JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
HISTOPLASMOSIS PRESENTING AS COLONIC STRICTURE IN HIV PATIENT
A RARE CASE OF PROSTHETIC VALVE ENDOCARDITIS DUE TO PROTEUS
L Miles, MD; J. Anderson, MD Department of Medicine, LSU Health Sciences Center - Baton Rouge
S. Gavini, DO; N. Turaga, MD; R. Patel, MD; N. Sells, MD Department of Internal Medicine, LSU Health Sciences Center - Lafayette
Introduction: Histoplasmosis capsulatum is one of the most common endemic fungi in Southern Louisiana. Histoplasmosis often manifests as flu-like or respiratory illness in the immunocompetent, but can disseminate and commonly affects the gastrointestinal system in immunocompromised patients. Case: A 30-year-old woman who had been diagnosed with HIV four months prior presented with body aches and fever during early June. Her CD4 count had improved robustly since starting ART at time of diagnosis from 40 to 360, with a 200-fold decrease in her viral load. CT scan demonstrated ascending and transverse colitis. The patient experienced occasional nausea, vomiting and abdominal pain but did not have diarrhea. She improved on piperacillin/tazobactam and rapidly defervesced and was discharged on ampicillin/sulbactam. Her symptoms resolved until one month later when she returned with intractable nausea and emesis. Repeat CT scan showed an apple core lesion in the transverse colon. The patient developed watery diarrhea on hospital day two. Colonoscopy showed high-grade ulcerated stricture suggestive of Crohn's disease. Yellow mucosa on endoscopy was sent for clostridium difficile testing, which was positive. She had persistent mechanical obstruction requiring subtotal colectomy with ileal descending colon anastomosis on hospital day four. Pathology from biopsies taken during colonoscopy demonstrated the presence of fungus, and she was initiated on amphotericin B for presumed disseminated histoplasmosis. Her serum and urine histoplasmosis antigens were both positive. She completed a 14-day course of inpatient therapy and was discharged with consolidation itraconazole therapy and a 14 day course of oral vancomycin for C. diff colitis. Discussion: Disseminated histoplasmosis can present with a variety of symptoms ranging from non-specific fever to intestinal obstruction. The patient’s initial presentation of fever and body aches may have been a manifestation of a brisk immune response to ART or of her initial histoplasmosis infection. On subsequent presentation, the appearance of an apple core lesion and endoscopic findings were misleading for malignancy or inflammatory bowel disease. Early recognition of disseminated histoplasmosis and initiation of therapy decreases length of hospitalization as well as unnecessary therapies.
Introduction: Proteus endocarditis is extremely rare and there is there is a lack of an optimal antimicrobial regimen. To our knowledge, we are reporting the first case of double prosthetic valve proteus endocarditis in a 60-year-old female patient who failed antibiotic treatment, ultimately requiring double prosthetic valve replacement. A 60-year-old woman with history of mechanical mitral and aortic valve replacement, Marfan syndrome, aortic aneurysm repair, atrial fibrillation and recent urinary tract infection presented with 1 day history of generalized weakness, lethargy and confusion. Vitals and physical exam were unremarkable except for blood pressure 98/52 mmHg and audible clicks in mitral and aortic areas. Labs were significant for INR > 15.0 and urinalysis was normal. ECG revealed ventricular paced rhythm. Computerized tomography of head without contrast was normal. She was started on ceftriaxone along with fluid replacement. Coverage was broadened to meropenem and vancomycin when she began having fevers while on ceftriaxone. Vancomycin was discontinued after cultures were grew Proteus penneri and Proteus hauseri. Transesophageal echocardiogram (TEE) revealed mechanical mitral valve with calcifications and normal mechanical aortic valve. The patient completed 6 weeks of IV meropenem and was discharged home on oral cefdinir to take indefinitely. She returned 3 weeks later with recurrent fever with proteus sepsis and was restarted on IV meropenem. Repeat TEE showed mitral regurgitation with densities on the anterior aspect of valve and vegetations on aortic valve. She subsequently underwent double valve replacement. Case: Discussion: Only three (0.1%) of cases of infective endocarditis were reported to be caused by Proteus species in one large study involving 2761 cases. Furthermore, only three cases of prosthetic valve proteus endocarditis have been reported. The majority of cases reported involve native valves with few successful outcomes with ampicillin and gentamicin. There is little evidence regarding the management of proteus endocarditis. Current recommendations suggest using a combination of beta-lactams and aminoglycoside due to potential synergism. With recurrent bouts of sepsis despite antibiotic therapy, we chose valve replacement for our patient.
J La State Med Soc VOL 170 MARCH/APRIL 2018 63
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