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Zika virus (ZIKV) recently emerged in the Western Hemisphere with previously unrecognized or unreported clinical presentations. Here, we identify two distinct binding mechanisms of ancestral and emergent ZIKV strains featuring the envelope (E) protein residue ASN154 and viral phosphatidylserine (PS). Short (20-mer) peptides representing the region containing ASN154 from strains PRVABC59 (Puerto Rico 2015) and MR_766 (Uganda 1947) were exposed to neuronal cells and fibroblasts, expecting interactions to be representative of ZIKV E protein/cell interactions, and bound MDCK or Vero cells and primary neurons significantly above a scrambled PRVABC59 control peptide. Peptides also significantly inhibited Vero cell adsorption by ZIKV strains MR_766 and PRVABC59, indicating that we have identified a binding mechanism of ancestral African ZIKV strains and emergent Western Hemisphere strains.Pretreatment of ZIKV MR_766 and PRVABC59 with the PS-binding protein annexin V significantly inhibited replication of PRVABC59, but not MR_766, suggesting that Western hemisphere strains are additionally utilizing PS-mediated entry to infect host cells. Taken together, these data indicate that we have identified an ancestral binding mechanism of ZIKV, and a secondary binding mechanism utilized by Western Hemisphere strains.

BACKGROUND To better understand clinical and epidemiologic patterns of blastomycosis, we report on a large series of blastomycosis in Indiana. Methods: All microbiologically and histopathologically confirmed cases of blastomycosis from four hospitals serving Central Indiana from 1985 to 2014 were identified. Available data were collected. Data on population estimates, annual precipitation, and construction in Indiana were evaluated for correlations with incidence rates of blastomycosis. Results: A total of 114 patients were identified. The mean age was 44.4 years; 27% had diabetes mellitus, and 16% were immunosuppressed. Most presented with pneumonia (90%); 48% had extrapulmonary disease (CNS involvement in 9%), and 15% developed ARDS. Cultures, cytopathology, and histopathology were positive in 86%, 27%, and 85% of the sample, respectively, and fungal antigen was positive in 76%. Amphotericin B was administered in 49%, and 87% received an azole. Total mortality was 12%. Immunosuppression (OR = 3.0), diabetes mellitus (OR = 2.9), and multilobar pneumonia (OR = 2.9) were associated with increased likelihood of ICU admission. There was a significant increase in incidence over time in Marion County. There was no correlation with amount of precipitation, but the rise in incidence coincided with a 2005 state initiative to expand Indiana's highway infrastructure. Conclusions The incidence of blastomycosis in Central Indiana may be on the rise. Physicians in endemic areas should be aware of the potentially fulminant consequences of the disease.

A 37-year-old Japanese woman with a past medical history of aortic valve replacement secondary to a congenital aortic aneurysm and presumed Takayasu's arteritis treated with prednisone (60 mg daily) presented to the inpatient service with shortness of breath, abdominal pain, and leg and foot pain.

Zika virus (ZIKV) recently emerged in the Western Hemisphere with previously unrecognized or unreported clinical presentations. Here, we identify two putative binding mechanisms of ancestral and emergent ZIKV strains featuring the envelope (E) protein residue asparagine 154 (ASN154) and viral phosphatidylserine (PS). Synthetic peptides representing the region containing ASN154 from strains PRVABC59 (Puerto Rico 2015) and MR_766 (Uganda 1947) were exposed to neuronal cells and fibroblasts to model ZIKV E protein/cell interactions and bound MDCK or Vero cells and primary neurons significantly. Peptides significantly inhibited Vero cell infectivity by ZIKV strains MR_766 and PRVABC59, indicating that this region represents a putative binding mechanism of ancestral African ZIKV strains and emergent Western Hemisphere strains. Pretreatment of ZIKV strains MR_766 and PRVABC59 with the PS-binding protein annexin V significantly inhibited replication of PRVABC59 but not MR_766, suggesting that Western hemisphere strains may additionally be capable of utilizing PS-mediated entry to infect host cells. These data indicate that the region surrounding E protein ASN154 is capable of binding fibroblasts and primary neuronal cells and that PS-mediated entry may be a secondary mechanism for infectivity utilized by Western Hemisphere strains.

This chapter provides practical guidance to facilitate compliance with current national and international regulations that govern the packing and shipping of hazardous materials and dangerous goods. Topics in this chapter include terminology, classification and naming of diagnostic specimens and infectious substances, marking and labeling packages, packaging material, documentation, training and certification of personnel, practical suggestions for classifying diagnostic specimens and infectious substances, and resources for additional information. Medical waste which is reasonably believed to have a low probability of containing infectious substances must be packed and shipped as Medical Waste. Department of Transportation (DOT) regulations, International Air Transport Association (IATA) requirements, and IATA packing instructions (PI) describe the minimum standards for the safe transport of various biological materials. The marking and labeling on the outer container communicate essential information regarding the shipper and consignee of the package, the nature and weight of the contents of the package, the potential hazard of the substance, how the substance is packed, and information to be used in case of an emergency. There are several simple but extremely important points which must be regularly and strongly emphasized to persons who pack and ship diagnostic specimens and infectious substances.

Answer: Streptobacillary rat bite fever or Haverhill fever. A presumptive identification of Streptobacillus moniliformis was issued upon the basis of the isolate's morphology, cellular arrangement, and relative biochemical inertness. Sequencing of a 1,442-bp 16S rRNA gene fragment of the isolate

A 5-year-old male was referred to the Riley Hospital for Children for evaluation of limping and refusal to use his right hand. Prior to presentation, he had been intermittently ill for 3 weeks with symptoms that included recurrent fevers (39°C to 41°C), chills, and an erythematous, macular rash on

Laboratorians continually seek methodologies that yield accurate results in a timely fashion, are cost effective, and require less technical expertise. Diagnosis of viral infections via viral antigen detection methods such as immunofluorescence (FA), immunochromatography (lateral flow) (IC), and enzyme immunoassays (EIA) offer many of these attractive features and are useful for direct detection of viral antigens in an array of clinical specimens and for identification of cultivated viruses. Whether the detection method is FA, rapid IC, or EIA, detection of antigens of the common respiratory viruses (i.e., adenovirus; influenza virus [Flu] A and B; parainfluenza virus [PIV] −1, −2, and −3 and respiratory syncytial virus [RSV]), has been shown to be more useful in patient management than either traditional virus isolation (1, 2, 3) or viral detection in rapid culture using centrifugation-enhanced inoculation (4). There is considerable variability in the sensitivity, specificity, technical considerations, and turnaround time among the various methods, and each method may perform differently depending on the viral target. This chapter deals with principles of FA, IC, and EIA and their contemporary applications in viral antigen detection.

The attachment organelles of bacterial species belonging to the Mycoplasma pneumoniae phylogenetic cluster are required for host cytadherence, gliding motility and virulence. Despite being closely related, these bacteria possess distinct cellular morphologies and gliding characteristics. The molecular mechanisms for most attachment organelle phenotypes, including shape and ability to power motility, are obscure. The attachment organelle-associated P30 protein of M. pneumoniae is implicated in both adherence and motility, with mutations negatively impacting cell morphology, adherence, gliding and virulence. To test whether the P30 alleles of different mycoplasma species confer species-specific attachment organelle properties, we created an M. pneumoniae strain in which the Mycoplasma genitalium P30 orthologue, P32, was substituted for the native P30. Selected clones were visualized by scanning electron microscopy to assess morphology and by indirect immunofluorescence microscopy to localize P32. Cytadherence ability and gliding motility were assessed by haemadsorption assay and phase-contrast microcinematography, respectively. Cell and attachment organelle morphologies were indistinguishable from wild-type M. pneumoniae as well as M. pneumoniae II-3 expressing a C-terminally 6×His-tagged P30 construct. P32 was localized to the tip of the attachment organelle of transformant cells. Although a specific role for P30 in species-specific phenotypes was not identified, this first test of orthologous gene replacement in different mycoplasma species demonstrates that the differences in the M. pneumoniae and M. genitalium proteins contribute little if anything to the different attachment organelle phenotypes between these species.

Cutaneous blastomycosis (CB) is associated with a variety of skin manifestations. Among other entities, CB may be mistaken for pyoderma gangrenosum due to overlap of findings on histopathologic examination. We report a case of CB, initially diagnosed as pyoderma gangrenosum and treated with steroids, leading to disseminated blastomycosis and acute respiratory distress syndrome (ARDS).

Introduction: Leishmaniasis is a neglected tropical disease caused by vector-borne protozoa of the genus Leishmania. Cutaneous and mucocutaneous forms result in disfiguration or mutilation, whilst visceral leishmaniasis (VL) affects multiple organs and is fatal if untreated. Notably, Leishmania are capable of establishing a chronic infection, which may reactivate years after initial infection when the host becomes immune-suppressed. Case Presentation: A 24-year-old human immunodeficiency virus (HIV)-positive male presented for excision of anal condylomas. At the time of his current condyloma excision, the patient had no additional symptoms or cutaneous findings, but was noted to have been only intermittently compliant with his antiretroviral therapy. Microscopic examination of the haematoxylin and eosin-stained anal condyloma tissue revealed koilocytic change, ulceration and brisk histiocytic inflammation containing numerous small intracellular bodies suggestive of Leishmania amastigotes. A bone marrow biopsy was performed and demonstrated similar intracellular forms. Anal condyloma tissue and bone marrow aspirate were sent to the Centers for Disease Control and Prevention's Parasitic Diseases Branch for confirmation of Leishmania and speciation. Specific immunohistochemical staining for Leishmania in the tissue section was positive and the species was confirmed as Leishmania donovani by PCR. Subsequently, the patient resumed highly active antiretroviral therapy and received anti-Leishmania therapy. Conclusion: Whilst the presentation of VL in HIV-positive patients is often similar to those without HIV, here we describe an unusual initial presentation of leishmaniasis in an HIV-positive patient where the parasite was found in an anal condyloma. VL is a critical diagnosis that should be considered and pursued when leishmaniasis is encountered in seemingly illogical clinical settings.

Measles virus, also called rubeola, and mumps virus are both RNA viruses of the family Paramyxoviridae, subfamily Paramyxovirinae; measles is in the Morbillivirus genus, and mumps virus is in the Rubulavirus genus. Rubella virus is also an RNA virus but is a member of the Togaviridae family. These three viruses, despite differences in their families and genera, are often considered together because the epidemiology of the infections they produce in humans and the preventive measures used against them are similar for all three. Measles and rubella, both of which produce rash-associated illness, and mumps, which typically infects the parotid glands, were all included among the expected illnesses of childhood in the United States prior to the introduction of vaccination programs in the late 1960s. Measles epidemics involving 500,000 to 700,000 cases occurred every 2 years (1), approximately 180,000 cases of mumps were reported annually (2), and approximately 58,000 rubella cases that included 60 congenital rubella syndrome (CRS) cases (3) were seen annually.

Mycoplasma insons sp. nov., first cultured from the choanae and tracheae of healthy green iguanas (Iguana iguana) from El Salvador, was readily distinguished from all previously described mollicutes and assigned to the Mycoplasma fastidiosum phylogenetic cluster by 16S rRNA gene sequence comparisons. Growth inhibition assays distinguished the isolates serologically from the other two members of that cluster. Many M. insons cells exhibit a remarkable twisted rod morphology despite lacking a cell wall. The organism is nonmotile, produces acid from glucose, but does not hydrolyze arginine, esculin, or urea. Mycoplasma insons 16S rRNA gene was also detected by PCR in packed blood cells from culture-negative iguanas. The type strain I17P1(T) has been deposited with the Mollicutes Collection at Purdue University and with the American Type Culture Collection (ATCC BAA-1435) in the USA. A limited number of cultures generated by the authors have also been deposited with the Culture Collection, University of Göteborg, in Sweden (CCUG 53461).

A paucity of effective, currently available antibiotics and a lull in antibiotic development pose significant challenges for treatment of patients with multidrug-resistant (MDR) Acinetobacter baumannii infections. Thus, novel therapeutic strategies must be evaluated to meet the demands of treatment of these often life-threatening infections. Accordingly, we examined the antibiotic activity of gallium protoporphyrin IX (Ga-PPIX) against a collection of A. baumannii strains, including nonmilitary and military strains and strains representing different clonal lineages and isolates classified as susceptible or MDR. Susceptibility testing demonstrated that Ga-PPIX inhibits the growth of all tested strains when cultured in cation-adjusted Mueller-Hinton broth, with a MIC of 20 μg/ml. This concentration significantly reduced bacterial viability, while 40 μg/ml killed all cells of the A. baumannii ATCC 19606 T and ACICU MDR isolate after 24-h incubation. Recovery of ATCC 19606 T and ACICU strains from infected A549 human alveolar epithelial monolayers was also decreased when the medium was supplemented with Ga-PPIX, particularly at a 40-μg/ml concentration. Similarly, the coinjection of bacteria with Ga-PPIX increased the survival of Galleria mellonella larvae infected with ATCC 19606 T or ACICU. Ga-PPIX was cytotoxic only when monolayers or larvae were exposed to concentrations 16-fold and 1,250-fold higher than those showing antibacterial activity, respectively. These results indicate that Ga-PPIX could be a viable therapeutic option for treatment of recalcitrant A. baumannii infections regardless of the resistance phenotype, clone lineage, time and site of isolation of strains causing these infections and their iron uptake phenotypes or the iron content of the media.

To better understand clinical and epidemiologic patterns of blastomycosis, we report on a large series of blastomycosis in Indiana.All microbiologically and histopathologically confirmed cases of blastomycosis from four hospitals serving Central Indiana from 1985 to 2014 were identified. Available data were collected. Data on population estimates, annual precipitation, and construction in Indiana were evaluated for correlations with incidence rates of blastomycosis.A total of 114 patients were identified. The mean age was 44.4 years; 27% had diabetes mellitus, and 16% were immunosuppressed. Most presented with pneumonia (90%); 48% had extrapulmonary disease (CNS involvement in 9%), and 15% developed ARDS. Cultures, cytopathology, and histopathology were positive in 86%, 27%, and 85% of the sample, respectively, and fungal antigen was positive in 76%. Amphotericin B was administered in 49%, and 87% received an azole. Total mortality was 12%. Immunosuppression (OR = 3.0), diabetes mellitus (OR = 2.9), and multilobar pneumonia (OR = 2.9) were associated with increased likelihood of ICU admission. There was a significant increase in incidence over time in Marion County. There was no correlation with amount of precipitation, but the rise in incidence coincided with a 2005 state initiative to expand Indiana's highway infrastructure.The incidence of blastomycosis in Central Indiana may be on the rise. Physicians in endemic areas should be aware of the potentially fulminant consequences of the disease.

Answer: Enteric fever. Manual and automated phenotypic methods identified the lactose-nonfermenting blood culture isolate as a Salmonella species. Subsequent serotyping of the isolate by use of O and Vi group D antisera definitively identified it as Salmonella enterica subsp. enterica serovar Typhi

Schwanniomyces species are largely unrecognized as being pathogenic, and a paucity of published reports exist regarding their role as infectious agents. Here, for the first time, we describe a case of human infection caused by Schwanniomyces etchellsii in a patient with cholecystitis.

A bloodstream infection with Staphylococcus aureus , including methicillin-resistant S. aureus (MRSA), is a serious condition that carries a high mortality rate and is also associated with significant hospital costs. The rapid and accurate identification and differentiation of methicillin-susceptible S. aureus (MSSA) and MRSA directly from positive blood cultures has demonstrated benefits in both patient outcome and cost-of-care metrics. We compare the next-generation Xpert MRSA/SA BC (Xpert) assay to the GeneOhm StaphSR (GeneOhm) assay for the identification and detection of S. aureus and methicillin resistance in prospectively collected blood culture broths containing Gram-positive cocci. All results were compared to routine bacterial culture as the gold standard. Across 8 collection and test sites, the Xpert assay demonstrated a sensitivity of 99.6% (range, 96.4% to 100%) and a specificity of 99.5% (range, 98.0% to 100%) for identifying S. aureus , as well as a sensitivity of 98.1% (range, 87.5% to 100%) and a specificity of 99.6% (range, 98.3% to 100%) for identifying MRSA. In comparison, the GeneOhm assay demonstrated a sensitivity of 99.2% (range, 95.2% to 100%) and a specificity of 96.5% (range, 89.2% to 100%) for identifying S. aureus , as well as a sensitivity of 94.3% (range, 87.5% to 100%) and a specificity of 97.8% (range, 96.1% to 100%) for identifying MRSA. Five of six cultures falsely reported as negative for MRSA by the GeneOhm assay were correctly identified as positive by the Xpert assay, while one culture falsely reported as negative for MRSA by the Xpert assay was correctly reported as positive by the GeneOhm assay.

Nosocomial respiratory infections are the most common acquired infections in patients with severe underlying conditions and are responsible for high morbidity and mortality in this patient population. Multidrug-resistant (MDR) pathogens are associated with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). This article describes the etiology, epidemiology, pathogenesis, diagnosis, and treatment of HAP and VAP associated with antibiotic-resistant bacterial pathogens.

Mycoplasmas that are known to exhibit gliding motility possess a differentiated tip structure. This polar organelle mediates cytadherence and gliding motor activity and contains a cytoskeleton-like component that provides structural support. Here, we describe gliding motility and a unique cytoskeleton in Mycoplasma insons , which lacks any obviously differentiated tip structure.

Zika virus (ZIKV) is responsible for an ongoing and intensifying epidemic in the Western Hemisphere. We examined the complete predicted proteomes, glycomes, and selectomes of 33 ZIKV strains representing temporally diverse members of the African lineage, the Asian lineage, and the current outbreak in the Americas. Derivation of the complete selectome is an ‘omics’ approach to identify distinct evolutionary pressures acting on different features of an organism. Employment of the M8 model did not show evidence of global diversifying selection acting on the ZIKV polyprotein; however, a mixed effect model of evolution showed strong evidence (P

Answer: a dicotyledonous plant seed. A differential identification of the object initially included both a small intestinal fluke and a cross-section of a nematode, among other possibilities. However, close inspection of the object did not reveal internal structures, such as reproductive and

A 13-year-old male presented to the Riley Hospital for Children at Indiana University Health emergency department with a 2-day history of constipation and a 1-day history of rectal bleeding. He had also passed several stools containing blood following administration of a laxative. At the time of evaluation, the patient was afebrile and denied anti-inflammatory drug ingestion, illicit substance abuse, epistaxis, hematemesis, travel outside Indiana, and consumption of raw or undercooked meat. Digital rectal examination revealed an ulcer in the posterior wall and a hemorrhoid in the anterior wall, while the remainder of the physical examination was unremarkable. A complete blood count and coagulation studies indicated mild anemia and an elevated neutrophil count, but other parameter values were within normal limits. A radiograph of the child's abdomen was also performed, which showed only a moderate amount of gas and stool retention. The patient's medical history was significant for developmental delay and Nissen fundoplication for esophageal reflux. Based on these findings, the patient was admitted for further evaluation by the gastrointestinal service. A colonoscopy performed the following morning confirmed the presence of a raised, erythematous, and friable rectal ulcer, while the rest of the colon and terminal ileum appeared normal. Biopsy specimens of the colon, terminal ileum, and rectal ulcer obtained during the colonoscopy did not reveal an obvious cause of the rectal ulcer, and the intestinal mucosa was unremarkable. However, one hematoxylin-and-eosin-stained section of the colon biopsy specimen revealed an ovoid object containing abundant eosinophilic granules measuring 1.0 by 0.75 mm in the greatest dimension (Fig. 1) in the lumen. The pathologist queried as to the presence of an intestinal parasite. FIG 1 Hematoxylin-and-eosin-stained colon biopsy specimen of the ovoid object (left; ×100 total magnification). The higher magnification demonstrates the cellular structure and outer wall (right; ×600 total magnification). (For answer and discussion, see page 3138 in this issue [doi:10.1128/JCM.00700-13].)