis, subpleural nodule, mild right pleural effusion and mediastinal lymphadenopathy. Bronchoalveolar lavage was negative for malignant cells and microorganisms including, MTB. However, no pleural biopsy was done. He was empirically treated with anti-tubercular therapy for 9 months duration and showed complete recovery. A high index of suspicion for TPE is required in individuals with immunosuppression living in regions endemic to tuberculosis. Targeted investigations and sound clinical judgement allow early diagnosis and prompt treatment initiation to prevent morbidity and mortality.

Pulmonary nocardiosis in Chronic Obstructive Pulmonary Disease: A new clinical challenge.

Pulmonary nocardiosis (PN) is a rare but severe disease caused by Nocardia spp. Despite the traditional description as opportunistic infection, case reports and case series of pulmonary nocardiosis have recently been reported in immunocompetent patients too, in particular among people with chronic pulmonary diseases such as advanced Chronic Obstructive Pulmonary Disease (COPD). PN is characterized by non-specific symptoms and radiological findings; bacteriological culture can be difficult. For the reasons above, diagnosis of PN is challenging, sometimes resulting in a misdiagnosis of tuberculosis. We report an interesting case of PN in a 75-year-old male with COPD. He complained a 3-months history of fatigue, evening rise in body temperature, night sweats, unexplained weight loss of 5 kg, worsening dyspnea, cough and mucopurulent sputum. The chest X-ray showed multiple nodules with cavitations bilaterally in the apical and subclavian regions. Nocardia cyriacigeorgica with 100% identity was identified in three sputum samples. Since the patient has never undergone a systemic and/or inhaled steroid therapy, and has no respiratory failure and comorbidities entailing immunodepression, it is conceivable that, in this immunocompetent patient, the COPD could represent an isolated risk factor for PN. Risk factors, clinical presentations, radiographic findings, differential diagnosis and review of the literature of PN cases in COPD, pointing out the similarities and differences, are also described.

Empyema associated with a cough-induced rib fracture.

A 44-year-old man presented to the emergency department with fever and right anterior chest pain. He reported a persistent cough and the development of sudden-onset right anterior chest pain after coughing. The inspiratory pain in the right lung was severe, and therefore deep breathing was impossible. Chest CT revealed a fracture in the right seventh rib with consolidation and pleural effusion. A pleural fluid culture test result was positive for methicillin-susceptible <iStaphylococcus aureus</i He was diagnosed with empyema associated with a cough-induced rib fracture. Thoracic drainage tube placement and intravenous antibiotic therapy successfully ameliorated his condition. He was discharged on day 13 and switched to an 8-week course of oral antibiotic therapy. There was no clinical relapse at the 6-month follow-up.

[Wegener's granulomatosis--a disease of many faces].

We describe a case of Wegener's granulomatosis. The first symptoms included severe headache subsiding only after administration of dexamethasone. Despite a great number of diagnostic tests involving CT and MR of the head, the cause of the headache remained unknown. Because a chest x-ray revealed a nodule in the right lung, the patient was sent to our Clinic. Reevaluation of CT and MR pointed to a massive ethmoid sinusitis. 7-days' course of antibiotics and corticosteroids induced remission of the lung nodule. Several diagnoses were made: neoplasm, bacterial ethmoid sinusitis, trigeminal neuritis, thrombotic cavernous sinusitis and tuberculosis. Results of the ethmoid sinus biopsy together with a high c-ANCA concentration gave the correct diagnosis.

[Two cases of rheumatoid arthritis developed after polymyositis].

We report two cases of rheumatoid arthritis (RA) who later had developed after polymyositis (PM). The first patient was 64-year old male who experienced muscular weakness of the four limbs in proximity 10 years ago. He was diagnosed as PM because of the elevated serum CK and the myogenic pattern of EMG, and his symptoms were improved by treatment with corticosteroid. He started to complain polyarthralgia 2 years ago, followed by interstitial pneumonia, pleuritis and skin ulcer. He was admitted because of exacerbated polyarthralgia, multiple subcutaneous nodules, skin eruption and fever. The level of serum CK was within normal range but CRP was elevated and CH 50 was decreased. The laboratory examination showed positive cryoglobulin and high titer of rheumatoid factor, but anti-Jo 1 antibody was negative. The hand X-ray showed bone erosions in bilateral wrist joints. Skin biopsy revealed leukocytoclastic vasculitis. Based on these findings, he was diagnosed as malignant RA. He was successfully treated with methylprednisolone pulse therapy, cyclophosphamide and prostaglandin E 1. The second patient was 77-year old male with pneumoconiosis who experienced muscular weakness of the four limbs in proximity 4 years ago. He was diagnosed as PM based on his clinical and laboratory findings and was treated with temporary corticosteroid. He started to have polyarthralgia last year, and he was admitted because of increasing arthralgia after the treatment of pulmonary tuberculosis. The level of serum CK was slightly elevated due to hypothyroidism, and CRP was highly elevated. Rheumatoid factor and cryoglobulin were positive, but anti-Jo 1 antibody was negative. The hand X-ray showed bone erosions in bilateral wrist joints. Crystals of pyrophosphate calcium was observed in knee joints. He was diagnosed as RA associate with pseudogout. His symptoms were relieved with corticosteroid, salazosulfapyridine and anti-tuberculous therapy. These two cases had altered their clinical features from PM to definite RA, and both had pulmonary complications. Previous reports described the cases of RA followed by PM, most of which were induced by such drugs as D-penicillamine, but the cases of PM who later had developed RA are extremely unusual. The overlapped cases of RA and PM tend to highly associate with pulmonary lesions.

A 66-year-old woman with fever, cough, and a tongue lesion.

A 66-year-old woman presented with acute onset of fever, chills, and productive cough associated with right-sided chest pain. During a recent hospitalization for dyspnea, she had been diagnosed with Coombs-positive autoimmune hemolytic anemia and had been taking a tapering dose of prednisone starting approximately 6 weeks prior to admission. In the interim, her dyspnea had resolved on treatment with steroids. At the time of presentation, her prednisone dose was 40 mg. Additional medical history included VTE, for which the patient was receiving anticoagulation therapy, and steroid-induced diabetes mellitus. Many years earlier, she had been treated for TB in her home country. The patient had immigrated to Queens, New York, from a Nepalese village 8 years prior. While still in Nepal, she had worked on a farm and had been in close proximity to cows. In Queens, she lived with her family in a house with a small garden but had no pets. Recent travel included a visit to Nepal 9 months ago and a trip to Syracuse, New York, one month prior to presentation. She was a never smoker and did not consume alcohol.

[Disseminated Nocardiosis Complicated by Multiple Brain Abscesses: A Case Report].

We report a relatively rare case of a disseminated type of nocardiosis without lung involvement. A 75-year-old man developed moderate fever and disturbed consciousness and was admitted to our hospital. Laboratory examinations revealed signs of inflammation. Chest X-rays indicated no abnormalities, but brain MRI showed ring-like enhancement lesions in the right temporal and left frontal lobes. Similar lesions were identified in the left kidney and right leg. The brain lesions were purulent and were surgically irrigated. Gram- and Kinyoun-positive bacteria were identified, and the patient was diagnosed as suffering from a disseminated type of nocardiosis without lung involvement. He was treated with trimethoprim-sulfamethoxazole for over 10 months. The postoperative course was uneventful, and he was discharged without any neurological sequelae two months after surgery. Kinyoun staining was important in early diagnosis and hence providing appropriate therapy for life-threatening nocardiosis.

InternalMed_Harrison

infiltrates on chest x-ray. One may also see nodules, cavities, pleural effusions, and hilar adenopathy. While serologic testing is of value in the immunocompetent host, serologies are negative in 25% of HIV-infected patients with coccidioidal infection. Invasive aspergillosis is not an AIDS-defining illness and is generally not seen in patients with AIDS in the absence of neutropenia or administration of glucocorticoids. When it does occur, Aspergillus infection may have an unusual presentation in the respiratory tract of patients with AIDS, where it gives the appearance of a pseudomembranous tracheobronchitis. Primary pulmonary infection of the lung may be seen with histoplasmosis. The most common pulmonary manifestation of histoplasmosis, however, is in the setting of disseminated disease, presumably due to reactivation. In this setting respiratory symptoms are usually minimal, with cough and dyspnea occurring in 10–30% of patients. The chest x-ray is abnormal in ~50% of patients,