No abstract

Scytalidium dimidiatum, a dematiaceous fungus, has been well established as an agent of dermatomycosis. There are few reports of invasive infection caused by S. dimidiatum; most infections occurred in immunocompromised hosts. We present an immunocompetent patient with pleural S. dimidiatum infection and review nine other published cases of invasive S. dimidiatum infections. CASE REPORTA 56-year-old male was admitted for evaluation after a few months of progressive dyspnea, fever, night sweats, and loss of weight. His past medical history was significant for rheumatic heart disease, which had necessitated mitral valve commissurotomy 20 years prior to his admission. As a consequence, he suffered from moderate mitral and tricuspid regurgitation and moderate right heart failure, manifesting as chronic pleural effusion. He was treated with 40 mg/day furosemide and warfarin due to chronic atrial fibrillation. The last thoracentesis, performed 3 years earlier, had yielded a bloody exudate, but no pathogen was isolated.On admission the patient appeared cachectic, had mild dyspnea, and was afebrile. The jugular veins were maximally distended. Chest examination revealed dullness to percussion and reduced breath sounds over the right lung base, and a systolic heart murmur was heard at the apex, compatible with mitral regurgitation. Hepatosplenomegaly and moderate peripheral edema were noted as well.Significant laboratory findings were as follows: leukocyte count, 5,600 cells/l with 61% neutrophils; hemoglobin level, 11.7 g/dl; platelet count, 164,000 platelets/l; serum creatinine level, 111 mol/liter; international normalized ratio, 2.41; lactate dehydrogenase, 751 IU/liter; ␥-glutamyl transpeptidase, 133 IU/liter; alkaline phosphatase, 257 IU/liter. Chest computed tomography revealed a large loculated pleural effusion on the right with pleural thickening and total passive collapse of the right middle and lower lobes. Numerous enlarged mediastinal lymph nodes, up to 1.5 cm, were noted. Echocardiography showed enlargement of the right atrium and ventricle, in addition to mitral valve stenosis and regurgitation and moderate pulmonary hypertension.A diagnostic thoracentesis revealed bloody exudative fluid with hemoglobin of 4.3 g/dl and white blood cell count of 2,600 cells/l with 66% neutrophils. The lactate dehydrogenase level was 22,600 IU/liter. Septate hyphae were detected by calcofluor staining (Fig. 1A). Culture on blood agar plates yielded a white hairy mold (Fig. 1B), which progressed into a grayish black fungus (Fig. 1C). MICs were determined by Etest (AB Biodisk, Solna, Sweden). The mold was found to be susceptible to amphotericin B and voriconazole (MICs, 0.032 mg/liter) and to posaconazole (MIC, 0.75 mg/liter) but resistant to fluconazole (MIC, Ͼ256 mg/liter) and itraconazole and caspofungin (MICs, Ͼ32 mg/liter).The patient was treated for 2 weeks with intravenous voriconazole at 4 mg/kg of body weight every 12 h with no clinical or radiological improvement, and an exploratory right thoracotomy was performed. Nec...

Patients admitted to hospital with influenza B and A in Jerusalem, Israel, during the 2015–2016 and 2017–2018 influenza seasons demonstrated similar rates of intensive care unit (ICU) admission and associated disease severity. Most (63%) influenza B ICU patients received influenza B–mismatched trivalent vaccine. These findings call into question the equivalence of trivalent and quadrivalent vaccines in preventing severe influenza B.

Persistent nephrogram, the hallmark of radiocontrast-induced kidney failure, is usually homogenous throughout the kidney and is considered as a generalized shutoff of glomerular filtration, the consequence of altered glomerular hemodynamics, affecting most glomeruli. Herein, we report an incidental finding of scattered persistent nephrogram that was noted in a septic prediabetic hypertensive patient during computerized tomography-guided drainage of a liver abscess. The peculiar patchy striated distribution pattern suggests more centrally altered renal hemodynamics, with hypoperfusion at the level of interlobar and intralobular arteries. Altered renal microcirculation in this case is likely related to the combined effects of prediabetes, sepsis and contrast medium upon renal blood flow regulation, perhaps with consequent focal hypoxic tubular damage.

Bacteremia is common following TIPS. Risk factors associated with bacteremia include failure to use prophylactic antibiotics, hypothyroidism, HCV and a long procedure. Our results strongly support the use of prophylaxis as a means to decrease early post TIPS infections.