Immune reconstitution inflammatory syndrome (IRIS) is a potentially life-threatening phenomenon associated with the initiation of antiretroviral therapy in patients with acquired immunodeficiency syndrome due to a human immunodeficiency virus (HIV) infection. It is thought to be an exaggerated inflammatory response to an existing pathogen or even its antigen. We present a case of IRIS due to a non-tuberculous mycobacteria infection in a young patient with HIV infection who was recently started on therapy. This case highlights the challenges of making such a diagnosis and the importance of multidisciplinary team discussions with pulmonary and infectious diseases for optimal management of these patients.

Cryptococcus neoformans is a global invasive mycosis that is known to cause significant morbidity and mortality. It is commonly observed that individuals with compromised immune systems are more prone to developing cryptococcal meningitis. Although ocular involvement is rare, previous studies have indicated that ocular lesions precede symptomatic meningitis in only 27 % of patients with central nervous system involvement. Intraocular infections typically manifest as chorioretinopathy and vitreous inflammation, often leading to severe vision loss. In this case, we present the clinical details of a 57-year-old immunocompetent woman who visited the ophthalmology department of West China Hospital of Sichuan University with a progressive loss of vision in her right eye. After a thorough evaluation, she was diagnosed with fungal endophthalmitis, and subsequently initiated on appropriate induction anti-fungal therapy for cryptococcal meningoencephalitis. This case highlights the importance of early recognition and treatment, which can potentially improve the prognosis for patients.

Assessment is an essential component for all educational programs and must check competence acquirement while foster and promote learning. Progress Test (PT) is well recognized to assess cognitive knowledge, clinical reasoning and decision making in the clinical context, offering important information about the individual performance and program quality. It is widely used in Brazilian and international medical schools; however, it still has little role in assessing medical residents in Brazil. We present the experience of a PT pilot implementation in an Infectious Diseases residency program over two years. The first, second and third-year residents did four serial exams with 40 multiple choice questions (item)/each. Preceptors were trained on best practices on item writing. All the items were reviewed by a panel of experts and, after approval, included in the item bank. All participants answered a survey on their perceptions about the experience. The final score was higher for the third-year residents in all exam applications. The level of satisfaction was high among the participants, who mentioned the learning opportunity with the exam and the feedback. PT can improve residents\' assessment along the training period and residents\' performance should guide review and improvement of the programs.

This case emphasizes the significance of recognizing and managing Brevibacterium species. Here, we present a unique case of Brevibacterium species isolated from the cerebrospinal fluid of a 60-year-old female with recently diagnosed human immunodeficiency virus (HIV) and small cell carcinoma of the lung. Management involved a two-week course of intravenous vancomycin. Brevibacterium species are infrequently encountered in clinical practice. Sharing this case report aims to enhance the limited understanding of Brevibacterium species infections and encourages discussion among healthcare professionals regarding its diagnosis and management.

Lyme disease is a multisystem disorder transmitted through the Ixodes tick and is most commonly diagnosed in northeastern and mid-Atlantic states, Wisconsin, and Minnesota, though its disease borders are expanding in the setting of climate change. Approximately 10%-15% of untreated Lyme disease cases will develop neurologic manifestations of Lyme neuroborreliosis (LNB). Due to varying presentations, LNB presents diagnostic challenges and is associated with a delay to treatment. We discuss three cases of LNB admitted to our referral center in a traditionally low-incidence state to highlight clinical pearls in LNB diagnosis. Three patients from low-incidence areas with prior diagnostic evaluations presented in August with neurologic manifestations of radiculoneuritis, cranial neuropathies, and/or lymphocytic meningitis. MRI findings included cranial nerve, nerve root, and leptomeningeal enhancement leading to broad differential diagnoses. Lumbar puncture demonstrated lymphocytic pleocytosis (range 85-753 cells/uL) and elevated protein (87-318 mg/dL). Each patient tested positive for Lyme on two-tiered serum testing and was diagnosed with LNB. All three cases were associated with a delay to health care presentation (mean 20 days) and a delay to diagnosis and treatment (mean 54 days) due to under-recognition and ongoing evaluation. With the geographic expansion of Lyme disease, increasing awareness of LNB manifestations and acquiring detailed travel histories in low-incidence areas is crucial to prompt delivery of care. Clinicians should be aware of two-tiered serum diagnostic requirements and use adjunctive studies such as lumbar puncture and MRI to eliminate other diagnoses. Treatment with an appropriate course of antibiotics leads to robust improvement in neurological symptoms.

Outpatient parenteral antibiotic therapy (OPAT) aims to facilitate antibiotic treatment in non-hospital settings while minimizing hospitalization costs and infection risks. However, ensuring patient adherence, especially among socially disadvantaged groups like the homeless may be challenging. Studies indicate that increased dosing frequency negatively impacts adherence rates. Simplified dosing schedules and addressing transportation barriers are protective measures. Dalbavancin, a weekly oral antibiotic with an extended half-life, may offer a solution for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in patients with adherence challenges. We present a case of a homeless patient with MRSA bacteremia and osteomyelitis successfully treated with dalbavancin. Our case highlights the potential of dalbavancin\'s once-weekly dosing to improve adherence and treatment outcomes in challenging outpatient scenarios.

Poor dentition as a source of infection causing bacteremia and spinal infections (such as paraspinal abscess, and discitis) should be considered even in the absence of recent dental surgery. The case presents a patient found to have an infection in the cervical and thoracic spine, methicillin-resistant Staphylococcus aureus bacteremia, and poor dentition. Although the patient had a history of drug use, he denied a history of intravenous drug use. He had Crohn\'s disease that resulted in periodontal and endodontal tooth disease. The patient was found to have poor dentition with erythematous gums. He had not been to the dentist in over 24 years and had active dental caries. Since he presented with bacteremia and a spinal infection, it is likely the patient had an infection in the oral cavity that spread hematogenously to the blood, and then the spine. This report highlights the importance of considering tooth infections as the source of bacteremia and spinal infections.

Elizabethkingia anophelis, a gram-negative bacillus belonging to the Flavobacteriaceae family, is found in various environmental sources and has been associated with community and hospital outbreaks. Correct identification is crucial, guided by advanced genomic techniques, i.e., matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) system with an updated database. The case fatality rate, ranging from 24 to 60%, underscores the need for timely recognition and appropriate management. Additionally, Elizabethkingia presents a challenge due to its recent discovery, misidentification history, and drug resistance. Here, we present a case of fatal infection in a 30-year-old male, who presented with pneumonia. It gradually progressed and ultimately proved fatal underscoring the virulence of the pathogen involved. It was a diagnostic challenge as it likely is the first reported instance of Elizabethkingia anophelis infection from Nepal.

Immune reconstitution inflammatory syndrome (IRIS) describes a constellation of inflammatory symptoms that develop following the initiation of antiretroviral therapy (ART) in patients with advanced human immunodeficiency virus (HIV). Here, we present a case of a 39-year-old male-to-female transgender patient with advanced HIV who was started on ART during a hospitalization for acute encephalopathy due to a combination of methicillin-resistant Staphylococcus aureus (MRSA) meningitis and varicella encephalitis. After adequate treatment of these infections and five weeks after initiation of ART, she developed inflammatory symptoms of malaise, fever, and tachycardia, as well as laboratory findings of leukocytosis consistent with an inflammatory process. Infectious workup did not reveal any evidence of a new infection, and no other undiagnosed inflammatory processes were discovered to explain these symptoms. A diagnosis of IRIS was suspected, possibly induced by a prior varicella infection. Diagnosis of IRIS can be difficult due to heterogeneous symptoms, differing etiologies, variable patient presentations, and the lack of universal diagnostic criteria. As instances of IRIS are not uncommon in patients with a low CD4 count who start on ART, there should be a high index of suspicion when patients present with inflammatory symptoms after initiation of ART. With increased recognition of the disease and improved standardization of diagnostic criteria, more could be understood about the underlying disease process which may allow for better targeted therapies and individualized treatments for patients who develop the immune reconstitution inflammatory syndrome.

This case report presents a difficult-to-diagnose case of American tegumentary leishmaniasis (ATL) caused by Leishmania (Viannia) guyanensis in a 24-year-old Hispanic male with a travel history to the Panama jungle, an endemic region for tropical infectious diseases. The patient initially presented with persistent skin lesions that progressed to abscesses with ulceration. Despite negative initial diagnostic tests, including microbiological investigations and histopathological examination, a comprehensive diagnostic workup and subsequent polymerase chain reaction (PCR) confirmed the presence of Leishmania parasites. This case underscores the need to consider tropical infectious diseases despite initial negative tests. Accurate species identification is vital for proper drug treatment, with miltefosine as an emerging option. Early, precise diagnosis and tailored management are essential for successful treatment. This report emphasizes the significance of conducting a comprehensive diagnostic workup, including PCR, in individuals with a history of travel to endemic regions, to accurately diagnose and effectively manage complex infectious diseases.