Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory condition leading to organ dysfunction and death. Primary HLH, driven by genetic mutations that impair immune regulation, predominantly affects children, whereas the secondary (acquired) form is more common in adults. Secondary HLH may be precipitated by various drivers, including medications such as immune checkpoint inhibitors (ICIs). Diagnosing this condition is difficult, as initial signs are often vague and overlap with those of other disorders; consequently, clinicians commonly use the Hemophagocytic Lymphohistiocytosis-2004 (HLH-2004) diagnostic criteria and the H-Score to support the diagnostic evaluation. We report a case of a patient with triple-negative inflammatory breast cancer who developed HLH following anticancer therapy with pembrolizumab. The patient's presentation with fever and cytopenias led to the initial management of neutropenic sepsis. However, following non-response to standard sepsis management, the patient was worked up for HLH. Diagnosis of HLH was supported by histopathological and laboratory findings; the patient fulfilled five HLH-2004 diagnostic criteria and responded to high-dose corticosteroid therapy. This case highlights the importance of considering HLH as a rare immune-related adverse event (irAE) in patients receiving ICIs when presumed diagnosis fails to respond as expected. It further illustrates the value of applying validated diagnostic tools to expedite immunosuppressive therapy.

Pyogenic ventriculitis is a rare and potentially fatal infection of the ventricular system. While most reported cases are nosocomial and catheter-associated, ventriculitis as a complication of community-acquired bacterial meningitis is uncommon, particularly in adults, and carries a poor prognosis. We report the case of an 82-year-old previously healthy and unvaccinated woman who presented with a one-day history of fever, confusion, and purulent left-sided otorrhea on a 2-week background of flu-like symptoms. Cranial computed tomography was consistent with otogenic meningitis complicated by pneumocephalus, and lumbar puncture confirmed purulent meningitis. Empirical therapy for meningitis with ceftriaxone, amoxicillin, metronidazole, and dexamethasone was initiated, and surgical source control of the otogenic focus was performed. Both blood and cerebrospinal fluid cultures grew Streptococcus pneumoniae with a penicillin minimum inhibitory concentration of < 0.03 mg/L. Serotyping by multiplex PCR with confirmatory Quellung reaction, performed at the Swiss National Reference Center for Invasive Pneumococci, identified Serotype 3. Despite penicillin G monotherapy, fever and impaired consciousness persisted, and repeat imaging revealed meningitis-associated pyogenic ventriculitis with intraventricular debris. Adjunctive rifampicin and a series of cerebrospinal fluid drainage interventions (lumbar drain followed by external ventricular drain) failed to substantially improve neurological outcome. Antibiotic therapy was continued for 9 weeks, after which the patient was transferred to long-term institutional care with severe residual neurological impairment. This case illustrates the diagnostic and therapeutic challenges of meningitis-associated pyogenic ventriculitis in adults and the disproportionate severity of disease caused by Serotype 3 S. pneumoniae, whose unusually thick mucoid capsule promotes immune evasion and the formation of viscous purulent debris that hampers source control. The case is consistent with Swiss surveillance data showing that Serotype 3 remains a leading cause of invasive pneumococcal disease in older adults and serves as a sentinel event highlighting persistent gaps in adult pneumococcal immunization.

A 79-year-old woman presents to the hospital with dyspnoea, fever, and hypotension, and is diagnosed with community-acquired pneumonia and septic shock. Resuscitation is initiated with fluids and vasopressors, and a central venous catheter is placed. However, during the procedure, the guide experiences resistance and cannot be removed, becoming trapped. This is confirmed with tomography and reconstruction, demonstrating intravascular position. The patient is then sent to interventional cardiology for extraction, which is successfully performed using the EN Snare (Merit Medical). The significance of this case lies in the complications of not guiding procedures with ultrasound and how to resolve them, such as the guide being trapped in this patient.

A 43-year old man presented with fever and cough and was initially treated for community-acquired pneumonia. Within 24 h, he deteriorated and was admitted with type 1 respiratory failure. A recent history of exposure to waterlogged fields, along with progressive decline in haemoglobin, platelet counts and deranged liver function tests, raised suspicion for leptospirosis, later confirmed by positive IgM serology. With progressive clinical and radiological worsening, severe pulmonary haemorrhagic syndrome was considered. He was managed with oxygen, noninvasive ventilation (NIV), ceftriaxone, doxycycline, cotrimoxazole, and pulse methylprednisolone. He showed significant improvement and was successfully weaned off NIV and oxygen. This case highlights the importance of early recognition and timely initiation of steroid therapy in severe leptospiral pulmonary involvement.

This study reported a 33-year-old male acquired immune deficiency syndrome (AIDS) patient with a 10-year human immunodeficiency virus (HIV) infection history, poor antiretroviral therapy (ART) adherence, and two previous Talaromyces marneffei infections. Self-discontinuation of ART led to severe immunosuppression and disseminated Mycobacterium avium complex (MAC) infection involving the bloodstream and bone marrow. After the restart of ART, the patient developed persistent high fever, which was clinically suspected to be MAC-associated immune reconstitution inflammatory syndrome (IRIS). However, due to the lack of serial HIV viral load and CD4[+] T lymphocyte data, a definitive diagnosis could not be established. The patient was admitted with fatigue, anorexia, and black stool as the main symptoms. MAC infection was confirmed by blood culture, bone marrow culture, and bone marrow metagenomic next-generation sequencing (mNGS) at a higher-level hospital. Notably, after transfer to our hospital, the microbiology laboratory performed blind subculture on routinely negative blood culture bottles and extended the incubation period to 15 days, successfully isolating MAC. This highlights the crucial significance of close clinical-laboratory collaboration and optimized pathogen detection for diagnosing non-tuberculous mycobacteria (NTM) infections. After initial infection control and ART restart, the patient developed recurrent fever. Given the temporal association with ART reinitiation and the dose-dependent correlation between fever and glucocorticoid adjustments, possible MAC-associated IRIS was suspected. The patient's clinical symptoms improved with glucocorticoid therapy, though this does not confirm the diagnosis. Complications including cytomegalovirus reactivation, adverse drug reactions, and human rhinovirus co-infection were managed in a standardized manner. This case suggests that the diagnosis of disseminated MAC infection in severely immunocompromised AIDS patients relies on efficient collaboration between clinicians and laboratories. However, in the absence of confirmatory immunological and virological evidence, the diagnosis of IRIS remains uncertain. Clinicians should remain vigilant for suspected IRIS when restarting ART while acknowledge that limited data may preclude a definitive diagnosis. Individualized comprehensive strategies covering anti-infection, immunomodulation, anti-inflammation, and supportive treatment are the key to managing such complex HIV-related opportunistic infections.

Background: Anaplasmosis is an emerging tick-borne infection that typically presents as a non-specific febrile illness, with variable degrees of cytopenias and liver tests abnormalities. Severe complications remain atypical and uncommon. Case Report: We report a case of acute pulmonary embolism (PE) occurring during confirmed anaplasmosis in a 73-year-old male with no traditional thromboembolic risk factors. The patient presented with fever, constitutional symptoms, thrombocytopenia, leukopenia, and abnormal liver tests, raising suspicion for a tick-borne illness. Despite early clinical improvement on doxycycline, persistent tachycardia triggered further evaluation and uncovered an acute PE. Comprehensive workup at admission and repeated 14 months later excluded inherited and acquired thrombophilias, malignancies, autoimmune diseases, and alternative infectious etiologies. The patient was treated with doxycycline 100 mg orally twice daily for 10 days and anticoagulation with unfractionated heparin followed by 6 months of apixaban for a first episode of provoked PE. He attained complete clinical recovery without recurrence of thrombosis at the two-year follow-up. Discussion: Infectious diseases are increasingly recognized as contributors to thrombosis through inflammation-mediated hypercoagulability and endothelial dysfunction. Pulmonary involvement in anaplasmosis typically manifests as pneumonitis, pneumonia or acute respiratory distress syndrome, but thrombotic complications such as PE are exceedingly rare. This case highlights a rare but clinically significant vascular complication of anaplasmosis and underscores the importance of considering thromboembolic events in patients with persistent or unexplained tachycardia. Conclusions: As the incidence of anaplasmosis continues to rise, greater awareness of its potential cardiovascular manifestations is essential. Early recognition and prompt treatment with doxycycline remain critical, while further studies are needed to better define the thrombotic risk associated with this infection.

Aspiration pneumonia is a prevalent and severe complication in stroke survivors, substantially affecting morbidity and mortality rates. Early identification of risk factors is crucial for implementing timely prevention and management strategies. We aimed to determine the prevalence and clinical associations of aspiration pneumonia in stroke patients admitted to Bolan Medical Complex Hospital, Quetta. This descriptive cross-sectional study looked at 201 stroke patients who were admitted over 6 months. Clinical, demographic, and radiological data were gathered utilizing a systematic proforma. Aspiration pneumonia occurred in 36.3% of patients. Hemiplegia was identified as the most significant independent association (odds ratio = 1.19, 95% confidence interval: 1.01-1.41, p=0.04). Nasogastric tube feeding was present in 77.1% of aspiration pneumonia cases. Dysphagia and dysarthria showed associations in univariate analysis but lost significance in multivariate modeling. Hospital-acquired cases exhibited elevated rates of fever, positive chest X-rays, and significant neurological impairments. Aspiration pneumonia is common among stroke patients, with motor impairments and mechanical feeding being major risk factors. Early screening and comprehensive management are crucial for decreasing its prevalence, particularly in resource-constrained environments.