Coccidioidomycosis (CM) is an emerging public health challenge due to an increasing number of cases in the U.S. Diagnosis may be challenging because of its nonspecific presentation, which may lead to treatment delays. In addition, the optimal management of severe pulmonary CM remains unclear. We present the case of an 18-year-old immunocompromised renal transplant recipient with a history of systemic lupus erythematosus who developed acute respiratory distress syndrome (ARDS) secondary to severe pulmonary CM. Following initiation of systemic corticosteroids treatment with standard-of-care antifungals, she demonstrated improved clinical response. Severe pulmonary CM may lead to a significant multiorgan inflammatory response in this infection. Our case explores corticosteroid treatment to downregulate this pathophysiologic process and help facilitate clinical resolution of the critical respiratory symptoms and limit morbidity associated with this infection.

Methicillin-resistant Staphylococcus aureus (MRSA) is an uncommon etiologic agent of hepatic abscess in children, particularly those without an underlying immunocompromised condition. We describe a rare case of community-acquired MRSA (CA-MRSA) hepatic abscess with rupture into the anterior abdominal wall in an otherwise healthy 3-year-old Filipino male, manifesting as a one-week history of an enlarging epigastric mass accompanied by abdominal pain and fever. He was treated noninvasively with ciprofloxacin (intravenous at 10 mg/kg every 12 hours for 14 days followed by oral at 15 mg/kg every 12 hours for 28 days), and clindamycin (intravenous at 10 mg/kg every 6 hours for 14 days followed by oral at 10 mg/kg every 6 hours for 28 days), resulting in the resolution of the hepatic abscess and its associated symptoms. CA-MRSA hepatic abscess is extremely rare in immuno-competent children, and an appropriate diagnostic approach involving imaging and culture studies is crucial in its diagnosis and management.

Human monocytic ehrlichiosis (HME) is a tick-borne infection caused by Ehrlichia chaffeensis, an obligate intracellular bacterium that infects monocytes and can lead to systemic inflammatory illness. Clinical manifestations typically include fever, malaise, cytopenias, transaminitis, and, in severe cases, neurologic or multiorgan involvement. Although HME is increasingly recognized in immunocompromised hosts, it remains uncommon in solid organ transplant recipients and is rarely reported outside peak seasonal exposure periods. In transplant patients, atypical presentations, baseline hematologic abnormalities, and the possibility of donor-derived or non-vector transmission can obscure the diagnosis and delay appropriate therapy. In addition, reactivation of ehrlichiosis following transplantation remains poorly characterized, with limited data available regarding its pathogenesis, diagnosis, and management. Here, we present a case of presumed reactivation of ehrlichiosis in a heart transplant recipient and discuss the diagnostic and therapeutic challenges associated with HME in immunosuppressed patients.

Aspergillus lentulus is a slow-growing and drug-resistant fungus, which has been primarily reported in adults, usually immunocompromised ones, suffering from invasive pulmonary aspergillosis (IPA). This condition is rare in children. Here, we report a case of invasive pulmonary aspergillosis due to Aspergillus lentulus in a boy with no history of recurrent infections who presented with a prolonged fever of unknown origin. Based on chest CT scan findings showing typical halo signs, a fungal infection was strongly suspected. Empirical antifungal therapy was initiated at early admission but failed to resolve the persistent fever in this case. The causative pathogen was confirmed by blood metagenomic next-generation sequencing (mNGS). Subsequent genetic analysis identified a pathogenic mutation in the X-linked CYBB gene, confirming chronic granulomatous disease (CGD). Eventually, following a combination therapy of voriconazole and micafungin, the boy became afebrile and was discharged, pending hematopoietic stem cell transplantation (HSCT). To our knowledge, no previous cases of Aspergillus lentulus infection in children with CGD have been reported in the literature. This case underscores the critical importance of identifying the causative microorganism. It also highlights the value of emerging detection methods, such as mNGS. At present, there is no consensus for the optimal antifungal regimen against pediatric Aspergillus lentulus infections. Clinical improvement was achieved in this patient following combination therapy with voriconazole and micafungin, offering a practical therapeutic reference for managing this refractory fungal infection.

Fever is a recognized manifestation of active ulcerative colitis (UC); however, isolated fever in the absence of GI symptoms or objective evidence of active colonic inflammation is exceedingly uncommon. The diagnostic challenge is amplified in immunocompromised patients receiving biologic therapy, in whom occult infection must be rigorously excluded. We present a 68-year-old woman with a history of well-controlled HIV infection and recently diagnosed UC who was initiated on vedolizumab, mesalamine, and a prednisone taper in the outpatient setting. She presented with persistent daily fevers and initial concern for an infectious etiology of pyrexia. Ulcerative colitis appeared to be well treated, with outpatient CT demonstrating resolution of colitis, and the patient denied diarrhea, abdominal pain, hematochezia, or other symptoms suggestive of active disease. An extensive infectious workup, including blood cultures, viral studies, fungal biomarkers, Lyme disease testing, tick-borne testing, and autoimmune serologies, was negative. During the laboratory evaluation, thrombocytopenia, markedly elevated inflammatory markers, and elevated D-dimer levels were noted. Despite a comprehensive multidisciplinary evaluation, no infectious, malignant, thrombotic, or rheumatologic etiology was identified. Throughout her hospital course, the patient developed sequelae of a severe inflammatory response, including atrial fibrillation. The patient's fevers were ultimately attributed to an atypical systemic inflammatory manifestation of UC. This case highlights a rare presentation of UC manifesting predominantly as fever of unknown origin (FUO) despite apparent clinical and radiographic remission. Clinicians should recognize that significant systemic inflammation may occur even in the absence of overt GI disease activity after exclusion of alternative causes.

Capnocytophaga canimorsus is a zoonotic Gram-negative bacterium commonly present in the oral flora of dogs and cats. Although human infection is uncommon, it can lead to rapidly progressive and life-threatening disease, particularly in immunocompromised individuals such as those with asplenia. Severe acute respiratory distress syndrome (ARDS) requiring extracorporeal membrane oxygenation (ECMO) has been rarely reported. We describe a 60-year-old woman with hypothyroidism and a remote history of splenectomy who presented with fever, malaise, and gastrointestinal symptoms one week after a dog bite. Blood cultures obtained early during hospitalization grew C. canimorsus. Her clinical course was complicated by rapidly progressive ARDS and multiorgan failure, requiring invasive mechanical ventilation. Despite optimized lung-protective ventilation, neuromuscular blockade, prone positioning, and broad-spectrum antimicrobial therapy, refractory hypoxemia persisted. Veno-venous (VV) ECMO was initiated as rescue therapy, resulting in progressive improvement in gas exchange and pulmonary mechanics. ECMO support was successfully discontinued after 11 days, followed by liberation from mechanical ventilation and full clinical recovery. Severe C. canimorsus infection can result in fulminant ARDS and multiorgan dysfunction. Early recognition and timely escalation to advanced supportive therapies, including VV-ECMO, may be lifesaving in selected patients.

Non-typhoidal Salmonella infection usually causes self-limiting gastroenteritis, but a minority of cases are complicated by bacteraemia and extraintestinal focal infection. Vertebral discitis and osteomyelitis are rare complications, most often described in patients with diabetes, haemoglobinopathy, or immunosuppression. We describe a 67-year-old man with hypertension and previous percutaneous coronary intervention who attended the emergency department five times over six weeks with fever, rigors, diarrhoea, and worsening thoracic back pain after travel to Sri Lanka and the Maldives. Blood cultures grew Salmonella Java susceptible to ceftriaxone, ciprofloxacin, and co-trimoxazole. Initial CT of the chest, abdomen, and pelvis was unremarkable. CT angiography performed several weeks later showed mid-thoracic vertebral destruction and disc space change. MRI confirmed severe T6-T7 discitis and osteomyelitis with prevertebral soft tissue involvement of the adjacent oesophagus and azygous vein, together with periaortic enhancement from T5/T6 to T9. CT angiography found no aortitis. A repeat echocardiogram showed no evidence of infective endocarditis. Treatment required several antimicrobial adjustments, including prolonged intravenous ceftriaxone and later oral step-down to amoxicillin. Back pain improved substantially and serial radiographs showed no vertebral collapse. This case illustrates that Salmonella Java can seed the spine without classical immunocompromising risk factors and that the diagnosis is often delayed when persistent back pain is initially attributed to travel-associated gastroenteritis. Recurrent or unresolved symptoms after a confirmed Salmonella bacteraemia warrant early spinal MRI.

BACKGROUND Photo recall dermatitis (PRD) is a phototoxic eruption that occurs in areas of previous ultraviolet-damaged skin following systemic administration of a drug, most commonly chemotherapeutic medications. Although generally considered a self-limited dermatologic phenomenon, its implications in immunocompromised patients have not been well characterized. Secondary infection complicating PRD has not been previously established in the literature. This case is unique because the patient had an unusual rash while neutropenic, then developed a bloodstream infection (BSI), with the skin as her most likely source. CASE REPORT We describe a case of a woman in her 80s with metastatic pancreatic adenocarcinoma enrolled in a clinical trial of a DNA methyltransferase-inhibiting nucleoside analog who presented with fever, neutropenia, and an erythematous rash localized precisely to areas of a recent sunburn. Dermatologic evaluation supported a diagnosis of photo recall dermatitis. Peripheral blood cultures grew Staphylococcus hominis in 1 of 4 bottles, while concurrent port cultures were negative. She developed clinical signs of a true BSI rather than culture contamination, with the presentation consistent with a skin source as the most likely route of entry rather than a central-line-associated BSI (CLABSI) usually observed with S. hominis infections. CONCLUSIONS This case is, to the best of our knowledge, the first reported instance of photo recall dermatitis complicated by bloodstream infection. It highlights the potential for inflammatory skin barrier disruption to serve as a portal of entry in neutropenic patients. Clinicians should be aware that photo recall dermatitis can lead to infections, including BSIs, in immunocompromised hosts.

Pulmonary tuberculosis typically exhibits characteristic imaging findings; however, radiological manifestations can be atypical in certain cases, leading to potential misdiagnosis based solely on CT imaging. We describe a 59-year-old man who developed a 4-month history of cough and a 2-week fever during postoperative radiotherapy following esophagectomy for esophageal cancer. CT scans revealed multiple, scattered cystic cavities in both lungs, characterized by regular shape and well-defined borders. Following anti-tuberculosis therapy, the pre-existing cystic cavities collapsed and evolved into nodular opacities, a change highly suggestive of cystic metastases given the patient's history of esophageal cancer. A biopsy confirmed granulomatous inflammation, and follow-up at eight months after the initiation of anti-tuberculosis therapy showed near-complete resolution of the lesions. Although cystic pulmonary tuberculosis is rarely reported, this case is notable for its distinct cystic characteristics. To our knowledge, this is the first case to systematically document the transformation of cystic lesions into nodules during anti-tuberculosis therapy-a finding that may raise suspicion for cystic metastases and highlights the diverse and atypical radiological manifestations of tuberculosis in immunocompromised hosts.

Campylobacter infection in children is a common bacterial illness that mostly causes gastroenteritis and typically presents with diarrhea that may or may not be bloody, emesis, or abdominal pain. However, pediatric cases of bacteremia are rarely reported. Our objective was to report our tertiary center experience with Campylobacter bacteremia in a pediatric population. This 16-year retrospective study was performed at a tertiary-affiliated pediatric medical center. Data were collected from all patients with Campylobacter bacteremia during the study period. We identified 37 pediatric patients with Campylobacter bacteremia. Most children (n = 30, 81%) had severe underlying medical conditions, including malignancy and primary immunodeficiency. Only 7 (18.9%) children were previously healthy. The median age was 6.8 years, and children with severe underlying medical conditions were older than previously healthy children (9 vs. 1.2 years, P = .02). Most children present with fever and/or gastrointestinal symptoms. Campylobacter jejuni was the most common species (n = 30, 81%), and most isolates tested for antibiotic susceptibility were susceptible to macrolides. While one child was hospitalized in the intensive care unit because of septic shock, the outcome for all children was favorable. Campylobacter bacteremia is an uncommon complication of Campylobacter infection in children and has been reported more frequently among immunocompromised patients. Most children present with fever or gastrointestinal symptoms. Even in this predominantly immunocompromised population, the outcome is generally favorable, with most cases resolving without complications. Macrolides remain the antibiotic of choice for Campylobacter infections, including bacteremia.