Royce H. Johnson

Intravenously administered ciprofloxacin was compared with imipenem for the treatment of severe pneumonia. In this prospective, randomized, double-blind, multicenter trial, which included an intent-to-treat analysis, a total of 405 patients with severe pneumonia were enrolled. The mean APACHE II score was 17.6, 79% of the patients required mechanical ventilation, and 78% had nosocomial pneumonia. A subgroup of 205 patients (98 ciprofloxacin-treated patients and 107 imipenem-treated patients) were evaluable for the major efficacy endpoints. Patients were randomized to receive intravenous treatment with either ciprofloxacin (400 mg every 8 h) or imipenem (1,000 mg every 8 h), and doses were adjusted for renal function. The primary and secondary efficacy endpoints were bacteriological and clinical responses at 3 to 7 days after completion of therapy. Ciprofloxacin-treated patients had a higher bacteriological eradication rate than did imipenem-treated patients (69 versus 59%; 95% confidence interval of -0.6%, 26.2%; P = 0.069) and also a significantly higher clinical response rate (69 versus 56%; 95% confidence interval of 3.5%, 28.5%; P = 0.021). The greatest difference between ciprofloxacin and imipenem was in eradication of members of the family Enterobacteriaceae (93 versus 65%; P = 0.009). Stepwise logistic regression analysis demonstrated the following factors to be associated with bacteriological eradication: absence of Pseudomonas aeruginosa (P < 0.01), higher weight (P < 0.01), a low APACHE II score (P = 0.03), and treatment with ciprofloxacin (P = 0.04). When P. aeruginosa was recovered from initial respiratory tract cultures, failure to achieve bacteriological eradication and development of resistance during therapy were common in both treatment groups (67 and 33% for ciprofloxacin and 59 and 53% for imipenem, respectively). Seizures were observed more frequently with imipenem than with ciprofloxacin (6 versus 1%; P = 0.028). These results demonstrate that in patients with severe pneumonia, monotherapy with ciprofloxacin is at least equivalent to monotherapy with imipenem in terms of bacteriological eradication and clinical response. For both treatment groups, the presence of P. aeruginosa had a negative impact on treatment success. Seizures were more common with imipenem than with ciprofloxacin. Monotherapy for severe pneumonia is a safe and effective initial strategy but may need to be modified if P. aeruginosa is suspected or recovered from patients.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.

Surveillance for coccidioidomycosis (CM) and a case-control study for risk factors among adults were conducted in Kern County, California. From January 1995 through December 1996, 905 cases of CM were identified, for an annual incidence of 86 cases per 100,000 population. A total of 380 adults were enrolled in the case-control study: 77 had severe pulmonary disease, 33 had disseminated disease, and 270 control patients had mild disease. Independent risk factors for severe pulmonary disease included diabetes, recent history of cigarette smoking, income of < $15,000 per year, and older age. Oral antifungal therapy before hospitalization was associated with a reduced risk of CM pneumonia. Risk factors for disseminated disease were black race, income of < $15,000 per year, and pregnancy. Early treatment of CM with oral antifungal agents may prevent severe pulmonary disease in groups considered to be at high risk, such as elderly individuals, persons with diabetes, and smokers. Persons at risk for severe CM may benefit from vaccination once an effective CM vaccine is available.

Residents of the area now occupied by the southwestern United States and northwestern Mexico have had to deal with coccidioidomycosis and complicating meningitis for >1500 years. The hundredth anniversary of the reporting of disseminated coccidioidomycosis has just passed. This year has the dubious distinction of being the hundredth anniversary of the first description of coccidioidal meningitis. Although intrathecal amphotericin B began to be used for therapy 50 years ago, and although we have benefited from azole therapy for >10 years, the morbidity and mortality associated with this all-too-common disease remain unacceptably high. This review will endeavor to discuss the pathogenic, pathophysiologic, clinical, laboratory, radiologic, and therapeutic features of meningitis secondary to Coccidioides infection.

This review of the complications which developed in twenty-three of thirty-one patients who underwent a combined intracranial facial approach to the paranasal sinuses indicates that the cribriform plate and ethmoid sinuses can be safely resected. Two deaths (7 per cent) were associated with four instances of meningitis, the most severe of the complications encountered. Complications such as facial edema, cellulitis, wound and bone infection, cerebrospinal fluid leaks, diplopia, postoperative bleeding, and slough of graft were treated without subsequent disability. A greatly increased survival free of disease in this group of patients, 68 per cent of whom had not responded to treatment, indicates that the procedure should continue to be more frequently used to control paranasal sinus malignancy.

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.

Coccidioidomycosis is a fungal infection of the Western hemisphere that is endemic to the soil in areas with limited rainfall. Human and animal infections result with inhalation of arthroconidia. Most often, this is an asymptomatic event. When illness occurs, it is primarily a pneumonic presentation. A small minority of infections eventuate in disseminated disease. Predominately, this presents as meningitis or osteoarticular or integumentary disease. Treatment may not be required for the mildest illness. Azoles are commonly prescribed. Severe infections may require amphotericin B.

Early studies have reported various electrolyte abnormalities at admission in patients with severe COVID-19. 104 out of 193 patients admitted to our institution presented with hypermagnesemia at presentation. It is believed this may be important in the evaluation of severe SARS-CoV-2 infections. This study evaluated the outcomes of hypermagnesemia in patients with COVID-19. A retrospective chart review of patients admitted to the hospital with confirmed SARS-CoV-2 infection was conducted. A review of the medical literature regarding hypermagnesemia, magnesium levels in critical care illness and electrolyte abnormalities in patients with COVID-19 was performed. Differences in demographic and clinical characteristics of patients with hypermagnesemia and normomagnesemia were evaluated using descriptive statistics. Other known variables of disease severity were analyzed. 104 patients (54%) were identified with hypermagnesemia (≥2.5 mg/dL). 48 of those patients were admitted to the intensive care unit (46%, p<0.001). 34 patients required ventilator support (32%, p<0.0001). With age-adjusted logistic regression analysis hypermagnesemia was associated with mortality (p=0.007). This study demonstrates that hypermagnesemia is a significant marker of disease severity and adverse outcome in SARS-CoV-2 infections. We recommend serum magnesium be added to the panel of tests routinely ordered in evaluation of severe SARS-CoV-2 infections.

Six cases of apparent and four cases of histopathologically confirmed vasculitis of the central nervous system (CNS), including one case of histopathologically documented vasculitis with encephalitis associated with coccidioidal meningitis (CM), are presented. Vasculitic complications included changes in mental status as well as stroke-like findings of aphasia, hemianopsia, and hemiparesis. Seven patients died. Vasculitic complications were unanticipated and often abrupt in onset, and delayed therapeutic intervention was characteristic. The diagnosis of vasculitis/encephalitis due to Coccidioides immitis infection must be based on clinical judgment, since serum antibody titers, cerebrospinal fluid findings, and initial radiological studies are not always helpful. Institution of both intravenous and intracisternal administration of amphotericin B and possibly concomitant intravenous administration of dexamethasone may be warranted in situations in which the association of C. immitis with CNS vasculitis or encephalitis appears likely before serologic or cultural confirmation of C. immitis infection involving the CNS is available.

The Journal of Bone and Joint Surgery. British volumeVol. 61-B, No. 2 ArticlesFree AccessReactivation of tuberculosis after total hip replacementR Johnson, KL Barnes, R OwenR JohnsonSearch for more papers by this author, KL BarnesSearch for more papers by this author, R OwenSearch for more papers by this authorPublished Online:1 May 1979https://doi.org/10.1302/0301-620X.61B2.438263AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited ByMycobacterial periprosthetic joint infection after primary total knee arthroplasty8 April 2021 | International Orthopaedics, Vol. 45, No. 12Unusual Microorganisms in Periprosthetic Joint Infection18 March 2021Total Hip Arthroplasty in 52 Active Advanced Tubercular Arthritic HipsThe Journal of Arthroplasty, Vol. 36, No. 3Hip and Knee Section, Prevention, Risk Mitigation: Proceedings of International Consensus on Orthopedic InfectionsThe Journal of Arthroplasty, Vol. 34, No. 2Successful Fixation of a Tuberculous Nonunion of the Humeral Shaft1 March 2019 | JBJS Case Connector, Vol. 9, No. 1A deceptive presentation of Tuberculosis hip as Staphylococcal infection, its successful management and literature review23 August 2018 | BMJ Case Reports, Vol. 2Tubercular prosthetic joint infection: two case reports and literature review30 October 2017 | Infection, Vol. 46, No. 1Total hip replacement in tuberculosis of hip: A systematic reviewJournal of Clinical Orthopaedics and Trauma, Vol. 9, No. 1Musculoskeletal Tuberculosis27 April 2017Musculoskeletal TuberculosisMicrobiology Spectrum, Vol. 5, No. 2Cementless total hip arthroplasty in advanced tuberculosis of the hip22 September 2015 | International Orthopaedics, Vol. 39, No. 11Total hip replacement for patients with active tuberculosis of the hipA systematic review and pooled analysisS-J. Kim, R. Postigo, S. Koo, J. H. Kim1 May 2013 | The Bone & Joint Journal, Vol. 95-B, No. 5Extra-pulmonary tuberculosis developing at sites of previous traumaJournal of Infection, Vol. 66, No. 4Skeletal Tuberculosis Following Proximal Tibia Fracture26 February 2013 | The International Journal of Lower Extremity Wounds, Vol. 12, No. 1Tuberculous Coxitis: Diagnostic Problems and Varieties of Treatment: A Case Report§The Open Orthopaedics Journal, Vol. 6, No. 1Rice Bodies, Millet Seeds, and Melon Seeds in Tuberculous Tenosynovitis of the Hand and WristAnnals of Plastic Surgery, Vol. 66, No. 6The chemotherapy of osteo-articular tuberculosis with recommendations for treatment of childrenJournal of Infection, Vol. 62, No. 6Cementless Total Hip Arthroplasty for the Treatment of Advanced Tuberculosis of the HipOrthopedics, Vol. 34, No. 2Total hip arthroplasty for active tuberculosis of the hip15 August 2009 | International Orthopaedics, Vol. 34, No. 8Post-tubercular stiff hip with fracture of the proximal femur treated with total hip arthroplasty: a rare case scenarioJournal of Clinical Orthopaedics and Trauma, Vol. 1, No. 2Reply to the comments on our article “Total hip arthroplasty for active tuberculosis of the hip”26 September 2009 | International Orthopaedics, Vol. 34, No. 3Total Hip Arthroplasty in Patients with Active Tuberculosis of the Hip with Advanced Arthritis30 June 2009 | Clinical Orthopaedics and Related Research®, Vol. 468, No. 2Reactivation of ancient joint tuberculosis of the knee following total knee arthroplasty after 61 years: A case reportThe Knee, Vol. 15, No. 4Pulmonary Tuberculosis with Delayed Tuberculosis Infection of Total Knee ArthroplastyJournal of the Formosan Medical Association, Vol. 106, No. 1Musculoskeletal TuberculosisDisease-a-Month, Vol. 53, No. 1Prosthetic Joint Infection by Mycobacterium tuberculosis: An Unusual Case Report with Literature ReviewSouthern Medical Journal, Vol. 100, No. 1Fungi, Mycobacteria, Zoonotic and Other Organisms in Prosthetic Joint InfectionClinical Orthopaedics and Related Research, Vol. 451Reactivación de una artritis tuberculosa de cadera tras veintidós años quiescenteRevista de Ortopedia y Traumatología, Vol. 49, No. 1Reactivación de una artritis tuberculosa de cadera tras veintidós años quiescenteRevista Española de Cirugía Ortopédica y Traumatología, Vol. 49, No. 1Haematogenous Spread of Pulmonary Tuberculosis to a Hemiarthroplasty of the Hip26 January 2018 | HIP International, Vol. 14, No. 4Tuberculosis infection complicating total knee arthroplastyThe Journal of Arthroplasty, Vol. 19, No. 3Tuberculosis of the HipClinical Orthopaedics and Related Research, Vol. 398Active tuberculosis of the hip treated with early total hip replacement--a report of 3 cases8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 72, No. 4Infected knee treated by total knee arthroplastyThe Knee, Vol. 7, No. 3Periprosthetic infections due to Mycobacterium tuberculosis in patients with no prior history of tuberculosisThe Journal of Arthroplasty, Vol. 11, No. 2Total Knee Arthroplasty in Tuberculous ArthritisClinical Orthopaedics and Related Research, Vol. 323Total hip arthroplasty complicated by tuberculous infectionThe Journal of Arthroplasty, Vol. 11, No. 1Rheumatology grand rounds loosening of a revision total hip replacement in a 60-year-old woman with longstanding rheumatoid arthritis clinicopathologic conferenceArthritis & Rheumatism, Vol. 38, No. 9Reactivation of a tuberculous coxitis due to loosening of a total hip endoprosthesisArchives of Orthopaedic and Trauma Surgery, Vol. 114, No. 5Advances in the Control of Perioperative Sepsis in Total Joint ReplacementRheumatic Disease Clinics of North America, Vol. 14, No. 3Deep sepsis from mycobacterium tuberculosis after total hip replacementArchives of Orthopaedic and Traumatic Surgery, Vol. 107, No. 3Tuberculous bone and joint infectionCurrent Orthopaedics, Vol. 2, No. 2Tuberculosis of the Lower-Limb JointsTotal hip replacement in old tuberculosis: A report of 14 cases8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 59, No. 4Arthroplasty in tuberculosis of the knee: Two cases of missed diagnos8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 58, No. 3Orthopedic surgeryArthritis & Rheumatism, Vol. 26, No. 3 Vol. 61-B, No. 2 Metrics Downloaded 157 times History Published online 1 May 1979 Published in print 1 May 1979 InformationCopyright © 1979, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download

ResearchCoccidioidomycosis (CM), also known as Valley fever, is caused by the dimorphic fungus Coccidioides immitis, endemic to the southwestern United States, Mexico, and Central and South America.In California before 1991, approximately 400 to 500 new cases were reported annually.During 1991 to 1994, the number of cases increased dramatically, with 1,200 new cases reported in 1991, 4,541 in 1992, and 4,137 in 1993 (1-4).C. immitis is a soil-dwelling organism that blooms after the rainy season.Infection usually occurs in the dry season, when arthroconidia become airborne and can be inhaled by the host.In California in 1991, increased rainfall following a drought allowed increased fungal proliferation, resulting in an increased rate of infection.The 1994 Northridge earthquake led to an increase in infections associated with landslides and dust clouds that aerosolized arthroconidia.Increased risk for symptomatic CM was directly proportional to time spent in the dust cloud (5).Of those infected, an estimated 60% are asymptomatic, with the only evidence of exposure being delayed-type hypersensitivity (DTH) reaction to a coccidioidal antigen skin test.Of the symptomatic patients, 90% to 99% experience only mild flulike symptoms.More severe chronic pulmonary disease or disseminated infection beyond the thoracic cavity occurs in 1% to 10% of symptomatic cases, depending on ethnicity (N.Ampel, pers.comm.).Disseminated CM is particularly devastating and usually requires lifelong antifungal treatment.Risk factors include male sex, compromised immune status, pregnancy, diabetes, advancing age, and smoking (6-9).Risk for disseminated CM seems to differ according to ethnicity (9).For example, during the 1977 windborne outbreak of CM in the nonendemic-disease region of Sacramento County, California, the rate per 100,000 of acute

Prior to the 1950s no effective therapy for coccidioidomycosis existed. The advent of amphotericin B ushered in the therapeutic era for coccidioidomycosis. Until this time amphotericin B and its lipid congeners have been regarded as the "gold standard" of therapy for severe pulmonary and disseminated coccidioidomycosis. The availability of azoles and later triazoles for the past three decades have relegated the amphotericins into a rescue mode, used mainly in widely disseminated cases, azole intolerance, or when there are contraindications to Azoles, such as pregnancy. In meningitis the intrathecal use of amphotericin B is still used frequently by some clinicians alone or with a triazole. The newer lipid preparations, while more expensive, have significantly reduced toxicity, particularly nephropathy.

Coccidioidal meningitis (CM) is a devastating complication of coccidioidomycosis. Since the late 1950s, intrathecal (IT) amphotericin B deoxycholate (AmBd) has been successfully used to treat and often cure this disease, reducing mortality rates from 100% to approximately 30%. The introduction of azoles further revolutionized the treatment of coccidioidal infections. However, IT AmBd remains the only known curative option in the management of CM. While the use of IT AmBd is well described in many articles, few discuss the actual methods behind preparation, titration, and dosing strategies utilized. The practitioners at Kern Medical (Bakersfield, California) have >60 years of experience in the utilization of IT AmBd and the treatment of CM. This article describes the practice experience in the treatment of CM, preparation of IT AmBd, and the different dosing strategies used in regard to route of administration (ie, cisternal, lumbar, ventricular).

In the middle of a pandemic, patients with cough and fever are thought to have SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2). It should be remembered that in the desert southwest of the United States, we have an ongoing epidemic of coccidioidomycosis (CM). There are additionally many other respiratory illnesses that could be confused with CoV-2 or overlooked. This is a case report of CoV-2 engrafted on chronic cavitary pulmonary CM. In a time where the coronavirus pandemic is becoming rampant, we demonstrate the case of a coinfection with cavitary pulmonary CM. In this case, the importance of detection of the coronavirus and treatment of the coinfection is explored.

purpose: Coccidioidal meningitis (CM) is a major source of. morbidity and mortality in endemic regions. The diagnosis of CM is a clinical challenge. Eosinophilic pleocytosis (EP) is an uncommon finding and present in a relatively limited number of conditions. In order to determine the frequency and the prognostic significance of EP in CM, we conducted the present study. patients and methods: Retrospective chart review of all patients diagnosed as having CM between 1986 and 1991 at Kern Medical Center. All patients had clinical and cerebrospinal fluid (CSF) findings confirmatory of CM. results: Nineteen patients (70%) in the study group had EP, and of these, 8 patients (30%) met the criteria for eosinophilic meningitis (greater than or equal to 10 eosinophils/mm3). No correlation was found between EP and age, sex, race, results of complement fixation test for coccidioidal antigen in CSF or serum, peripheral eosinophilia, or outcome. conclusion: The presence of EP is a frequent observation in CM. Although we did not demonstrate any prognostic correlation with EP, this finding is of major diagnostic significance and its presence should bring attention to the diagnosis of CM.

Patients with coccidioidal meningitis require lifelong antifungal therapy. Cumulative toxicity and lack of antifungal efficacy require salvage therapy in the treatment of some patients. In a retrospective review of nine patients with coccidioidal meningitis treated with isavuconazole, successful therapy was seen in three patients and stable disease was confirmed in six patients. Isavuconazole may be a useful addition to the therapeutic choices currently available for coccidioidal meningitis.

Coccidioidal infection can manifest as pulmonary or extrapulmonary disease. Pulmonary coccidioidomycosis occurs in 95% of all cases and can be divided into three main categories: primary, complicated, and residual pulmonary coccidioidomycosis. The primary infection occurs with inhalation of airborne arthroconidia. As few as 10 arthroconidia are capable of causing an infection in animal models. Sixty percent of infected individuals will remain asymptomatic. This results in a positive skin test and, with rare exception, lifelong immunity. The other 40% will develop symptomatic disease that manifests with variable signs and symptoms, predominantly an influenza-like syndrome, pneumonia, or pleural effusion. The category of complicated pulmonary coccidioidomycosis includes clinical entities as severe and persistent pneumonia, progressive primary coccidioidomycosis, fibrocavitary coccidioidomycosis, cavities, and empyema, a complication of a ruptured cavity. Progression of primary pulmonary disease to acute respiratory distress syndrome (ARDS) can also qualify as a complication. The third category of residual disease comprises only two entities: pulmonary nodule and fibrosis. This review focuses on uncomplicated and complicated pulmonary coccidioidomycosis and its management as outlined earlier in addition to special considerations of coccidioidal fungemia, pulmonary coccidioidomycosis in pregnancy, and organ transplantation.

Coccidioidomycosis (‘Valley Fever’), caused by the inhalation of the fungus Coccidioides, remains a recalcitrant health problem in large parts of California. The incidence and severity of the disease continues to rise in many parts of the state. In this manuscript, we highlight unanswered questions about the disease. Specifically, the extent of disease burden, genetic determinants of host susceptibility, diagnostic and treatment guidelines, natural reservoirs of the pathogens, antifungal drug resistance, and fungal determinants of mild or severe disease are all areas awaiting in depth investigations. We also recommend establishment of a California Coccidioidomycosis Registry to improve clinical care and translational research.

Coccidioidal meningitis (CM) has high morbidity, and adjunctive measures to improve outcomes are needed. Using an established multicenter retrospective cohort study of CM (N = 221), we found that patients receiving adjunctive corticosteroids had a significant reduction in secondary cerebrovascular events (P = .0049). Those with CM-associated cerebrovascular events (8%) may benefit from short-term corticosteroids.

Abstract Central nervous system infection with Coccidioides spp. is fatal if untreated and complications occur even when therapy is directed by experienced clinicians. We convened a panel of clinicians experienced in the management of coccidioidal meningitis to summarize current controversies and provide consensus for the management of this difficult infection.

Coccidioidomycosis is a fungal infection with a range of clinical manifestations. Currently used antifungal agents exhibit variable efficacy and toxicity profiles that necessitate evaluation of additional therapeutic options. Improvement was observed in the majority of patients treated with isavuconazole, with clinical failures observed only in those with coccidioidal meningitis.

Abstract Coccidioidomycosis, histoplasmosis, and blastomycosis are underrecognized and frequently misdiagnosed fungal infections that can clinically resemble bacterial and viral community-acquired pneumonia. This guidance is intended to help outpatient clinicians test for these fungal diseases in patients with community-acquired pneumonia to reduce misdiagnoses, unnecessary antibacterial use, and poor outcomes.

A wide array of clinical manifestations follow infection with Coccidioides immitis or Coccidioides posadasii, ranging from asymptomatic infection to life-threatening pulmonary disease or extrapulmonary dissemination and meningitis. Epidemiological studies require consistent definitions of cases and their comparative clinical features. Understanding host and pathogen determinants of the severity of coccidioidomycosis also requires that specific clinical features (such as coccidioidal meningitis) and their overlap be precisely defined and quantified. Here we propose a system for categorization of outcomes of coccidioidomycosis in individuals who are not overtly immunocompromised that harmonizes clinical assessments during translational research of this increasingly common disease.

Severe coccidioidomycosis presenting with respiratory failure is an uncommon manifestation of disease. Current knowledge of this condition is limited to case reports and small case series.A retrospective multicenter review of patients with coccidioidomycosis-associated acute respiratory distress syndrome (CA-ARDS) was conducted. It assessed clinical and laboratory variables at the time of presentation, reviewed the treatment course, and compared this cohort with a national database of patients with noncoccidioidomycosis ARDS. Survivors and nonsurvivors of coccidioidomycosis were also compared to determine prognostic factors.In this study, CA-ARDS (n = 54) was most common in males, those of Hispanic ethnicity, and those with concurrent diabetes mellitus. As compared with the PETAL network database (Prevention and Early Treatment of Acute Lung Injury; n = 1006), patients with coccidioidomycosis were younger, had fewer comorbid conditions, and were less acidemic. The 90-day mortality was 15.4% for patients with coccidioidomycosis, as opposed to 42.6% (P < .0001) for patients with noncoccidioidomycosis ARDS. Patients with coccidioidomycosis who died, as compared with those who survived, were older, had higher APACHE II scores (Acute Physiology and Chronic Health Evaluation), and did not receive corticosteroid therapy.CA-ARDS is an uncommon but morbid manifestation of infection. When compared with a national database, the overall mortality appears favorable vs other causes of ARDS. Patients with CA-ARDS had a low overall mortality but required prolonged antifungal therapy. The utility of corticosteroids in this condition remains unconfirmed.

To describe the clinical and laboratory parameters of patients with septic shock following infection with Coccidioides immitis, estimate the incidence of septic shock from coccidioidomycosis, and outline clues that may be helpful in early diagnosis of this syndrome.Retrospective, descriptive case series.A 250-bed general public hospital in Kern County, CA.Eight patients diagnosed with septic shock from infection with C. immitis from September 1991 to December 1993. Five were Hispanic, two were Filipino, and one was African-American. The diagnosis of C. immitis was made by microscopic examination and culture of the organism from sputum or other sites. Septic shock was diagnosed using criteria formulated by the American College of Chest Physicians Consensus Conference/Society of Critical Care Medicine.No patient had traditional immunocompromising conditions. All patients had pulmonary symptoms and were symptomatic for a mean duration of 19.4 +/- 19.8 days before admission. One patient presented with septic shock and the remaining seven developed shock during their hospital course. Serology for coccidioidomycosis was positive in six patients. The mean cardiac index was 5.8 +/- 1.9 (SD) L/min/m2, the mean arterial pressure was 71.0 +/- 16.7 mm Hg, the mean pulmonary artery occlusion pressure was 16.9 +/- 3.5 mm Hg, and the mean systemic volume resistance index was 846.6 +/- 224.1 dyne-sec/cm5xm2. All patients developed acute respiratory distress syndrome. Coccidioidomycosis was recognized or considered in only five of eight patients before they developed septic shock. Despite therapy with amphotericin B, all patients died. One patient died of progressive pulmonary disease, two patients suffered an acute arrest, and five patients developed progressive multiple organ system failure and died with additional organ involvement.Septic shock following infection with C. immitis is an ominous yet underrecognized condition. Hemodynamic parameters and cytokine concentrations were not significantly different from values seen in gram-negative septic shock. Clinical clues to the diagnosis include duration of illness and conspicuous pulmonary involvement. Patient outcome in this series was poor but may improve with increased recognition of septic shock in infections from C. immitis.

PURPOSE To characterize MR findings in acute and chronic coccidioidomycosis meningitis and relate the imaging features to the clinical course. METHODS We reviewed MR scans and clinical findings of 12 patients with coccidioidal meningitis. RESULTS Patients with active or untreated disease were found to have hydrocephalus and intense enhancement of the cervical subarachnoid space, basilar, sylvian, and interhemispheric cisterns on postcontrast MR scans. Focal parenchymal signal abnormalities suggesting ischemia or infarction were common. Abnormal MR enhancement decreases during therapy, although patients develop cortical and/or brain stem atrophy. CONCLUSIONS Widespread cisternal and cervical subarachnoid meningeal involvement is common in coccidioidal meningitis. Serial contrast MR imaging reflects the effects of therapy in patients with coccidioidal meningitis.

Abstract : Coccidioidomycosis (CM) is a fungal infection endemic to the southwestern United States, northwestern Mexico, and parts of Central and South America. CM has been recognized as a complicating factor in pregnancy since at least the 1940s, and seems to be a relatively uncommon infection during pregnancy. The disease presentation during pregnancy includes a wide clinical spectrum that ranges from mild influenza‐like illness and pneumonia, especially in the first two trimesters of pregnancy. The third trimester of pregnancy is a time of high risk for dissemination. Immunologic and hormonal changes during pregnancy and the postpartum period may account for any increased frequency and severity of disease observed during pregnancy. Early diagnosis and appropriate aggressive therapeutic intervention with careful monitoring usually result in good outcome.

ABSTRACT Patients with severe coccidioidomycosis infections are often treated with either amphotericin B lipid complex (ABLC) or liposomal amphotericin B (L-AmB). Outcome data with these agents in severe coccidioidomycosis cases are currently lacking. The purpose of this study is to evaluate the efficacy and toxicity of ABLC and L-AmB in treating severe coccidioidomycosis. A retrospective pre-post study design was employed. Chart reviews were completed from 1 January 2005 to 31 December 2014 for all patients who received lipid-based amphotericin B. Inclusion criteria included having a follow-up complement fixation (CF) titer or a treatment emergent adverse event (TEAE) prior to follow-up. Patients with meningeal involvement and pregnant patients were excluded. Treatment outcomes were assessed based on documented completion of therapy as well on symptoms, complement fixation titer, and changes to laboratory monitoring parameters. A total of 108 patients were identified, 69 of whom met the inclusion criteria. There were no statistical differences in demographics or disease burden in those that received ABLC and those that received L-AmB, except that those who received L-AmB were more likely to have previously diagnosed chronic kidney disease ( n L-AmB = 4, 12.5% vs n ABLC = 0, 0.0%; P = 0.042) and to have a lower creatinine clearance at the start of therapy (L-AmB = 79.6 mg/dl versus ABLC = 100.4 mg/dl; P = 0.008). Successful treatment was achieved in 27 (73.0%) of ABLC patients and 22 (68.8%) of L-AmB patients ( P = 0.700). Amphotericin B was discontinued due to documented completion of therapy for 17 (45.9%) ABLC patients and 18 (56.3%) L-AmB patients ( P = 0.553). Acute kidney injury (AKI) was the documented reason of treatment cessation for 10 (27.0%) ABLC and 1 (3.1%) L-AmB patient ( P = 0.007). ABLC and L-AmB both appear to be equally efficacious in the treatment of severe coccidioidomycosis. L-AmB may have less renal toxicity than ABLC and may be the preferred agent in baseline renal impairment.

Objective Granulomatous disorders may be associated with hypercalcemia. In sarcoidosis, the pathogenesis of hypercalcemia has been clarified, whereas in other granulomatous disorders, such as coccidioidomycosis, the mechanism is unclear. We present 13 patients with coccidioidomycosis and hypercalcemia to illustrate the clinical course and the mechanism of hypercalcemia. Methods We retrospectively reviewed all patients admitted to Kern Medical Center, a 270-bed public hospital, from 1990 through 1997 with coccidioidomycosis and a serum calcium level of greater than 10.5 mg/dL on at least 3 occasions. In addition, no other causes for hypercalcemia were identified. Results The mean highest serum calcium level was 12.7 ± 1.8 mg/dL. All patients had disseminated disease. Six patients were nonambulatory and 4 had bone involvement. Of the 9 patients in whom parathyroid hormone was measured, it was normal in 6 and suppressed in 3. Of the 9 patients in whom 25-hydroxyvitamin D was measured, it was normal in 6, suppressed in 2, and elevated in 1. Of the 7 patients in whom 1,25-dihydroxyvitamin D was measured, it was normal in 3 and suppressed in 4. Urinary calcium was elevated in 2 patients, both of whom were ambulatory. Nonambulatory patients had significantly higher serum calcium levels (14.3 ± 1.0 mg/dL) than ambulatory patients (11.3 ± 0.46 mg/dL) (P < 0.001). Conclusions The mechanism of hypercalcemia in coccidioidomycosis is unrelated to increased production of 1,25-dihydroxyvitamin D. Nonambulatory status is associated with higher mean serum calcium.

Metastases to the eye or orbit as the initial presentation of genitourinary malignancy are unusual and can be a diagnostic challenge.We report an 81-year-old man who presented with pain and proptosis in an eye that had been blind for 50 years.Radiologic investigations identified a mass involving the left globe and orbit.Histology of the enucleation specimen was consistent with a metastatic poorly differentiated carcinoma suggestive of a prostate primary.With the constellation of obstructive urinary symptoms, an abnormal digital rectal examination, elevated prostate-specific antigen and a positive bone scan, androgen deprivation therapy was initiated for metastatic prostate cancer.After an initial response to treatment, the patient's disease progressed in a manner atypical for prostate cancer.After describing our case, we review the literature on ocular and orbital metastases and their relation to genitourinary malignancies.

PurposeCoccidioidomycosis (CM) is a systemic fungal disease caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. In its endemic areas of the United States, CM is growing as a public health challenge with a marked increase in incidence in the last 15 years. Although Coccidioides infection is asymptomatic in most cases, symptomatic pulmonary disease occurs in ~40% and disseminated coccidioidomycosis (DCM) occurs in ~1% of previously healthy children and adults. DCM is markedly more common in immunocompromised people, who often experience life-threatening disease despite use of antifungal medications. Although options for antifungal therapy have improved, lifelong therapy is needed for those who develop coccidioidal meningitis. The purpose of this article was to review the state of antifungal therapy and recent studies of host–pathogen interactions in CM in light of advances in immunomodulatory therapy.MethodsThe study included a review of PubMed and abstracts of the Coccidioidomycosis Study Group (years 2000–2019).FindingsCurrent therapy for CM relies upon azole and polyene antifungal agents. Murine models and studies of DCM in patients with monogenic primary immunodeficiency states and acquired immunodeficiency have revealed the importance of both innate and adaptive immune responses in the control of infections with Coccidioides species. In particular, defects in sensing of fungi and induction of cellular immune responses have been frequently reported. More recently, polymorphisms in key signaling pathways and in the generation of Th17 and Th1 immune responses have been linked with DCM.ImplicationsAntifungal therapy is sufficient to control disease in most cases of CM, but treatment failure occurs in cases of severe pulmonary disease and nonmeningeal disseminated disease. Lifelong therapy is recommended for meningitis in view of the very high risk of recurrence. Corticosteroid therapy is advised by some experts for severe pulmonary disease and for some neurologic complications of DCM. DCM is only rarely the result of a severe monogenic immunodeficiency. Case studies suggest that reorienting cellular immune responses or augmenting effector immune responses may help resolve DCM. Systematic investigation of immunotherapy for coccidioidomycosis is advisable and may help to address the recent marked increase in reports of the disease in endemic areas.

Coccidioides immitis and posadasii are closely related fungal species that cause coccidioidomycosis. These dimorphic organisms cause disease in immunocompetent as well as immunocompromised individuals and as much as 40% of the population is infected in the endemic area. Although most infections resolve spontaneously, the infection can be prolonged and, in some instances, fatal. Coccidioides has been studied for more than 100 years and many aspects of the organism and the disease it causes have been investigated. There are over 500 manuscripts concerning Coccidioides (excluding clinical articles) referenced in PubMed over the past 50 years, so there is a large body of evidence to review. We reviewed the most accurate and informative basic research studies of these fungi including some seminal older studies as well as an extensive review of current research. This is an attempt to gather the most important basic research studies about this fungus into one publication. To focus this review, we will discuss the mycology of the organism exclusively rather than the studies of the host response or clinical studies. We hope that this review will be a useful resource to those interested in Coccidioides and coccidioidomycosis.

Herein described is a case of biofilm obstructing ventriculoperitoneal shunt due to Cutibacteirum acnes infection in a patient with coccidioidal meningitis. Cutibacterium acnes infects and obstructs cerebral shunts by the production of biofilm; however, diagnosis is usually missed by routine aerobic cultures. Obtaining anaerobic cultures routinely in patients with foreign body implants leading to central nervous system infections could prevent a missed diagnosis of this pathogen. Penicillin G is the first-line treatment.

Coccidioides spp are thermally dimorphic fungi found in geographically defined areas of the Western Hemisphere. The primary portal of entry is respiratory, with a symptomatic pneumonic disease as the most common presentation. Subsequent pulmonary complications as well as extrapulmonary metastatic infection may occur, either of which may be the presenting disease manifestation. Cavitary lung disease may be found incidentally or when investigating symptoms such as cough or hemoptysis. This study aims to explore the spectrum of coccidioidal cavities and the evaluation and management in a cohort of patients seen at Kern Medical over the last 12 years.

Coccidioides species are thermally dimorphic fungi found in geographically defined areas of the Western Hemisphere. The primary portal of entry is respiratory, with symptomatic pneumonic diseases as the most common presentation. Subsequent pulmonary complications as well as extrapulmonary metastatic infection may occur, either of which may be the presenting disease manifestation. Cavitary lung disease may be found incidentally or when investigating symptoms such as cough or hemoptysis. This study aims to explore the spectrum of coccidioidal cavities and the evaluation and management in a cohort of patients seen at Kern Medical over the last 12 years.

Prosthetic joint infection associated with coccidioidomycosis is uncommon, and there is no single publication that addresses the treatment of this infection. With the increasing number of prosthetic joint replacements in the Coccidioides endemic area, it is inevitable that there will be more infections associated with prosthetic joints. We reviewed 6 cases of prosthetic joint infections associated with coccidioidomycosis from the literature and clinical practice. The patients and their clinical issues were analyzed and approaches to the treatment of this infection were developed so that physicians can use the information as a guide to therapy, depending on the individual circumstances.

Coccidioides, a dimorphic fungus endemic within the Americas, primarily causes pulmonary disease but may disseminate. We describe a case of confirmed Coccidioides endocarditis, the seventh reported in literature. Coccidioides endocarditis often requires tissue diagnosis and combined surgical and medical treatment.

Coccidioidomycosis is an invasive fungus found primarily in the soil of Southwestern United States, Mexico, and Central America. Primary disease mostly presents as a pulmonary disease although multiple organ systems can be affected through lymphohematogenous dissemination, with ocular seeding extremely rare. When present, the anterior segment structures are most commonly affected. Isolated choroid and/or vitreal disease has been reported infrequently. This is a case of chorioretinitis with vitreal involvement.

Meningitis follows approximately 0.15% to 0.75% of cases of extrapulmonary coccidioidomycosis. Successful treatment of coccidioidal meningitis (CM) has generally required intrathecal therapy with amphotericin B, which often causes significant toxic effects and discomfort to the patient. Prior to fluconazole, azoles had not been efficacious in CM either because of toxicity at elevated doses or because of poor cerebrospinal fluid distribution. Fluconazole however, has been found to have both good cerebrospinal fluid penetration and a favorable side effect profile.We studied 11 patients with CM who were maintained with amphotericin B and were then switched to oral fluconazole therapy alone at a dosage of 400 mg/d for a period of up to 19 months. The patients were evaluated clinically for evidence of deterioration measured by need for hospitalization, development of extrameningeal disease during the study period, need to reinstitute intrathecal amphotericin B therapy because of worsening disease, cerebrospinal fluid leukocyte count, protein level, and serologic tests for complement-fixing antibody.Three patients required hospitalization during the study, two patients for reasons unrelated to CM. No patient developed extrameningeal disease or required discontinuation of fluconazole therapy because of deteriorating disease. Patients at exit reported no symptoms related to meningitis or adverse effects related to fluconazole therapy. There was no deterioration in general health or neurologic status.Our study demonstrates that conversion from amphotericin B to fluconazole was associated with a stable disease course of CM for up to 19 months. Further studies delineating both optimal dosage and characteristics of patients likely to respond to fluconazole therapy alone are needed.

Abstract A recent multicentre clinical study evaluated the safety and efficacy of iv ciprofloxacin therapy compared with imipenem- cilastatin in hospitalized patients with severe pneumonia. Monotherapy with iv ciprofloxacin was at least equivalent to imipenem in terms of bacteriological eradication and clinical response. In a single-centre, retrospective, post-therapy evaluation of persistent and subsequent infection, the incidence of Gram-negative infections and associated costs were compared. The main elements of the economic analysis included costs of additional antimicrobial therapy and hospitalization. Thirty-two patients were randomized into the study, of whom 27 were efficacy-valid. The 13 patients randomized into the ciprofloxacin group were not significantly different from the 14 patients in the imipenem group in terms of clinical parameters. Clinical cure occurred in ten of 13 patients (77%) in the ciprofloxacin group and in seven of 14 (50%) in the imipenem group. Bacteriological eradication was achieved in 11 of 13 (85%) ciprofloxacin-treated and eight of 14 (57%) imipenem-treated patients. Five of 13 (38%) patients in the ciprofloxacin group and nine of 14 (64%) in the imipenem group experienced persistent or subsequent infection requiring post-treatment antimicrobials. In these five ciprofloxacin patients, three had cultures with Gram-positive organisms only and two had cultures with both Gram-positive and Gram-negative organisms. In the nine imipenem-treated patients requiring post-study antimicrobials, all had Gram-negative bacteria and three also had Gram-positive organisms. The incidence of subsequent Gram-negative infection in the two groups (15% vs 64%) was significantly different (P &amp;lt; −0.05). Pseudomonas aeruginosa was isolated from seven patients in the imipenem group but only one in the ciprofloxacin group (P &amp;lt; 0.05). Subsequent costs for post-therapy antimicrobials and hospital stay while receiving study and post-study drug therapy were evaluated; the cost per patient cure was US$29,000 for ciprofloxacin and US$76,000 for imipenem. Initial treatment of severe pneumonia with ciprofloxacin resulted in significantly less subsequent Gram-negative infection and was associated with substantially lower curative costs.

Stenotrophomonas maltophilia is an inherently multidrug resistant (MDR) opportunistic pathogen with many mechanisms of resistance. SENTRY studies reveal decreasing sensitivities of S. maltophilia to trimethoprim-sulfamethoxazole and fluoroquinolones. Ceftolozane-tazobactam (Zerbaxa, Merck &amp; Co., Inc.) a novel intravenous combination agent of a third-generation cephalosporin and β -lactamase inhibitor was demonstrated to have in vitro activity against many Gram-positive, Gram-negative, and MDR organisms. Data for ceftolozane-tazobactam’s use outside of Food and Drug Administration (FDA) approved indications has been limited thus far to two case reports which demonstrated its efficacy in pan-resistant Pseudomonas aeruginosa pneumonia. Herein, we describe the first published case of treatment of MDR S. maltophilia in polymicrobial osteomyelitis with long-term (&gt;14 days) ceftolozane-tazobactam and metronidazole. Ceftolozane-tazobactam may offer a possible alternative for clinicians faced with limited options in the treatment of resistant pathogens including MDR S. maltophilia.

Coccidioidomycosis a fungal infection endemic to southwestern United States. It is caused by inhalation of spores of Coccidioides immitis. Sixty percent of infections are asymptomatic; the remaining 40% are primarily pulmonary disease. In &lt;1% of infections, dissemination can occur. Dissemination usually affects those with impaired cellular immunity and pregnant women, and can involve bones, joints, meninges, and skin. We present the case of a 29-year-old Hispanic male who presented to the emergency department (ED) complaining of pain and swelling of right wrist and ankle as well as left knee for 2 months. He was referred to rheumatology clinic but returned to the ED as he developed spontaneous purulent drainage from his wrist. In the ED, an arthrocentesis of 2 of the joints showed total nucleated cells of 520 000/cm 2 and 90 000/cm 2 with 61% and 93% neutrophils, respectively. Fungal culture eventually grew Coccidioides immitis from his wrist and knee. Coccidioidomycosis complement fixation titer came back &gt;1:512. Bone scan showed uptake of adjacent bones in the affected joints. Superimposed bacterial infection of the wrist complicated the treatment course and delayed the start of liposomal amphotericin B. Eventually patient received 12 weeks of intravenous liposomal amphotericin-B with slow clinical improvement and then switched to oral isavuconazonium for maintenance therapy. This case shows that although disseminated polyarthritis coccidioidomycosis is very rare, clinicians should keep the diagnosis of disseminated synovial coccidioidomycosis in mind in patients with risk factors.

To the authors' knowledge, there is a paucity of published accounts of management of radiation-induced optic neuropathy (RION) by optic nerve sheath fenestration (ONSF) in the conventional medical literature. With higher doses of radiation being given by using conformal techniques, more radiation-induced optic neuritis and neuropathy will be identified. We report here the successful use of ONSF to restore vision to three consecutive patients with pending anterior RION, and the importance of early identification and intervention in these potentially reversible cases.

Locus minoris resistentiae refers to decreased resistance in any internal organ or external body region, leaving it more vulnerable to disease processes than other regions. These changes, either congenital or acquired, alter the defense capacity. The concept of locus minoris resistentiae is widely accepted in the medical field and presents itself across specialties. Antecedent trauma is a known risk factor for hematogenous dissemination of infection; this also applies to coccidioidal species. In this article, we describe 2 patients who suffered from pulmonary coccidioidomycosis with subsequent trauma resulting in osseous dissemination to the site of injury.

Coccidioidomycosis is a fungal infection endemic in the southwestern United States (US). Primary pulmonary coccidioidomycosis (PPC) is a leading cause of community-acquired pneumonia (CAP) in this region, although its diagnosis is often delayed, leading to lag in antifungal treatment and subsequent morbidity. The impact of early empiric antifungal therapy as part of treatment for CAP in endemic areas on clinical outcomes is unknown.Phase IV randomized, double-blind, placebo-controlled trial in individuals aged 18 years or older with CAP who met all eligibility criteria in Coccidioides endemic regions in the US. Eligible participants with CAP were randomized to receive either fluconazole (400 mg daily) or matching placebo for 42 days and were subsequently monitored for clinical resolution of their illness.The primary objective was to assess the clinical response of early empiric antifungal therapy with fluconazole through Day 22 in subjects with PPC who were adherent to the study intervention. Secondary objectives included: assessments of the impact of early empiric antifungal therapy with fluconazole through Day 22 and 43 in subjects with PPC regardless of adherence, comparisons of the clinical response and its individual components over time by treatment group in subjects with PPC, assessments of days lost from work or school, hospitalization, and all-cause mortality.This trial was halted early due to slow enrollment (72 participants in one year, 33 received fluconazole and 39 received placebo). Of those enrolled, eight (11%) met the study definition of PPC. The study design and challenges are discussed.

Coccidioidomycosis is a fungal disease endemic to the southwestern United States, Mexico, and Central and South America. Prevalence rates are increasing steadily, and new endemic areas of Coccidioides are emerging. Standard treatment is often administered for months to decades, and intolerance to medications and treatment failures are common. No new treatments for coccidioidomycosis have been approved in the United States in nearly 40 years. On 5 August 2020, the US Food and Drug Administration convened experts in coccidioidomycosis from academia, industry, patient groups, and other government agencies to discuss the disease landscape and strategies to facilitate product development for treatment of coccidioidomycosis. This article summarizes the key topics concerning drug development for coccidioidomycosis presented by speakers and panelists during the workshop, such as unmet need, trial designs, endpoints, incentives, research and development support, and collaborations to facilitate antifungal drug development.

The skin is frequently a site of extrapulmonary dissemination in patients with coccidioidomycosis. Clinical experience in an endemic area suggests an association between facial cutaneous coccidioidomycosis and meningitis. Awareness of this association is important because coccidioidal meningitis is the most ominous site of spread in coccidioidomycosis. In this study, we assess whether cutaneous dissemination involving the face is associated with meningitis to a greater degree than that limited to the body. We retrospectively reviewed the medical records of 201 patients from 1987 to 1996 with disseminated coccidioidomycosis and found 30 patients with cutaneous involvement. Their mean age was 29.5 +/- 11.6 years; 20 patients were male; 14 were African American, 12 were Hispanic, 3 were white, and 1 was Asian. Nineteen patients had facial involvement, and 11 had isolated body involvement. Meningitis developed in 11 patients, 10 with facial involvement and 1 with only body involvement. Patients with facial lesions were more likely to have meningitis (odds ratio, 11.1; 95% confidence interval, 1.1 to 529, P = .023). The identification of a subgroup of patients at significant risk of developing meningitis may allow earlier detection and perhaps improved management of patients with meningeal disease.

Abstract Coccidioidomycosis is the second most common endemic fungal infection in the United States. Prior descriptions of coccidioidal peritonitis include only single cases. We describe 17 new cases previously unreported from healthcare institutions in California. The majority of cases presented with nonspecific abdominal complaints. PubMed and Google Scholar were searched for additional case series and only single case reports and reviews of single cases were found. The diagnosis was confirmed by culture or histopathology and/or serology in each patient. All patients were treated with anti-fungal therapy. This case series demonstrates that coccidioidal peritonitis may be asymptomatic or present with only subtle abdominal symptoms. In a minority of our patients, the diagnosis was established incidentally during surgery. Based on this series, the overall outcome of coccidioidal peritonitis is favorable with long-term triazole treatment. The term cure is not usually used in disseminated coccidioidal disease because of the risk of late relapse.

Coccidioidomycosis is a disease found in the southwestern United States and caused by inhalation of arthroconidia of Coccidioides immitis and posadasii. Although the disease is most commonly asymptomatic or respiratory, it has a propensity to disseminate to any tissue in the body with the most common being skin, bone, joints, and central nervous system. This case demonstrates the dissemination of coccidioidomycosis to several foci along with a rare form of parenchymal dissemination with an unusual neuroradiological finding.

A 49-year-old man with no significant past medical history received dexamethasone as part of his treatment for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Less than 3 weeks later, the patient developed acute respiratory distress syndrome. Radiological and serological testing led to a diagnosis of acute hypoxic miliary coccidioidomycosis. A 52-year-old man with a past medical history of chronic kidney disease (CKD) was treated with prednisone for focal segmental glomerulosclerosis (FSGS). Within 2 weeks, this patient developed bilateral lower extremity weakness. Radiology, serology, and lumbar puncture proved a diagnosis of reactivated coccidioidomycosis with miliary pattern and coccidioidomycosis meningoencephalitis with arachnoiditis. Whether treatment with glucocorticoids caused reactivation of coccidioidomycosis is discussed in this case series.

A 19-year-old Hispanic woman with an intrauterine pregnancy at 37 weeks was admitted to the labor and delivery department for tachycardia and signs of oligohydramnios. On admission, she complained of chest pain, sore throat, and dry cough of 3 weeks in duration, and fevers and dyspnea for the last 3 days. She denied photophobia, sputum production, nausea or vomiting, rigors, or night sweats, but noted a painless skin lesion on her right upper forearm for at least several weeks. She was otherwise a healthy woman originally from Mexico, with no previous medical or surgical problems. At the time of hospital admission, she was a housewife residing in central California with her husband. There was no history of sick contacts, recent travel, exposure to birds, or illicit drug use.

Cryptococcus gattii is a species that has received more recognition in the recent past as distinct from Cryptococcus neoformans. C gattii is known to cause meningeal disease in both immunocompetent and immunosuppressed hosts. Patients may be clinically asymptomatic until immunosuppressive conditions occur such as corticosteroid treatment or an HIV infection. HIV-associated cryptococcal infections are most often due to C neoformans. C gattii is found in a minority. Speciation and subtyping of Cryptococcus are not always accomplished. In many parts of the world, there is no availability for speciation of Cryptococcus. Travel history may provide a clue to the most probable species. This case demonstrates a case of C gattii meningitis with a multiplicity of complications. These include advanced HIV disease secondary to nonadherence, immune reconstitution inflammatory syndrome, and superior sagittal sinus thrombosis. The patient represented diagnostic and therapeutic dilemmas over time. Headache was the primary symptom in cryptococcal meningitis, immune reconstitution inflammatory syndrome, and superior sagittal sinus thrombosis. All are discussed in detail as potential etiologies for the primary disease. Isavuconazonium is a relatively new broad-spectrum antifungal azole that was used as salvage therapy.

Coccidioides spp is a soil-dwelling, dimorphic fungus that causes coccidioidomycosis. It is endemic to the western hemisphere. Although primarily a respiratory disease, it can also cause a myriad of clinical manifestations, from asymptomatic disease to meningitis. In fact, Coccidioides species is probably the most common etiologic agent of long-term meningitis in California and Arizona. Early diagnosis and treatment are critical to avoid fatal complications. With treatment, the cerebral spinal fluid analysis may return to normal. Relapse of coccidioidal meningitis is usually suspected with recurrence of meningitis symptoms. The patient is a 53-year-old man with a 2-decade history of coccidioidal meningitis who was diagnosed with an asymptomatic relapse of coccidioidal meningitis.

Abstract Background Coccidioidomycosis is a fungal infection with a range of clinical manifestations. Currently used antifungal agents exhibit variable efficacy and toxicity profiles necessitating evaluation of additional therapeutic options. Methods Patients with coccidioidomycosis who received Isavuconazole were identified by cross-indexing ICD-9 and ICD-10 codes from patients and data abstracted. Responses to Isavuconazole therapy were measured using a modified Mycoses Study Group Coccidioidomycosis Scoring system as described previously. Results 82 patients met the criteria for inclusion. Over half of the patient exhibited pulmonary involvement 45/82 (55%), although meningitis 32/82 (39%), bone and joint disease 14/82 (17%) and skin/soft tissue infection 7/82 (9%) were also seen. The majority of patients experienced a decrease in their MSG score following initiation of Isavuconazole therapy (median MSG score change across all patient groups 7 → 2, p&amp;lt; 0.0001). Overall improvement was noted in 58/82 (71%) patients, while no change was observed in 19/82 (23%) and 5/82 (6%) who were unresponsive to antifungal changes. Conclusion Isavuconazole demonstrated efficacy in the majority of patients treated, with failures observed only in a subgroup of patients with coccidioidal meningitis. Disclosures Rupam Sharma, PGY-1/MD, Astellas: Grant/Research Support George R. Thompson, III, MD, Astellas: Advisor/Consultant|Astellas: Grant/Research Support|Cidara: Advisor/Consultant|Cidara: Grant/Research Support|F2G: Advisor/Consultant|F2G: Grant/Research Support|Mayne: Advisor/Consultant|Mayne: Grant/Research Support|Melinta: Advisor/Consultant|Melinta: Grant/Research Support|Mundipharma: Advisor/Consultant|Mundipharma: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support

Abstract Background Coccidioidal meningitis (CM) is a potentially devastating manifestation of disseminated infection caused by Coccidioides spp., generally requiring lifelong therapy with triazole antifungals (TA). Given the complexity of assessing treatment response in coccidioidomycosis, which can be impacted by host immune response, pharmacokinetics, antifungal pharmacodynamics, and medication adherence, therapeutic drug monitoring (TDM) of TA therapy, which is not currently common practice for most TA, has been proposed to improve clinical evaluation of such variables. Consistent TDM is anticipated to increase the probability of a successful CM treatment outcomes. Methods This is a retrospective review of patients with CM who received adjunctive TA TDM at the Valley Fever Institute at Kern Medical from November 2019 to December 2022. Approval and a waiver of consent were obtained from the Institutional Review Board. The combination of a patient and TA was considered a unique therapy regimen, with each TA course evaluated separately for patients who received multiple triazoles over the course of their CM treatment. The primary endpoint was improvement in the cerebrospinal fluid (CSF) score, which was derived from the Mycoses Study Group scoring system for meningeal disease, over the available follow-up period.Table 1.CSF Score (based on the Mycoses Study Group scoring system for meningeal disease) Results Twenty-seven TA regimens were found to be eligible for inclusion in this study, with fluconazole comprising the majority of these courses (52%) and the remainder divided between isavuconazole (22%), voriconazole (11%), itraconazole (7%), and posaconazole (7%). Of the serum triazole levels obtained, 34% were considered to be therapeutic, 45% were subtherapeutic, and 21% were supratherapeutic. Greater improvements were noted in CSF scores of TA regimens with the higher serum levels compared to TA regimens resulting in lower serum levels (see figure 1). Figure 1. CSF Scores on Fluconazole: Lowest vs. Highest Quartile CSF scores of fluconazole regimens resulting in the lowest quartile (Q1, n=4) of serum fluconazole levels over 24 months were compared to regimens resulting in the highest quartile (Q4, n=4) of serum levels. A decrease in the CSF score generally represent improvement in meningeal disease. Conclusion TA TDM is expected to advantage the care of patients with CM. The possible correlation between higher TA serum levels and improvements in CSF parameters shown in this study emphasizes the potential role of TDM for maximizing TA efficacy in CM, in addition to discernment of medication nonadherence or suboptimal pharmacokinetics. Disclosures All Authors: No reported disclosures

Abstract Background While a majority of Coccidioides infections are asymptomatic, it is estimated that 1% develop severe disease and can be fatal. Prior retrospective reviews that attempt to identify risk factors for fatal disease have been limited to public health data hampered by reporting challenges and accuracies. Morbidity review of fatal cases identified by clinical criteria rather than ICD-9/ICD-10 reporting may improve accuracy of conclusions. Methods At an academic center in an endemic area, medical records from three sequential electronic medical record systems were reviewed from approximately January 2000 to January 2023. Patients with coccidioidomycosis were identified by microbiological, pathological, serological, or skin testing criteria. Deaths were determined by in hospital records, insurance reporting, review of death certificate if available, or public record. Demographics, clinical course, outcomes and causes of death are compared. Incomplete medical records to make comparison were excluded. Retrospective root cause analysis was performed. Results To date, at least 50 patients met clinical criteria for having coccidioidomycosis at one point in their life and died. ICD coding was wrong in about half of the cases. Data integrity has been a challenge when extracting data across three electronic medical record systems. New risk factors found by root cause analysis not previously identified. Conclusion Patients were found to have died either with coccidioidomycosis or from coccidioidomycosis. ICD coding was inconsistent. Precise and accurate description of coccidioidomycosis staging is important when trying to determine risk factors for fatal disease. Disclosures All Authors: No reported disclosures

Abstract Background The majority of literature on cavitary pulmonary coccidioidomycosis is from four decades ago which was prior to the advent of triazoles and focused on surgical treatment. This observational study is a comprehensive retrospective study of pulmonary cavitary coccidioidomycosis from patients at Valley Fever Institute at Kern Medical over the last 12 years. This observational study aims to explore the spectrum of coccidioidal cavities and the evaluation and management of those cavities. Methods IRB approved, retrospective review of electronic medical records of the Valley Fever Institute database was conducted. Demographics, comorbidities, types, and the number of cavities, complications, and medical and surgical treatment were gathered and compared to the literature. PubMed and Google Scholar were searched for cavitary pulmonary coccidioidomycosis Results Of the initially 276 identified patients, 137 met the inclusion criteria. This study found 52 (37.2%) patients with hemoptysis. One case (0.7%) required radiologic intervention to occlude the bleeding vessel, and one (0.7%) case of hemorrhage required right upper lobe lobectomy. Nine (6.6%) cases exhibited a ruptured cavity. Eight of those cases had initial chest tube placement, of which three (3/8, 37.5%) did not require surgical intervention. Seven of 137 (5.1%) cases presented with a pleural effusion not associated with a cavity rupture. Five (3.7%) were due to primary coccidioidomycosis. Three of the coccidioidal effusions required therapeutic thoracentesis, and none required a chest tube or surgery. The mean duration of the initial antifungal treatment was found to be 563 days (n=80). In 35% (28/ 80) of them, a triazole was switched to another triazole for variable reasons, including treatment failure or side effects. Conclusion Coccidioidal pulmonary cavitation remains a complex disease to evaluate and treat. This study's ethnic demographic differed from other cohorts. It also contradicts the notion that pulmonary coccidioidal cavitary disease and dissemination infrequently manifest in the same patient. In the present age of triazole therapy, indications and the need for surgery continue to decline. Further investigation needs to be conducted to evaluate medical therapy’s efficacy and long-term outcomes. Disclosures Rupam Sharma, PGY-1/MD, Astellas: Grant/Research Support George R. Thompson, III, MD, Astellas: Advisor/Consultant|Astellas: Grant/Research Support|Cidara: Advisor/Consultant|Cidara: Grant/Research Support|F2G: Advisor/Consultant|F2G: Grant/Research Support|Mayne: Advisor/Consultant|Mayne: Grant/Research Support|Melinta: Advisor/Consultant|Melinta: Grant/Research Support|Mundipharma: Advisor/Consultant|Mundipharma: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support

This paper reports a rare complication of ovarian cancer, emphasising the role of computed tomographic scanning (CT) in the evaluation of the disease. The aetiology of the case is discussed with reference to a similar clinical case originally reported in 1667.

Coccidioidal meningitis typically presents with symptoms that may include headache, altered mental status including personality changes, fever, nausea, vomiting, gait abnormalities, and focal neurological deficits. This is a case of coccidioidal meningitis that initially presented as 4 consecutive crescendo cerebrovascular transient ischemic attacks with focal neurological deficits that resolved within minutes. Imaging showed a left basilar coccidioma. Follow-up at 4 months showed treatment response to conservative therapy of fluconazole 1000 mg with a dexamethasone taper. Crescendo cerebrovascular transient ischemic attacks are a unique initial presentation of coccidioidal meningitis.

We describe the case of a 41-year-old Hispanic male, inconsistently adherent to visits and workup due to socioeconomic challenges, who presented with a right testicular mass. Because of the overriding concern that this was malignant, he underwent a right orchiectomy. Pathology revealed granulomatous disease with no evidence of malignancy. No specific diagnosis was made histologically or microbiologically on primary laboratory investigation. Six months later, he developed swelling of the left testicle and was subsequently seen in consultation at the Infectious Disease Clinic Kern Medical. An extensive evaluation for granulomatous inflammation was undertaken without a positive result. A clinical diagnosis of tuberculous epididymal orchitis was made and the patient was initiated on standard 4-drug antituberculous therapy. There was a gradual resolution of pain and swelling. After 6 months of therapy, there was no evidence of residual disease. The patient remains asymptomatic after 8 months of post-therapy follow-up.

Coccidioidomycosis (CM) is an endemic fungal infection that is found in the Southwestern United States and adjacent areas of Mexico as well as Central and South America. In the United States, 150 000 to 300 000 infections occur annually. The majority are asymptomatic. Of the symptomatic cases, the majority are primary pneumonic disease that varies from mild to very severe. A minority of persons develop disseminated disease (extrapulmonary disease). These typically manifest as meningitis, osteomyelitis, synovitis, and integumentary. CM has been described in virtually every part of the body, including the genitourinary system. Disseminated CM to the genitourinary tract is well known to occur but is rarely documented. It is believed this is the first case to report disseminated CM to the renal parenchyma. Diagnosis and treatment are described in a 56-year-old Hispanic male.

Coccidioidomycosis is an infection caused by inhalation of arthroconidia of Coccidioides. Forty percent of patients will develop mild and self-limited respiratory infection, and a small fraction of these individuals will develop extrapulmonary disseminated disease. This is the case of a patient with a known history of disseminated coccidioidomycosis, who initially presented for symptoms of persistent pneumonia. On evaluation, the patient was found to have a hepatic abscess for which he underwent percutaneous drainage. Culture grew Coccidioides immitis, and the patient was treated with systemic antifungal. This is a rare case of disseminated coccidioidomycosis in the liver.

Coccidioidomycosis (CM) is a fungal infection endemic to the southwestern United States with a wide range of clinical presentations depending on the infected organ systems. Most infections are asymptomatic. Coccidioidomycosis causes a primary pulmonary infection and when symptoms occur, they most often resemble community-acquired pneumonia. One percent of cases disseminate, typically via hematogenous or lymphatic spread. It is in these cases that more severe symptoms may present and potentially overlap with those characteristics of other systemic illnesses. This is a case of CM disseminated to lymph nodes in a 24-year-old man with concomitant metastatic embryonal carcinoma. It is difficult to identify the primary etiology for many components of this patient’s presentation, including diffuse lymphadenopathy and multiple pulmonary nodules. Furthermore, the relationship between these 2 concurrent disease processes is not entirely clear. Factors that may contribute include the well-known phenomenon of locus minoris resistentiae (LMR) or potentially a shared immune failure between infectious organisms and malignant cells.

Immunologic responses in 15 patients with severe pulmonary coccidioidomycosis and in 50 patients with disseminated coccidioidomycosis were measured by determination of complement-fixing (CF) antibody titers to coccidioidin in serum, toecidioidin (I: 100) skin tests, and sensitization to dinitrochlorobenzene. Among the patients with disseminated coccidioidomycosis, the nine with CF antibody titers of ⩽ 1:8 had normal responses to dinitrochlorobenzene, but the 41 with titers of ⩾ 1:16 had responses that were significantly lower than those of controls (P < 0.001). In contrast, all patients with severe pulmonary coccidioidomycosis had CF antibody titers of ⩾ 1:16 and had responses to dinitrochlorobenzene that were greater (but not significantly greater) than those of controls. Among subjects with antibody titers of ⩾ 1:16, responsiveness to coccidioidin was found in 27% of those with severe pulmonary disease and in 39% of those with disseminated disease. Thus impaired responsivity to dinitrochlorobenzene in coccidioidomycosis is restricted to patients who have disseminated illness and high titers of CF antibody and is separable from lack of responsiveness to coccidioidin.

In Brief Objective To determine presentation, clinical course, and outcome of a cohort of pregnant women with coccidioidomycosis and compare findings with common observations reported in the literature. Methods Thirty-two women who delivered live infants or aborted fetuses in 1993 and had confirmed diagnoses of coccidioidomycosis were included in the study. Medical records were evaluated retrospectively for clinical characteristics, laboratory results, and disease course. Results Dissemination occurred in three of 32 cases. The most common management was supportive and symptomatic care. At 1 year, 26 of 32 had recovered. There were no maternal deaths. Conclusion The common depiction of coccidioidomycosis in pregnancy has overstated morbidity and mortality likely because of reporting bias. Many women will have favorable outcomes without drug treatment, and the practice of abortions or early delivery in subjects with active infection should be rare. Maternal morbidity and mortality from coccidioidomycosis in pregnancy may be less than previously thought.

Reactive cutaneous coccidioidal skin manifestations are commonly noticed during the early stage of coccidioidomycosis. These skin lesions are devoid of any active coccidioidal organism, and the immune trigger mechanisms are not elucidated. We describe 6 cases of unusual reactive cutaneous coccidioidal manifestation, characterized by painful vesiculobullous lesions known as erythema sweetobullosum. The biopsy of the lesions revealed neutrophilic dermatosis with inflammatory cells resulting in a cleft and elevation of the most superficial layer of the skin forming a bulla. The reactive cutaneous lesion is self-limited and requires no specific therapy.

Patients with coccidioidal meningitis require life-long antifungal therapy and cumulative toxicity from these agents may occur. Isavuconazole is the newest triazole antifungal and has demonstrated a lower toxicity profile than voriconazole and may represent a useful therapy in meningitis, although no data regarding efficacy in coccidioidal meningitis has yet been presented. We conducted a retrospective analysis of all coccidioidal meningitis patients treated at our centers. Data abstracted included demographic and clinical information, results of laboratory and radiographic studies, serologic results, and outcomes. Responses to therapy were measured using a previously validated scoring system used in clinical trials of coccidioidal meningitis (MSG Coccidioidomycosis Scoring System). Nine patients met criteria for inclusion. Seven of nine were previously treated with voriconazole and transitioned to isavuconazole following: photodermatitis, five patients; transaminitis and photodermatitis one patient; failure of therapy, one patient. Two other patients failed fluconazole therapy and were transitioned to isavuconazole as salvage therapy. All patients transitioned to isavuconazole had a complete response to therapy five patients; or were deemed partial response (stable disease), four patients. Isavuconazole therapy resulted in symptomatic and laboratory improvement in five of nine patients. The remaining patients exhibited clinical resolution of symptoms or continued with stable disease following adverse reactions to prior alternative triazole therapy. Isavuconazole may be a useful addition to the therapeutic choices currently available for coccidioidal meningitis. All authors: No reported disclosures.

This is a case of a 56-year-old man diagnosed with coccidioidal meningitis 42 years ago at the age of 14. He was treated with intrathecal amphotericin B deoxycholate by cisternal puncture for 15 years before switching to fluconazole once it became available in 1991. Over 42 years of treatment, he developed hearing loss due to auditory nerve neurotoxicity, hydrocephalus requiring ventriculoperitoneal shunting with associated malfunctions, lumbar arachnoiditis, and hypokalemic paralysis. Regular cerebrospinal fluid studies to this day do not show disease clearance. Many of the lessons from his clinical history are enshrined in the current iteration of the Infectious Diseases Society of America Coccidioidomycosis Treatment Guidelines. To our knowledge, he is the longest surviving coccidioidal meningitis patient.

Background: Early studies have reported various electrolyte abnormalities at admission in patients with severe coronavirus disease (COVID-19). 64 out of 112 patients admitted to our institution presented with hypermagnesemia at presentation. It is believed this may be important in the evaluation of severe SARS-CoV-2 infections. This study evaluated the outcomes of hypermagnesemia in patients with COVID-19.Methods: A retrospective chart review of patients admitted to the hospital with confirmed SARS-CoV-2 infection. A review of the medical literature regarding hypermagnesemia, magnesium levels in critical care illness and electrolyte abnormalities in COVID-19 patients was performed. Differences in demographic and clinical characteristics of patients with hypermagnesemia and normomagnesemia were evaluated using descriptive statistics. Other known variables of disease severity were analyzed.Results: 64 patients (57%) were identified with hypermagnesemia (≥ 2.5mg/dl). 30 of those patients were admitted to the ICU (47% p < 0.001). 21 patients required ventilator support (33% p < 0.0001). With age adjusted logistic regression analysis hypermagnesemia was associated with mortality (p = 0.037).Conclusion: Potential pathogenetic mechanisms were explored and discussed for hypermagnesemia and its relation to severe SARS-CoV-2. This study demonstrates that hypermagnesemia is a significant marker of disease severity and adverse outcome in SARS-CoV-2 infections. We recommend serum magnesium be added to the panel of tests routinely ordered in evaluation of severe SARS-CoV-2 infections.Funding Statement: The author(s) received no financial support for the research, authorship, and/orpublication of this article.Declaration of Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.Ethics Approval Statement: The Institutional Review Board of Kern Medical approved this study asminimal risk research.

In this article, we describe a case of neutrophilic dermatosis of the dorsal hands (NDDH) complicated with myelodysplastic syndrome and chronic active hepatitis C infection. NDDH was first suggested by Galaria et al in 2000. After comparing features of NDDH with Sweet syndrome in terms of encompassing clinical, laboratory, and histological characteristics, it can be concluded that “distributional or localized variant” of Sweet syndrome is classified as NDDH. Early diagnosis and treatment can improve prognosis. Systemic glucocorticoids are the mainstay of treatment.

Genomic variants of the hepatitis B virus (HBV) preS/S protein are well-known to occur. Typically, immunity is gained through recovered HBV infection or by immunization. Very rarely, there are certain mutations that may enable HBV escape from the immune detection. PreS/S mutants may present with unpredictable pathobiologic, clinical, and transmittable implications. Standard laboratory testing for genomic HBV variants is not routinely performed by reference guidelines. s-variant HBV management remains challenging. Herein is a case of s-variant chronic HBV infection in a 55-year-old man. Diagnosis and treatment are described.

Letters3 June 2003Urinary Catheters: A One-Point Restraint?Royce H. Johnson, MDRoyce H. Johnson, MDKern Medical Center; Bakersfield, CA 93305Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-138-11-200306030-00018-w1 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:I read with great interest the editorial by Saint and colleagues on indwelling urinary catheters (1). As indicated by the studies referenced by the authors, particularly those by Beeson (2) and by Platt and colleagues (3), we have understood the danger of this procedure's significant complication rate, as well as the inconvenience and pain it causes, for more than 40 years. Clearly, thousands of people have died unnecessarily because of this procedure.I believe all physicians endeavor not to use restraints unless they are absolutely necessary. There are exceptions, of course, and adverse outcomes have infrequently resulted ...References1. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? [Editorial]. Ann Intern Med. 2002;137:125-7. [PMID: 12118969] LinkGoogle Scholar2. Beeson PB. The case against the catheter. Am J Med. 1958;24:1-3. CrossrefMedlineGoogle Scholar3. Platt R, Polk BF, Murdock B, Rosner B. Mortality associated with nosocomial urinary-tract infection. N Engl J Med. 1982;307:637-42. [PMID: 7110215] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Kern Medical Center; Bakersfield, CA 93305 PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoIndwelling Urinary Catheters: A One-Point Restraint? Sanjay Saint , Benjamin A. Lipsky , and Susan Dorr Goold Metrics Cited byEvidence Rocks in Long-term Care, But Does It Roll? 3 June 2003Volume 138, Issue 11Page: W-51KeywordsCatheterizationCathetersPatients ePublished: 3 June 2003 Issue Published: 3 June 2003 Copyright & PermissionsCopyright © 2003 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

The genus Yersinia consists of 17 species. Only three species are consistently pathogenic for humans. These are Yersinia pestis, the agent of plague, Yersinia enterocolitica, and Yersinia pseudotuberculosis, which are usually, but not entirely, gastrointestinal pathogens.

Metastases to the eye or orbit as the initial presentation of genitourinary malignancy are unusual and can be a diagnostic challenge. We report an 81-year-old man who presented with pain and proptosis in an eye that had been blind for 50 years. Radiologic investigations identified a mass involving the left globe and orbit. Histology of the enucleation specimen was consistent with a metastatic poorly differentiated carcinoma suggestive of a prostate primary. With the constellation of obstructive urinary symptoms, an abnormal digital rectal examination, elevated prostate-specific antigen and a positive bone scan, androgen deprivation therapy was initiated for metastatic prostate cancer. After an initial response to treatment, the patient’s disease progressed in a manner atypical for prostate cancer. After describing our case, we review the literature on ocular and orbital metastases and their relation to genitourinary malignancies.

The Yersinia genus includes Yersinia enterocolitica, Yersinia pseudotuberculosis, Yersinia pestis, Yersinia frederiksenii, Yersinia kristensenii, Yersinia intermedia, Yersinia aldovae, and Yersinia rohdei. The first three species are pathogenic for immunocompetent humans. Y. enterocolitica has emerged as an increasing worldwide pathogen. Recent studies have elucidated new data on its epidemiology, the pathogenic mechanisms of invasion, and new clinical problems. Y. pseudotuberculosis is a much less common pathogen that produces gastrointestinal manifestations similar to Y. enterocolitica, and also on rare occasions sepsis. It will not be discussed further in this review. Y. pestis is the etiologic agent of plague. This pathogen produces one of the classic infectious diseases with enormous historic implications and is still a significant problem in the United States and many parts of the third world.

Yersinia genus includes several species. The most important for human disease are Yersinia enterocolitica, Yersinia pseudotuberculosis, and Y. pseudotuberculosis subspecies pestis. More commonly Y. pseudotuberculosis subspecies pestis is listed as Yersinia pestis. Yersinia pseudotuberculosis and Y. pestis are clearly closely related species by analysis of the genome. However, Y. enterocolitica and Y. pseudotuberculosis produce clinically similar disease and both are quite distinct from that produced by subspecies Y. pestis; hence, in this chapter the older terminology Y. pestis will be used, and Y. enterocolitica and Y. pseudotuberculosis discussed separately.

Coccidioidomycosis is a systemic fungal infection endemic to the southwestern United States. Although most cases are self-limiting and restricted to the lungs, the disease can disseminate to the bone, soft tissue, and central nervous system (CNS). First-line therapy generally consists of fluconazole or itraconazole. In cases refractory to first-line therapy, the management is less well defined. Newer triazole antifungals, such as posaconazole (POSA) and voriconazole (VORI), have demonstrated efficacy in refractory cases, but data are limited. Isavuconazole (ISAV) has in vitro activity against Coccidioides spp., but in vivo data are limited to nine cases of primary pulmonary disease. To our knowledge, there are no published studies regarding its role in refractory cases. Any treatment outcomes data with these agents would contribute to the limited scientific body. Retrospective chart review of patients with refractory coccidioidomycosis whose therapy was changed to ISAV, POSA, or VORI between January 1, 2010 and April 18, 2018. Outcome was defined as improved, stable, or unresponsive utilizing the Mycosis Study Group (MSG) score (a composite score for symptoms, serology, radiographic findings) and the documented impressions of treating physicians. For CNS patients, a separate point system was used to compute the score. Of the patients meeting study criteria, 15 patients received ISAV, 32 patients received POSA (suspension n = 12, tablets n = 19), and 21 patients received VORI. In the ISAV group, 73.3% of patients were improved, and 26.7% were stable. In the POSA suspension group, 83.3% were improved and 16.7% were stable compared with 78.9% improved and 21.1% stable in the POSA tablet group. In the VORI group, 61.9% were improved, 19% were stable, and 19% were unresponsive. MSG scores across all treatment groups were reduced (P < 0.003) with a median change of −2, −4, −2.5, −2 for ISAV, POSA suspension, POSA tablets, and VORI, respectively. Isavuconazole, posaconazole, and voriconazole are reasonable options for treatment of refractory coccidioidomycosis. Prospective comparative trials are required to provide further insights into their efficacy and utility. All authors: No reported disclosures.

Human choriocarcinoma has been transplanted to the pulmonary vasculature of seven adult rhesus monkeys and to the brains of ten adult rhesus and four newborn cynomolgus monkeys. Progressive tumor growth was noted in all of the adults receiving solid implants of tumor in the cerebral cortex and half of the newborns who had a mince of choriocarcinoma injected into the cortex through a needle placed through the coronal suture. Tumor was transplanted from these lesions back into the cheek pouch of hamsters as a test of viability. Death of the monkeys bearing transplants was preceded by localizing neurologic signs of expanding intracranial lesions. The administration of heterologous antilymphocyte sera did not affect the pattern of tumor growth nor the host's cellular reaction around the tumor. No growth was seen when tumor was injected into the inflow tract of the right side of the heart and then flushed into the pulmonary vasculature. Three monkeys treated this way received cortisone and a progestational agent. The other four underwent thymectomy and then received heterologous antilymphocyte sera, a form of treatment which had been shown to be effective in suppressing a homograft response in this species.

Camas (<italic>Camassia quamash</italic>) is well documented as a traditional native food source throughout the Northwestern United States and Canada. A better understanding of the historic distribution of camas in Idaho would help to distinguish root foraging in this region from the Pacific Northwest. Modern grazing, development, climate change, and other factors have decimated native camas in this region. This study uses a species distribution model (MaxEnt) to provide a well-informed geospatial projection of the historic distribution and habitat characteristics of camas in Southern Idaho. Understanding the most significant landscape and climate characteristics for camas allows us to estimate suitable habitats, and therefore the potential influence of camas on human diet breadth and mobility in the Late Archaic.

This chapter deals with the genus <italic>Yersinia</italic>, which consists of 17 species; only three of which are consistently pathogenic for humans. Most famously, <italic>Y. pestis</italic> is the agent of plague, whereas <italic>Y. enterocolitica</italic> and <italic>Y. pseudotuberculosis</italic> are gastrointestinal pathogens. <italic>Y. pestis</italic> is an ancient organism that has largely existed as a rodent pathogen over the course of time, with only occasional human transmission since its divergence from <italic>Y. pseudotuberculosis</italic> 1,500 to 20,000 years ago. Alexandre Yersin first isolated <italic>Y. pestis</italic> in 1894. The chapter analyzes natural infections caused by <italic>Yersinia</italic> that occur most commonly through the bite of an infected flea and in which the majority of patients present with febrile lymphadenitis or bubonic plague.

From the Department of Internal Medicine, UCLA School of Medicine, Los Angeles, California the Department of Internal Medicine, Division of Infectious Disease, Valley Fever Center of California, Kern Medical Center, Bakersfield, California