Sharjeel Ahmad

Actinomyces europaeus is an uncommon cause of human infection and a rare cause of septic arthritis. We report an 81-year-old woman with diabetes mellitus, chronic kidney disease, gout, and dementia who developed septic arthritis of the distal interphalangeal joint of the right third finger during hospitalization for Escherichia coli bacteremia. Computed tomography demonstrated erosive joint destruction with an adjacent abscess. Surgical incision, drainage, and arthrotomy revealed septic arthritis with associated abscess formation and degeneration of the terminal extensor tendon. Operative cultures grew A. europaeus together with multiple anaerobic organisms. The patient underwent surgical debridement, followed by prolonged oral doxycycline therapy and a short course of metronidazole for polymicrobial anaerobic coverage, resulting in complete clinical resolution. This case highlights an uncommon cause of native joint septic arthritis and emphasizes the importance of considering unusual pathogens in patients with pre-existing joint disease and atypical clinical presentations.

Rothia kristinae is usually found in the environment, on normal skin and mucosal surfaces of humans, and there is a limited medical literature available on this organism and its pathogenicity. Our case describes a woman in her early 70’s with left hip osteoarthritis presented with generalized weakness, fever, and altered mentation associated with left hip and back pain. Laboratory workup was significant for leukocytosis and elevated inflammatory markers. Blood culture demonstrated Gram‐positive cocci, later identified as Rothia kristinae . She was subsequently diagnosed with native aortic valve endocarditis, multilevel discitis, and left hip septic arthritis. She completed 2 weeks of intravenous vancomycin. Treatment was complicated by a drug reaction to vancomycin and switched to linezolid. She developed a left hip abscess and underwent left hip arthroplasty. Follow‐up transthoracic echocardiogram showed resolution of infective endocarditis. This case describes the extent of disseminated infection the organism can cause and its pathogenic potential warranting a low threshold for clinicians to initiate treatment.

Transplant recipients have a high risk of infection with opportunistic pathogens. The type, dose, and duration of immunosuppression and use of prior broad‐spectrum antimicrobials contribute to overall risk of infections. Aspergillosis is a known opportunistic infection that can occur as mid or late infection after visceral transplant. Aspergillus fumigatus is the commonly isolated species, but with the use of prophylactic broad‐spectrum antifungals, other species such as Aspergillus calidoustus are emerging. We report a case of invasive sinusitis and brain mass due to this species of Aspergillus that was identified using next‐generation sequencing (NGS). Use of NGS early in clinical presentation may help in effective management of opportunistic infections in immunocompromised hosts.

Loeys-Dietz syndrome (LDS) is a rare, autosomal dominant multisystem disorder that is caused by mutations of transforming growth factor-β receptors. Mutations in SMAD3 and TGFB3 have been recently reported. LDS is characterised by the triad of arterial tortuosity, hypertelorism and a bifid uvula or cleft palate among other cardiovascular, craniofacial and orthopaedic manifestations. Patients with LDS show clinical and genetic variability and there is a significant risk of reduced life expectancy due to widespread arterial involvement, aortic root dilation, aneurysms and an aggressive vascular course. Thus early genetic testing is warranted if clinical signs and history are suggestive of this potentially catastrophic disorder. LDS predisposes patients to aortic aneurysms and early death due to vascular malformations, but neurological emergencies, such as seizures and febrile status epilepticus, have not been reported. Febrile status epilepticus is the most common neurological emergency in childhood. Neurological manifestations of COVID-19 in the paediatric population are not as well described in medical literature. To the best of our knowledge, this is the first reported case of febrile status epilepticus with COVID-19 infection in an infant with LDS. Our patient had focal epileptiform activity emanating over the left posterior hemisphere, which evolved into an electrographic seizure on video EEG. Such patients have a heightened risk of epilepsy in the future, and this occurrence is consistent with a diagnosis of focal epilepsy. Neurological complications such as epilepsy and status epilepticus in a patient with LDS have never been reported before. A brief review of literature is also given here.

Coronavirus disease 2019 (COVID-19) infection is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This infection usually presents with upper respiratory symptoms; however, it can also present with a wide variety of other multisystem and neurological symptoms, including seizures. There are several proposed mechanisms by which COVID-19 can cause systemic signs of infections, including neurological complications and seizures. This case report describes a pediatric patient without a previously documented history of epilepsy who was admitted for new-onset focal seizures with impaired consciousness. No other cause and triggers of seizures were found, and the child was tested positive for COVID-19 infection. The patient had six electroclinical seizures during EEG. Video EEG findings showed atypical features of onset of intermittent rhythmic delta activity (IRDA) slowing over the left hemisphere with evolution/generalization of rhythmic delta/theta activity and without clear typical generalized epileptiform discharges. These EEG findings correlated with a clinical change of behavior arrest, staring, and yawning. Similar spells were reported multiple times a day prior to the admission, and past EEG was normal. A review of current literature on COVID-19 and neurological manifestations in children, including new seizures and prior diagnosis of epilepsy, is also provided in this case report. The clinical experience in children with newly diagnosed or chronic epilepsy suggests that exacerbation of seizures, especially from systemic effects such as those caused by severe COVID-19 infection, will be a major concern.

Francisella tularensis causes severe infections and is a Category A potential bioterrorism agent but its microbiological diagnosis can be challenging. The diagnosis of tularemia is limited by non-specific protean clinical symptoms that overlap with other infectious syndromes, the fastidious nature of Francisella tularensis, along with insensitivity and poor specificity of serology. Rapid, non-invasive diagnosis of tularemia by microbial cell-free DNA (mcfDNA) next-generation sequencing (NGS) of plasma offers a means to overcome these limitations. The Karius Test™ (KT) detects and quantifies mcfDNA in molecules/µL (MPM) from >1400 organisms in plasma (performed at the CLIA certified/CAP accredited Karius laboratory). KT detections of Francisella tularensis were compiled from three medical centers with clinical review by healthcare providers. KT detected Francisella tularensis in four patients. All were adult males in whom the diagnosis was unexpected. The most common symptoms were fever and chest pain. White blood cell count neutrophilic predominance and abnormal chest X-ray findings were found in three cases. A broad infectious disease work-up was performed with the initiation of broad spectrum empiric antibiotics in all cases. KT was the first test to identify Francisella tularensis as the microbiological diagnosis with a time to diagnosis of 2.25 days (avg) +/- 0.5 from sample collection (one day from sample receipt in all cases), enabling narrowed, targeted antibiotic treatment. Francisella tularensis mcfDNA concentration was 1772 MPM (avg) +/- 1914. KT was the only test to establish the diagnosis in two cases; tularemia serologies were confirmatory in two cases, one of which had confirmatory culture from lymph node biopsy. Three patients were diagnosed with the pneumonic form of the illness and one with a visceral glandular form. Possible epidemiological exposures were identified in all cases. KT enabled rapid, non-invasive, plasma-based diagnosis of diverse clinical manifestations of invasive tularemia against a competing broad infectious and non-infectious differential diagnosis. Timely diagnosis enabled targeted narrowing of antibiotic therapy and successful treatment of pneumonic and glandular forms of the infection. All Authors: No reported disclosures

Mild encephalopathy with reversible splenial lesion (MERS) is a disorder characterised by prodromal symptoms such as fever, cough, vomiting or diarrhoea, followed by mild encephalopathy 1–7 days later with a documented reversible corpus callosum splenial lesion. MERS is mostly reported in children in the region of East Asia. To the best of our knowledge, this is the first reported case of MERS associated with mycoplasma infection in a child in North America. A brief review of literature is also a part of this report.

Pulmonary coccidioidomycosis and pulmonary actinomycosis are unheard of as co-pathogens. Infection with these organisms on their own can mimic lung cancer, thus presenting a diagnostic challenge. We present the case of a 75-year-old woman presenting with haemoptysis with a chest CT chest finding of a lung mass suggestive of lung cancer. A diagnosis of concomitant infection by Coccidioides posadasii/immitis and Actinomyces odontolyticus was made based on culture and histopathology results. The patient was successfully treated with a combination of antifungal and antibacterial therapy. This is the first reported case of co-infection by these two microorganisms.

The Central Illinois COVID-19 Registry is designed to study outcomes of patients residing in central Illinois who have been diagnosed with COVID-19. The registry is intended to be a collaborative project between three healthcare systems serving the rural areas of central Illinois, and a County Department of Health and University both in central Illinois.