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Burkholderia pseudomallei causes melioidosis, a potentially life-threatening infection that can rapidly progress to septic shock and multi-organ failure if not promptly recognized and treated. Current international guidelines recommend meropenem as first-line therapy for severe melioidosis, whereas prolonged oral eradication therapy is essential to prevent relapse. We report a 39-year-old man with diabetes mellitus and chronic hepatitis B who initially improved on intravenous ceftazidime for disseminated melioidosis, but relapsed after an inadequate eradication phase consisting of only one week of oral amoxicillin-clavulanate. During the second admission, he presented with septic shock and multiple deep abscesses. He initially stabilized on combination therapy including meropenem and ceftazidime, but deteriorated after de-escalation to meropenem monotherapy despite repeated in vitro susceptibility. Clinical improvement occurred after reintroduction and continuation of high-dose ceftazidime together with drainage of accessible abscesses. This case highlights that apparent clinical failure on meropenem monotherapy may be confounded by inadequate eradication therapy, incomplete source control, borderline baseline susceptibility, and possible pharmacokinetic factors. It also underscores the need to interpret in vitro susceptibility cautiously in severe relapsed melioidosis.

African tick bite fever (ATBF) is a spotted fever group rickettsiosis caused by Rickettsia africae and is often identified among travelers returning from sub-Saharan Africa. Clinical presentation may be mild or nonspecific, often delaying diagnosis despite characteristic findings such as inoculation eschars. A 52-year-old male presented to the preoperative holding area prior to a scheduled left-sided inguinal hernia repair after recently returning from a game-hunting trip to Africa. During preoperative intake, he was noted to have a fever of 106 °F despite being otherwise asymptomatic. Physical examination revealed two black eschars on the patient's back and right shin. Given the presence of high-grade fever, the scheduled procedure was canceled, and the patient was discharged for outpatient evaluation. He was subsequently treated with a 10-day course of doxycycline for suspected African tick bite fever. At two-week follow-up, the patient remained asymptomatic, his fever had resolved, and repeat preoperative evaluation was unremarkable. Surgical repair of the inguinal hernia was performed without complications. Although laboratory confirmation was not obtained, the clinical presentation, including characteristic eschars, high-grade fever, and recent travel to sub-Saharan Africa, was highly suggestive of ATBF. This case underscores the importance of maintaining clinical suspicion for ATBF in returning travelers and highlights the diagnostic value of inoculation eschars, even in the absence of systemic symptoms. Early recognition of suspected ATBF and empiric doxycycline therapy may result in rapid clinical improvement and help prevent unnecessary delays in care.

Nonadherence to trimethoprim-sulfamethoxazole (TMP-SMX) is a known risk factor for nocardiosis treatment failure, often due to adverse effects. However, reports linking relapse to treatment interruption caused by poor adherence are scarce. A 70-year-old male with chronic bronchitis presented with persistent fever, cough, and sputum. Nocardia asiatica was identified. Initial improvement followed a 28-day TMP-SMX course, but the patient discontinued therapy. Multiple readmissions over three years resulted from relapses due to poor adherence. Whole-genome sequencing of isolates from the first and third episodes revealed 99.9% genetic similarity, confirming relapse from the original strain. Only after completing a full six-month TMP-SMX course did the patient achieve sustained remission with no recurrence for five years. This case provides molecular evidence supporting that premature TMP-SMX discontinuation contributed to relapse, emphasizing that adherence is as critical as accurate diagnosis for cure.

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Zika virus (ZIKV) is an arbovirus commonly transmitted to humans through the bite of an infected Aedes mosquito. Clinically, ZIKV is known to cause a wide range of symptoms, from febrile rash to severe neurological conditions, with congenital microcephaly being one of the most notable. Herein, we present a case of concurrent ZIKV infection in dizygotic twins, where only one twin developed microcephaly and severe encephalic malformations, while the other exhibited normal encephalic architecture. Our findings shed light on the complex interplay between ZIKV infection and the manifestation of neurological disorders while providing potential insights into the underlying pathological basis of ZIKV neuropathogenicity, particularly in relation to its association with the development of Dandy-Walker malformation. By examining the differential outcomes in twins exposed to the same viral infection, we contribute to the understanding of factors that may influence the development of severe neurological complications in ZIKV-infected individuals. Further research in this direction is crucial for developing targeted interventions and preventive strategies to mitigate the devastating effects of ZIKV infection, especially in pregnant women and their offspring.

Chronic rhinosinusitis (CRS), defined as persistent inflammation of the sinuses lasting longer than 12 weeks, and recurrent acute rhinosinusitis (RARS), characterized by multiple distinct episodes of acute bacterial sinusitis within a year, are among the most common chronic illnesses in the US. Several risk factors, including gastroesophageal reflux disease (GERD) are associated with CRS and RARS. For exacerbations of CRS and recurrent episodes of RARS, antibiotic therapy is the mainstay of treatment; however, a significant subpopulation of patients remain resistant to treatment, despite rigorous and prolonged treatment. Consequently, patients experience frequent recurrences and more complex infections involving multiple organisms. Multidrug resistant bacterial strains, such as methicillin-resistant Staphylococcus aureus (MRSA), are increasingly implicated in treatment failure. Thus, there is a need for new therapies to treat patients with CRS and RARS effectively. Omadacycline is a tetracycline derivative antibiotic approved by the FDA to treat adult patients with community-acquired bacterial pneumonia and acute skin and skin structure infections. Omadacycline has broad spectrum activity against select pathogens and was proven to be effective against select multidrug resistant bacteria, including MRSA. Presented here are three cases of patients with underlying GERD and polymicrobial chronic sinusitis involving MRSA, along with several gram-negative enteric organisms, who were successfully treated with omadacycline after many years of recurrent infections. Omadacycline was shown to be an oral option for patients with infectious exacerbations of CRS and RARS involving antibiotic resistance and was well tolerated. These findings suggest that further investigation of omadacycline in this setting is warranted.

Recurrent symptomatic urinary tract infections (rUTIs) in pediatric patients with neurogenic bladder and chronic kidney disease can be particularly difficult to manage with an appropriate prophylaxis and treatment, especially when caused by multidrug-resistant organisms. Intravesical aminoglycoside instillation may provide a safe renal-sparing prophylactic option. A 9-year-old female with neurogenic bladder due to voiding dysfunction, stage 2 chronic kidney disease and bilateral hydronephrosis, who presented with high-grade fever, flank pain and vomiting. She had had 3 hospitalizations for multi-drug resistant urinary tract infections (MDR-UTIs) in the past 6 months, despite previous use of oral prophylaxis. Initially, she was receiving sulfamethoxazole/trimethoprim, then switched to nitrofurantoin for 6 months. The urine culture grew Klebsiella pneumoniae (ESBL-producing), with sensitivity to amikacin, meropenem and imipenem. The patient was treated with intravenous meropenem for 14 days, with both clinical and microbiological resolution. To minimize the chance of recurrence, a prophylaxis regimen started as intravesical amikacin instillation (250 mg in 50 mL normal saline) via self-intermittent catheterization - daily for 2 weeks, alternate days for 10 weeks, and finally twice weekly for 12 weeks. At 2-week follow-up visit, she was additionally started on prophylactic sulfamethoxazole/trimethoprim. Approximately 18 months follow-up after discharge, the patient remained asymptomatic with no further UTIs. This case report provides useful information on effective long-term prophylaxis of multi-drug resistant recurrent urinary tract infection or rUTI, using intravesical amikacin in a child with neurogenic bladder and renal injury. Utilizing specific protocols for dosage standardization and prospective studies to assess the safety and effectiveness would be beneficial.

Streptococcus pneumoniae remains a leading cause of invasive bacterial infection worldwide and is classically associated with community-acquired pneumonia. However, fulminant pneumococcal septic shock in the absence of radiographic pneumonia is uncommon and may delay diagnosis and treatment. We present the case of a 48-year-old immunocompetent female who developed severe septic shock secondary to Streptococcus pneumoniae bacteremia despite initially negative chest imaging for focal pneumonia. The patient presented with profound hypotension, lactic acidosis, thrombocytopenia, acute kidney injury, and acute hypoxic respiratory failure requiring vasopressor support and intensive care admission. Blood cultures grew Streptococcus pneumoniae. Initial chest radiography and computed tomography angiography of the chest demonstrated no focal consolidative pneumonia, although delayed bibasilar pulmonary infiltrative changes developed later during hospitalization. Extensive evaluation did not identify alternative infectious sources including endocarditis or meningitis. The patient improved rapidly with aggressive resuscitation and targeted antimicrobial therapy. This case highlights the importance of recognizing invasive pneumococcal disease even in the absence of classic radiographic findings and emphasizes that early imaging may underestimate evolving pulmonary infection in severe sepsis.

Pertussis is a highly contagious infection associated with significant morbidity and mortality in young infants despite widespread vaccination programs. Early recognition and treatment are important to reduce disease severity, shorten symptom duration, and limit transmission. We report the case of a 51-day-old previously healthy boy who presented with a 4-day history of whooping cough, apnea, circumoral cyanosis, post-tussive emesis, and reduced oral intake. Pertussis was confirmed by a nasopharyngeal respiratory multiplex PCR panel detecting Bordetella pertussis. The patient initially received two doses of oral azithromycin (10 mg/kg/dose); however, approximately 20-30 min after the second dose, he developed facial puffiness and lip swelling consistent with a probable immediate hypersensitivity reaction. This complicated management because alternative antimicrobial agents, including trimethoprim-sulfamethoxazole and fluoroquinolones, were considered unsuitable owing to age-related safety concerns and limited clinical applicability. Following multidisciplinary evaluation and individualized risk-benefit assessment, azithromycin desensitization was undertaken. The initial desensitization attempt was discontinued because of recurrent hypersensitivity symptoms, prompting modification of the protocol. A second desensitization attempt using extended infusion and observation intervals was successfully completed. Following tolerance of intravenous azithromycin, the patient was transitioned back to oral therapy and completed the full 5-day treatment course without recurrence of hypersensitivity symptoms or delayed reactions. His cough gradually improved, and apnea episodes resolved before discharge. This case highlights azithromycin desensitization as a potential individualized therapeutic strategy in carefully selected infants with pertussis and suspected macrolide hypersensitivity when safer alternative treatment options are limited. Further evidence is required before broader conclusions regarding safety, efficacy, and reproducibility can be drawn.

Fever, suppurative lymphadenitis, and suppurative parapharyngeal and mediastinal abscesses are typically indicative of deep neck infections. However, in rare instances, such deep neck infections may obscure underlying autoimmune conditions. This can lead to delayed or missed diagnosis with serious consequences. This case report describes the diagnostic uncertainty in a child presenting with suppurative deep neck and mediastinal abscesses concurrently with lymph-node-first Kawasaki disease features. Early clinical suspicion based on partial antibiotic response, timely detection of bilateral coronary artery dilatation and aneurysm, and prompt dual management with abscess drainage and intravenous immunoglobulin led to complete recovery of the child. This case highlights the importance of maintaining a high index of suspicion for Kawasaki disease in children with persistent lymphadenopathy and fever spikes despite intravenous antibiotics, while also recognizing the potential for true deep neck infection.

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Necrotizing fasciitis is a rare but life-threatening soft-tissue infection characterized by rapid progression, extensive tissue destruction, and high morbidity and mortality. Secondary bacterial infections may occur after varicella-zoster virus infection; however, the timing and clinical context are essential when interpreting causality. We report the case of an 8-year-old previously healthy girl who presented with high-grade fever, severe pain, and rapidly progressive necrotic soft-tissue infection involving the right leg and buttock. She had a documented history of chickenpox two months before presentation, with residual healed scars noted on examination. Given the prolonged interval and absence of active varicella lesions, a direct causal relationship between varicella and necrotizing fasciitis could not be confirmed. Laboratory investigations showed leukocytosis, severe anemia, hyponatremia, markedly elevated C-reactive protein, and a Laboratory Risk Indicator for Necrotizing Fasciitis score of 10, supporting a high-risk diagnosis. Wound culture grew Proteus mirabilis, an uncommon organism in necrotizing fasciitis, and treatment was guided by culture sensitivity. The patient improved following prompt supportive care, intravenous antibiotics, urgent surgical debridement, and continued wound management. This case highlights the importance of cautious interpretation of remote varicella history, early recognition of necrotizing fasciitis, timely surgical intervention, culture-guided antimicrobial therapy, and multidisciplinary care, particularly in resource-limited settings.

Chlamydia trachomatis (C. trachomatis) is the most commonly reported bacterial sexually transmitted infection among sexually active women. Although often asymptomatic or associated with non-specific clinical manifestations, it can cause inflammatory exudates and encapsulated fluid collections that are similar to adnexal masses on imaging. In rare cases, it may also present with massive ascites, a constellation of findings that may mimic ovarian malignancy. We report the case of a 32-year-old female with a nearly 3-month history of abdominal pain, adnexal masses and massive ascites. The initial workup did not reveal obvious evidence of infection and cytological examination showed no malignant cells. However, advanced gynecological originated cancer could not be fully excluded. Metagenomic next-generation sequencing (mNGS), which detected C. trachomatis in ascitic fluid, facilitated the diagnosis. The patient showed satisfactory clinical improvement following doxycycline treatment. For young, sexually active women presenting with unexplained ascites and adnexal masses, after excluding malignancy and common infectious diseases such as tuberculosis, C. trachomatis infection should be considered. Modern etiological detection methods, such as mNGS, can be employed to facilitate the diagnosis.

Tuberculosis is a significant component of global public health issues, where the diagnosis and treatment of skeletal and soft tissue tuberculosis are particularly complex and challenging. In recent years, Maggot Debridement Therapy (MDT) as a novel wound treatment method has gained increasing attention. However, the application of MDT in the treatment of tuberculous wounds has not been thoroughly studied. The purpose of this case report is to present a case of successful treatment of a tuberculous wound with MDT and discuss the potential value of MDT in the treatment of tuberculous wounds. Our case report provides preliminary clinical data suggesting the effectiveness and safety of MDT in treating tuberculous wounds. We anticipate future research to further explore the application of MDT in the treatment of tuberculous wounds to improve the prognosis of these patients.

Nocardia cyriacigeorgica, an emerging pathogen, poses significant risks to immunocompromised patients. We report a rare case of N.cyriacigeorgica-induced osteomyelitis in an 82-year-old woman undergoing chemotherapy for relapsed follicular lymphoma. Her complex medical background included chronic kidney disease, heart failure, and recent skin infections. She presented with severe pain and swelling in a surgically replaced right knee. Initial evaluations, complicated by neutropenia and a necrotic lung lesion, suggested atypical infections. Despite broad-spectrum antibiotic therapy, the infection persisted. Synovial fluid analysis confirmed N.cyriacigeorgica, prompting surgical debridement and a modified antibiotic regimen. However, resistance issues and severe side effects complicated treatment, leading to a progressive decline in her condition. This case underscores the challenges of diagnosing and treating N.cyriacigeorgica infections, highlighting the need for enhanced diagnostic methods and personalized treatment approaches to manage resistance and complex patient profiles effectively.

Syphilis is a protean infection capable of mimicking various dermatological and systemic diseases, often complicating diagnosis in its later stages. A 26-year-old HIV-negative man with a history of inadequately monitored syphilis presented with headache, cough, and widespread erythematous plaques with central atrophy. Investigations revealed an RPR titer of 1:128 and positive CSF treponemal serology. Chest CT demonstrated peripheral nodular lung consolidations, and ophthalmologic exam showed signs of prior uveitis. A skin biopsy confirmed late-stage syphilis, revealing extensive dermal tuberculoid granulomas and gummatous necrosis. Following a 14-day course of intravenous penicillin G, the pulmonary lesions completely resolved, cutaneous lesions markedly improved, and the RPR titer appropriately declined at the six-month follow-up. This case illustrates a rare presentation of late syphilis with concurrent pulmonary involvement and widespread granulomatous skin lesions, emphasizing the need for clinicians to maintain a high index of suspicion for atypical manifestations of Treponema pallidum.

Melioidosis, caused by Burkholderia pseudomallei (B. pseudomallei), is a life-threatening tropical infection that is frequently underdiagnosed because of its heterogeneous and nonspecific clinical presentation. We report a critically ill patient from an endemic area who developed fulminant pneumonia that progressed to septic shock and severe acute respiratory distress syndrome. Despite empirical broad-spectrum antimicrobial therapy, respiratory failure worsened, prompting early etiologic investigation with metagenomic next-generation sequencing, which identified B. pseudomallei and was subsequently confirmed by culture. The patient required early venovenous extracorporeal membrane oxygenation (ECMO) for refractory hypoxemia. Management included a targeted antimicrobial therapy in accordance with current guidelines and CT-guided drainage of a pulmonary abscess as definitive source control. The patient achieved full recovery without recurrence at follow-up. Early identification of the causative pathogen and timely source control were central to the management of melioidosis-associated severe ARDS. Advanced supportive measures, including ECMO, may be considered in selected patients with refractory hypoxemia as part of management involving multiple specialties.

The recently described Corynebacterium (C.) silvaticum is a diphtheria toxin (tox-) gene bearing species so far mainly found in wild boar and deers. Due to its close relationship to C. ulcerans a zoonotic potential has been proposed. To date, only two cases of human C. silvaticum infections have been reported in the literature. Here we present the case of a 63-year-old male game-hunting butcher with recurrent and difficult-to-treat axillary lymphadenitis and abscess formation. This case underlines the zoonotic potential of this novel member of the C. diphtheriae species complex and suggests zoonotic transmission from wild boars via direct contact to infectious tissue and possible microtrauma lesions during unprotected animal processing.

Tuberculosis remains a major global health concern with extrapulmonary manifestations contributing to approximately 15-20% of cases in immune-competent hosts. In 2022, National Tuberculosis Elimination Program (NTEP) reported multidrug resistance in 2.5% of new tuberculosis cases and 13% in previously treated cases. Among extrapulmonary tuberculosis pleural tuberculosis is one of the most common forms. It becomes a diagnostic challenge when microbiological tests are inconclusive. In most developing countries, antitubercular drugs are initiated empirically in patients on the basis of clinical decision. In today's day and age, physicians emphasize more on evidence-based medicine practice. We report a case of a young man who presented with exudative pleural effusion unresponsive to empirical antibiotics. Thoracoscopic pleural crush biopsy showed granulomatous inflammation with caseating necrosis and acid-fast bacilli, confirming tuberculous pleuritis that was multidrug resistant. This case illustrates the role of medical thoracoscopy in patients where suspicions for tuberculosis are raised without clear answers from the initial tests. Relying only on standard antitubercular treatment may delay the detection of underlying drug resistance that is a growing public health challenge. Early tissue diagnosis through thoracoscopy allowed timely identification of multidrug resistance and directed proper management.