Publications by authors named "Holenarasipur R Vikram"

73 Publications

Mild to moderate COVID-19 illness in adult outpatients: Characteristics, symptoms, and outcomes in the first 4 weeks of illness.

Medicine (Baltimore) 2021 Jun;100(24):e26371

Division of Infectious Diseases.

Abstract: Most patients with coronavirus disease 2019 (COVID-19) have mild to moderate illness not requiring hospitalization. However, no study has detailed the evolution of symptoms in the first month of illness.At our institution, we conducted remote (telephone and video) visits for all adult outpatients diagnosed with COVID-19 within 24 h of a positive nasopharyngeal polymerase chain test for SARS-CoV-2. We repeated regular video visits at 7, 14, and 28 days after the positive test, retrospectively reviewed the prospective data collected in the remote visits, and constructed a week by week profile of clinical illness, through week 4 of illness.We reviewed the courses of 458 symptomatic patients diagnosed between March 12, 2020, and June 22, 2020, and characterized their weekly courses. Common initial symptoms included fever, headache, cough, and chest pain, which frequently persisted through week 3 or longer. Upper respiratory or gastrointestinal symptoms were much shorter lived, present primarily in week 1. Anosmia/ageusia peaked in weeks 2 to 3. Emergency department visits were frequent, with 128 visits in the 423 patients who were not hospitalized and 48 visits among the 35 outpatients (7.6%) who were eventually hospitalized (2 subsequently died). By the fourth week, 28.9% said their illness had completely resolved. After the 4-week follow up, 20 (4.7%) of the 423 nonhospitalized patients had further medical evaluation and management for subacute or chronic COVID-19 symptoms.Mild to moderate outpatient COVID-19 is a prolonged illness, with evolving symptoms commonly lasting into the fourth week of illness.
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http://dx.doi.org/10.1097/MD.0000000000026371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213280PMC
June 2021

COVID-19 pneumonia in a patient with granulomatosis with polyangiitis on rituximab: case-based review.

Rheumatol Int 2021 08 6;41(8):1509-1514. Epub 2021 Jun 6.

Division of Pulmonary and Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA.

A 77-year-old man with past medical history of granulomatosis with polyangiitis (GPA) on rituximab and prednisone, presented to the hospital with worsening cough and shortness of breath. He had tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by nasal swab polymerase chain reaction (PCR) while asymptomatic, 6 weeks earlier. He started with cough and shortness of breath 2 weeks after his initial positive test. After developing symptoms, he tested negative twice by nasal swab PCR, but the PCR of his bronchioloalveolar lavage was positive for SARS-CoV-2. He did not develop antibodies against coronavirus. Prednisone 15 mg daily was continued, and he received remdesivir, and convalescent plasma with quick recovery. We reviewed the literature to search for similar cases. Our case suggests that SARS-CoV-2 infection in patients on rituximab may have an atypical presentation and the diagnosis may be delayed due to negative PCR testing in the nasal swab. Patients may benefit from treatment with convalescent plasma.
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http://dx.doi.org/10.1007/s00296-021-04905-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180184PMC
August 2021

Ibrutinib-associated necrotic nasal lesion and pulmonary infiltrates.

BMJ Case Rep 2021 Jan 19;14(1). Epub 2021 Jan 19.

Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona, USA

Herein, we report a case of a 68-year-old woman receiving ibrutinib for chronic lymphocytic leukaemia, who presented with septic shock and a progressive necrotic lesion on her nose. Surgical pathology of the nasal lesion revealed evidence of tissue necrosis, and both tissue and blood culture grew A diagnosis of ecthyma gangrenosum was made. Additional investigations also led to the discovery of invasive pulmonary aspergillosis. To our knowledge, this is the first case of ecthyma gangrenosum secondary to sepsis and concurrent invasive pulmonary aspergillosis associated with ibrutinib use.
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http://dx.doi.org/10.1136/bcr-2020-237085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817807PMC
January 2021

Prospective Validation of PREDICT and Its Impact on the Transesophageal Echocardiography Use in Management of Staphylococcus aureus Bacteremia.

Clin Infect Dis 2021 10;73(7):e1745-e1753

Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Background: Infective endocarditis (IE) is the most feared complication of Staphylococcus aureus bacteremia (SAB). Transesophageal echocardiogram (TEE) is generally recommended for all patients with SAB; however, supporting data for this are limited. We previously developed a scoring system, "PREDICT," that quantifies the risk of IE and identifies patients who would most benefit most from undergoing TEE. The current prospective investigation aims to validate this score.

Methods: We prospectively screened all consecutive adults (≥18 years) hospitalized with SAB at 3 Mayo Clinic sites between January 2015 and March 2017.

Results: Of 220 patients screened, 199 with SAB met study criteria and were included in the investigation. Of them, 23 (11.6%) patients were diagnosed with definite IE within 12 weeks of initial presentation based on modified Duke's criteria. Using the previously derived PREDICT model, the day 1 score of ≥4 had a sensitivity of 30.4% and a specificity of 93.8%, whereas a day 5 score of ≤2 had a sensitivity and negative-predictive value of 100%. Additional factors including surgery or invasive procedure in the past 30 days, prosthetic heart valve, and higher number of positive blood culture bottles in the first set of cultures were associated with increased risk of IE independent of the day 5 risk score.

Conclusions: We validated the previously developed PREDICT scoring tools for stratifying risk of IE, and the need for undergoing a TEE, among cases of SAB. We also identified other factors with predictive potential, although larger prospective studies are needed to further evaluate possible enhancements to the current scoring system.
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http://dx.doi.org/10.1093/cid/ciaa844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8492221PMC
October 2021

Coccidioidomycosis in Patients Treated With Ruxolitinib.

Open Forum Infect Dis 2020 Jun 19;7(6):ofaa167. Epub 2020 May 19.

Division of Infectious Diseases, Mayo Clinic in Arizona, Phoenix, Arizona, USA.

We report 8 cases of coccidioidomycosis associated with ruxolitinib treatment. Among 135 patients living in the coccidioidal-endemic region receiving ruxolitinib, 5 cases were diagnosed after starting and 4 had extrathoracic dissemination. Periodic serological screening while on ruxolitinib is warranted for patients residing in the coccidioidal-endemic region.
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http://dx.doi.org/10.1093/ofid/ofaa167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7284005PMC
June 2020

Tuberculosis transmission across three states: The story of a solid organ donor born in an endemic country, 2018.

Transpl Infect Dis 2020 Dec 8;22(6):e13357. Epub 2020 Jul 8.

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Transmission of tuberculosis (TB) from a deceased solid organ donor to recipients can result in severe morbidity and mortality. In 2018, four solid organ transplant recipients residing in three states but sharing a common organ donor were diagnosed with TB disease. Two recipients were hospitalized and none died. The organ donor was born in a country with a high incidence of TB and experienced 8 weeks of headache and fever prior to death, but was not tested for TB during multiple hospitalizations or prior to organ procurement. TB isolates of two organ recipients and a close contact of the donor had identical TB genotypes and closely related whole-genome sequencing results. Donors with risk factors for TB, in particular birth or residence in countries with a higher TB incidence, should be carefully evaluated for TB.
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http://dx.doi.org/10.1111/tid.13357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879577PMC
December 2020

Unexpected pathogen presenting with purulent meningitis.

BMJ Case Rep 2020 Mar 18;13(3). Epub 2020 Mar 18.

Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona, USA

Herein we report a case of a 67-year-old man with chronic lymphocytic leukaemia who developed acute onset of fever and altered mental status while receiving ibrutinib therapy. He was eventually found to have meningitis. Timely diagnosis and appropriate antimicrobial therapy was associated with a favourable outcome. We describe challenges associated with appropriate identification of, and briefly review infections caused by sp. To our knowledge, this is the first case of invasive infection in the setting of ibrutinib therapy, and adds to the growing list of serious infections that have been associated with this agent.
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http://dx.doi.org/10.1136/bcr-2019-231825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101038PMC
March 2020

Cardiovascular implantable electronic device infections due to enterococcal species: Clinical features, management, and outcomes.

Pacing Clin Electrophysiol 2019 10 3;42(10):1331-1339. Epub 2019 Sep 3.

Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.

Background: Enterococcal cardiovascular implantable electronic device (CIED) infections are not well characterized.

Methods: Data from the Multicenter Electrophysiologic Device Infection Cohort, a prospective study of CIED infections, were used for descriptive analysis of adults with enterococcal CIED infections.

Results: Of 433 patients, 21 (4.8%) had enterococcal CIED infection. Median age was 71 years. Twelve patients (57%) had permanent pacemakers, five (24%) implantable cardioverter defibrillators, and four (19%) biventricular devices. Median time from last procedure to infection was 570 days. CIED-related bloodstream infections occurred in three patients (14%) and 18 (86%) had infective endocarditis (IE), 14 (78%) of which were definite by the modified Duke criteria. IE cases were classified as follows: valvular IE, four; lead IE, eight; both valve and lead IE, six. Vegetations were demonstrated by transesophageal echocardiography in 17 patients (81%). Blood cultures were positive in 19/19 patients with confirmed results. The most common antimicrobial regimen was penicillin plus an aminoglycoside (33%). Antibiotics were given for a median of 43 days. Only 14 patients (67%) underwent device removal. There was one death during the index hospitalization with four additional deaths within 6 months (overall mortality 24%). There were no relapses.

Conclusions: Enterococci caused 4.8% of CIED infections in our cohort. Based on the late onset after device placement or manipulation, most infections were likely hematogenous in origin. IE was the most common infection syndrome. Only 67% of patients underwent device removal. At 6 months follow-up, no CIED infection relapses had occurred, but overall mortality was 24%.
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http://dx.doi.org/10.1111/pace.13783DOI Listing
October 2019

Progressive Back Pain due to Vertebral Osteomyelitis in an Immunocompetent Patient: Surgical and Antifungal Management.

Case Rep Orthop 2019 2;2019:4268468. Epub 2019 Jul 2.

Department of Neurological Surgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.

Case Report: osteomyelitis is a destructive and progressive infection that has been described both in immunosuppressed and in immunocompetent hosts. We describe a case of lumbar vertebral osteomyelitis in a 61-year-old immunocompetent patient due to that was successfully treated with a combination of extensive surgical debridement, spinal stabilization, and a prolonged course of antifungal therapy. Imaging demonstrated findings consistent with L3 discitis. The biopsy grew fungus and was treated with vorconizole. Imaging showed progressive destructive osteomyelitis at L3-L4. Patient underwent anterior L3 and L4 partial corpectomies, anterior interbody fusion L3-L5, and posterior T11-S2 pedicle screw and rod fixation. Antifungal treatment resulted in resolution of infection. markers remain negative. One year following definitive treatment, the patient's back pain remains resolved.

Conclusion: Definitive surgical resection of the infection, spinal stabilization, and aggressive antifungal therapy were required to eradicate the infection.
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http://dx.doi.org/10.1155/2019/4268468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6636486PMC
July 2019

Subconjunctival Dirofilariasis Presenting as Orbital Cellulitis.

Ophthalmic Plast Reconstr Surg 2019 Jul/Aug;35(4):e97-e99

Department of Orbit and Oculoplasty, Prabha Eye Clinic and Research Center.

Human ocular Dirofilariasis is a relatively rare, zoonotic disease, caused by a filarial nematode, Dirofilaria repens. This parasitic infestation usually presents as a subconjunctival nodule with hyperemia. The authors present a case of subconjunctival dirofilariasis in a 91-year-old gentleman, who presented with manifestations of orbital cellulitis. The live worm was surgically removed and identified to be D. repens.
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http://dx.doi.org/10.1097/IOP.0000000000001415DOI Listing
December 2019

Heart transplantation for infective endocarditis: Viable option for a limited few?

Transpl Infect Dis 2019 Feb 28;21(1):e13006. Epub 2018 Oct 28.

Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona.

Active infection in the recipient is considered a relative contraindication for solid organ transplantation. However, heart transplantation (HT) can be curative in patients with ventricular assist device infections. For patients with infective endocarditis (IE), valve replacement is part of the management strategy based on emergent, acute, or elective indications. HT has been utilized as an uncommon and sporadic treatment option for carefully selected patients with refractory or recurrent IE after all other surgical treatment options have been exhausted or are not feasible. Herein, we review 19 published cases of IE in whom HT was undertaken in the setting of ongoing active infection with reported good outcomes. We attempt to propose general criteria for HT in the setting of IE and discuss challenges and hurdles that clinicians might encounter when considering HT for active IE in the absence of robust data or clearly defined criteria.
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http://dx.doi.org/10.1111/tid.13006DOI Listing
February 2019

Reactivation of Chagas disease among heart transplant recipients in the United States, 2012-2016.

Transpl Infect Dis 2018 Dec 2;20(6):e12996. Epub 2018 Oct 2.

Parasitic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: Heart transplantation has been shown to be a safe and effective intervention for progressive cardiomyopathy from chronic Chagas disease. However, in the presence of the immunosuppression required for heart transplantation, the likelihood of Chagas disease reactivation is significant. Reactivation may cause myocarditis resulting in allograft dysfunction and the rapid onset of congestive heart failure. Reactivation rates have been well documented in Latin America; however, there is a paucity of data regarding the risk in non-endemic countries.

Methods: We present our experience with 31 patients with chronic Chagas disease who underwent orthotopic heart transplantation in the United States from 2012 to 2016. Patients were monitored following a standard schedule.

Results: Of the 31 patients, 19 (61%) developed evidence of reactivation. Among the 19 patients, a majority (95%) were identified by laboratory monitoring using polymerase chain reaction testing. One patient was identified after the onset of clinical symptoms of reactivation. All subjects with evidence of reactivation were alive at follow-up (median: 60 weeks).

Conclusions: Transplant programs in the United States are encouraged to implement a monitoring program for heart transplant recipients with Chagas disease. Our experience using a preemptive approach of monitoring for Chagas disease reactivation was effective at identifying reactivation before symptoms developed.
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http://dx.doi.org/10.1111/tid.12996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6289649PMC
December 2018

Impact of Nasopharyngeal FilmArray Respiratory Panel Results on Antimicrobial Decisions in Hospitalized Patients.

Can Respir J 2018 13;2018:9821426. Epub 2018 Jun 13.

Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ, USA.

Objective: To determine whether results of the nasopharyngeal FilmArray respiratory panel (NP-FARP) influenced antibiotic decisions.

Methods: We reviewed the medical records of nonintensive care unit (ICU) inpatients that had an NP-FARP performed at our institution between June 2013 and June 2014. The inpatient records were reviewed 48 hours after the NP-FARP for the following data: demographic information; NP-FARP, serum procalcitonin, and methicillin-resistant nasal swab (MRSA NS) results; antibiotics prior and post-48 hours of the NP-FARP result; and the current immunosuppression status. Clinical outcome data were not obtained. Patients were categorized into those who had a positive (+) or a negative (-) NP-FARP. We further subdivided these two categories into groups A, B, and C based on the antibiotic modifications 48 hours after their NP-FARP result. Group A included patients who were never initiated on antimicrobial therapy. Patients whose antibiotics were discontinued or deescalated were placed in group B. Patients with antibiotic escalation or continuation without change constituted group C. We compared and analyzed groups A, B, and C in the (+) and (-) NP-FARP cohorts.

Results: A total of 545 patients were included. There were 143 (26%) patients with positive and 402 (74%) patients with negative NP-FARPs. Comparison of groups A, B, and C between those with a (+) and (-) NP-FARP were as follows: (+) A and (-) A, 28/143 (20%) and 84/402 (21%); (+) B and (-) B, 59/143 (41%) and 147/402 (37%); and (+) C and (-) C, 56/143 (39%) and 171/402 (43%), respectively. We found no statistically significant differences between groups (+) A versus (-) A, (+) B versus (-) B, and (+) C versus (-) C with respect to age, gender, MRSA NS result, procalcitonin result, or concurrent immunosuppression.

Conclusion: In non-ICU inpatients, NP-FARP alone or in combination with procalcitonin or MRSA NS did not influence antibiotic decisions during the study period.
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http://dx.doi.org/10.1155/2018/9821426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6020531PMC
April 2019

Comparison of Dual β-Lactam therapy to penicillin-aminoglycoside combination in treatment of Enterococcus faecalis infective endocarditis.

J Infect 2018 11 30;77(5):398-404. Epub 2018 Jun 30.

Division of Infectious Diseases, MayoClinic, Rochester, MN, USA; Department of Cardiovascular Diseases, MayoClinic, Rochester, MN, USA.

Background: Dual β-lactam therapy and a penicillin-aminoglycoside combination are first line regimens in the treatment of penicillin-susceptible Enterococcus faecalis infective endocarditis (EFIE). Our aim was to compare ampicillin plus ceftriaxone (A+C) to ampicillin plus gentamicin (A+G) in the treatment of EFIE.

Methods: This was a retrospective cohort study of adults (≥18 years) patients diagnosed with EFIE at Mayo Clinic campuses in Rochester, Minnesota, and Phoenix, Arizona and treated with either A+C or A+G. Main outcome measurements were 1 year mortality, nephrotoxicity, and EFIE relapse rates.

Results: Eighty-five cases of EFIE were included in this investigation. The majority (n=67, 79%) of patients received A+G while 18 (21%) patients received A+C as initial treatment. On admission, patients who received A+C had a higher Charlson Comorbidity Index (median [IQR], 4 [3, 4 vs. 2 [1, 4]; P=.008) and a higher baseline serum creatinine (median [IQR], 1.2 [0.9, 1.6] vs. 0.9 [0.8, 1.2] mg/dL, P=.020). The 1 year mortality rates were similar for both treatment groups, 17% vs. 17%, P=.982. Each group had 1 case of relapsing EFIE. Patients who received A+G had worse kidney function outcome demonstrated by a greater increase in serum creatinine at end of therapy (median [IQR] difference, +0.4 [0.2, 0.8] vs. -0.2 [-0.3, 0.1] mg/dL, P≤.001).

Conclusion: A+C appears to be a safe and efficacious regimen in the treatment of EFIE. Patients treated with A+C had lower rates of nephrotoxicity and no differences in relapse rate and 1-year mortality as compared to that of the A+G group.
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http://dx.doi.org/10.1016/j.jinf.2018.06.013DOI Listing
November 2018

Basidiobolomycosis: an unusual, mysterious, and emerging endemic fungal infection.

Paediatr Int Child Health 2018 05 24;38(2):81-84. Epub 2018 Apr 24.

b Division of Infectious Diseases , Mayo Clinic , Phoenix , AZ , USA.

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http://dx.doi.org/10.1080/20469047.2018.1458772DOI Listing
May 2018

Impact of Abandoned Leads on Cardiovascular Implantable Electronic Device Infections: A Propensity Matched Analysis of MEDIC (Multicenter Electrophysiologic Device Infection Cohort).

JACC Clin Electrophysiol 2018 02 15;4(2):201-208. Epub 2017 Nov 15.

Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, Miami, Florida. Electronic address:

Objectives: This study sought to evaluate the impact of abandoned cardiovascular implantable electronic device (CIED) leads on the presentation and management of device-related infections.

Background: Device infection is a serious consequence of CIEDs and necessitates removal of all hardware for attempted cure. The merits of extracting or retaining presumed sterile but nonfunctioning leads is a subject of ongoing debate.

Methods: The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled patients with CIED infections at 10 institutions in the United States and abroad between January 1, 2009, and December 31, 2012. Within a propensity-matched cohort, relevant clinical information was compared between patients who had 1 or more abandoned leads at the time of infection and those who had none.

Results: Matching produced a cohort of 264 patients, including 176 with no abandoned leads and 88 with abandoned leads. The groups were balanced with respect to Charlson comorbidity index, oldest lead age, device type, sex, and race. At the time of admission, those with abandoned leads were less likely to demonstrate systemic signs of infection, including leukocytosis (p = 0.023) and positive blood cultures (p = 0.005). Conversely, patients with abandoned leads were more likely to demonstrate local signs of infections, including skin erosion (p = 0.031) and positive pocket cultures (p = 0.015). In addition, patients with abandoned leads were more likely to require laser extraction (p = 0.010).

Conclusions: The results of a large prospective registry of CIED infections demonstrated that patients with abandoned leads may present with different signs, symptoms, and microbiological findings and require laser extraction more than those without abandoned leads.
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http://dx.doi.org/10.1016/j.jacep.2017.09.178DOI Listing
February 2018

Clinical presentation of CIED infection following initial implant versus reoperation for generator change or lead addition.

Open Heart 2018;5(1):e000681. Epub 2018 Mar 30.

Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA.

Objective: To explore differences in clinical manifestations and outcomes in those patients who develop infection after undergoing initial implantation versus reoperation.

Methods: We compared cases of cardiac implantable electronic device (CIED) infection based on initial implantation versus reoperation from 11 centres.

Results: There were 432 patients with CIED infection, 178 occurring after initial device placement and 254 after repeat reoperation. No differences were seen in age, sex or device type. Those with infection after initial implant had a higher Charlson Comorbidity Score (median 3 (IQR 2-6) vs 2 (IQR 1-4), p<0.001), shorter time since last procedure (median 8.9 months (IQR 0.9-33.3) vs 19.5 months (IQR 1.1-62.9), p<0.0001) and fewer leads (2.0±0.6vs 2.5±0.9, p<0.001). Pocket infections were more likely to occur after a reoperation (70.1%vs48.9%, p<0.001) and coagulase negative staphylococci (CoNS) was the most frequently isolated organism in this group (p=0.029). In contrast, initial implant infections were more likely to present with higher white cell count (10.5±5.1 g/dL vs 9.5±5.4 g/dL, p=0.025), metastatic foci of infection (16.9%vs8.7%, p=0.016) and sepsis (30.9%vs19.3%, p=0.006). There were no differences in in-hospital (7.9%vs5.2%, p=0.31) or 6-month mortality (21.9%vs14.0%, p=0.056).

Conclusions: CIED infections after initial device implant occur earlier, more aggressively, and often due to . In contrast, CIED infections after reoperation occur later, are due to CoNS, and have more indolent manifestations with primary localisation to the pocket.
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http://dx.doi.org/10.1136/openhrt-2017-000681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5888434PMC
March 2018

Central nervous system histoplasmosis: Multicenter retrospective study on clinical features, diagnostic approach and outcome of treatment.

Medicine (Baltimore) 2018 03;97(13):e0245

Mira Vista Diagnostics University of Kentucky School of Medicine, Lexington, Kentucky Emory University Rollins School of Public Health Indiana University School of Medicine Indiana University Health, Indianapolis, Indiana Yale University School of Medicine, New Haven, Connecticut University of Michigan Health System, Ann Arbor, Michigan St. Luke's University Hospital and Health Network, Bethlehem Stanford University School of Medicine, Stanford University of Arizona College of Medicine, Tucson University of Tennessee Health Sciences Center, Memphis Mercy Hospital, Joplin Vanderbilt University School of Medicine, Nashville, Tennessee University of California at San Francisco School of Medicine, San Francisco University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Lahey Hospital and Medical Center, Burlington, Massachusetts University of Alabama- Birmingham, Birmingham, Alabama University of Missouri-Kansas City, Kansas City Sparks Center for Infectious Diseases, Fort Smith, Arkansas Mayo Clinic, Phoenix, Arizona Jacobi Medical Center, Bronx Metro Infectious Diseases, Chicago University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma Children's Mercy Hospital, Kansas City, Missouri University of Texas Medical Branch, Galveston Kaiser Permanente, Los Angeles, California Infectious Disease Consultants, Wichita, Kansas Premier Physicians, Midland, Texas Southern Illinois University School of Medicine, Springfield, Illinois Courage Fund, National University of Singapore, Singapore Carolinas Medical Center, Charlotte, North Carolina Icahn School of Medicine at Mount Sinai, New York, New York Emory University School of Medicine, Atlanta, Georgia.

Central nervous system (CNS) involvement occurs in 5 to 10% of individuals with disseminated histoplasmosis. Most experience has been derived from small single center case series, or case report literature reviews. Therefore, a larger study of central nervous system (CNS) histoplasmosis is needed in order to guide the approach to diagnosis, and treatment.A convenience sample of 77 patients with histoplasmosis infection of the CNS was evaluated. Data was collected that focused on recognition of infection, diagnostic techniques, and outcomes of treatment.Twenty nine percent of patients were not immunosuppressed. Histoplasma antigen, or anti-Histoplasma antibodies were detected in the cerebrospinal fluid (CSF) in 75% of patients. One year survival was 75% among patients treated initially with amphotericin B, and was highest with liposomal, or deoxycholate formulations. Mortality was higher in immunocompromised patients, and patients 54 years of age, or older. Six percent of patients relapsed, all of whom had the acquired immunodeficiency syndrome (AIDS), and were poorly adherent with treatment.While CNS histoplasmosis occurred most often in immunocompromised individuals, a significant proportion of patients were previously, healthy. The diagnosis can be established by antigen, and antibody testing of the CSF, and serum, and antigen testing of the urine in most patients. Treatment with liposomal amphotericin B (AMB-L) for at least 1 month; followed by itraconazole for at least 1 year, results in survival among the majority of individuals. Patients should be followed for relapse for at least 1 year, after stopping therapy.
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http://dx.doi.org/10.1097/MD.0000000000010245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5895412PMC
March 2018

Attempted salvage of infected cardiovascular implantable electronic devices: Are there clinical factors that predict success?

Pacing Clin Electrophysiol 2018 05 3;41(5):524-531. Epub 2018 Apr 3.

Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, CA, USA.

Background: Published guidelines mandate complete device removal in cases of cardiovascular implantable electronic device (CIED) infection. Clinical predictors of successful salvage of infected CIEDs have not been defined.

Methods: Data from the Multicenter Electrophysiologic Device Infection Collaboration, a prospective, observational, multinational cohort study of CIED infection, were used to investigate whether clinical predictors of successful salvage of infected devices could be identified.

Results: Of 433 adult patients with CIED infections, 306 (71%) underwent immediate device explantation. Medical management with device retention and antimicrobial therapy was initially attempted in 127 patients (29%). "Early failure" of attempted salvage occurred in 74 patients (58%) who subsequently underwent device explantation during the index hospitalization. The remaining 53 patients (42%) in the attempted salvage group retained their CIED. Twenty-six (49%) had resolution of CIED infection (successful salvage group) whereas 27 patients (51%) experienced "late" salvage failure. Upon comparing the salvage failure group, early and late (N = 101), to the group experiencing successful salvage of an infected CIED (N = 26), no clinical or laboratory predictors of successful salvage were identified. However, by univariate analysis, coagulase-negative staphylococci as infecting pathogens (P = 0.0439) and the presence of a lead vegetation (P = 0.024) were associated with overall failed salvage.

Conclusions: In patients with definite CIED infections, clinical and laboratory variables cannot predict successful device salvage. Until new data are forthcoming, device explantation should remain a mandatory and early management intervention in patients with CIED infection in keeping with existing expert guidelines unless medical contraindications exist or patients refuse device removal.
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http://dx.doi.org/10.1111/pace.13319DOI Listing
May 2018

Reply to Babbel et al., "Application of the DRIP Score at a Veterans Affairs Hospital".

Antimicrob Agents Chemother 2018 03 23;62(3). Epub 2018 Feb 23.

Division of Pulmonary and Critical Care Medicine at Intermountain Medical Center and the University of Utah, Salt Lake City, Utah, USA.

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http://dx.doi.org/10.1128/AAC.02337-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5826170PMC
March 2018

Culture-Proven Thorn-Associated Infections in Arizona: 10-Year Experience at Mayo Clinic.

Open Forum Infect Dis 2017 10;4(1):ofx017. Epub 2017 Feb 10.

Division of Infectious Diseases.

Background: Thorn injuries are common in the desert Southwest; however, the frequency and microbiology of thorn-associated infections have not been systematically described. Most information comes from case reports describing infections from atypical or environmental microorganisms. Our aim was to summarize the spectrum of thorn-associated infections.

Methods: We conducted a retrospective review of electronic health records for patients presenting to our institution from January 1, 2005 to December 31, 2014 for treatment of thorn-associated injuries and then focused on the patients with cultures.

Results: Of 2758 records reviewed, 1327 patients had thorn-associated injuries; however, only 58 (4.4%) had cultures. Of these patients, 37 (64%) had positive findings; 5 had polymicrobial infection. The most commonly identified organisms were (n = 22, 59.0%) and coagulase-negative species (n = 8, 21.6%). Other pathogens included species (n = 3, 8.1%), species (n = 2, 5.4%), Gram-negative bacteria (n = 2, 5.4%), species (n = 2, 5.4%), (n = 1, 2.7%), and species (n = 1, 2.7%). There were no infections caused by , , or spp.

Conclusions: In contrast to most published case reports, we found that typical cutaneous microorganisms, such as species, caused the majority of culture-positive, thorn-related infections.
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http://dx.doi.org/10.1093/ofid/ofx017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5414025PMC
February 2017

Reimplantation and Repeat Infection After Cardiac-Implantable Electronic Device Infections: Experience From the MEDIC (Multicenter Electrophysiologic Device Infection Cohort) Database.

Circ Arrhythm Electrophysiol 2017 Mar;10(3)

From the Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, FL (T.A.B.); Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); Department of Medicine, Division of Cardiology, University of Washington, Seattle (J.M.P.); Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, PA (A.J.G.); Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, MN (L.M.B., K.L., M.R.S.); Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston (S.B.D.); Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Spain (J.M.T., J.M.M.); Department of Medicine, Division of Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC (J.P.); and Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, AZ (H.R.V.).

Background: Infection is a serious complication of cardiovascular-implantable electronic device implantation and necessitates removal of all hardware for optimal treatment. Strategies for reimplanting hardware after infection vary widely and have not previously been analyzed using a large, multicenter study.

Methods And Results: The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled subjects with cardiovascular-implantable electronic device infections at multiple institutions in the United States and abroad between 2009 and 2012. Reimplantation strategies were evaluated overall, and every patient who relapsed within 6 months was individually examined for clinical information that could help explain the negative outcome. Overall, 434 patients with cardiovascular-implantable electronic device infections were prospectively enrolled at participating centers. During the initial course of therapy, complete device removal was done in 381 patients (87.8%), and 220 of them (57.7%) were ultimately reimplanted with new devices. Overall, the median time between removal and reimplantation was 10 days, with an interquartile range of 6 to 19 days. Eleven of the 434 patients had another infection within 6 months, but only 4 of them were managed with cardiovascular-implantable electronic device removal and reimplantation during the initial infection. Thus, the repeat infection rate was low (1.8%) in those who were reimplanted. Patients who retained original hardware had a 11.3% repeat infection rate.

Conclusions: Our study findings confirm that a broad range of reimplant strategies are used in clinical practice. They suggest that it is safe to reimplant cardiac devices after extraction of previously infected hardware and that the risk of a second infection is low, regardless of reimplant timing.
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http://dx.doi.org/10.1161/CIRCEP.116.004822DOI Listing
March 2017

Microbiologic yield of bronchoalveolar lavage specimens from stem cell transplant recipients.

Transpl Infect Dis 2017 Jun 12;19(3). Epub 2017 Apr 12.

Division of Infectious Diseases, Mayo Clinic Hospital, Phoenix, AZ, USA.

Purpose: Stem cell transplant (SCT) recipients commonly undergo bronchoalveolar lavage (BAL) collection as an infectious pulmonary work-up. Previous studies report the utility and overall diagnostic yield of fiberoptic bronchoscopy with BAL in this vulnerable population, though none focused purely on microbiologic yield or made comparisons with less invasive means of pathogen detection. We sought to determine and elaborate on the microbiologic yield of BAL in SCT recipients, assess a correlation between BAL studies and less invasive means of pathogen detection, and assess the utility of repeating a BAL within 30 days.

Methods: Between January 1, 2009, and July 31, 2013, we reviewed medical records of 125 SCT recipients who underwent 179 BALs. In addition to demographic information and details pertaining to their SCT, a comprehensive review of their microbiologic data was performed and recorded.

Results: Our study showed an overall BAL microbiologic yield of 40%, despite 92% of patients receiving broad-spectrum antimicrobial therapy at the time of the BAL procedure.

Conclusions: Although an initial BAL sample in this population provides crucial microbiologic information, repeating the procedure within 30 days may have minimal additional microbiologic yield. BAL continues to be an essential diagnostic tool in SCT recipients undergoing an infectious pulmonary work-up.
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http://dx.doi.org/10.1111/tid.12684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169705PMC
June 2017

Coccidioidomycosis in Patients with Selected Solid Organ Cancers: A Case Series and Review of Medical Literature.

Mycopathologia 2016 Dec 4;181(11-12):787-798. Epub 2016 Aug 4.

Division of Infectious Diseases, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.

Coccidioidomycosis is a common infection in the desert southwestern USA; approximately 3 % of healthy persons in Arizona alone become infected annually. Coccidioidomycosis may be severe in immunocompromised persons, but experience among patients with solid organ cancer has not been fully described. Therefore, we aimed to describe the clinical courses of patients whose cancers were complicated by coccidioidomycosis at our institution, which is located in an area with endemic Coccidioides. To do so, we conducted a retrospective review from January 1, 2000, through December 31, 2014, of all patients with breast, colorectal, or ovarian cancer whose cancer courses were complicated by coccidioidomycosis. We identified 17,576 cancer patients; 14 (0.08 %) of these patients met criteria for proven or probable coccidioidomycosis diagnosed within the first 2 years after the cancer diagnosis. All of these patients had primary pulmonary coccidioidomycosis, none had relapsed prior infection, and 1 had possible extrapulmonary dissemination. Five had active coccidioidal infection during chemotherapy, 1 of whom was hospitalized for coccidioidal pneumonia. All were treated with fluconazole, and all improved clinically. Eleven did not require prolonged courses of fluconazole. There were no clearly demonstrated episodes of relapsed infection. In conclusion, coccidioidomycosis was not a common complication of breast, colorectal, or ovarian cancers in patients treated at our institution, and it was not commonly complicated by severe or disseminated infection.
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http://dx.doi.org/10.1007/s11046-016-0044-1DOI Listing
December 2016

Gastric lap-band infection due to Mycobacterium abscessus presenting as new-onset ascites in a cirrhotic patient.

Infect Dis (Lond) 2016 Aug 25;48(8):632-5. Epub 2016 May 25.

g Division of Infectious Diseases , Mayo Clinic Hospital , Phoenix , AZ , USA.

Nontuberculous mycobacteria are ubiquitous environmental organisms that are infrequently implicated as pathogens. Peritoneal infection with nontuberculous mycobacteria is rare and published reports are most commonly associated with peritoneal dialysis. This study describes a case of a 41-year-old woman with cirrhosis who had Mycobacterium abscessus peritonitis and an abdominal abscess resulting from infection of a remotely placed gastric band (Lap-Band; Apollo Endosurgery, Inc).
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http://dx.doi.org/10.3109/23744235.2016.1143116DOI Listing
August 2016

Derivation and Multicenter Validation of the Drug Resistance in Pneumonia Clinical Prediction Score.

Antimicrob Agents Chemother 2016 05 22;60(5):2652-63. Epub 2016 Apr 22.

Division of Pulmonary and Critical Care Medicine at Intermountain Medical Center and the University of Utah, Salt Lake City, Utah, USA.

The health care-associated pneumonia (HCAP) criteria have a limited ability to predict pneumonia caused by drug-resistant bacteria and favor the overutilization of broad-spectrum antibiotics. We aimed to derive and validate a clinical prediction score with an improved ability to predict the risk of pneumonia due to drug-resistant pathogens compared to that of HCAP criteria. A derivation cohort of 200 microbiologically confirmed pneumonia cases in 2011 and 2012 was identified retrospectively. Risk factors for pneumonia due to drug-resistant pathogens were evaluated by logistic regression, and a novel prediction score (the drug resistance in pneumonia [DRIP] score) was derived. The score was then validated in a prospective, observational cohort of 200 microbiologically confirmed cases of pneumonia at four U.S. centers in 2013 and 2014. The DRIP score (area under the receiver operator curve [AUROC], 0.88 [95% confidence interval {CI}, 0.82 to 0.93]) performed significantly better (P = 0.02) than the HCAP criteria (AUROC, 0.72 [95% CI, 0.64 to 0.79]). At a threshold of ≥4 points, the DRIP score demonstrated a sensitivity of 0.82 (95% CI, 0.67 to 0.88), a specificity of 0.81 (95% CI, 0.73 to 0.87), a positive predictive value (PPV) of 0.68 (95% CI, 0.56 to 0.78), and a negative predictive value (NPV) of 0.90 (95% CI, 0.81 to 0.93). By comparison, the performance of HCAP criteria was less favorable: sensitivity was 0.79 (95% CI, 0.67 to 0.88), specificity was 0.65 (95% CI, 0.56 to 0.73), PPV was 0.53 (95% CI, 0.42 to 0.63), and NPV was 0.86 (95% CI, 0.77 to 0.92). The overall accuracy of the HCAP criteria was 69.5% (95% CI, 62.5 to 75.7%), whereas that of the DRIP score was 81.5% (95% CI, 74.2 to 85.6%) (P = 0.005). Unnecessary extended-spectrum antibiotics were recommended 46% less frequently by applying the DRIP score (25/200, 12.5%) than by use of HCAP criteria (47/200, 23.5%) (P = 0.004), without increasing the rate at which inadequate treatment recommendations were made. The DRIP score was more predictive of the risk of pneumonia due to drug-resistant pathogens than HCAP criteria and may have the potential to decrease antibiotic overutilization in patients with pneumonia. Validation in larger cohorts of patients with pneumonia due to all causes is necessary.
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http://dx.doi.org/10.1128/AAC.03071-15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4862530PMC
May 2016

Laryngeal cryptococcosis: Literature review and guidelines for laser ablation of fungal lesions.

Laryngoscope 2016 07 4;126(7):1625-9. Epub 2015 Nov 4.

Division of Otolaryngology-Head and Neck Surgery, Mayo Clinic Hospital, Phoenix, Arizona.

Objectives/hypothesis: To describe the demographics, clinical manifestations, diagnosis, treatment, and outcomes of laryngeal cryptococcosis. Antifungal therapy guidelines are provided and the use of laser ablation is discussed.

Data Sources: PubMed, OVID MEDLINE, and Embase databases and one patient who presented to our institution's otolaryngology department.

Review Methods: A review of the English-language international medical literature was conducted using the terms ("larynx" or "laryngeal diseases") and ("Cryptococcus" or "cryptococcosis") to identify reported cases of laryngeal cryptococcosis. Databases were searched from inception through January 2015.

Results: Eighteen cases were identified and reviewed, including the first reported case of potassium-titanyl-phosphate laser ablation. All patients presented with hoarseness, and two (11%) presented with acute airway obstruction that required tracheotomy. Six patients (33%) were immunocompromised, including three (17%) who had an underlying human immunodeficiency virus infection. Seven cases (39%) described an exophytic mass. Histopathology indicated pseudoepitheliomatous hyperplasia in seven of the 17 reported results (41%). Methenamine silver stain was used in 12 of the 15 described cases (80%) to identify the fungus. Lumbar puncture results were reported for seven patients, none of whom had meningitis. Antifungal therapy was used in 15 cases (83%), and two (11%) received additional laser ablation treatment. Eleven patients (61%) had complete resolution.

Conclusions: Laryngeal cryptococcosis is a rare cause of persistent hoarseness. Most patients have complete resolution after treatment. For complex and obstructive cases, laser ablation coupled with antifungal therapy can successfully manage laryngeal cryptococcosis in select patients.

Level Of Evidence: NA Laryngoscope, 126:1625-1629, 2016.
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http://dx.doi.org/10.1002/lary.25749DOI Listing
July 2016

FilmArray Respiratory Panel Assay: Comparison of Nasopharyngeal Swabs and Bronchoalveolar Lavage Samples.

J Clin Microbiol 2015 Dec 16;53(12):3784-7. Epub 2015 Sep 16.

Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA

The FilmArray respiratory panel (FARP) reliably and rapidly identifies 17 viruses and 3 bacterial pathogens. A nasopharyngeal swab FARP (NP FARP) is performed for many patients with respiratory symptoms. For patients who are acutely ill or immunocompromised or fail to improve, a bronchoalveolar lavage sample FARP (BAL FARP) is performed in addition to the NP FARP. To date, no studies have compared the yield of a BAL FARP with that of an NP FARP. We retrospectively studied all patients who had a BAL FARP within 7 days after an NP FARP between June 2013 and May 2014. Demographic information, comorbidities, FARP results, and all microbiologic data from BAL fluid were collected. Eighty-six patients had a BAL FARP performed within 7 days (mean, 1.6; median, 1) after an NP FARP. Of these, 66 (77%) had concordant BAL and NP FARP results: 15 (23%) had the same pathogen identified from the NP and BAL FARPs, and 51 (77%) had concordant negative FARP results. In 18 of the 86 patients (21%), a pathogen was detected from the NP FARP; of these, 15 (83%) had a concordant match on a subsequent BAL FARP, and the remaining 3 had negative BAL FARPs. In 17 of the 86 patients (20%), pathogens were identified from the BAL FARPs that were not detected by the NP FARPs; of these, 16 (94%) had initial negative NP FARPs. The data suggest that once a pathogen is identified by an NP FARP, a subsequent BAL FARP is unlikely to add new microbiologic information. However, a BAL FARP may provide new, useful microbiologic information when performed within 7 days after a negative NP FARP.
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http://dx.doi.org/10.1128/JCM.01516-15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4652125PMC
December 2015

Coccidioidal Tenosynovitis of the Hand and Wrist: Report of 9 Cases and Review of the Literature.

Clin Infect Dis 2015 Nov 3;61(10):1514-20. Epub 2015 Aug 3.

Division of Infectious Diseases.

Background: Tenosynovitis is an uncommon manifestation of disseminated infection with Coccidioides fungal species. Most experts treat this infection with combined surgical debridement and antifungal medication. The aim of our study was to examine the outcomes of patients with coccidioidal tenosynovitis of the hand and wrist.

Methods: We retrospectively searched for the records of patients with coccidioidal tenosynovitis of the hand and wrist at our institution. between 1987 and 2013. We also conducted a review of the literature from 1950 to 2014 to identify additional cases.

Results: We identified 9 cases of coccidioidal tenosynovitis of the hand and wrist at our institution, along with 5 other cases found in a review of the literature. The relapse rate was high overall (50%) and was higher after discontinuation of antifungal therapy (71%) in both immunocompromised and immunocompetent patients. Results of serologic testing were not predictive of relapse.

Conclusions: A treatment strategy for coccidioidal tenosynovitis should focus on long-term administration of antifungal agents.
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http://dx.doi.org/10.1093/cid/civ642DOI Listing
November 2015

Histopathology of Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Immunotherapy for Urothelial Carcinoma.

Int J Surg Pathol 2015 May 22;23(3):189-95. Epub 2015 Jan 22.

Mayo Clinic, Scottsdale, AZ, USA.

Intravesical instillation of Bacillus Calmette-Guérin (BCG) is a mainstay of adjunctive therapy for superficial bladder cancer. Disseminated BCG infection ("BCG-osis") after this therapy is rare and potentially life-threatening; only isolated case reports detail the histopathologic findings thereof, few of which had a diagnosis confirmed by molecular testing. We report 3 additional cases of BCG-osis complicating BCG therapy, all confirmed by cultures and molecular assays, including the first cases of wedge biopsy-confirmed BCG pneumonia and BCG olecranon bursitis. When suggested by a relevant clinical history, recognition of randomly distributed granulomas in any organ should prompt consideration of BCG-osis and liberal performance of AFB stains, aided by targeted molecular assays. Physicians should maintain a high index of suspicion when miliary infiltrates arise after intravesical BCG instillation, and close multidisciplinary communication is essential. Pathologist awareness of this rare cause of granulomatous inflammation aids recognition of BCG-osis and facilitates prompt initiation of antimycobacterial therapy.
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http://dx.doi.org/10.1177/1066896914567332DOI Listing
May 2015
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