Bartels, Helen Caroline

Abstract Background: Group G streptococcal species can represent normal human flora as asymptomatic colonization. In the setting of infection, group G streptococcus can invade multiple structures and present broadly including bacteremia, toxic shock syndrome, endocarditis, septic arthritis, osteomyelitis, necrotizing skin infections, pharyngitis, and others. Severe cases tend to be more common in patients of increasing age or with chronic illnesses. Here we report a case of disseminated group G streptococcus mimicking systemic vasculitis. Case Presentation: A 41-year-old white male was hospitalized with a five-day history of fevers, chills, painful bilateral leg rash, generalized arthralgias, and right eye redness, pain and severe vision loss. Medical history was significant for minimal change disease treated with prednisone and cyclosporine. On admission, he was noted to be cushingoid with edematous erythema at the left hand, and bilateral lower limb rash. The right eye was inflamed with hypopyon. Laboratory studies demonstrated mild leukocytosis, modest thrombocytopenia, hyponatremia, hyperglycemia, with elevated CRP and creatinine. Urinalysis was positive for proteinuria, microscopic hematuria, and pyuria. CT chest demonstrated right upper lobe consolidation. There was concern for systemic vasculitis and cellulitis of the left hand. Intravenous methylprednisolone and empiric antibiotics were initiated. Ophthalmology was consulted for right uveitis and aspirated fluid from the anterior chamber. Dermatology biopsied the lower limb rash and identified leukocytoclastic vasculitis. Pulmonology performed bronchoscopy and bronchoalveolar lavage of the right upper lobe. Prior renal pathology was re-reviewed. Rheumatology was consulted due to suspicions for systemic vasculitis. Lancefield group G streptococcus was ultimately cultured from multiple blood samples, bronchoalveolar lavage fluid and right eye aspirate. There was no evidence of endocarditis on imaging. It was concluded that the source of the bacteremia and disseminated infection was most likely the left-hand cellulitis. Conclusions: To our knowledge, we present the first case of disseminated Group G streptococcal infection presenting with the constellation of bacteremia, endophthalmitis, focal mass-like lung consolidation, and leukocytoclastic vasculitis of lower extremities. The multi-organ distribution mimicked a systemic small vessel vasculitis. This case highlights the importance of infectious etiologies in the differential diagnosis of vasculitis – especially in the setting of infectious risk factors.

Abstract Most patients with coronavirus disease 2019 (COVID-19) have mild to moderate illness not requiring hospitalization. However, no study has detailed the evolution of symptoms in the first month of illness. At our institution, we conducted remote (telephone and video) visits for all adult outpatients diagnosed with COVID-19 within 24 h of a positive nasopharyngeal polymerase chain test for SARS-CoV-2. We repeated regular video visits at 7, 14, and 28 days after the positive test, retrospectively reviewed the prospective data collected in the remote visits, and constructed a week by week profile of clinical illness, through week 4 of illness. We reviewed the courses of 458 symptomatic patients diagnosed between March 12, 2020, and June 22, 2020, and characterized their weekly courses. Common initial symptoms included fever, headache, cough, and chest pain, which frequently persisted through week 3 or longer. Upper respiratory or gastrointestinal symptoms were much shorter lived, present primarily in week 1. Anosmia/ageusia peaked in weeks 2 to 3. Emergency department visits were frequent, with 128 visits in the 423 patients who were not hospitalized and 48 visits among the 35 outpatients (7.6%) who were eventually hospitalized (2 subsequently died). By the fourth week, 28.9% said their illness had completely resolved. After the 4-week follow up, 20 (4.7%) of the 423 nonhospitalized patients had further medical evaluation and management for subacute or chronic COVID-19 symptoms. Mild to moderate outpatient COVID-19 is a prolonged illness, with evolving symptoms commonly lasting into the fourth week of illness.

Abstract Approximately 5 to 15% of patients with pulmonary coccidioidomycosis subsequently develop pulmonary cavities. These cavities may resolve spontaneously over a number of years; however, some cavities never close, and a small proportion causes complications such as hemorrhage, pneumothorax or empyema. The impact of azole antifungal treatment on coccidioidal cavities has not been studied. Because azoles are a common treatment for symptomatic pulmonary coccidioidomycosis, we aimed to assess the impact of azole therapy on cavity closure. From January 1, 2004, through December 31, 2014, we retrospectively identified 313 patients with cavitary coccidioidomycosis and excluded 42 who had the cavity removed surgically, leaving 271 data sets available for study. Of the 271 patients, 221 (81.5%) received azole therapy during 5-year follow-up; 50 patients did not receive antifungal treatment. Among the 271 patients, cavities closed in 38 (14.0%). Statistical modeling showed that cavities were more likely to close in patients in the treated group than in the nontreated group (hazard ratio, 2.14 [95% CI: 1.45–5.66]). Cavities were less likely to close in active smokers than nonsmokers (11/41 [26.8%] vs 97/182 [53.3%]; P = 0.002) or in persons with than without diabetes (27/74 [36.5%] vs 81/149 [54.4%]; P = 0.01).We did not find an association between cavity size and closure. Our findings provide rationale for further study of treatment protocols in this subset of patients with coccidioidomycosis. Lay Summary Coccidioidomycosis, known as valley fever, is a fungal infection that infrequently causes cavities to form in the lungs, which potentially results in long-term lung symptoms. We learned that cavities closed more often in persons who received antifungal drugs, but most cavities never closed completely.