Osteomyelitis is an inflammation of bone caused by a pyogenic organism. Osteomyelitis is one of the most important musculoskeletal infections, commonly occurring in long bones. Vertebral osteomyelitis is fairly rare and is often overlooked. It is usually acquired hematogenously, although there are other ways of infection. Only about half of patients develop fever > 38 °C and symptoms are unspecific. The most common organism is Staphylococcus aureus, with Pseudomonas aeruginosa being an unexpected pathogen accounting for about 6%. We present a case of a 56-year-old Hispanic male that visited emergency room presenting with back pain of 3 weeks of evolution being discharged home. Patient returned 2 days after with no improvement. Blood test returned under normal range. Physical exam showed a focal tenderness at thoracic level. Blood culture recovered Pseudomonas aeruginosa sensitive to levofloxacin. CT/MRI was performed and showed vertebral osteomyelitis. Antibiotic was started for 6 weeks. Therapy was guided with erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP). Patient was evaluated monthly for 6 months and improved. Vertebral osteomyelitis is a challenging diagnosis. The consequences of the disease are dire if not diagnosed on time. Historically, the diagnosis of vertebral osteomyelitis remains in a positive culture of bone biopsy. Nowadays, when handling a suspected hematogenous vertebral osteomyelitis, blood culture has gained importance. Whether a blood culture recovered a pathogen, therapy should be based on sensitivity and can be guided following ESR/CRP levels. This type of management can preclude invasive and expensive methods, such as bone biopsy.

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Introduction: Pneumonia is defined as an infection of the parenchyma of the lung and is one of the most common causes of death from infectious diseases in the United States (US). Pneumonia is classified into two groups; community acquired pneumonia (CAP) and hospital acquired pneumonia (HAP). Most CAPs are secondary to bacterial pathogens. Methicillin resistant Staphylococcus aureus (MRSA) is identified as a potential pathogen in 8.9% of CAP cases. Community acquired methicillin resistant Staphylococcus aureus (CA-MRSA) produces a cytotoxin called Panton–Valentine leukocidin (PVL), which causes white blood cell destruction and necrosis, resulting in necrotizing pneumonia when it reaches the lungs. Vancomycin and linezolid are most common recommended antibiotics when treating MRSA necrotizing pneumonia. Ceftaroline fosamil, a fifth-generation cephalosporin, is approved for the treatment of skin and soft tissue infection caused by MRSA and pneumonia, but it has not been approved for MRSA pneumonia. Case Report: A 72-year-old Hispanic male presented with a medical history of hypertension, diabetes mellitus type 2, chronic kidney disease stage 3B, unspecified chronic thrombocytopenia and asthma developed an upper respiratory tract infection that manifested with fever and rhinorrhea and resolved without treatment. Ten days later, the patient arrived at the emergency room due to productive cough of rust colored sputum that started three days before admission. Associated symptoms included malaise, fever, chills and shortness of breath. The patient was admitted to medicine ward with diagnosis of CAP and was initially managed with azithromycin/ceftriaxone. However, persistent fever and tachypnea resulted in the need for reassessment. Sputum culture revealed MRSA and the patient was switched to ceftaroline fosamil for a 21-day course of treatment. Patient was discharged home and has been followed at the outpatient clinic with none of the aforementioned symptoms. Conclusion: Methicillin resistant Staphylococcus aureus necrotizing pneumonia is an uncommon cause of CAP, but its incidence has increased during the recent years. This type of CAP has gained notoriety due to the PVL cytotoxin, with its dire results. Vancomycin and linezolid are the most recommended antibiotics; vancomycin is recommended if the bacteria show a minimum inhibitory concentration (MIC) < 2. In this case, the S. aureus recovered at sputum culture showed a MIC >2 and since the patient presented with several additional comorbidities management was started with ceftaroline fosamil, a fifth-generation cephalosporin that has no hepatic adjustment and has no problem in thrombocytopenic patients. The ceftaroline fosamil was administered at 400 mg intravenously every 12 hours for 21 days. The patient improved clinically and was discharged home and followed the next week then monthly for two months.

Cryptococcus is a fungus related to bird droppings (especially pigeons). It is described as an opportunistic pathogen. The leading defense against this fungus is the T-cell immunity, reason why it is related to immunocompromised patients (human immunodeficiency virus (HIV), organ transplant patients among others). The annual incidence is 0.4 -1.3 per 100,000. The central nervous system (CNS) involvement is the most common manifestation in an immunocompromised patient; conversely it is a very uncommon manifestation in non-immunocompromised patients. A 32-year-old Hispanic male patient with no medical history, heterosexual and no toxics habits visited our institution, after visiting three emergency rooms for 1 week, complaining of general malaise, constant non-throbbing holocephalic headache 4/10 and low-grade fever of 12 days of evolution. Labs were unremarkable and vital signs showed fever of 38.6 °C. Physical exam was remarkable for neck stiffness. Patient was admitted with suspected meningitis. HIV test was negative and lumbar puncture showed increased opening pressure and India ink stain was positive. Patient was managed successfully with fluconazole. CNS cryptococcosis in non-immunosuppressed patients is extremely unusual. Diagnosis could be delayed because of low suspicious index in healthy population. Most experts recommend amphotericin B combined with flucytosine. Our patient was managed successfully with fluconazole IV followed with oral fluconazole. Patients from countries where flucytosine is unavailable and cannot tolerate amphotericin B can benefit from fluconazole.