We report a case of adenovirus nephritis (ADVN) in a kidney transplant recipient (KTR) occurring within 8 days post-transplantation. The patient, a 35-year-old male, displayed systemic symptoms, high-grade fever, and acute kidney injury (AKI) without signs of hemorrhagic cystitis (HC). Extensive diagnostic workup revealed widespread necrotizing granulomatous inflammation in the allograft, leading to the identification of adenovirus (ADV) via histopathology and polymerase chain reaction (PCR) testing. The source of ADV transmission remained uncertain, raising questions about the potential donor-derived infection. Unlike typical ADVN cases, the patient exhibited no hematuria or urinary symptoms. The case underscores the atypical presentation of ADVN in KTRs, challenging the conventional understanding of its timeline, transmission routes, and associated clinical features. We discuss the diagnostic challenges, histological findings, and management strategies for ADVN, emphasizing the importance of considering this entity in KTRs with unexplained fever and AKI, even in the absence of classical urinary symptoms or hematuria.

BACKGROUND Klebsiella pneumoniae invasive syndrome (KPIS), a rare severe multi-site infection, typically caused by hypervirulent Klebsiella pneumonia, has a high mortality rate, usually ranging from 10% for antimicrobial-sensitive strains to 24% for resistant strains, and often requires prolonged treatment. Most cases have been reported in East Asia, with a handful documented in India, to date. The incidence is also rising in Western countries. CASE REPORT We report the case of a 45-year-old Indian man who presented with fever, low back pain, and asymmetric arthralgia for the past 20 days, along with new acute-onset right-sided hemiparesis and slurred speech. Laboratory test results were significant for elevated leukocyte counts and inflammatory markers (ESR and CRP). MRI of the brain revealed multiple lesions, with accompanying hemorrhage and edema at grey white-matter junction. PET-CT revealed septic collections at multiple sites, including the spleen, kidney, left knee joint, and L5-L6 vertebrae, along with paravertebral and psoas abscesses. Cultures of vertebral abscess confirmed Klebsiella pneumoniae, with a positive string test, consistent with a hypermucoviscous phenotype; however, genetic testing for hypervirulent genes could not be performed, due to unavailability. Given these findings, KPIS diagnosis was likely. Treatment was 6 weeks of antibiotics, empiric vancomycin and gentamicin, followed by de-escalation to amoxicillin-clavulanic acid. CONCLUSIONS KPIS can occur in immunocompetent hosts and should be considered in cases of unexplained systemic inflammation with multifocal abscesses. Hepatic involvement, while characteristic, is not essential for diagnosis. When genotypic testing is unavailable, a positive string test can serve as a useful surrogate marker for identifying hypervirulent strains.

Daptomycin-resistant Enterococcus faecium (DRE) poses an increasing therapeutic challenge, particularly in immunocompromised patients and solid organ transplant recipients. Surveillance data from the Centers for Disease Control and Prevention indicate that approximately 6.5% of E. faecium isolates are daptomycin-resistant, underscoring the need for heightened clinical vigilance, particularly for prompt identification and treatment. In this case series, three patients with advanced liver disease, including two status post orthotopic liver transplantation, are described who developed DRE during treatment for bloodstream infection. These cases illustrate the dynamic nature of antimicrobial susceptibility under daptomycin exposure and highlight the contributions of persistent source control issues, intravascular infection, and altered host factors to treatment failure. All patients were successfully managed by escalating to combination therapy with high-dose daptomycin and ceftaroline, alongside appropriate source control. This series emphasizes the importance of periodic susceptibility reassessment during daptomycin therapy and cautions clinicians against assuming sustained susceptibility in patients with prolonged bacteremia or complex infections. Early recognition of evolving resistance and timely therapeutic adjustment may improve outcomes in this high-risk population.

BACKGROUND Histoplasma is a common fungus that lives in the environment, and in the form of disseminated histoplasmosis (DH) it can often present with a long range of unspecific symptoms, mimicking other diseases. For these reasons, missed or delayed diagnoses of DH are common, and often fatal. Limitations in the diagnostic testing techniques used for suspected histoplasmosis further aggravate the difficulties that arise with cases of this infection. Previous cases of misdiagnosis or delayed diagnosis leading to bowel obstruction have been reported. CASE REPORT A 64-year-old woman with a history of rheumatoid arthritis on TNF-alpha inhibitor presenting with abdominal pain, bloating, and severe weight loss was found to have a stricture in the ileum with ulceration and inflammation, raising suspicion for Crohn's disease. Additionally, symptomatic hypercalcemia, dyspnea, and findings suggestive of primary sclerosing cholangitis (PSC) developed later. Intestinal obstruction due to an ileal stricture ultimately resulted in the patient undergoing an ileocolic resection with creation of a primary ileocolic anastomosis and diverting loop ileostomy. Repeated false-negative Histoplasma urine antigen and PCR testing further complicated the case, delaying the diagnosis and treatment of the histoplasmosis infection. CONCLUSIONS This report highlights the immense difficulties involved in the diagnosis of abnormal cases of histoplasmosis and stresses the importance of maintaining a high index of suspicion for this opportunistic infection in immunocompromised patients, especially those residing in, or with recent travel to, areas of high endemicity to avoid misdiagnosis or delays in diagnosis leading to complications.

Candida krusei empyema is a rare but serious manifestation of invasive candidiasis, characterized by intrinsic resistance to fluconazole, biofilm formation, and high mortality, with limited case-level data to inform management. This review aims to systematically identify and synthesize all reported English-language cases of Candida krusei empyema from January 2005 to June 2025 using PubMed, ScienceDirect, OVID MEDLINE, and Gale OneFile and perform descriptive analysis on them. Screening, data extraction, and eligibility assessment were performed, and those articles not clearly meeting eligibility criteria were reviewed by additional reviewers with consensus resolution. Seven publications (six individual cases and two cohorts) were included. We additionally describe the clinical course, management, and outcome of a 70-year-old bilateral lung transplant patient who developed persistent C. krusei empyema despite optimized antifungal therapy. Patients ranged from 11 to 74 years of age (median 62.5 years). Predisposing factors included esophageal perforation (n = 4), post-transplant hemorrhage (n = 1), community-acquired empyema (n = 1), and thoracic surgery (n = 1). Empiric fluconazole was switched to caspofungin (3/4), with others receiving amphotericin B, voriconazole, or combination therapy. Source control varied: chest tube drainage (n = 3), percutaneous catheter (n = 3), and surgical decortication (n = 2). Mortality was 14.3% (1/7). In the absence of clear guidelines and robust literature, the management approach remains heterogeneous. Optimal care requires early recognition, aggressive multimodal antifungal therapy, and effective source control tailored to patient risk. Standardized antifungal protocols and larger case series are needed to guide clinicians in managing this challenging infection.

Cervicofacial actinomycosis is a well-recognized infectious disease caused by Actinomyces, a Gram-positive filamentous bacterium. In contrast, Nocardia, a morphologically similar, hyphae-forming organism, is an exceedingly rare cause of cervicofacial abscesses, and even more uncommon associated osteomyelitis of mandible. We present such a case involving a kidney transplant recipient who presented with opioid-induced constipation, along with left jaw pain and swelling. CT scan of the soft tissue in the neck revealed a complex cervicofacial abscess with enhancement of underlying mandible. Culture growth and RNA sequencing of USG-guided aspirate identified a Nocardia species closely related to N. beijingensis/exalbida. The patient initially received broad-spectrum antibiotics, including ceftriaxone, imipenem, and trimethoprim-sulfamethoxazole (TMP-SMX). Imipenem was later discontinued in view of new-onset unexplained encephalopathy and replaced with linezolid, which was subsequently switched to minocycline following thrombocytopenia development. Minocycline therapy was intended for a total of 12 months. TMP-SMX was avoided long-term due to avoid nephrotoxicity risk in kidney transplant patients. On six-month follow-up, the patient showed clinical and radiological improvement; minocycline was discontinued after additional six months. This case highlights the importance of considering Nocardia as a differential diagnosis in immunosuppressed patients presenting with cervicofacial symptoms, especially following orofacial surgery or trauma. Early recognition, prompt diagnosis, and appropriate antibiotic therapy with adequate bone penetration seem crucial for optimal management and may help avoid the need for surgical intervention.