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Large granular lymphocytic (LGL) leukemia is a rare form of incurable chronic leukemia frequently complicated by life-threatening cytopenias. The less common NK-cell variant of this disorder poses a diagnostic challenge and its etiologic basis is poorly understood. Here we present the case of an elderly man diagnosed with LGL leukemia after presenting with severe Coombs-negative hemolytic anemia, who had a robust durable response to oral cyclophosphamide. Close to two years after initial diagnosis, he developed a florid Mycobacterium avium-intracellulare (MAI) infection of the lungs. We discuss the clinical and pathologic features of this case, highlighting aspects common to this disorder and areas of clinical uncertainty. We hope to both raise awareness of the risk for pulmonary MAI infection in patients treated with lymphodepleting drugs and to motivate the prospective evaluation of strategies to prevent opportunistic infections in LGL leukemia.

Cryptococcus neoformans is a fungus that can cause pulmonary, central nervous system, and dermatological infections, especially in an immunocompromised patient. This is a case report of a patient, who was presumptively immunocompetent that developed isolated cryptococcemia while being treated for coronavirus disease 19 (COVID-19) infection. We report a case of a 59-year-old Hispanic man with a past medical history of hypertension, well-controlled diabetes mellitus, and class I obesity who was admitted for severe acute respiratory distress syndrome coronavirus 2 (SARS-COV-2) and subsequently was diagnosed with cryptococcal fungemia. The patient received 21 days of dexamethasone and during this period, blood and fungal cultures grew C. neoformans. The patient was alert and oriented, did not have focal neurological deficits or meningeal irritation signs; nonetheless, a lumbar puncture was attempted, but not successful. He was treated with intravenous amphotericin B for two weeks, followed by oral fluconazole for six weeks. Repeat blood cultures demonstrated clearance and he improved clinically. In conclusion, this case report describes the possibility of an association between the use of dexamethasone in COVID-19 patients and the development of cryptococcal fungemia. In the review of literature, rare case reports worldwide have discussed this topic. This is clinically challenging as the emergence of opportunistic infections in these debilitated hosts can be detrimental. Maintaining a high clinical suspicion for this opportunistic infection while treating COVID-19 patients is necessary to prevent further mortality associated with this pandemic.

Retinitis is the most frequent manifestation of Cytomegalovirus (CMV) disease in patients with HIV infection. The virus reaches the retina by hematogenous spread, therefore patients with serum CMV load are at increased risk of developing CMV retinitis. The evolution of retinitis without specific treatment causes irreversible visual loss. Proper treatment is essential for controlling the disease progression, prevention of relapses, and contralateral eye involvement. This report describes a 56-year-old white male who started a progressive decrease in visual acuity (VA) of the right eye, without pain or inflammatory signs. Initial fundoscopy identified a dispersed preretinal hemorrhage and yellowish exudates. For the hypothesis of CMV retinitis, serology for HIV was requested and the subsequent result was positive. Other opportunistic infections, as well as manifestations of CMV infection in other organs, were ruled out. The patient was discharged on valganciclovir and highly active antiretroviral therapy (HAART) with progressive improvement in retinal changes, but without full recovery from VA due to chronic vitritis and tractional retinal detachment. Slow recovery of lymphocyte populations and sustained decrease in viral load were observed. CMV retinitis as an initial and sole manifestation of HIV infection is rare and requires screening. The importance of this case lies in its rarity, since CMV retinitis was the only manifestation of CMV infection and the only opportunistic infection in this patient. Early diagnosis and initiation of targeted therapy decrease the morbidity associated with this infection.

Nocardiosis is an opportunistic infection that most commonly affects immunocompromised patients, with clinical presentations ranging from localized to disseminated disease. In the United States, the reported incidence is approximately 500 to 1,000 cases per year, with an observed male-to-female predominance of 3:1. We present the case of a 37-year-old male with a past medical history of malaria who presented with watery, non-bloody diarrhea for four days associated with a fever for two weeks. The human immunodeficiency virus (HIV) was positive in the emergency room before admission. Computerized tomography (CT) of the chest with contrast revealed an irregular pleural base mass in the right lower lobe with several small air foci. CT of the abdomen and pelvis revealed the right pleural base lung mass to be adherent to the diaphragm, as well as mild splenomegaly. The cluster of differentiation 4 (CD4) count was 9 cells/mm3. An acid-fast bacilli (AFB) sputum culture was positive for Nocardia farcinica. Trimethoprim-sulfamethoxazole was started for a Nocardia farcinica pulmonary infection, in addition to antiretroviral therapy. The patient was strongly encouraged to follow-up at the outpatient department.

Immune thrombocytopenia (ITP) is a prevalent disease that may need immunosuppressant treatment, which increases the risk of an opportunistic infection. We present the case of a woman with corticosteroid-resistant ITP who was electively admitted to the hospital to initiate second-line treatment. On the second day, she presented with a high fever and altered mental status, with no lesions on the cerebral tomography and inconclusive cerebrospinal fluid analysis. Nonetheless, she was promptly started on empiric antibiotics for meningitis which were then adjusted for Listeria monocytogenes, isolated in blood culture. The cerebral magnetic resonance showed signs of cerebritis and pyogenic foci. The patient was discharged after 73 days of treatment, asymptomatic and with no neurological sequelae. The mortality rate of neurolisteriosis can be as high as 50%. The median time between the initial symptoms and their detection is seven days, with many patients already developing cerebral abscesses. The favorable outcome of this patient was due to the precocious detection and start of the treatment.

A 69-year-old man presented to the ED of our hospital with fever, loss of appetite, malaise, and pyuria and was admitted. He was diagnosed as having Cronobacter sakazakii urinary infection. We instituted treatment with cefmetazole, and he was discharged on hospital day 7. C. sakazakii is a rare infection in adults in Japan. C. sakazakii urinary infection usually occurs as an opportunistic infection in immunocompromised adults or older adults. This patient was not immunocompromised, so Cronobacter spp. should be recognized as potential pathogens in non-diabetic, non-immunocompromised adults.

Pneumocystis pneumonia (PCP) is an opportunistic infection caused by Pneumocystis jirovecii. PCP due to immunosuppressive drugs is rarely reported in the literature. Herein we present a case of PCP in a 49-year-old patient who presented with progressive shortness of breath, dry cough, and low-grade fever. History revealed that he was taking prednisolone daily for his hyperactive airway disease. His temperature was 99oF, and he had bilateral crackles in the lungs with resonant wheezing. High-resolution computed tomography showed diffuse ground-glass haze and cystic lesions in the middle and upper zones of both lungs. He was commenced on intravenous ceftriaxone and methylprednisolone based on provisional diagnosis of interstitial pneumonia. However, his condition worsened. His human immunodeficiency virus (HIV) test was reactive, and his CD4+ count was 275 cells/mm3. Bronchoalveolar lavage revealed PCP by direct immunofluorescent assay. Additional serum testing revealed marked elevation of beta-D-glucan, consistent with PCP diagnosis due to glucocorticoid use. Trimethoprim-sulfamethoxazole and voriconazole were initiated, and his respiratory symptoms started improving. His respiratory condition improved on day 9, and he was discharged with follow-up.

Mycobacterium avium intracellulare (MAI) is an opportunistic infection that typically manifests itself as pulmonary infection. In immunocompromised patients, however, MAI can uncommonly cause disseminated disease and diffuse gastrointestinal involvement. Small bowel obstruction with concurrent MAI infection is rarely documented in literature. Here, a 60-year-old female with a past medical history significant for a gastrointestinal stromal tumor, two small bowel obstructions, and a bowel perforation repair presented to the emergency department with sharp abdominal pain due to a small bowel obstruction. Cultures obtained from the laparoscopic release of small bowel obstruction confirmed the presence of MAI. An antibiotic course of ethambutol, azithromycin, and rifampin was initiated and continued upon transfer to a long-term acute care facility. We describe this case to highlight the possibility of MAI infection in patients with postoperative abdominal pain resulting from small bowel obstruction, review the underlying pathophysiology, and discuss its epidemiology.

Cryptococcosis is a life-threatening opportunistic infection caused by Cryptococcus gattii and Cryptococcus neoformans. It affects both immunocompetent and immunosuppressed hosts. Disseminated cryptococcal infection is rare in immunocompetent patients, but the cryptococcal disease's neurological sequelae may be more prominent in this group. We present a case of a 58-year-old male patient with medical comorbidities of monoclonal gammopathy of undetermined significance (MGUS) and polycythemia vera. The patient presented with gradual worsening of mental status over one week. He was found to have Cryptococcus neoformans meningoencephalitis and fungemia. The patient received two weeks of liposomal amphotericin B (LAmB) and flucytosine with excellent clinical response. He was discharged on high dose fluconazole, and he returned to the hospital in one week with new-onset hemiplegia and cryptococcomas on imaging. Prolonged intravenous (IV) treatment of six weeks duration resulted in significant clinical improvement and disease-free state at two years follow-up. This article aims to stress the importance of individualized prolonged IV treatment with liposomal amphotericin B and flucytosine despite good initial response in patients with polycythemia vera and MGUS. This is the first reported case of cryptococcal disease, to the best of our knowledge, in a patient with MGUS and the third case of cryptococcal infection in patients with polycythemia vera in a non-HIV non-transplant state. Prolonged individualized IV treatment should be considered in immunocompetent patients with the above conditions, as this condition, if not adequately treated and relapses, lead to high morbidity and mortality.

Introduction Rhinocerebral mucormycosis (RCM) is a rare, frequently lethal, opportunistic infection of the paranasal sinuses and brain caused by fungi of the Mucoracea family. The overall global incidence is low, with the condition most commonly found in India and the Middle East. Early diagnosis and aggressive treatment are essential. Overall mortality is high; reported rates range from 25-60%. Its infrequent presentation can pose both diagnostic and therapeutic challenges for centers not familiar with the condition. Objective We aimed to evaluate patient demographics, clinical presentation, diagnosis, management, and the complications of this uncommon condition. Methods We carried out a retrospective case-series analysis of all patients with a confirmed diagnosis of RCM presenting to a single tertiary-level hospital between 2000-2010. Hospital patient records were used to attain the specific clinical details for each case. Results A total of nine patients (eight males and one female) were diagnosed with RCM during this period. All patients had diabetes mellitus; the mean age was 58.2 years. The most common presenting features were foul-smelling blood-stained rhinorrhoea (100%), nasal congestion (100%), reduced visual acuity (89%), and hard palate ulceration (67%). Two patients had a cerebral abscess at presentation; two patients had skull base erosions with associated cranial nerve palsies. All patients received systemic amphotericin B and surgical debridement. The overall mortality rate was 78%. Conclusions Rhinocerebral mucormycosis is a notoriously difficult infection to treat. Our case series demonstrates how patients often present late with a disease that has already spread beyond the paranasal sinuses. Despite treatment with antifungals and extensive surgical debridement, mortality remains high.

Invasive pulmonary aspergillosis (IPA) is an opportunistic infection that usually threatens immunocompromised patients. However, there are some reports of IPA in immunocompetent patients without the obvious classic risk factors. We present the case of an 82-year-old woman with a prior medical history of chronic obstructive pulmonary disease (COPD) and a recent short-term corticosteroid regimen for an acute exacerbation. She was admitted with dyspnoea, cough, and pleuritic pain and was diagnosed with pneumonia. Clinical deterioration occurred, and a diagnosis of IPA was made. She received treatment with voriconazole but died 14 days after admission. This case highlights the importance of considering IPA among the possible causes of infection in this population. Prompt institution of appropriate antifungal therapy is paramount for the management of this condition.

Nocardiosis is an uncommon opportunistic infection caused by aerobic, gram-positive, weakly acid-fast, filamentous bacteria of the genus Nocardia that presents as a suppurative disease in immunocompromised hosts. Herein the authors describe the case of an elderly male with granulomatosis with polyangiitis (GPA) on chronic immunosuppressive therapy that presented initially with visual symptoms and developed focal neurological deficits. Nocardia should be considered as a potential pathogen in any immunosuppressed patient presenting with endogenous endophthalmitis and new-onset focal neurological deficits. Early recognition and treatment may prevent irrevocable neurological compromise stemming from misdiagnosis.

In this report, we describe a case of a 61-year-old male patient who had the bacterium Dolosigranulum pigrum growing in a blood culture. It was susceptible to ampicillin, ceftriaxone, levofloxacin, and vancomycin but was intermediately resistant to erythromycin. The patient did not have a negative outcome as a consequence of this bacterium, which retrospectively could have been predicted based on the epidemiological data within the patient's profile.

The incidence of acquired immunodeficiency syndrome (AIDS)-related opportunistic infections has declined dramatically following the introduction of potent antiretroviral therapy (ART). However, pulmonary infections remain a significant cause of morbidity and mortality. The spectrum of pulmonary disease that can affect patients with human immunodeficiency virus (HIV) is wide and includes opportunistic infections with many bacterial, fungal, viral, and parasitic organisms. In this case, we present a 65-year-old woman with HIV, non-compliant with ART, who presented with subacute melena, fatigue, dyspnea, and hemoptysis. After extensive evaluation, she was found to have pneumonia caused by four different pathogens: Strongyloides stercoralis, Pneumocystis jirovecii, Cytomegalovirus (CMV), and Pseudomonas aeruginosa. She received trimethoprim-sulfamethoxazole, steroids, and ivermectin. However, her clinical condition did not improve and she passed away.

Objective Nocardiosis is a rare opportunistic infection caused by the Nocardia species. Nocardia bacteremia is a life-threatening presentation of disseminated nocardiosis that presents diagnostic and therapeutic challenges. We performed this retrospective analysis in a Chinese hospital from 2010 to 2019 to describe the characteristics of this rare bloodstream infection. Methods We searched the database of the real-time nosocomial infection surveillance system and identified patients whose blood cultures showed Nocardia bacteria growth. The medical records of these patients were extracted and analyzed by two independent researchers. The data included age, gender, complicating disease, duration from blood drawing to reporting, clinical signs and symptoms, blood routine and C-reactive protein results, radiological examinations, sites of involvement, antibiotic treatments, and outcomes. Results Seven patients with Nocardia bacteremia were found. There were four male and three female patients, whose ages ranged from 41 to 75 years. Six (85.7%) patients had predisposing conditions and were administrated corticosteroids for various reasons before the identification of Nocardia infection. The most common symptom was fever (100%). Five patients presented with lung or skin involvement; meanwhile, three patients presented with brain involvement. One patient presented with pelvic and peritoneum involvement, respectively. The most common findings of chest CT imaging were consolidation, followed by nodules and cavitations. Trimethoprim/sulfamethoxazole was prescribed to all patients after the diagnosis of Nocardia bacteremia. Six patients recovered, and one patient ultimately died. Conclusions Nocardia bacteremia is a rare bloodstream infection that usually occurs in immunocompromised patients. Clinical manifestations of patients are nonspecific. It often causes multiple organ involvement, and early diagnosis and prompt aggressive interventions are important to improve the outcome of this disease.

Streptococcus mitis (S. mitis) is a commensal bacterial species that commonly colonizes the oropharynx and gastrointestinal tract. It is seldom reported as a human pathogen. However, immunocompromised individuals may be at risk of infection. We describe a 62-year-old male with prostate cancer who presented with multiple S. mitis abscesses masquerading as metastases. In addition, we discuss the differential diagnosis and treatment options for this rare opportunistic infection.

Conventionally, Lactobacillus species are considered as low virulence organisms and rarely cause infection in immunocompetent individuals. However, it might be an opportunistic infection source in immunocompromised patients and can cause invasive serious infections. To our knowledge, there are only a handful of cases in the literature reporting primary bloodstream infection caused by Lactobacilli spp. in transplant recipients. Here, we report a case of a kidney transplant recipient with Lactobacillus rhamnosus bacteremia.

Nocardia is an uncommon gram-positive, weakly acid-fast bacterium that causes systemic or localized suppurative disease in humans and animals. Nocardiosis is typically regarded as an opportunistic infection, but approximately one-third of the patients are immunocompetent. The most common presentation is pulmonary disease (39%) followed by systemic involvement, defined as involvement of more than two sites; cutaneous presentation constitutes only 8% of the cases. Nocardia is widely distributed geographically; however, in the US, it is mostly found in warm and dry areas of South West and South East. We present a perfect case of cutaneous nocardiosis of a 70-year-old male, who presented with a traumatic splinter injury, leading to pustules formation on the right index finger, along with erythema and induration of the right arm. The patient was empirically diagnosed and treated for cellulitis, with amoxicillin and clavulanic acid, resulting in deterioration of the wound. The patient underwent incision and drainage and wound culture grew nocardia. The index of suspicion should be kept in mind while treating infectious blisters which have failed outpatient cellulitis treatment, immunocompromised hosts, and in nocardia prevalent regions.

Mucormycosis is an opportunistic fungal infection. Cardiac involvement is a rare, yet fatal, complication that can occur in disseminated disease. A strong index of suspicion is necessary for prompt treatment, especially in high-risk patients. We present a 62-year-old male patient with a history of diabetes and acute myeloid leukemia; he had pulmonary mucormycosis that was complicated by cardiac involvement as part of disseminated mucormycosis syndrome.

Pneumocystis carinii pneumonia (PCP) is a common opportunistic infection of the pulmonary parenchyma seen in the immunocompromised host. The clinical presentation and radiographic findings are varied, with the latter ranging from normal to bilateral ground-glass opacities with cyst formation. We present a case of a 46-year-old woman with a history of human immunodeficiency virus (HIV) with multiple treated prior episodes of PCP, who was found to have an impressive presentation on high-resolution chest computed tomography (HRCT).

Nocardiosis is an opportunistic infection in patients with depressed cell-mediated immunity. Inhalation is the primary route for exposure via dust particles. Patients with acquired immune deficiency syndrome (AIDS) are at increased risk of disseminated disease. A challenge in the diagnosis of pulmonary nocardiosis is that it can mimic other pulmonary diseases. Nocardia farcinica tends to be a more virulent, multidrug-resistant strain with an increased tendency to disseminate. This report describes a 64-year-old man with AIDS found to have pulmonary nocardiosis that did not respond to standard antibiotic therapy. Further evaluation revealed the virulent, multidrug-resistant Nocardia farcinica species. Targeted antibiotic therapy was initiated, after which the patient had an improvement in pulmonary symptoms. It is important to suspect pulmonary nocardiosis in immunocompromised patients who fail to respond to standard antimicrobial therapy. Susceptibilities should be obtained so that appropriate therapy can be promptly initiated as Nocardia farcinica is highly resistant to multiple antimicrobials.

The differential diagnosis of a pulmonary mass in an immunosuppressed host with a history of cancer is broad and includes malignant, infectious and inflammatory etiologies. Mycobacterium avium complex (MAC) is a rare cause of opportunistic infection in susceptible individuals that can present as either localized or disseminated disease. On radiologic studies, the pulmonary disease can manifest as heterogeneous linear or nodular densities, a mass-like lesion, or thin-walled cavitary lesions. We present the case of pulmonary MAC in a patient with a history of lung cancer requiring lobectomy, and splenic lymphoma being treated with chemotherapy, presenting with extreme fatigue and a fludeoxyglucose (FDG)-avid mass on positron emission tomography–computed tomography (PET-CT). The patient had a CT-guided biopsy of the mass that demonstrated non-caseating granulomas followed by a right middle lobe transbronchial biopsy that upon histologic examination revealed mild acute and chronic inflammation, and necrotizing caseating granulomas. The acid-fast culture of bronchoalveolar lavage showed the growth of acid-fast bacilli that were identified by deoxyribonucleic acid (DNA) probe as Mycobacterium avium complex. We discuss the typical radiological manifestations of MAC as well as the role of immunosuppression and B cell-depleting therapy from the predisposition to infection.

Nocardiosis is a rare cause of opportunistic infection post hematopoietic stem cell transplant (HSCT) occurring in about 0.3% of patients. The risk factors include delayed immune reconstitution, prolonged neutropenia, and graft-versus-host disease. The most common site of infection is the lung, followed by the brain and the skin. Concomitant pulmonary and central nervous system (CNS) nocardiosis is an extremely rare entity as presented in our case. We present the case of a 72-year-old male at 137 days post transplant presenting with complaints of headache and slurred speech. A magnetic resonance imaging (MRI) brain scan revealed two ring-enhancing lesions: 1.6 cm in the right frontal lobe and 1 cm in the left parietal lobe. The patient had an outpatient computed tomography (CT) chest scan a month prior showing a 1.4 cm solid right upper lobe nodule prompting bronchoalveolar lavage (BAL) that was nondiagnostic. On repeat inpatient CT chest scan, the nodule had increased in size to 3.3 x 2.5 x 2.1 cm, prompting a percutaneous fine-needle aspiration biopsy. He was started on empiric trimethoprim-sulfamethoxazole (TMP-SMX) and liposomal amphotericin B. The tissue mycology and acid-fast cultures were reported positive for nocardia species. The patient was discharged on intravenous TMP-SMX. A follow-up CT chest scan and MRI brain scan four months later showed resolution of the right upper lobe nodule and significant decrease in size of the brain lesions. The patient will continue TMP-SMX for a total of nine to 12 months. Given the increase in transplant recipients and the ongoing risk of developing nocardiosis several months post transplant, there is a need for standardized diagnostic and treatment guidelines. Meanwhile, our case highlights the importance of aggressiveness in pursuing a prompt diagnosis including invasive procedures, if required, in order to begin specific treatment.

Cytomegalovirus (CMV), a member of the Herpesviridae family, is an opportunistic infection with a typically benign course in the healthy host but has a more ominous course in the immunocompromised population. CMV infection commonly affects the visceral organs, particularly the respiratory and the gastrointestinal tract. CMV cutaneous lesions are rare and can be easily missed. We present a case of a 76-year-old woman presenting with a diffuse non-pruritic macular lesion with scattered vesicles and bullae, which was initially treated as a varicella zoster virus infection and herpes simplex viral infection, but was later found on biopsy to be due to cytomegalovirus. She has a history of Sjögren's syndrome, interstitial lung disease, and being on chronic immunosuppression therapy. This case highlights the importance of considering CMV infection in the differential diagnosis of vesicular skin lesions in immunocompromised patients. Based on a PubMed search for “cutaneous cytomegalovirus”, “cutaneous CMV”, “cytomegalovirus skin”, and “skin CMV” in material published in the last 20 years (from 1996 to 2016) and reviewing any applicable referenced material outside of those dates, cases of cutaneous CMV are not well documented.