Coinfection of Pseudomonas and Aspergillus has not been previously reported in patients with chronic obstructive pulmonary disease (COPD). A middle-aged, thinly built woman (Body Mass Index: 18.1 kg/m²) who smokes bidi (a type of tobacco) and has a history of exposure to open log fires for cooking, has been suffering from COPD for the last 4 years. She has been taking inhaled betamethasone and tiotropium. Additionally, she had uncontrolled diabetes for a few months. She presented with fever, productive cough, shortness of breath and chest pain for 5 days. She required non-invasive ventilation support for type-2 respiratory failure. Chest X-ray and CT confirmed pneumonia, cavities and abscesses in both lungs. Repeated sputum and bronchoalveolar lavage confirmed coinfections with Pseudomonas aeruginosa and Aspergillus fumigatus, respectively. Along with supportive therapy, she was treated with tablet levofloxacin and injection amikacin for 6 weeks based on culture sensitivity reports, and capsule itraconazole for 6 months. She recovered completely to her baseline COPD and diabetes status. This case study confirms that coinfections can occur in COPD and diabetes, highlighting the need for clinicians to be vigilant for the possibility of such symbiotic coinfections.

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Purpose: Cefepime is an antibiotic associated with cefepime induced neurotoxicity (CIN), particularly in those with reduced renal function, or in cases of inappropriate medication dosing. This report describes a case of CIN associated with a change in infusion duration from 180 to30 minutes, which to the best of our knowledge has not been previously reported in the literature. Summary: A 73-year old male was treated with extended infusion cefepime over 180 minutes while hospitalized with recurrent pneumonia. On discharge, cefepime was continued as outpatient parenteral antimicrobial therapy (OPAT) administered over 30 minutes. The patient began to experience symptoms of neurotoxicity after 1 day of receiving OPAT, which subsequently led to a readmission as neurological symptoms worsened. Cefepime was discontinued and symptoms resolved within 48 hours. Renal function was stable throughout treatment and no other causes for neurotoxicity were noted. Conclusion: This is a unique case of CIN secondary to shortened infusion time, which is clinically relevant, particularly during transitions of care. Further investigation, including more widespread use of therapeutic drug monitoring will be beneficial to further elucidate the relationship between infusion time and CIN development.

Actinomycosis is a rare endogenous infection characterised by indolent progression, contiguous spreading, abscess formation and draining sinuses. Here, we present a case of Schaalia odontolytica causing a mediastinal abscess that is unique in its acuity and location. Our patient presented with worsening dysphagia, and CT of her chest revealed a new mass in the posterior mediastinum displacing the oesophagus. Oesophagram revealed mild motility disorder, but no masses or ulcers within the oesophagus. Oesophagogastroduodenoscopy with endoscopic ultrasound revealed extrinsic compression of the oesophagus. Fine-needle aspiration of the mass yielded purulent fluid, which was cultured. A single colony of S. odontolytica was isolated. Initially, medical treatment was favoured, but as she developed worsening dysphagia, the abscess was drained. She continued on long-term antibiotic therapy after drainage and had complete resolution of the abscess at 1 year.

Streptococcus equi subspecies zooepidemicus (S. zooepidemicus) is a zoonotic pathogen that primarily infects horses, pigs, and dogs. Although rare, it has also been shown to infect humans who consume unpasteurized dairy food or have direct contact with horses. Here, we present a case of S. zooepidemicus bacteremia in a patient without a clear mode of transmission. An 86-year-old male with a past medical history of coronary artery disease, heart failure with reduced ejection fraction, complete heart block status post pacemaker, hypertension, hyperlipidemia, and type 2 diabetes mellitus presented to the Emergency Department with fever and chills. He had fevers and rigors for three days but denied weight loss, cough, sore throat, or rashes. In the Emergency Department, vital signs revealed a fever of 101.2 degrees Fahrenheit and a heart rate of 110 with other stable vital signs. The physical exam was unremarkable except for tachycardia, and laboratory work revealed no leukocytosis but elevated inflammatory markers and elevated lactate. Computed tomography of the chest, abdomen, and pelvis did not reveal any source of infection. Blood cultures grew S. zooepidemicus and the Infectious Diseases team was consulted, who started the patient on Penicillin G. Due to concern for pacer-lead infective endocarditis, transthoracic and transesophageal echocardiograms were performed, which did not show valvular vegetations. Repeat blood cultures showed clearance of the infection, and the patient was ultimately discharged on amoxicillin. While our patient denied consuming unpasteurized dairy products or having direct contact with horses, upon further questioning, he did endorse family members who occasionally interacted with horses. This case is valuable as it adds to the sparse literature on S. zooepidemicus infections specifically in humans. Extensive history taking is of utmost importance when a clear source of infection is not easily identifiable. Further research is also needed to better understand the various modes of transmission of this bacterium to better target and caution those at an increased risk of infection.

UNASSIGNED: Myocarditis is challenging to diagnose due to its varied presentations. Endomyocardial biopsy is the gold standard for diagnosis, but its invasive nature has led to alternative non-invasive modalities, notably cardiovascular magnetic resonance (CMR). Identifying the precise aetiology of myocarditis is crucial for effective treatment, yet extra-cardiac causes are often overlooked. In this paper, we spotlight the underexplored role of CMR in diagnosing extra-cardiac aetiologies, utilizing three insightful cases for illustration.
UNASSIGNED: The first case is a 31-year-old patient with myocarditis secondary to a pyogenic liver abscess, identified through CMR, who improved after abscess drainage. The second case involves a 54-year-old patient with myocarditis attributed to adult T-cell leukaemia-lymphoma, with the loco-regional thickening process identified thanks to CMR. This patient had an unfavourable disease progression due to the underlying malignancy. The third case concerns a 23-year-old patient suffering from myocarditis associated with pneumonia, again illustrated effectively through CMR imaging, who recovered after antibiotic treatment.
UNASSIGNED: These cases underline the overlooked potential of CMR in diagnosing extra-cardiac aetiologies of myocarditis, even though such causes are rare. Despite current guidelines recognizing the importance of identifying the aetiology of myocarditis, they do not explicitly address the role of CMR in diagnosing extra-cardiac aetiologies. This article, therefore, proposes that future guidelines could emphasize the utility of CMR in exploring these causes, potentially leading to more accurate diagnoses and improved patient outcomes. It also advocates for a comprehensive, multidisciplinary approach to myocarditis diagnosis, encouraging vigilance for potential loco-regional causes, and calls for further research in this area.

Surgically induced necrotizing scleritis (SINS) is a rare delayed hypersensitivity reaction following ocular surgeries, characterized by pain and redness at the surgical site. While commonly reported in various ocular surgeries, its occurrence after vitreoretinal procedures remains infrequent. We present a case of a 61-year-old diabetic male who developed progressive scleral melting and uveal exposure two months after an uneventful 23-gauge vitrectomy for retinal detachment. The infectious and immunologic profile was negative. Despite aggressive medical and surgical interventions, the patient exhibited advancing scleral melting. The diagnostic challenge lies in determining the relative contributions of trauma, epithelial breakdown, immune activation, and infection in these patients. Our patient\'s uncontrolled diabetes potentially aggravated vascular disruption, contributing to delayed wound healing and immune complex deposition. The treatment involved topical steroids with broad-spectrum antibiotics, followed by conjunctival flap and oral corticosteroids. This case underscores the importance of early diagnosis, cautious immunosuppression, and thorough infection evaluation in managing postoperative scleritis. The limitations include a single culture test and the patient being lost to follow-up.

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UNASSIGNED: Common cardiac arrhythmias seen in patients with leptospirosis are usually atrial fibrillation or first-degree atrioventricular block, with bradyarrhythmia being rare in this group. It is essential to prioritize the examination of the patient\'s medical background, clinical symptoms, and comprehensive physical evaluation in order to promptly identify and address the patient\'s condition.
UNASSIGNED: Leptospirosis, a zoonotic disease that is widespread worldwide, has a significant impact on tropical areas and can affect various organs throughout the infection. During the initial stage, symptoms are typically non-specific. Although cases of all three cardiac layers being affected have been reported, issues with the conduction system are especially significant in the early phase of the disease. The most frequent discoveries in these patients are atrial fibrillation or first-degree atrioventricular block, with bradyarrhythmia being rare. We describe a 37-year-old male farmer who initially sought medical attention for general symptoms that had been deteriorating despite receiving outpatient treatment for 3 days for a presumed diagnosis of influenza. During his initial assessment, he exhibited sinus bradycardia, anemia, leukocytosis, elevated levels of direct and total bilirubin, and abnormal liver function test results. Through thorough history-taking, physical examination, and laboratory analyses, a diagnosis of leptospirosis was conclusively established for him. Focusing on the patient\'s medical history, clinical manifestations, and thorough physical assessment is crucial for promptly diagnosing and treating patients. This becomes particularly significant for individuals who exhibit atypical symptoms, exemplified by our patient presenting with nonspecific indications and cardiac issues manifested as bradycardia.

BACKGROUND: The connections between fine particulate matter (PM2.5) and coarse particulate matter (PM2.5-10) and daily mortality of viral pneumonia and bacterial pneumonia were unclear.
OBJECTIVE: To distinguish the connections between PM2.5 and PM2.5-10 and daily mortality due to viral pneumonia and bacterial pneumonia.
METHODS: Using a comprehensive national death registry encompassing all areas of mainland China, we conducted a case-crossover investigation from 2013 to 2019 at an individual level. Residential daily particle concentrations were evaluated using satellite-based models with a spatial resolution of 1 km. To analyze the data, we employed the conditional logistic regression model in conjunction with polynomial distributed lag models.
RESULTS: We included 221,507 pneumonia deaths in China. Every interquartile range (IQR) elevation in concentrations of PM2.5 (lag 0-2 d, 37.6 μg/m3) was associated with higher magnitude of mortality for viral pneumonia (3.03%) than bacterial pneumonia (2.14%), whereas the difference was not significant (p-value for difference = 0.38). An IQR increase in concentrations of PM2.5-10 (lag 0-2 d, 28.4 μg/m3) was also linked to higher magnitude of mortality from viral pneumonia (3.06%) compared to bacterial pneumonia (2.31%), whereas the difference was not significant (p-value for difference = 0.52). After controlling for gaseous pollutants, their effects were all stable; however, with mutual adjustment, the associations of PM2.5 remained, and those of PM2.5-10 were no longer statistically significant. Greater magnitude of associations was noted in individuals aged 75 years and above, as well as during the cold season.
CONCLUSIONS: This nationwide study presents compelling evidence that both PM2.5 and PM2.5-10 exposures could increase pneumonia mortality of viral and bacterial causes, highlighting the more robust effects of PM2.5 and somewhat higher sensitivity of viral pneumonia.