JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
ALL HURTING IN A PRISONER IS NOT MALINGERING
CONCURRENT PERSISTENT CRYPTOCOCCOMA AND MYCOBACTERIUM AVIUM COMPLEX INFECTIONS IN HUMAN IMMUNODEFICIENCY VIRUS-INFECTED PATIENT: FIGHTING TWO MONSTERS
S. Igbinedion, MD; M.S. Mavuram, MD; J. Bienvenu, MD; M. Boktor, MD, FACG Department of Medicine, LSU Health Sciences Center-Shreveport Pyogenic liver abscesses are uncommon, although recent studies have shown increasing incidence of 8 to 15 per 100,000 population in the United States. In nearly 40% of cases of pyogenic liver abscess, the source of infection is unknown. Introduction: Case: A 21-year-old man presented from prison with abdominal pain, multiple episodes of nausea, vomiting, and diarrhea for 5 days. He reported associated intermittent fevers. He was a previous smoker but quit two years ago. Physical examination was remarkable for tachycardia and fever with temperature recorded as 103.7F. He was weak and diaphoretic. He had right upper quadrant tenderness. Laboratory findings revealed leukocytosis of 15.6 K/UL with 83% neutrophils, ALT of 30, AST of 43, alkaline phosphatase of 240, and total bilirubin of 1.5 mg/dL. INR was 1.72. Initial blood cultures obtained in the emergency department returned positive for methicillin-susceptible staphylococcus aureus (MSSA). CT scan of the abdomen and pelvis with IV contrast showed a large multi-lobulated right hepatic mass, measuring 8.4 cm with soft tissue extension into the upper pole of the right kidney. The patient underwent a CT-guided percutaneous drainage of the suspicious liver abscess with initial return of 150 ml of serosanguinous fluid. Two drains were left in place but were subsequently removed after output became minimal. Cultures obtained from the aspirate subsequently grew MSSA. Broad spectrum antibiotic therapy was narrowed down to IV Nafcillin continued for 4 weeks postdate of negative blood cultures. Follow-up in clinic 1 month after discharge revealed stable clinical condition as the patient reported resolution of symptoms and return to baseline functional status. Discussion: Infections of the biliary tract involving gram- negative bacteria, are the most common source of pyogenic liver abscess. On initial encounter of patients with pyogenic liver abscess, clinicians should consider broadening antibiotic coverage to include gram-positive organisms if the patient presents with severe illness and significant risk factors for gram positive infections such as recent incarceration. It is also important for the clinician to consider early percutaneous drainage in patients with presumed liver abscess for guidance in antibiotic therapy.
A. Joury, MD Department of Medicine, Ochsner Medical Center, New Orleans, LA
Introduction: Cryptococcosis is an important opportunistic infection among HIV patients with estimated mortality of more exceeding 600,000 death worldwide. The diagnosis of cryptococcosis is based on yeast isolation of from cerebrospinal fluid (CSF) or serumdetectionof cryptococcal antigen. Treatment of cryptococcosis has three main steps, first with antifungal treatment, management of increased intracranial pressure and restoration of immune system upon initiation of antiretroviral therapy. Cryptococcosis and mycobacterium avium complex (MAC) are considered to be in the low incidence among HIV patients with prevalence of 8% and 11.3%, respectively. Co- infection of cryptococcosis and MAC is extremely rare even in immunocompromised individuals. Case: A 28-year-old man presented to emergency department with one month history of a band-like headache that started gradually and became worse over the course of the last month. The headache was associated with fever, diplopia, altered sensorium nausea, ten-pound weight loss, productive cough, occasional bloody sputum and significant night sweat. Brain magnetic resonance imaging (MRI) showed multifocal rim enhancing lesions with extensive associated vasogenic edema throughout the bilateral convexities. Chest computerized tomography (CT) scan showed cavitary appearing lesion within the right lower lobe peripherally, with relatively thin wall. Cerebrospinal fluid grew Cryptococcus neoformans. Treatment included amphotericin B liposome intravenous 300 mg daily with oral flucytosine 1500 mg four times daily. Sputum culture resulted positive for Mycobacterium Avium-Intracellulare complex, and azithromycin switched to daily dose and rifampin 300 mg, ethambutol 400 mg and pyrimethamine 25 mg daily were started. Discussion: Central nervous system involvement of Cryptococcosis is most likely secondary to hematological spread. Treatment of Cryptococcus infection should be initiated prior start anti-retroviral medication. Neurological symptoms among immunocompromised individuals urge immediate medical attention and radiological investigation is crucial to monitor treatment response. Clinical improvement and regular radiological monitor are important steps to determine treatment from persistence infection or other underlying pathology.
62 J La State Med Soc VOL 170 MARCH/APRIL 2018
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