Bacillus cereus Bacteremia: An Unusual Case Following Food Poisoning

Introduction/Objective Bacillus cereus is a spore-forming, gram-positive rod, well known for causing food poisoning. In addition, this bacterium often presents as a contaminant of blood cultures. Differentiating true bacteremia from contamination of blood samples is important as it has treatment implications. Early recognition is necessary, as it can cause septic shock if untreated. We present a challenging case of food poisoning with concomitant bacteremia in a young patient with a history of diabetes mellitus (DM), celiac disease, and new-onset chronic kidney disease (CKD). Methods/Case Report A 23-year-old adult male with a history of DM, new-onset CKD, and celiac disease presented with nausea, intermittent vomiting, and lower abdominal pain for 2 weeks. On initial evaluation, he had normal blood pressure but tachypnea and tachycardia. Physical examination was significant for left lower quadrant and flank tenderness. The symptoms were persistent and progressed to point that he could not tolerate meals due to vomiting. Two weeks earlier, he presented with similar complaints along with dysuria and was treated for suspected urinary tract infection with Co-trimoxazole. This time, further workup revealed normal white blood cell count (11.8 k/µL) with 81% neutrophils, elevated creatinine (3.56 mg/dL), blood urea nitrogen (49 mg/dL), and procalcitonin (0.39 ng/mL), with abnormal urinalysis showing increased turbidity, pyuria, and nitrituria. He was started on ceftriaxone, fluids, antiemetics and was admitted to the hospital for further management. The urine culture had no bacterial growth. Two sets of peripheral blood cultures (different sites at different times) had gram-positive rods which eventually turned out to be B. cereus, identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Levofloxacin was started, and he reported improvement in nausea and vomiting by the next day of admission and was discharged. Results (if a Case Study enter NA) NA Conclusion Differentiating true B. cereus bacteremia from blood sample contamination is important. Additionally, no symptoms are specific for B. cereus-associated food poisoning, and the presence of risk factors doesn’t always favor this entity over other entities, hence adding difficulty to the diagnosis. A high index of suspicion is needed, as early intervention can prevent the development of life-threatening complications.

Relationship of the platelet distribution width/platelet count ratio with thyroid antibody levels in patients with Hashimoto's thyroiditis

Objective I investigated whether the platelet distribution width/platelet count (PDW/PC) ratio, which is an inexpensive and simple test performed for almost all patients, is applicable in the follow-up of patients with Hashimoto’s thyroiditis and examined the relationship of this ratio with thyroperoxidase and thyroglobulin antibody levels. Materials and methods The study groups consisted of 67 patients with Hashimoto’s thyroiditis and 17 controls. All participants were aged 20 to 75 and treated the Internal Medicine outpatient clinic of my institution. The PDW/PC ratio and thyroid antibody levels were retrospectively evaluated in patients with normal liver and renal function and normal white blood cell counts, hemoglobin levels, and hematocrit levels. Results Thyroid antibody levels were significantly higher in patients with Hashimoto’s thyroiditis than in controls. PC was higher in patients with Hashimoto’s thyroiditis, whereas the PDW/PC ratio was lower. However, these differences were not statistically significant. Conclusion In this study, I did not find a statistically significant relationship between thyroid antibody levels and PDW/PC. However, a weak correlation between these variables was identified.

Neither Blood Culture Positivity nor Time to Positivity is Associated with Mortality among Patients Presenting with Severe Manifestations of Sepsis: The FABLED Cohort Study

Background Sepsis is a leading cause of morbidity, mortality, and health care costs worldwide. Methods We conducted a multi-center, prospective cohort study evaluating the yield of blood cultures drawn before and after empiric antimicrobial administration among adults presenting to the emergency department with severe manifestations of sepsis (ClinicalTrials.gov: NCT01867905). Enrolled patients who had the requisite blood cultures drawn were followed for 90 days. We explored the independent association between blood culture positivity and its time to positivity in relation to 90-day mortality. Findings 325 participants were enrolled; 90-day mortality among the 315 subjects followed-up was 25·4% (80/315). Mortality was associated with age (mean age in those who died was 72·5 ±15·8 vs. 62·9 ±17·7 years among survivors, p<0·0001), greater Charlson Comorbidity Index (2 (IQR 1,3) vs. 1 (IQR 0,3), p=0·008), dementia (13/80 (16·2%) vs. 18/235 (7·7%), p=0·03), cancer (27/80 (33·8%) vs. 47/235 (20·0%), p=0·015), positive qSOFA score (57/80 (71·2%) vs. 129/235 (54·9%), p=0·009), and normal white blood cell counts (25/80 (31·2%) vs. 42/235 (17·9%), p=0·02). The presence of bacteremia, persistent bacteremia after antimicrobial infusion, and shorter time to blood culture positivity were not associated with mortality. Neither the source of infection nor pathogen affected mortality. Interpretation Although severe sepsis is an inflammatory condition triggered by infection, its 90-day survival is not influenced by blood culture positivity nor its time to positivity. Funding Vancouver Coastal Health; St-Paul’s Hospital Foundation Emergency Department Support Fund; the Fonds de Recherche Santé – Québec (CPY); Intramural Research Program of the NIH, Clinical Center (AL); the Maricopa Medical Foundation

The Great Gut Mimicker: A case report of MIS-C and appendicitis clinical presentation overlap in a teenage patient

Background Abdominal pain and other gastrointestinal symptoms are common presenting features of multisystem inflammatory syndrome in children (MIS-C) and can overlap with infectious or inflammatory abdominal conditions, making accurate diagnosis challenging. Case Presentation We describe the case of a 16-year-old female who presented with clinical symptoms suggestive of appendicitis and an abdominal computed tomography (CT) that revealed features concerning for appendicitis. After laparoscopic appendectomy, histopathology of the appendix demonstrated only mild serosal inflammation and was not consistent with acute appendicitis. Her overall clinical presentation was felt to be consistent with MIS-C and she subsequently improved with immunomodulatory and steroid treatment. Conclusions We note that MIS-C can mimic acute appendicitis. This case highlights MIS-C as a cause of abdominal imaging with features concerning for appendicitis, and MIS-C should be considered in the differential for a patient with appendicitis-like symptoms and a positive COVID-19 IgG. Lab criteria, specifically low-normal white blood cell count and thrombocytopenia, appears to be of high relevance in differing MIS-C from acute appendicitis, even when appendix radiologically is dilated.

Co-infection of COVID-19 and influenza A in a hemodialysis patient: a case report

Background Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus that was first discovered in December 2019 in Wuhan, China. With the growing numbers of community spread cases worldwide, the World Health Organization (WHO) declared the COVID-19 outbreak as a pandemic on March 11, 2020. Like influenza viruses, SARS-CoV-2 is thought to be mainly transmitted by droplets and direct contact, and COVID-19 has a similar disease presentation to influenza. Here we present a case of influenza A and COVID-19 co-infection in a 60-year-old man with end-stage renal disease (ESRD) on hemodialysis. Case presentation A 60-year-old man with ESRD on hemodialysis presented for worsening cough, shortness of breath, and diarrhea. The patient first developed a mild fever (37.8 °C) during hemodialysis 3 days prior to presentation and has been experiencing worsening flu-like symptoms, including fever of up to 38.6 °C, non-productive cough, generalized abdominal pain, nausea, vomiting, and liquid green diarrhea. He lives alone at home with no known sick contacts and denies any recent travel or visits to healthcare facilities other than the local dialysis center. Rapid flu test was positive for influenza A. Procalcitonin was elevated at 5.21 ng/mL with a normal white blood cell (WBC) count. Computed tomography (CT) chest demonstrated multifocal areas of consolidation and extensive mediastinal and hilar adenopathy concerning for pneumonia. He was admitted to the biocontainment unit of Nebraska Medicine for concerns of possible COVID-19 and was started on oseltamivir for influenza and vancomycin/cefepime for the probable bacterial cause of his pneumonia and diarrhea. Gastrointestinal (GI) pathogen panel and Clostridioides difficile toxin assay were negative. On the second day of admission, initial nasopharyngeal swab came back positive for SARS-CoV-2 by real-time reverse-transcriptase polymerase chain reaction (RT-PCR). The patient received supportive care and resumed bedside hemodialysis in strict isolation, and eventually fully recovered from COVID-19. Conclusions We presented a case of co-infection of influenza and SARS-CoV-2 in a hemodialysis patient. The possibility of SARS-CoV-2 co-infection should not be overlooked even when other viruses including influenza can explain the clinical symptoms, especially in high-risk patients.

Clinical Analysis of Covid-19 Infections in Children with Cancer in A Tertiary Care Hospital in Bangladesh

Background: Children suffering from cancer are more vulnerable than others. This study performed to outline the clinical characteristics and outcome of children with cancer with severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection in Dhaka Medical College Hospital, Dhaka. Methods: Clinical data and epidemiologic history of 24 children with cancer with laboratoryconfirmed COVID-19 infection by real-time reverse transcription-PCR (RNA-PCR) were admitted in the Dhaka Medical College Hospital, Dhaka from May, 2020 to June, 2020. Clinical data and epidemiologic history of these patients were restrospectively collected and analyzed. Results: Among the 24 cases, 16 (67%)were males and 8 (33%) were females. The median age was 5 years (range 0.11–12 years). The most common symptoms were fever (11 cases, 45%) and runny nose (8 cases, 33%), cough (8 cases, 33%), 6 (24%) were asymptomatic. Acute Lymphoblastic Leukemia were the most common (50%) and second most were Wilms tumor (17%). Among the 24 cases, on admission, 17 (71%) had normal white blood cell counts, while only 2 (8%) more than 10x109/L and 5 (21%) less than 4x109/L, respectively. 16 cases (67 %) had normal neutrophil count and 7 cases (29%) had neutropenia. Lymphocyte counts were normal in 50% cases, lymphocytopenia in 10 (42%). C Reactive protein and serum ferritin raised in 19(79%) cases, D-dimer raised, prothrombin time, activated partial thromboplastin time raised in 8(33%) cases. X-ray chest was abnormal in 6 cases (25%). 16 cases (66%) received intravenous antibiotics, 5 cases (21%) needed oxygen therapy and 4 cases (17%) needed corticosteroid. Ninteen (79%) patients were discharged from hospital, 3cases (13%) were discharged on request and death was 2 cases (8%). Conclusions: Children at all ages appeared susceptible to COVID-19 and there was significant gender difference. Clinical manifestations of children’s COVID-19 cases were generally less severe than those of adult patients. Death rate is more in children with cancer than others. J Dhaka Medical College, Vol. 29, No.2, October, 2020, Page 165-170

A critical COVID-19 patient managed with timely evaluation, early prone positioning ventilation, and a multi-pronged pharmacotherapy

There is not yet a standard drug regimen for the treatment of coronavirus disease 2019 (COVID-19) patients. Here, we summarize our experience and successful treatment plan with a critical COVID-19 patient who required mechanical ventilation (MV). A 56-year-old man presented with a fever, cough, and dyspnea. He had not been to a medium/high risk epidemic area in the past year and had no family history of a disease cluster. COVID-19 was suspected based on clinical symptoms and radiologically detected ground-glass lung changes in the context of a normal white blood cell count (WBCC) and lymphocyte fraction (L%). A diagnosis of COVID-19 was confirmed by nucleic acid testing. Initially, he was started on noninvasive ventilation (NIV). Because his respiratory distress worsened over the following 2 h, he was transitioned to mechanical ventilation (MV), placed in prone positioning 12 h/day, and given a multi-pronged pharmacotherapy regimen that included an antiviral cocktail (lopinavir/ritonavir plus α-interferon), an immunity enhancer (thymosin α1), an anti-coagulant to prevent thrombosis (heparin). He was given an antibiotic to treat an opportunistic nosocomial infection. The patient has recovered well. The regimen applied in this case of timely evaluation, early prone positioning with MV, and a multi-pronged pharmacotherapy may be an effective strategy for patients with critical COVID-19, particularly with respect to preventing life-threatening worsening of the illness.

Detection and Classification of White Blood Cells through Deep Learning Techniques

Leukemia is one of the deadliest diseases in human life, it is a type of cancer that hits blood cells. The task of diagnosing Leukemia is time consuming and tedious for doctors; it is also challenging to determine the level and type of Leukemia. The diagnoses of Leukemia are achieved through identifying the changes on the White blood Cells (WBC). WBCs are divided into five types: Neutrophils, Eosinophils, Basophils, Monocytes, and Lymphocytes. In this paper, the authors propose a Convolutional Neural Network to detect and classify normal white blood cells. The program will learn about the shape and type of normal WBC by performing the following two tasks. The first task is identifying high level features of a normal white blood cell. The second task is classifying the normal white blood cell according to its type. Using a Convolutional Neural Network CNN, the system will be able to detect normal WBCs by comparing them with the high-level features of normal WBC. This process of identifying and classifying WBC can be vital for doctors and medical staff to make a decision. The proposed network achieves an accuracy up to 96.78% with a dataset including 10,000 blood cell images.

Cerebrospinal fluid findings and hypernatremia in COVID-19 patients with altered mental status

Background The objective of the study was to assess the cerebrospinal fluid (CSF) findings in COVID-19 patients. Aims This was an observational retrospective cohort from electronic medical records of hospitalized patients (n = 2655) with confirmed COVID-19 between February 15, 2020, and April 15, 2020, in 182 hospitals from a large health system in the USA. The review of data yielded to a total of 79 patients in 20 hospitals who had CSF analysis. Methods Outcomes during hospitalization, including hospital length of stay, disease severity, ventilator time, and in-hospital death were recorded. Independent variables collected included patient demographics, diagnoses, laboratory values, and procedures. Results A total of 79 patients underwent CSF analysis. Of these, antigen testing was performed in 73 patients. Ten patients had CSF analysis for general markers such as total protein, cell count, glucose, clarity, and color. Seven of the 10 cases (70%) had normal total cell count and normal white blood cell count in CSF. Sixty-three percent (5/8) had elevated total protein. Two patients had normal levels of lactate dehydrogenase (LDH) and 1 patient had significantly elevated (fourfold) neuron-specific enolase (NSE) level in CSF. Conclusion Unlike bacterial infections, viral infections are less likely to cause remarkable changes in CSF glucose, cell count, or protein. Our observations showed no pleocytosis, but mild increase in protein in the CSF of the COVID-19 patients. The fourfold elevation of NSE may have diagnostic/prognostic value as a biomarker in CSF for COVID-19 patients who have altered mental status. Graphical abstract

Refractory Thrombocytopenia in SLE with Evans Syndrome : A Case Report

Background: Evans syndrome (ES) is a rare autoimmune disorder of unknown etiology. It is characterized by the occurrence of two or more hematologic immune cytopenias, most often immune thrombocytopenia and autoimmune hemolytic anemia (AIHA). In this study we present a rare case of a 9-year-old girl, who was diagnosed with secondary ES associated with active systemic lupus erythematosus (SLE). Case presentation: On November 16th, 2018, a 9-year old girl, presented for the first time with recent onset of gum bleeding and decreased level of consciousness for two weeks. On examination, she was conscious but not oriented, unable to walk, showed scanty hair with oral and gum bleeding, and had multiple bruises and massive hepatosplenomegaly. No parental consanguinity, and no similar history in the family was noted. She had low platelet count (1×103 /μL), with high mean platelet volume (19 fl), anemia (HB 5.5 g/dL), with normal white blood cell count, positive direct Coombs test, and hemolysis with no malignant cells on a peripheral blood smear. Bone marrow evaluation showed hypercellularity, and increased number of megakaryocytes, with no other significant abnormalities. Her flowcytometry study was normal. Brain computed tomography (CT) revealed left subdural hematoma with elements of old brain atrophy (Photo 1), with significant dilatation of ventricular system. Chest X-ray showed mild right pleural effusion. Abdominal ultrasonography showed hepatosplenomegaly with no focal lesions, and mild-to-moderate ascites. Both antinuclear antibody and anti-phospholipid antibody tests showed positive results and C3 was low. Hepatitis and human immunodeficiency virus (HIV) serology were negative.Autoimmune lymphoproliferative syndrome gene sequence analysis was negative. The patient was diagnosed with SLE, after she fulfilled the American Rheumatology Association criteria, associated with Evans syndrome. Any planned surgery was postponed until thrombocytopenia correction, and their aim was to increase the platelet count to a level of above 100.The patient received packed red blood cells (RBCs) and platelets several times. To control her condition, several medications were tried. These medications included intravenous immunoglobulin (1 gm/kg) for two successive days, prednisolone (2 mg/kg/day); however, no improvement was observed after 10 days. Therefore, all of these medications were replaced with methylprednisolone pulse therapy (30 mg/kg for three days), with one dose of anti-D (75 mcg/kg IV). Our next choice was mycophenolate mofetil, which was stopped after finishing the course of five weeks, but the patient did not show any improvement. Moreover, platelets failed to respond to four doses of Rituximab (370 mg/m2/dose) for four weeks and to two cycles of high dose of dexamethasone 20mg/m2 for 4 days every 4 weeks. On 12/29/2018, chloroquine (4 mg/kg/day) was administered for two weeks in conjunction with cyclosporine (4 mg/kg/day). Splenectomy was an option but was not performed because her platelet levels never recovered. Her anemia started to improve on 1/9/2019 with combination of prednisolone and cyclosporine and Coombs test results were negative. On 1/23/2019, the patient was started on Eltrombopag, in a dose-escalated manner starting with 25 mg/kg/day up to 75 mg/kg/day in addition to corticosteroids. One week later, her platelet counts markedly improved (Photo 2). No major side effects were reported. On 2/12/2019, the patient underwent left side burr-hole evacuation of subdural hematoma, but her consciousness was never regained. She was maintained in intensive care unit and ventilated, but she developed multiple postoperative complication, including sepsis with high inflammatory markers and spiking fever. Her platelet count was continuously high, so the dose of Eltrombopag was decreased to 50 mg/kg/day to just keep the level between 50 and 100. Despite all of therapeutic interventions, she passed away one month later, on 3/13/2019, due to respiratory failure. Conclusion: The incidence of ES is quite rare, especially in children. Eltrombopag is a safe and effective drug for management of refractory thrombocytopenia in cases of ES associated with SLE. Figure Disclosures No relevant conflicts of interest to declare.