Images of Infectious Diseases

6 mo post-tx: H&E (400x) of cervical biopsy of 46F s/p living unrelated donor kidney tx for adult PCKD.

Belatacept. MMF. Prednisone.
Acute cellular + antibody-mediated rejection.

CMV D+/R-. valganciclovir prophylaxis.

DDx / Rx? #MayoIDQ next Image
2/
Case diagnosis: breakthrough CMV disease with cervicitis

H&E intranuclear / intracytoppasmic inclusions within endothelial cells in ectocervical stroma.

Immunohistochemistry stain for CMV shows infected endothelial cells with CMV inclusions.

doi.org/10.1111/tid.13… Image
3/
#MayoIDQ Breakthrough CMV disease, while receiving valGCV prophylaxis, is concerning for over-immunosuppression, under-dosing of val GCV, and/or drug-resistant virus.

If gene sequencing shows the most common CMV gene mutation, what drug would be recommended Rx?
4/
#CMV in kidney #transplantation

Risks:
1. CMV D+/R- mismatch
2. Rejection: cellular / antibody-mediated
3. T cell depletion: thymoglobulin, alemtuzumab
4. T cell dysfunction: combined IS
5. Low ALC <610

doi.org/10.1111/tid.13…
5/
#CMV #belatacept

Belatacept - selective T-cell costimulation blocker. Binds CD80 / CD86 on antigen-presenting cells —> block CD28-costimulation of T cells

High risk of CMV disease and prolonged viral replication in CMV D+/R- kidney recipients

doi.org/10.1111/ajt.16…
6/
Resistant / refractory #CMV
Risks: prolonged GCV use in face of lack of CMV-immunity due to prolonged intense over-immunosuppression

1. CMV D+/R-
2. High level immunosuppression (e.g., due to rejection)
3. Prolonged antiviral use

link.springer.com/article/10.100…
7/
Resistant #CMV mutations

UL97 mutation most common: impairs GCV phosphorylation
- GCV (and Maribavir)

UL54 polymerase mutation
- GCV/cidofovir (often cross-resistant)
- Foscarnet (pyrophosphate binding)

UL56 terminase mutation
- Letermovir

doi.org/10.1080/216787…
8/
Resistant #CMV Rx
1. Reduce immunosuppression
2. UL97 mutation: foscarnet drug of choice (answer to MCQ: 74% correct)

Why not:
Cidofovir - 2nd choice (after foscarnet)
Maribavir - investigational
Letermovir- not approved in SOT/Rx

doi.org/10.1111/ctr.13…
/9
Case resolution:
Breakthrough CMV disease

Risks: D+/R-, cellular and humoral rejection, over immunosuppression, belatacept

H/o cervix adenoma malignum. Biopsy: invasive CMV disease.

Prolonged Rx w/ foscarnet and cautious reduction in IS.

doi.org/10.1111/tid.13…

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More from @MayoClinicINFD

28 Nov
Weekend Digest

Giemsa stain of blood smear of a 50M who returned to the US after a 10-year missionary work in Mali and Senegal. He presented with episodic angioedema and eosinophilia.

Name the pathogen, its treatment and complication of Rx. Image
2/
#Loa loa

Bite of chrysops deer fly

Larva migrates in tissues; matures into adult worm in 5 months, and live for 20 years.

Adults produce microfilaria that gets into lymphatics / blood —> tissues. Microfilaria does not mature into adult but lives for a year. Image
3/
#Loa loa migrates in tissues

Most infected people ASYMPTOMATIC

1. Calabar swelling - transient localized, non-tender swellings usually on arms and legs and near joints

2. Eye worm - visible movement of adult worm across the surface of eye

3. Eosinophilia and pruritus
Read 5 tweets
23 Aug
Images of Infectious Diseases

This is GMS stain and culture of a skin biopsy from a patient’s leg.

Who is the host? What is the syndrome? Name the pathogen. How to treat?
#MayoIDQ and case details to follow... Image
2/
66M. 4 mo after heart Tx: painless leg nodules that spread distally x 5 weeks. No pain. No fever.

PE unremarkable except lesions in left leg / foot + tinea pedis

Biopsy: GMS fungal elements in dermis. Culture: Trichophyton rubrum

What is true of this condition?
3/
Case diagnosis:
#Majocchi’s Granuloma due to #Trichophyton rubrum

Histopath shows fungal elements (GMS) - not sufficient for identification.

Important: Send specimen for culture identification!!!

Treatment: Itraconazole Rx
Read 9 tweets
13 Aug
A series of images presented by an ID fellow to a faculty panel in the “Challenging Cases” session of the #MayoIDFellowsForum

The fellow asked the experts: What diagnosis comes to mind?

#IDTwitter, what do you think?
Clinical details, #MayoIDQ and MCQ to follow...
2/
Awesome list of potential pathogens... from staphylococcus / streptococcus to nocardia, TB, fungi (Mucor, Candida, endemics) and toxoplasma, and others.

Without knowing the host and scenario, all are possible. Thank you #IDTwitter.
Now let us learn about the case details..
3/
45M found unconscious.
PMH: alcohol use disorder. No IDU.
PE: T103F RR32 PR110
Meningismus.
Murmur. Rales.
No skin lesions.
WBC 27K.
Imaging (photo). No PFO.
CSF TNC 9450 /N92% /prot 150 / glu 20

Name the pathogen.
Read 16 tweets
26 Jul
70M with swollen R 5th digit, hand and forearm. No fever / chills.

MRI: complex multi-compartment fluid collection with extensive flexor and extensor tenosynovitis

Debridement. Culture (photo).

What is your diagnosis and Rx?
#MayoIDQ MCQ to follow... Image
Elderly man with swollen right hand and forearm. MRI: complex fluid collection, extensive tenosynovitis. Debridement performed. Culture is shown (photo prior tweet).

Which of the following is the exposure associated with this infection?
3/
Beaver dam and blastomyces

When #IDBR says #beaverdam - you think #BLASTOMYCOSIS

nejm.org/doi/10.1056/NE…
Read 9 tweets
16 Jul
Images of Infectious Diseases

This is the histopath and gram stain of culture of a lymph node biopsy of a person with tender purulent inguinal adenopathy.
Dr. @dwchallener
Dr. @ali_eberly
MCQ #MayoIDQ to follow Image
72M. Crohn’s. 2 pet dogs. 1 pet cat.
2 mo after L knee surgery —> tender L inguinal node with purulence. No F/C. No response to TMP-SMX.

Biopsy (see photo): Stellate suppurative granuloma with central necrosis and clumps of bacteria.

What is the most likely diagnosis?
1/
#Gram stain: a first step in bacterial identification —> two major groups:
1. Gram-positive: retains primary stain (crystal violet)
2. Gram-negative: does not retain crystal violet but counterstained by safranin/fuchsine —> red / pink

Named after Hans Christian Gram (photo) Image
Read 12 tweets
6 Jul
On day 14 of neutropenia, an astute ID fellow noted this finding (photo) while examining a patient with fever. Underlying AML and ongoing chemotherapy.

What do you suspect? What work up do you suggest? Details and #MayoIDQ MCQ to follow...
65M acute myeloid leukemia. Rx: CLAG-M. Prophy ACV, posaconazole, Levo, inhaled pentamidine

D14 neutropenia: fever / chills
Exam: onychomycosis, rapidly evolving lesions in arms and torso (photo)

You asked for skin biopsy. Blood culture will grow what fungus?
2/
Case diagnosis: disseminated fusariosis

Majority got the diagnosis correctly!
Blood culture: Fusarium sp.

Rx: AmBisome / voriconazole
Hope for neutrophil recovery!!!
Read 12 tweets

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