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We discuss a case report of a 38-year-old uncircumcised male on pre-exposure prophylaxis for human immunodeficiency virus who presents to the emergency department for painful lesions over his penile region following unprotected sexual intercourse. Following the development of these lesions he developed painless, itchy pustules over his bilateral arms and back. He also had extensive pain and swelling over his penile region, which prevented him from unretracting his foreskin. Chlamydia trachomatis, Herpes simplex virus, Neisseria gonorrhoeae, and syphilis tests were negative. He was positive for orthopoxvirus using polymerase chain reaction. A diagnosis of paraphimosis as a complication of monkeypox infection was made.

Signs and symptoms of atypical pneumonia include fever, shortness of breath, cough, and chest pain. During the coronavirus disease 2019 (COVID-19) pandemic, identifying other causes of febrile respiratory illness in patients who tested positive for COVID-19 has been very challenging. Concerns over infecting healthcare personnel and other patients can impede further evaluations like bronchial lavage, lung biopsies, and other invasive tests. A very high index of suspicion, perhaps unreasonably so, is required to perform invasive tests to investigate alternative possible causes of the illness. We present the case of a 63-year-old man who presented to the hospital with dyspnea. Chest X-ray demonstrated a consolidation in the left lower lobe lung field with a possible underlying mass, and the patient tested positive for COVID-19. He received the standard treatment for COVID pneumonia at the time in our institution (remdesivir and dexamethasone), empiric antibiotics for community-acquired pneumonia, and was eventually discharged home with supplemental oxygen. Several days later, the patient returned to the hospital again with worsening dyspnea and was readmitted. Persistent illness and worsening imaging prompted bronchoscopy. The bronchoscopy showed narrowing of the airway in the left upper lobe, and Nocardia asteroides was isolated from bronchial aspirate. The isolation of Nocardia prompted an investigation for central nervous system involvement with an magnetic resonance imaging (MRI) of the head. The MRI demonstrated multiple bilateral ring-enhancing lesions in the brain. To our knowledge, this is the first reported case of disseminated nocardiosis superimposed on COVID-19 pneumonia.

Neurocysticercosis (NCC) is a common infection that is found worldwide but is often neglected in the United States (US). This case report aims to illustrate the presentation of the disease, provide information on this globally prevalent pathogen, and shed light on the diagnostic workup and treatment of the infection. We discuss the case of a 31-year-old male patient of Central American origin presenting with a new-onset seizure. He had no significant past medical history and had never experienced similar events before. The diagnosis was made through neuroimaging, serum antibody testing, and biopsy of the brain lesion. This case highlights the importance of performing a good clinical history and a proper diagnostic workup that would help in the prompt recognization and treatment of this common worldwide illness that may not be endemic to the clinician’s geographical area.

Background In the United States, bloodstream infections (BSIs) are predominated by Staphylococcus aureus . The proportion of community-acquired methicillin-resistant S aureus (MRSA) BSI is on the rise. The goal of this study is to explore the epidemiology of BSI caused by S aureus within Staten Island, New York. Methods This is a case-case-control study from April 2012-October 2014. Cases were comprised of patients with BSI secondary to MRSA and methicillin-sensitive S aureus (MSSA). The control group contained patients who were hospitalized during the same time period as cases but did not develop infections during their stay. Two multivariable models compared each group of cases with the uninfected controls. Results A total of 354 patients were analyzed. Infections were community acquired in 76% of cases. The major source of BSI was skin-related infections (n = 76). The first multivariable model showed that recent central venous catheter placement was an independent infection risk factor (odds ratio [OR] = 80.7; 95% confidence interval [CI], 2.2-3,014.1). In the second model, prior hospital stay >3 days (OR = 4.1; 95% CI, 1.5-5.7) and chronic kidney disease (OR = 3.0; 95% CI, 1.01-9.2) were uniquely associated with MSSA. Persistent bacteremia, recurrence, and other hospital-acquired infections were more likely with MRSA BSI than MSSA BSI. Conclusion Most infections were community acquired. The presence of a central venous catheter constituted a robust independent risk factor for MRSA BSI. Patients with MRSA BSI suffered worse outcomes than those with MSSA BSI.

Gastrointestinal anisakidosis is an under-reported and often misdiagnosed parasitic infection caused by the larvae of a nematode anisakis. The majority of cases are seen in Japan due to the consumption of raw and undercooked seafood; however, the incidence is likely to rise in the United States given the rising popularity of Japanese cuisine like sashimi or sushi. This unique report highlights the importance of considering anisakiasis in the differential diagnoses for patients with nonspecific abdominal symptoms with a recent history of raw or undercooked fish consumption.

Accurate diagnosis of pneumococcal pneumonia in the acute-care setting remains a challenge due to the inadequate sensitivity of conventional diagnostic tests. Sputum cultures, which are likely to have the highest diagnostic yields of all specimen types, have been considered unreliable, due to their inability to differentiate colonization from infection. Our objective was to evaluate the potential clinical utility of a rapid quantitative real-time PCR assay using sputum samples for Streptococcus pneumoniae in adult patients with community-acquired pneumonia (CAP). A prospective clinical observational study of consecutively enrolled emergency department patients with CAP was performed; only those patients with excess good-quality sputum samples were included for evaluation. Sputum samples were tested for the presence of S. pneumoniae by using a quantitative PCR that targets the pneumolysin gene. PCR findings were compared with those of a composite reference standard comprising Gram staining of sputum samples and sputum/blood cultures. The area under the curve (AUC) and a log-transformed threshold, which provides the maximal sensitivity and specificity, were calculated. Of 487 subjects enrolled, 129 were evaluable. Receiver operating characteristic curve analysis demonstrated an AUC of 0.87. Sensitivity and specificity were 90.0 percent and 80.0 percent, respectively; positive and negative predictive values were 58.7 percent and 96.2 percent, respectively. We have demonstrated that a quantitative rapid pneumolysin PCR assay has favorable accuracy for diagnosis of pneumococcal pneumonia in adult patients with CAP; this assay may be a useful diagnostic adjunct for clinicians, particularly those practicing in the acute-care setting, where rapid pathogen identification may assist in selection of the most appropriate antibiotics.

Muscle pain and weakness in a rheumatoid arthritis (RA) patient has a broad differential, and myositis should be considered early in the disease course as serious limb and life-threatening sequelae may occur. A 55-year-old woman with a past medical history of methotrexate-controlled RA presented with right leg pain for 4 days. The patient suffered sensory loss in the right foot and decreased strength in the toes. Lab tests revealed elevated creatine kinase, ESR, and anti-rheumatoid factor antibody titers. CT scan revealed myositis of posterior compartment muscles. Progressive edema, pain, and neuromuscular deficits persisted despite steroid and antibiotic therapy, so the patient was taken for urgent fasciotomy for acute compartment syndrome. The muscle biopsy showed diffuse mononuclear cell infiltration as well as perivascular and perineural involvement consistent with rheumatoid myositis (RM). The patient did well post-op on a prednisone taper. This case underlines the systemic nature of RA and exemplifies the severity of inflammation that may lead to grave consequences such as compartment syndrome. The histopathology is diagnostic when there is evidence of mononuclear cell infiltration; however, this is not entirely specific. Early, aggressive therapy with immunosuppressives is warranted in such patients. RM has not, to our knowledge, been recorded to cause acute compartment syndrome. Clinicians should be aware of this uncommon manifestation of RA keeping the various presentations of rheumatoid disease in mind when faced with these patients.

Objectives: To evaluate the performance of a simple screening tool for chest radiography for identification of community-acquired pneumonia (CAP) among emergency department (ED) patients who present with respiratory-related complaints. Our screening tool is a modification of a previously published guideline, which relied only on the presence of vital-sign abnormality (97% sensitivity, 19% specificity). We included respiratory symptoms to improve the specificity, defining our screening tool as the presence of any one respiratory symptom (cough, chest pain or shortness of breath) and any abnormality of the vital signs (temperature >38 °C, heart rate >100 beats/min, respiration rate >20 breaths/min, or pulse oximetry Methods: This was a 3-month retrospective chart review of all ED visits from an inner city teaching hospital. CAP was defined as the presence of a new radiographic infiltrate compatible with CAP. Patients with asthma were excluded. Results: Of 8811 patient visits evaluated, 1948 presented with a respiratory symptom. Of these, 198 had definitive CAP. Sensitivity, specificity, positive and negative predictive values of the ED screening tool were 90% (95% CI 85% to 94%), 76% (95% CI 74% to 78%), 30% and 99%, respectively. Positive and negative likelihood ratios were 3.72 (95% CI 3.38 to 4.09) and 0.13 (95% CI 0.08 to 0.19), respectively. Conclusions: A simple screening tool with high sensitivity and specificity was used in an urban inner city ED to decide on the requirement for chest radiographs for patients with respiratory symptoms for identification of CAP. Validation studies are required to determine the utility of this screening tool for improving time to diagnosis and treatment.