A 29-year-old man with type 1 diabetes presented to the emergency department with shortness of breath and chest pain that had lasted for one week. The patient initially reported no systemic symptoms. However, upon further questioning, he stated that he had felt generally unwell for the past year, with fevers, night sweats and weight loss. He had not been coughing and had not felt chest pain or shortness of breath before this presentation. He had no recent travel history or sick contacts. The patient was taking insulin and pantoprazole. In addition, he reported that he had been inhaling marijuana daily through a vapourizer for the past 18 months to relieve neuropathic pain secondary to his diabetes. The marijuana was street purchased and always from the same supplier. He did not use any other illicit substances, and he was not taking any narcotics at the time of admission, but he had used oxycodone periodically during the previous year to relieve neuropathic pain. The patient worked as a professional in an urban area.His diabetes had been diagnosed one year earlier and was heralded by a six-month history of neuropathy. He was also found to have diabetic retinopathy. Two months after the diagnosis, the patient had received treatment for community-acquired pneumonia with evidence of infiltrate in the left lower lobe on chest radiograph. A follow-up radiograph was not performed. Computed tomography of the patient's abdomen several months later, performed for unrelated reasons, had shown evidence of ongoing left basilar and pleural consolidation.On physical examination, the patient's temperature was 36.6°C, his heart rate was 80 beats/ min, his respiratory rate was 18 breaths/min and his blood pressure was 125/85 mm Hg. He had an oxygen saturation of 100% on room air. A respiratory examination showed decreased air entry to his left lung base. The rest of the examination was unremarkable.A radiograph of the patient's chest showed a left pneumothorax with air space disease in the left lower lobe (Figure 1). Computed tomography of the chest showed a left pneumothorax and left lower lobe consolidation with cavitation, likely communicating with the pleura (Figure 2). Despite treatment with a chest tube, the pneumothorax persisted. Video-assisted thoracoscopic surgery was done for diagnostic and therapeutic purposes. Diffuse pleural adhesions were found, which required decortication and a wedge resection of the superior segment of the left lower lobe.Tissue samples from the wedge resection grew Aspergillus rugolosa, confirmed by DNA sequencing, a Penicillium species and a nonsporulating fungus. Samples of the patient's pleural fluid grew Aspergillus fumigatus. Histopathologic examination of biopsy specimens confirmed parenchymal and pleural invasion by hyphal elements (Figure 3). The result of a serum galactomannan test was negative, as was an immunoglobulin E assay for A. fumigatus.The patient's immunoglobulins were normal, with the exception of a mildly low level of immunoglogulin G4. HIV serology was negative, lymphocyt...

Introduction: Candidemia carries significant morbidity and mortality for hospitalized patients. Local epidemiology is needed to develop strategies to reduce infections. This article describes the epidemiology of candidemia at a tertiary-care hospital in Edmonton, Canada. Methods: Between 2004 and 2013, 250 episodes of candidemia were identified using an infection control database. Binary logistic regression analysis was used to identify risk factors for non-albicans isolates and for mortality. Results: The candidemia rate increased significantly, from 0.387/10,000 patient days (PD) in 2004 to 1.45/10,000 PD in 2013 (p=0.0061). The 30-day and overall in-hospital mortality rates were 38% and 47%, respectively. Candida albicans and C. glabrata represented 80% of isolates. Overall, 48% of episodes were attributable to central venous catheter (CVC) infections. The ratio of C. albicans to non-albicans isolates and the rate of CVC infections did not change significantly over the study period (p=0.98 and 0.14, respectively). Preceding azole therapy within 30 days of candidemia conferred an increased risk of a non-albicans isolate (odds ratio [OR] 2.59, 95% CI 1.24 to 5.43). Mortality was increased with immunosuppression (OR 3.30, 95% CI 1.74 to 6.24) and age, with an OR of 2.78 (95% CI 1.21 to 6.38) for the 61- to 68-year-old age group and an OR of 4.30 (95% CI 1.84 to 10.04) for the >69-year-old age group. Mortality was similar among C. albicans and non-albicans infections (OR 0.85, 95% CI 0.49 to 1.45). Conclusion: Candidemia at the authors' institution increased during the study period without a significant change in the ratio of C. albicans to other Candida spp. The risk of non-albicans candidemia was affected by previous azole therapy, and the risk of mortality was higher with increased age and immunosuppression. The etiology of the increased candidemia rate is likely complex, and strategies to address this, as well as the high mortality rate seen with candidemia, are needed.

BACKGROUND: Patients with chronic hepatitis B (CHB) are at risk of complications and require lifelong monitoring. We evaluated the care of newly diagnosed CHB patients. METHODS: Adult CHB cases newly diagnosed in Alberta between January 1, 2008, and December 31, 2012, were identified, with follow-up through June 1, 2014. Rates of completion of baseline investigations, receipt of antiviral therapy when indicated, and adherence to hepatocellular carcinoma (HCC) screening recommendations in a cohort of high-risk patients were compared between those who did or did not see a CHB specialist. RESULTS: Of 3,333 patients with CHB, 87.1% ( n = 2,904) received non-specialty care. Specialty assessment was associated with higher completion of alanine aminotransferase, hepatitis B e antigen (HBeAg), anti-HBe, and hepatitis B DNA ( p <0.0001) and all four parameters (86.5%) compared with non-specialist care (42.7%; p <0.0001). In a subgroup of high-risk patients for HCC, specialty care was associated with higher completed baseline abdominal ultrasounds ( n = 44; 89.8%,) compared with non-specialist care (62.5%; n = 320; p = 0.0001) and greater adherence to annual surveillance (30.6% versus 15.2%; p = 0.0057). Patients in the HBeAg-positive chronic hepatitis phase meeting criteria for antiviral therapy were more likely to receive treatment under specialty care ( n = 6; 75.0%) than non-specialty care ( n = 27; 33.3%; p = 0.0478). CONCLUSIONS: Our study highlights inadequate care among newly diagnosed CHB patients in Alberta. Specialty assessment was associated with improved quality of care. Interventions are needed to improve linkage to specialty care.