BK virus encephalitis in an immunocompetent patient

OBJECTIVES: To describe a previously healthy patient now suffering from monophasic encephalitis caused by a primary infection with BK virus and to discuss possible risk factors for developing BK virus encephalitis. DESIGN: Case report. SETTING: Referral hospital. PATIENT: The patient was examined on referral. MAIN OUTCOME MEASURES: The main diagnostic tests performed were serology, polymerase chain reaction on cerebrospinal fluid samples, and cranial magnetic resonance imaging. RESULTS: During the course of the patient's encephalitis, an IgM titer developed against polyomavirus, followed by anti-polyomavirus IgG. Wild-type BK virus was demonstrated in cerebrospinal fluid samples. Cranial magnetic resonance imaging showed diffuse reversible white matter changes most prominent on T2-weighted images. CONCLUSION: We conclude that diagnostic tests for BK, a human polyomavirus, should be included in the screening program for encephalitogenic pathogens.     

Aspergillus spondylodiscitis in an immunocompetent paraplegic patient

A case of an immunocompetent 60 year old patient is reported, who suffered extensive thoracic spinal injury and paraplegia after polytrauma. In the course of rehabilitation he developed aspergillus spondylodiscitis in a part of the thoraco-lumbar spine which was primarily uninjured. The diagnostic assessment and therapeutic approach of this rare disorder is elucidated and discussed in the context of paraplegia and polytrauma. Possible mechanisms of inoculation and spreading of the moulds as well as predisposing factors of the disease are discussed in this paper and a review of the recent literature is provided.     

Progressive outer retinal necrosis in an immunocompetent patient

Progressive outer retinal necrosis syndrome is a variant of necrotizing herpetic retinopathy, a group of retinal infections caused by the herpes viruses. It has been described only in immunosuppressed patients. We present a healthy immunocompetent 16-year-old male who suffered a bilateral progressive outer retinal necrosis. Varicella-zoster virus infection was confirmed on the basis of serologic study. Treatment with intravenous acyclovir and oral prednisone was successful.     

Approach to the pediatric patient with diarrhea

Numerous viral, bacterial, and parasitic pathogens are known to cause diarrheal illnesses with increased frequency in children. Oral rehydration can be used to treat and prevent dehydration, the major sequela of diarrhea in children. The impact of diarrhea on nutrition may also be reduced through the rapid restoration of a normal, age-appropriate diet. Most diarrheal illnesses are acute and self-limited; however, increased knowledge of persistent diarrheal syndromes in children may lead to prompt recognition and diagnosis in children with diarrhea lasting more than 2 weeks.     

Pulmonary tuberculosis revealed by lupus vulgaris in an immunocompetent patient

In patients with severe carotid stenosis or total occlusion, episodic contralateral motor dysfunction is more likely related to cerebral hypoperfusion than epileptogenic activity. A man with orthostatic-mediated right-sided limb shaking was found to have total left internal carotid artery occlusion. There was prominent reduction of cerebrovascular reserve seen on single photon emission computed tomography (SPECT) performed with and without acetazolomide. During assumption of an upright position transcranial Doppler (TCD) revealed a marked attenuation of the left middle cerebral artery flow pattern not associated with changes during electroencephalographic monitoring, even after administration of acetazolomide. In this man, limb shaking episodes were attributed to hypoperfusion of the contralateral cerebral hemisphere, and not to epileptogenic activity.     

Transfusion-associated graft-versus-host disease in immunocompetent patient: early diagnosis and therapy

Splenic marginal zone lymphoma (SMZL) most commonly presents with splenomegaly and stage IV disease. To our knowledge, there have been only two reported cases of SMZL without associated splenomegaly; one was detected incidentally after a bicycle accident. This previously reported case represented an early-stage SMZL with monoclonality confirmed by immunohistochemistry. We report a case of early-stage SMZL detected incidentally following a motor vehicle accident; monoclonality was confirmed by polymerase chain reaction analysis of paraffin-embedded tissue owing to the inability of confirmation by immunohistochemical techniques. We describe our findings and emphasize the importance of recognizing early stages of SMZL in incidental splenectomies by polymerase chain reaction analysis of paraffin-embedded tissue. Frozen tissue is not generally available in such cases.     

Cerebral and pulmonary miliary tuberculosis in an immunocompetent patient: aggravation in an adequately treated patient

BACKGROUND: Extrapulmonary localizations are observed in 20% of tuberculosis cases, mainly in immunosuppressed patients. Prognosis is poor in case of relatively uncommon cerebral localizations and miliary dissemination, especially if treatment is initiated in late stages. We report a case of disseminated tuberculosis associated with cerebral and pulmonary localizations in an immunocompetent patient. THe disease progressed despite adapted treatment. CASE REPORT: A young immunocompetent man with an uneventful history developed miliary tuberculosis with pulmonary localizations visualized on the computed tomography (CT) of the thorax. Brain CT was normal, but magnetic resonance imaging revealed several intracranial lesions. The disease course was marked by development of neurological symptoms and progression of the cerebral lesions after one month of treatment. No evidence of therapeutic failure (insufficient dosing, non-compliance, primary resistance) could be identified. DISCUSSION: Magnetic resonance imaging provides a more precise evaluation of tuberculosis lesions in the brain. Early antituberculosis therapy associated with corticosteroids can improve prognosis. Clinicians should be aware that cerebral lesions may continue to progress despite appropriate treatment, a course which is not satisfactorily explained by any current pathogenic hypothesis.     

Fatal pulmonary infection with Mycobacterium celatum in an apparently immunocompetent patient

Mycobacterium celatum is a recently described mycobacterium isolated from patients who have suppressed cell-mediated immunity, such as AIDS. We present here, to our knowledge, the first report of a fatal pulmonary infection caused by M. celatum in a 73-year-old immunocompetent female patient. The mycobacterium was identified by a 16S rRNA sequence analysis.     

Retinochoroiditis as a diagnostic indication of acute systemic toxoplasmosis in an immunocompetent patient

HISTORY AND GENERAL INVESTIGATIONS: In February 1993 a 53-year-old immunocompetent man presented at our department with blurred vision on the right eye for 6 weeks. Following a journey to Guatemala in November 1992 he had developed undulating fever up to 40 degrees C (later subfebrile temperature) with loss of weight (15 kg), dysesthesia mainly in the feet and general weakness. He was hospitalized at a general hospital and treated with different antibiotics. Various examinations showed normal results, like cranial computer tomography, and serological tests for virus, bacteria or malaria. Only the transaminases and the borrelia serology (IgG: 1:80, IgM:neg.) were slightly elevated, and the abdominal sonography revealed a moderate hepatomegaly. OPHTHALMOLOGICAL FINDINGS: Visual acuity was 1.0 in both eyes. The right eye showed fatty retrocorneal precipitates, cellular infiltration of the anterior chamber and vitreous and a focal retinochoroiditis next to the superior temporal vessels (Fig. 1a), with corresponding defect in visual field and nerve fiber layer (Fig. 1b, c). Serology established the diagnosis of an acute generalized toxoplasmosis (IgM ISAGA i.S.: 1:1,600; IgM-AK IFT i.S.: 1:128, KBR i.S.: 1:320). THERAPY AND CLINICAL COURSE: After adequate chemotherapy ocular symptoms and dysesthesia improved rapidly. The temperature stayed low and the liver parameters returned to normal. CONCLUSION: The ophthalmoscopic finding of an acute focal retinochoroiditis played an important role for the diagnosis of an acute generalized toxoplasmosis in a patient with fever of unknown origin. Ocular manifestation is rare in acute generalized toxoplasmosis.     

Molecular diagnosis of Ureaplasma urealyticum in an immunocompetent patient with destructive reactive polyarthritis

Polymerase chain reaction (PCR) amplification, which is a useful method for detecting infectious agents in joints, has potential utility in the molecular diagnosis of venereal-associated arthritis. Among pathogens detected by this technique, Ureaplasma urealyticum, which is primarily associated with reactive arthritis (ReA), is also implicated in septic arthritis in immunocompromised patients. We report here a case of destructive polyarthritis, initially suggestive of septic arthritis, in an immunocompetent patient whose PCR positivity for U. urealyticum DNA in one joint, in conjunction with the disease outcome and histologic findings, led to the diagnosis of destructive ReA.     

Widespread tinea corporis in an immunocompetent patient resistant to all conventional forms of treatment

A 70-year-old immunocompetent man with a more than forty-year history of tinea corporis unresponsive to multiple systemic and topical antifungal agents, including systemic terbinafine, is described. The literature with respect to persistent dermatophyte infection is reviewed.