Background: Multiple choroidal granulomas are a rare presentation of tuberculosis. Choroidal granulomas in immunocompetent patients can pose difficulty in diagnosis as in most cases systemic examination may not reveal any evidence of tuberculosis. We report a case of bilateral multiple choroidal granulomas with systemic vasculitis-like features and disseminated tuberculosis in an immunocompetent patient without pulmonary involvement. Findings: A 26-year-old male Indian patient presented with bilateral blurred vision and systemic illness with vasculitis-like features. Examination revealed bilateral multiple choroidal granulomas and multisystem involvement without pulmonary involvement. Aqueous tap was positive for mycobacterium by polymerase chain reaction along with tissue biopsy leading to diagnosis. There was a good systemic and ocular response to anti-tubercular therapy with resolution of lesions.
radiograph and computed tomography indicated extensive bilateral infiltrates. She was transferred to the intensive care unit and was intubated. B. cereus was also isolated from five blood sample cultures at that time. After isolating B. cereus , we switched antibiotics to a combination of imipenem and levofloxacin, which were effective. She had no history of immunodeficiency, surgery, ill close contacts, risk factors for HIV or tuberculosis, recent central venous catheter insertion, or anthrax vaccination. She improved and was discharged from the intensive care unit after several days. Conclusion: This is a rare case of B. cereus pneumonia in an immunocompetent patient, who subsequently recovered. Bacillus should be considered as a potential pathogen when immunocompetent patients develop severe pneumonia. Keywords: Bacillus cereus , Pneumonia, Immunocompetent patient
In conclusion, the appearance of a Cryptococcus central nervous system infection in an immunocom- petent patient may be different from that commonly encountered in the immunocompromised. Cryptococ- cosis should be considered in the differential when multiple cystic lesions are noted in the basal ganglia, even in an immunocompetent patient. Marked ring enhancement of the basal ganglia lesions may be seen; this enhancement probably represents the pa- tient’s ability to mount an immune response, which would be uncommon in an immunocompromised pa- tient. Marked surrounding edema may also be a fea- ture of this infection. An interesting finding seen in this patient was the changing patterns of restricted diffusion in the lesions (findings somewhat similar to those seen in other infections with different stages of evolution) and the increased uptake on the thallium– single-photon emission tomography imaging.
Copyright © 2012 Andre Pinto et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A 55-year-old HIV-negative white male presented with right ear deafness, right axillary lymphadenopathy, and weight loss. Laboratory findings included anemia, marked leukocytosis, and thrombocytopenia. Examination of the peripheral smear demonstrated the presence of increased circulating blast-like cells of intermediate size, with basophilic cytoplasm and nuclei with open chromatin. MRI of the brain was compatible with hemorrhagic labyrinthitis. Excisional biopsy of the axillary mass revealed an enlarged lymph node with eﬀaced architecture and “starry sky” appearance. The cells expressed CD20, CD10, BCL6, and surface kappa immunoglobulin light chain, with a high proliferative index by immunohistochemistry and flow cytometry. Subsequent bone marrow biopsy was hypercellular (approximately 95%), with blast-like cells virtually replacing all hematopoietic elements. Routine karyotype as well as FISH analysis of bone marrow cells demonstrated rearrangement of the MYC gene at chromosome 8q24 region, IGH/MYC fusion, and additional signal for IGH gene. We present herein a case of sporadic Burkitt lymphoma occurring in a previously healthy HIV-negative male. The unusual clinical findings in this case include the relatively older age at presentation (55 years), an immunocompetent patient who had nodal involvement and leukemic phase of Burkitt, coupled with partial deafness. A brief educational review of this neoplasm is made.
Nocardial brain abscesses present as characteristic hyperenhanced multiloculated ring lesions. Perilesional edematous changes also might be present. It is some- times difficult to differentiate a brain abscess from intra- cranial metastatic malignancy on regular MRI . However, diffusion weighted imaging (DWI) and appar- ent diffusion coeffient (ADC) map could be very helpful in the differentiate diagnosis, with brain abscess showing the characteristic homogeneously heperintense lesions on DWI and hypointense lesion on ADC. The restricted Brownian motion of water molecules in the organized purulent milieu of microorganisms, macromolecules and inflammatory cells contributes to the signal of restricted diffusion on DWI . Our patient displayed these imaging characteristics and clinical manifestation without fever, and she is an immunocompetent patient. As a result, we made a diagnosis as metastatic tumor when combined the clinical presentation and preoperative CT of lungs and MRI scans without DWI and ADC when patient admitted. And then, the diagnosis of brain abscess were made when DWI and ADC map were completed.
A 32-year-old male chronic smoker (16 cigarettes per day; 8 pack years) presented with long standing non-productive cough with streaky hemoptysis and low grade fever for the preceding 4 months, associated with significant weight loss (17 kg over a 4-month period) and loss of appetite. The patient received symptomatic management for the cough and fever before presenting to the clinic. Routine blood investigations showed elevated total leucocyte count to 14,000 per cubic millimeters (70% neutrophils, 25% lymphocytes, 5% monocytes) and an elevated ESR value (45 mm/ hour). A routine sputum examination for acid fast bacilli (AFB) and a smear and culture for Mycobacterium tuberculosis was done in light of the patient's long-standing cough in an endemic area. However, the smear/culture was negative for AFB. The chest radiograph of the patient showed left parasternal opacity suggestive of To cite this article: Anandpara KM, Aswani Y, Hira P. Large solitary pulmonary cryptococcoma mimicking lung carcinoma in an immunocompetent patient. Malays J Med Sci. 2018;25(1):114–118. https://doi. org/10.21315/mjms2018.25.1.13
Tuberculosis (TB) remained as one of the top 10 causes of death worldwide despite an overall decline in its incidence rate globally. Extrapulmonary TB is uncommon and only accounts for 10–20% of overall TB disease burden. Abdominopelvic TB is the sixth most common location of extrapulmonary TB. The symptoms and signs are often insidious and nonspecific. Diagnosing abdominopelvic TB can be very challenging at times and poses great difficulties to the clinician. Infection with nontuberculous Mycobacterium (NTM) is even rarer especially in an immunocompetent patient. We report a case of NTM in abdominopelvic TB. A 37-year-old foreign worker, para 3, presented with a one-week history of suprapubic pain associated with fever. An assessment showed presence of a right adnexal mass. She was treated as tuboovarian abscess with intravenous antibiotics. Unfortunately, she did not respond. She underwent exploratory laparotomy. Intraoperatively, features of the mass were suggestive of a right mature cystic teratoma with presence of slough and cheesy materials all over the abdominal cavity as well as presence of ascites. Diagnosis of NTM was confirmed with PCR testing using the peritoneal fluid. This case was a diagnostic dilemma due to the nonspecific clinical presentation. Management of such rare infection was revisited.
36-year-old patient (6). S. schenckii sensu lato is a complex of phylogenetically distinct species that differ in geographical distribution and biochemical, phenotypic, and genetic characteristics (6, 7). Members of the complex are found worldwide, especially in cellulose-rich soils of tropical and subtropical areas with temperatures around 30°C and high humidity (6, 7). S. schenckii has the ability to switch between ﬁlamentous (mold) and yeast forms in response to thermal stimuli and other environmental cues. In nature, the fungus grows in its mycelial form, producing abundant infectious conidia (7, 8). After transmission to humans or other mammalian hosts, the fungus converts to the yeast form, which can cause serious chronic infections (8).
The reactivation of VZV infection in immunocompetent persons that presented by aseptic meningitis or other neurological disease with or without rash, is reported previously (8). Given the atypical rash in our patient, we didn’t think of VZV reactivation at the outset which resulted in delayed institution of antiviral agent. Therefore, awareness of the protean VZV manifestations is of utmost importance to prevent permanent damage.
Pulmonary nocardiosis is an important opportunistic infection that seen in immunosuppressed patients. After inhalation of bacteria, acute, subacute, and chronic disease may occur. As there are no specific clinical and radiological findings, there may be some difficulties in its diagnosis. Because of this, although there is specific treatment, nocardiosis has a high rate of mortality. The patient presented with cough, high fever and hemoptysis. He had neither immunosup- pressive disease nor immunosuppressive therapy background. A case with pulmonary nocardiosis presented here with the review of literature due to difficulties in diagnosing and rare occurrence. Key words: Nocardiosis, pneumonia, oppurtunistic infection.
A 43-year-old African American female, with no significant family history or past medical history, presented to the emergency department (ED) on day 8 of worsening bilateral leg pain after taking five doses of SMX-TMP 800 - 160 mg for a suspected urinary tract infection. The patient stated that after two days of SMX-TMP therapy the initiation and intensifying leg pain caused her to return to her primary care physician where she was re-evaluated, and SMX-TMP was replaced with ciprofloxacin. Her leg pain continued to intensify, and she pre- sented to our ED rating her painasa 10 out of 10, stating the pain was alleviated by nothing, aggravated by bearing weight and she had never experienced similar symptoms in the past.
easily overlooked, and the diagnosis often is not considered . It is unlikely for a physician in developed countries to come across an anthrax patient; therefore, the diagnosis may be difficult. This disease should be considered in any patient who shows painless ulcers associated with vesicles and oedema and history of direct contact with animal’s products , but coinfection or secondary infection may mask the lesion and appear like an ordinary infected ulcer as presented in the current case. Outbreaks of anthrax have been reported in animals after ingestion of feedstuffs containing meat or bone meal-based concentrates made from carcasses contaminated with anthrax spores . In our case, the disease might have been transmitted by direct contact with infected sheep or sheep’s products like Venetian ceruse which is made from sheep’s spinal cord and this patient was regularly using it for skin cleaning. The patient did not recall any trauma or injuries, but it is possible that spores might have invaded the dermis through microscopic epidermal defects. Babamahmoodi et al.  reported three rare cases of anthrax (gastrointestinal, oropharyngeal, and meningitis) from the same source in northern Iran (Mazandaran province) which was coming from a single family after consuming half- cooked meat of the contaminated sheep. In addition, Erkek et al.  presented an unusual extensive case of cutaneous anthrax in a patient with type II diabetes mellitus; although cutaneous anthrax is usually self-limiting, complications may arise in untreated cases. Duri´c et al.  reported three probable cases of cutaneous anthrax in the eastern part of the autonomous province of Vojvodina, Serbia. All cases were involved in slaughtering of a heifer that was suspected to have anthrax. In the same village, anthrax was confirmed in other animals. Recently, several heroin-associated anthrax cases have been reported from Europe which can become a new continuous source of injectional anthrax across Europe [6, 8, 22]. Epidemiological evidence still implicates Venetian ceruse (skin whitener) as one of the main sources of spore transmission in long term application as was seen in our case reported here. Venetian ceruse may be a continuous source of anthrax in the Middle East leading to both outbreaks and sporadic cases. It is assumed that the contamination with anthrax spores occurs during either direct contact with infected sheep or by using Venetian ceruse. Bacillus anthracis, the causative agent of anthrax, is susceptible to antibiotics and treatment is effective in the early stages; however, treatment of other agents due to coinfections is crucially important, as in the case reported here. T. interdigitale which is a filamentous
strain of B. henselae, thereby establishing B. henselae bac- teremia. The patient’s serum tested negative for antibodies against B. henselae, B. koehlerae, or Bartonella vinsonii subsp. berkhoffii genotypes I, II or III antigens . Subse- quently, using 16S-23S ITS primers, B. henselae DNA (SA2 strain by DNA sequencing) was amplified and sequenced from paraffin blocks containing material from the initial liver resection (January 2009) and from the fol- low-up biopsy obtained in September of 2010 (Figure 5). These data demonstrated the presence of the SA2 B. hen- selae strain in the patient ’ s liver throughout her course. Immunohistochemical staining for B. henselae using a recently described B. henselae monoclonal antibody assay  showed rare coccobacilli with positive staining and appropriate morphology for B. henselae, however, clusters of organisms were not visualized (data not shown).
All species of the genus Pantoea can be isolated from feculent material, plants, and soil . However, our pa- tient had no contact with these sources. The isolate was susceptible to amikacin, cefepime, cefotaxime, ciproflox- acin, MEPM, and aztreonam, and resistant to cefazolin. Fortunately, our patient survived because appropriate antibiotic therapy was rapidly started. These results were similar to those of previous reports [4–6]. Of note, P. dispersa bacteremia can occur not only in immunocom- promised hosts but also in immunocompetent patients. Although all cases improved, the pathogenic and clinical importance of P. dispersa infection are unclear. Add- itional case reports of P. dispersa infections could help physicians understand the pathogenetic potential of this organism.
At admission, our patient had a fever of 38.8°C and physical examination revealed tenderness of his epigas- trium and right upper hypochondrium. Results from blood tests are reported in Table 1. Microbiological blood and urine investigations were negative for bacteria. A chest radiograph was normal while an abdominal sonography revealed an enlarged liver, thickened chole- docus, dilatation of the intra-hepatic biliary tree, spleno- megaly and lymphadenopathy of the hepatic hilus. A colonoscopy showed erythema of the colonic mucosa from the rectum to the cecum, with areas of increased erythema and telangiectasia in the ascending colon. Ran- dom biopsy showed focal atrophy of the colonic mucosa with edema and chronic inflammatory infiltrates, but specific investigations for CMV were not carried out. Imipenem 500mg IV four times daily was administered. Three days later, due to our patient’s persisting fever and abdominal pain, imipenem was substituted with tigecyc- line 50mg IV BID. Further blood and urine cultures for bacteria were negative. Both the erythrocyte sedimentation rate (ESR) and C-reactive protein level (C-RP) remained high, whereas the white blood cell (WBC) and neutrophil counts decreased (Table 1) and the procalcitonin level
We found that 72.7% of patients developed reactivated CMV proctitis following a preceding acute, life- threatening disease. This finding, however, was also ob- served in previous reports of CMV colitis in immuno- competent patients [7, 8]. In a previous review, CMV diseases were reported in 0–36% of critically ill immuno- competent patients, mostly developing 4–12 days after ICU admission . Disruption of the colonic mucosa caused by preceding conditions, such as medication, in- flammatory bowel disease, radiation therapy, and cardio- genic shock, may result in CMV reactivation [8–10]. Sepsis may also lead to CMV reactivation through the inability of interleukin-2 to restore natural killer cell function, which is important in controlling the virus after acute infection and reactivation . Complex in- teractions among the inflammatory cascade, the reacti- vation stimulus, and viral load on the pathogenesis of CMV reactivation in immunocompetent patients require further investigation .
The fever disappeared 5 days after the second admission with no anti-CMV therapy. The patient presented no fur- ther chest pain. He felt very tired for two months. Hepatitis was at its maximum 10 days after the second admission but liver tests returned to normal after one month. Heparin was replaced by six months of fluindione. The coagulation work-up included prothrombin time and tests for activated protein C resistance, antithrombin activity, and proteins C and S, as well as an assay for anticardiolipin and anti-beta 2 glycoprotein-1 antibodies. All results were normal.
GW was the chief author of the manuscript. RN was involved in revising the manuscript critically for important intellectual content. KB was involved in the patient ’ s care and the acquisition of the imaging data. He also obtained the patient ’ s consent for publication of this case report and accompanying images. RR was the specialist biomedical scientist who examined and identified the organism. AS was the consultant who supervised the case report. All authors read and approved the final manuscript.
The patient was admitted to the intensive care unit and begun on mannitol and dexamethasone to reduce intracranial swelling. A stereotactic needle aspiration and biopsy of the cerebral mass was performed 2 days later. Cytologic analysis of the aspirated material showed rare pleomorphic septate fungal elements in a background of neutrophils, lymphocytes, multinucleated histiocytes, and necrotic debris (Fig. 1). Histo- logic sections of the stereotactic brain biopsy tissue demon- strated brain parenchyma with granulomatous inflammation
Onychomycosis can be divided into four groups: distal lateral subungual onychomycosis, proximal white onychomycosis, white superficial onychomycosis, and candidial onychomycosis -. Proximal white ony- chomycosis is relatively rare compared to the other types of onychomycosis with distal lateral subungual ony- chomycosis occurring in approximately 90% of cases , while white superficial onychomycosis occurs in 9% of cases and proximal white onychomycosis and candidial onychomycosis occur less than 1% of the time . In addition, proximal white onychomycosis is frequently combined with immune compromise status, like HIV positive individuals . In fact, the incidence of proximal white onychomycosis in the immunocompetent popu- lation is 0.3% while proximal white onychomycosis in the HIV-positive population is roughly 15 times greater at 4.2% - 5.0%  .