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27 Feb
Weekend Digest

Name the disease and its pathogen, risk factor, prevention and treatment.
2/
Disease: #Anisakiasis

Pathogens (most common):
Anisakis simplex complex
Pseudoterranova decipiens complex
Contracecum osculatum complex

Photo credit: doi.org/10.1016/j.ijid…
3/
Risk factor #Anisakiasis

Consumption of raw / undercooked fish / squid

“Ascaridoid” nematodes (roundworm) of whales, seals (“seal worm”), marine mammals —> eggs excreted in water —> larva in crustaceans —> ingested by fish (“herringworm”, “codworm”) —> consumed by humans
Read 7 tweets
25 Feb
Images of Infectious Diseases

28F SLE on MTX
CC chest pain, vaginal DC
Rx pred for lupus

2 mo: fatigue, pruritic rash, visual floaters Rx pred

1 mo: blurred vision. PE iritis / chorioretinitis. Rx pred

Now b/l vision loss. PE panuveitis + chorioretinitis

DDx? #MayoIDQ Image
2/
28F HIV/HBV/HCV(-) SLE on MTX w chronic pain Rx as flare, vaginal discharge due to BV Rx metro (negative GC/chlamydia), skin rash x 2 w and progressive vision loss (photo). CXR clear. Indiana / no foreign travel. No animal exposures.

What is most likely diagnostic test?
3/
Case diagnosis: bilateral ocular syphilis with neurosyphilis

RPR 1:512
Syphilis antibody with reflex: positive
CSF VDRL 1:1

Rx: IV penicillin
Read 8 tweets
6 Feb
Weekend Digest

What happens when a person ingests this “egg packet”?

Name the pathogen and its treatment.
2/
What happens when a person ingests this “egg packet”?

Nothing!
#Dipylidium caninum eggs are NOT infectious to humans.

Then,
How do humans get infected?
3/
How do humans get infected?

Humans (often children) are infected when they accidentally ingest a flea that contains #Dipylidium larvae (cysticercoid).

Infected fleas in pet dogs and cats

doi.org/10.12980/APJTB…
Read 6 tweets
4 Feb
#MayoIDQ 69M was brought to the ED because of weakness. PE: intoxicated disheveled man with multiple skin ulcers / excoriations.
WBC 27. CK 1486. AST 76.
Wound culture: Clostridium botulinum

Which of the following is most consistent with wound botulism?
2/
#Botulism

#Botulinum neurotoxin binds to cholinergic nerve terminals and cleaves intracellular proteins needed for #acetylcholine release —> reduced acetylcholine —> neuromuscular blockade —> bulbar palsies, hypotonia, and symmetric, descending, #flaccid #paralysis.
3/
#Botulism

Clinical features
1. Flaccid paralysis
2. Prominent cranial nerve palsies
3. Descending progression
4. Symmetrical presentation
5. No sensory nerve dysfunction.

43% are correct in MCQ

cdc.gov/botulism/healt…
Read 11 tweets
19 Dec 20
Weekend Digest

Name the pathogen!

H & E stain of heart tissue of a 27M who developed severe intractable heart failure 2 months after an allogeneic bone marrow transplant for acute leukemia.

Clue: consumption of food / water contaminated with feces of snakes
2/
#Sarcocystosis
1. Sarcocystis hominis, suihominis, nesbetti, others
2. Zoonotic: 2 forms for human infection
3. Intestinal and muscular sarcosystosis
4. Dx: intestinal (O/P), muscular (biopsy)
5. Rx: not well defined; TMP-SMX, albendazole, others

cmr.asm.org/content/28/2/2…
3/
Intestinal #Sarcocystosis
1. Ingestion of sarcocyst (S. hominis / beef, suihominis / pork) in tissue
2. Sarcocyst digested —> bradyzoites —> intestinal infection / gametes —> oocysts / sporocyst detected in stool
3. Self limited. No Rx needed

cmr.asm.org/content/28/2/2…
Read 5 tweets
17 Dec 20
Images of Infectious Diseases

GMS of sinus tissue of 20F with no PMH. She presented with fever and sinus pain. CT pansinusitis. Labs: WBC 1.7 ANC 0. Serum BDG and GM negative.

What is your differential diagnosis and empiric therapy? #MayoIDQ to follow... Image
2/
Histopath of surgically resected tissue shows fungal elements. You suggested Mucor/Rhizopus, Fusarium, Trichosporon.

Lack of serum BDG suggests Mucor/Rhizopus

The patient was started on AmBisome.

Few days later, the fungal culture of the same sinus sample shows (photo) Image
3/
#MayoIDQ Surgical debridement of the sinuses was performed plus liposomal Amphotericin B was initiated. Patient lives in rural MN and asks you if an oral option is available as step down Rx.
Read 9 tweets
28 Nov 20
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.
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.
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
26 Nov 20
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?
Read 9 tweets
23 Aug 20
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 20
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 20
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 20
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 20
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
25 Jun 20
Images of Infectious Diseases

56M Mexico. Chronic abdominal pain, weight loss, anorexia.

Work up: elevated markers (CA19-9, CA-125, AFP). CXR normal. CT peritoneal carcinomatosis.

Laparoscopy (photo). Biopsy showed granuloma. What is your DDx? #MayoIDQ MCQ next... Image
#MayoIDQ
Thank you for your responses.

Culture of tissue (peritoneal nodules) of this 56M (see prior tweet) with granuloma on biopsy: Mycobacterium tuberculosis complex. Resistant to pyrazinamide.

Which of these choices is the most likely mechanism of transmission?
1/
Case diagnosis: Peritoneal #tuberculosis due to #Mycobacterium #bovis

Path: granuloma and positive #AFB stain
Culture: M tuberculosis complex

Clue: #PZA resistance —> THINK M. bovis

Reported by @GaboMotoa during his rotation in Mayo Clinic

doi.org/10.1002/ccr3.3…
Read 11 tweets
10 Jun 20
Images of Infectious Diseases

This is the peripheral blood smear of a 71M s/p splenectomy. Rural Wisconsin. No travel.

CC: fever, sweats, dyspnea
ROS: dark urine
PE: jaundice
Hgb 10. Low haptoglobin.
TBI 3.3 LDH 1075

What is the diagnosis and recommended Rx?
#MayoIDQ MCQ next
1/
71M. WI. (see prior tweet)
S/p splenectomy.
Fever, jaundice, hemolytic anemia.

Your diagnosis: babesiosis (parasitemia 7.3%).

3 days after starting Rx: tinnitus and hypoacusis

What Rx most likely caused this adverse effect?
2/
Treatment of #Babesiosis
1. Atovaquone-azithromycin
2. Quinine-clindamycin

The two regimens have comparable efficacy in non-life-threatening babesiosis.

BUT safety profile of Atovaquone-azithromycin was better

nejm.org/doi/full/10.10…
Read 10 tweets
2 Jun 20
Images of Infectious Diseases

In addition to these CT findings, there are multiple wedge-shaped peripheral areas of hypoattenuation in the spleen.

Name the host and the risk factor.
28 PWID. No PMH.
Fever, chills, sweats. cough, abdominal pain x 1 week

PE: ill-looking, murmur, scattered rales, petechiae
WBC 19.5, Cre 2.16
Blood culture: MSSA
CT (prior tweet)
TEE ordered.

Whic of the following options is best for Rx?
1/
Case diagnosis:
#MSSA #Endocarditis in #PWID

TEE: TV multiple vegetations + small aortic valve lesion. PFO with small right to left shunt
Read 17 tweets
17 Mar 20
There is no proven effective antiviral drug for the treatment of #SARSCoV2

Several compounds are suggested for Rx of #COVID19. Based on the available in vitro and clinical data, which one is your preferred Rx, if available? #MayoIDQ references follow...
1/
#Chloroquine
Anti-malaria

Several potential mechanisms: change in cell membrane pH, impairs viral fusion, interferes with glycosylation of viral proteins

#chloroquine and #redemsivir are active against SARS-COV2 in experimental models

doi.org/10.1038/s41422…
2/
#Hydroxychloroquine
- Analogue of chloroquine
- Anti inflammatory effect

Hydroxychloroquine was more potent than chloroquine against #SARS-CoV2 in vitro.

doi.org/10.1093/cid/ci…
Read 17 tweets
29 Feb 20
35M DM with severe influenza B
CXR (photo). WBC 30. N80%

Required mechanical ventilation. VV ECMO.
Rx: peramivir —> oseltamivir

D+1 Blood / sputum culture: MRSA
TEE (-). Rx: vancomycin.
#MayoIDQ MCQ next Image
35M MRSA pneumonia / bacteremia during severe influenza.

D+5: vanco —> linezolid
D+6: T40C. Sweating. Loose stools.
PE: BP 150/100. PR 120. Agitated. Confused. Shivering. No focal deficits.
Blood / sputum culture: negative
WBC 12. AST 32. Cre 1.5

What is most likely cause?
1/
Case diagnosis:
Severe #Influenza B infection complicated by #MRSA pneumonia and bacteremia

#Linezolid associated #serotonin syndrome (interaction with fentanyl)

Let us discuss....
Read 14 tweets
7 Feb 20
52M. HIV, Rx non compliant
Current VL / CD4 not known

CC: 2mo cough, progressive dyspnea
2 wks: chills, HA, night sweats

Exposures: parakeets / pigeons

Chest imaging (photo)
BAL: Galactomannan +
Serum CrAg 1:320

Comment on diagnostic and treatment approach? #MayoIDQ MCQ next Image
52M HIV not on Rx, CD4?, presents with likely disseminated cryptococcosis. BAL culture: Cryptococcus neoformans.
CT head no mass.

LP performed. Which of the following CSF findings confers higher mortality? #MayoIDQ
The HIV-infected patient (prior thread) with disseminated cryptococcosis and meningitis was started on induction Rx with AmBisome + 5FC.

HIV VL 120K. CD4 36. He tells you he will now be compliant to ART. No resistance mutations detected.

When do you start antiretroviral Rx?
Read 16 tweets
24 Dec 19
Images of Infectious Diseases

74M Iowa farmer s/p Dacron graft repair of abdominal aortic aneurysm

2y later: back pain
MRI (photo) + enhancement of graft + aneurysm

Surgery (photo): bacteria, fungi/TB cultures (-)

DIF with anti-Coxiella Ab in fibroblasts (photo).
(MCQ next) Image
In a 74M farmer with multilevel vertebral osteomyelitis and soft tissue abscess contiguous with vascular graft and mycotic aneurysm, which serological pattern is most consistent with a diagnosis of chronic Q fever? #MayoIDQ (PI phase 1; PII phase 2 titers)
1/
Case diagnosis: Chronic #Coxiella burnetti infection (#QFever): vascular graft, vertebral osteomyelitis, soft tissue abscesses

MCQ answer: choice B

Description reported by @AbinashVirkMD, @DOCElie and colleagues

ncbi.nlm.nih.gov/pmc/articles/P…
Read 10 tweets