Abstract Objectives: To determine the immediate post-operative course and outcome of pediatric patients with complicated acute mastoiditis (CAM) following surgical treatment. Study Design: A retrospective chart review of children diagnosed with CAM who underwent mastoid surgery during 2012-2019. Setting: Tertiary care university hospital. Participants: the study includes 33 patients, divided into two groups: 17 patients with subperiosteal abscess (SPA) alone - single complication group (SCG) and 16 patients with SPA and additional intracranial or intratemporal complications -multiple complications group (MCG). Main Outcome Measures: post-operative fever course and pattern (POF). Results :33 patients belong to the SCG 17(51%) and 16(49%) belonged to the MCG, respectively. 6/17(35.3%) SCG patients experienced POF vs. 12/16(75%) in the MCG (P=0.012). At post-operative day 2 (POD2), 10/13(77%) febrile patients belonged to MCG and 3/13(23%) to SCG (P=0.013). POF was recorded until POD6 in both groups. Seven patients, all from MCG with POF, underwent second imaging with no new findings. Conclusion: Following a cortical mastoidectomy for CAM, POF is not unusual in the first 6 days and seem to be benign condition. POF is more common, higher, and persistent for a longer duration in MCG compared with SCG. At POD 6, fever is expected to normalize in both groups, so if fever persists further evaluation should be considered.

Achilles tendon rupture is a well-documented adverse effect of Fluoroquinolones; however, herein we present a case of complete iliopsoas and Achilles, and partial semimembranosus tendon rupture secondary to Levofloxacin.

COVID-19 cases are increasing worldwide. With such emerging disease the medical community should be aware of atypical clinical presentations in order to help with correct diagnosis, and to take the proper measures to isolate and treat patients to avoid healthcare professionals being infected and to limit its spread (SARS-CoV-2).

Opportunistic infections are common in human immunodeficiency virus (HIV)-infected patients. Co-infections with Cryptococcus neoformans together with Mycobacterium and Pneumocystis jiroveci pneumonia (PCP) are rare, and typically occur in immunocompromised individuals, particularly AIDS patients.

Acute decompensation in patient with COVID19 is usually a consequence of worsening ARDS , however acute pulmonary embolism and acute pneumothorax are frequently recognized causes of acute decompensation , the later causes are treatable and having high index of suspicion is very important in order not to miss them.

FDG-PET/CT is expensive but useful for diagnosing difficult cases of reactive arthritis. It can reveal enthesitis and arthritis, which are a feature of reactive arthritis.

A 61 years old male had minimally symptomatic SARS-CoV-2 infection while taking everolimus. He remained RT-PCR positive for viral RNA for 52 days. Pegylated interferon for 4 weeks led to viral RNA clearance. The observations support consideration and further evaluation of combination therapy with everolimus plus interferon for COVID-19.

This report describes Streptococcus suis meningitis with ventriculitis in a 66-year-old kushiyaki chef, which presented with fever and meningeal irritation signs. Cerebrospinal fluid testing revealed increased cell counts and protein levels, and presence of gram-positive cocci. Kushiyaki chefs are at high risk of this infection and prophylaxis should be considered.

A patient with coronavirus disease 2019 showed complete atrioventricular block on electrocardiogram. The patient was undergoing mechanical ventilator treatment for severe hypoxia. Intrathoracic pressure was reduced by adjusting the tidal volume and the positive end-expiratory pressure of the mechanical ventilator. After that, complete atrioventricular block didn't occur during the hospitalization.

Klebsiella pneumoniae can cause community-acquired and hospital-acquired infection. It increases morbidity and mortality in high-risk patients. We present a case of invasive Klebsiella pneumoniae in poorly controlled diabetes mellitus, who ended up having a metastatic spread of Klebsiella pneumoniae involving the liver, lungs, kidneys, brain, and muscle.

We are reporting a case of breast tuberculosis (BT) that was initially misdiagnosed as a breast abscess. Fine needle aspiration cytology (FNAC) helped in diagnosing BT faster by avoiding different invasive diagnostic methods. FNAC can be used as the primary diagnostic method of choice for the diagnosis of BT.

Objectives: To determine the immediate post-operative course and outcome of pediatric patients with complicated acute mastoiditis (CAM) undergoing simple mastoidectomy. Study Design: A retrospective chart review of children diagnosed with CAM who underwent a mastoidectomy during 2012-2019. Setting: Tertiary care university hospital. Participants: 33 patients were divided into two groups: 17 patients with subperiosteal abscess (SPA) alone- single complication group (SCG) and 16 patients with SPA and additional complications (sigmoid sinus vein thrombosis, perisinus fluid/abscess, epidural abscess)-multiple complications group (MCG). Main Outcome Measures: post-operative data were collected. Demographics, microbiology data, inflammatory parameters, hospitalization length, and POF pattern were recorded, compared, and analyzed. Results: Of 162 acute mastoiditis patients, 33(20.4%) underwent surgery due to CAM; 17(51%) and 16(49%) belonged to the SCG and MCG, respectively. 6/17(35.3%) SCG patients experienced POF vs. 12/16(75%) in the MCG (P=0.012). At post-operative day 2 (POD2), 10/13(77%) febrile patients belonged to MCG and 3/13(23%) to SCG (P=0.013). POF was recorded until POD6 in both groups. Seven patients, all from MCG with POF, underwent second imaging with no new findings; A total of 18 positive cultures were reported. Fusobacterium necrophorum counted for 8/18(44.5%) of all positive cultures, 7/9(77.8%) in the MCG vs. 1/9(11.1 %) in the SCG, P=0.004. Streptococcus pneumoniae was reported only in SCG (5/9, 55.5%, vs. 0/9, P=0.008). Conclusion: Post-mastoidectomy fever due to CAM is not unusual and seems to be a benign condition for the first 5-6 days following surgery. MCG patients are more prone to develop POF. F. necrophorum is more likely to be associated with MCG, and S. pneumoniae is common in SCG patients. Keywords: Mastoiditis, post-operative fever, complications, microbiology

The pandemic of severe acute respiratory syndrome virus 2 (SARS-CoV-2) is a serious threat to global health. Since tuberculosis-COVID-19 co-infection is a great risk for tuberculosis patients. This is the first report from Iran. Rapid screening of respiratory infections caused by COVID-19, isolation, and treatment of tuberculosis patients is vital.

We report mild COVID-19 manifestation in high-risk patient with sufficient plasma 25-OH-Vitamin D3 level. Given the global pandemic of vitamin D deficiency, as well as its likely beneficial effects during SARS-CoV-2 infection, report highlights importance of routine 25-OH-Vitamin D3 measurement, either for clinical course prediction or deciding on supplementation.

With the emergence of the acquired immunodeficiency syndrome, we witnessed a higher incidence of disseminated and extrapulmonary tuberculosis. It poses a significant diagnostic challenge for the physicians; therefore, a high index of suspicion should be maintained. Here we present a case of isolated chest wall tuberculosis in an immunocompetent patient.

A 14-year-old boy presented to our Emergency Department complaining of fever, and abdominal pain. An abdominal computed tomography showed a large abscess of the spleen. Percutaneous aspiration of the lesion was performed. Splenectomy was performed 38 days after percutaneous aspiration because of the abscess's considerable size.

This is the first case of adefovir dipivoxil (ADV)-induced hypophosphatemic osteomalacia (HO) and Fanconi’s syndrome in which bone mineral density (BMD) is continuously reduced after drug discontinuation. Sustained elevation of urine β2-MG also supports the recent view that ADV-induced renal injury is not completely reversible.

Cutaneous Larva MigransTakahiro Matsuo M.D.1, Toshiaki Nakano M.D.2, Nobuyoshi Mori M.D.11 Department of Infectious Diseases, St. Luke’s International Hospital, Tokyo, Japan2 Department of Dermatology, St. Luke’s International Hospital, Tokyo, JapanKeywords: cutaneous larva migrans, bilateral, hookwormTotal word count: 99 words

Snake bite is a common and very important issue threatening health worldwide. Patients who develop hemorrhagic or non-hemorrhagic blisters following snakebite, in addition to anti-venom, need broad-spectrum antibiotics and sometimes emergency surgical procedures and hospitalization to prevent serious complications such as necrotizing fasciitis, compartment syndrome.

Aims: To optimize the dosing regimen in patients with severe renal impairment based on population pharmacokinetic/pharmacodynamic (PPK/PD) analysis. Methods: The pharmacokinetics and safety of nemonoxacin was evaluated in a single-dose, open-label, nonrandomized, parallel-group study after single oral dose of 0.5 g nemonoxacin capsule in 10 patients with severe renal impairment and 10 healthy controls. Both blood and urine samples were collected within 48 hours after admission and determined the concentrations. A PPK model was built using nonlinear mixed effects modelling. The probability of target attainment (PTA) and the cumulative fraction of response (CFR) against S. Pneumoniae and S. aureus was calculated by Monte Carlo simulation. Results: The data best fitted to a two-compartment model, from which the PPK parameters were estimated, including clearance (8.55 L/h), central compartment volume (80.8 L), and peripheral compartment volume (50.6 L). The accumulative urinary excretion was 23.4±6.5% in severe renal impairment patients and 66.1±16.8% in healthy controls. PPK/PD modeling and simulation of 4 dosage regimens found that nemonoxacin 0.5 g q48h was the optimal dosing regimen in severe renal impairment patients, evidenced by higher PTA (92.7%) and CFR (>99%) at nemonoxacin MIC ≤ 1 mg/L against S. pneumoniae and S. aureus. The alternative regimens (0.25 g q24h; loading dose 0.5 g on Day 1 followed by 0.25 g q24h) were insufficient to cover the pathogens even if MIC ≤ 0.5 mg/L. Conclusion: An extended dosing interval (0.5 g q48h) may be appropriate for optimal efficacy of nemonoxacin in case of severe renal impairment.

We reported 24 years old Nepalese male who presented with epigastric pain and jaundiced found to have pancreatic and liver abscess suspected by abdominal CT scan and MRI, that confirmed later on by EUS-FNA with pus smear and PCR came for acid-fast bacilli. The patient responded remarkably to ATT.

As the novel Coronavirus pandemic continues to affect people worldwide, immune-mediated inflammatory syndromes have been reporting related to this virus. We presented a case of novel Coronavirus pneumonia, who developed a purpuric rash, abdominal pain, and hematuria, diagnosed with Henoch--Schoenlein purpura.

Bedaquiline, a novel drug was approved for the treatment of multi-drug resistance tuberculosis (MDR-TB) by the US FDA in 2012. It is majorly caused because of the transmission of multi-resistant strain from a diseased person to a healthy individual and by genetic factors. Safety, efficacy, and bactericidal activity of Bedaquiline were reported in various studies, but the pharmacokinetic analysis of Bedaquiline in clinical settings was unclear. This study serves as evidence for the physicians regarding the pharmacokinetic data and managing drug therapy and for better patient outcome in routine clinical practice. This study is conducted in a total of 58 patients with newly diagnosed, smear-positive, MDR-TB patients who received Bedaquiline as per RNTCP guidelines. Plasma samples were collected after the Bedaquiline administration. The patient samples were analyzed. The pharmacokinetic data were drawn by using software kinetic-2000, version 5.03.The observed Cmax was 2523.08 ng/mL, Tmax was reached at 4 hrs, AUC(0-24) was 21727.1 ng *hr/mL, AUMC (0-24) was 222953.8 ng *hr2/mL. Whereas the half-life of the drug was found at 7 .02 hrs and mean residence time (MRT) was found to be 10.25 hrs respectively. The data was even on the 14th day of therapy. The Cmax is shown to be 5937.1ng/mL reaching the Cmax at about 5 hours. While the AUC(0-24) was found to be 65780 ng *hr/mL. Conclusively, pharmacokinetic parameters were evaluated and found to be within the desired limits with minimal changes. This method can be further used for the quantification of Bedaquiline in routine clinical practice.

An 83 year old female had asymptomatic SARS-CoV-2 infection while taking ruxolitinib. She remained RT-PCR positive for viral RNA for >120 days, Pegylated interferon for 4 weeks led to viral RNA clearance. The observations support combination therapy of ruxolitinib + interferon for COVID-19.