Isolated Streptococcus agalactiae tricuspid endocarditis in elderly patient without known predisposing factors: case report and review of the literature

Group B streptococcal [GBS] tricuspid infective endocarditis is a very rare clinical entity. It affects intravenous drug users, pregnant, postpartum women, and the elderly. We report the case of a 68-year-old patient without known predisposing factors who presented a GBS tricuspid endocarditis treated by penicillin and aminoglycosides with no response. The patient was operated with a good evolution. Our case is the 25th reported in the literature. GBS disease is increasing in the elderly and is mainly associated to comorbid conditions. Tricuspid infective endocarditis with Group B streptococcus predominantly presents as a persistent fever with respiratory symptoms due to pulmonary embolism. Therefore, it requires a medicosurgical treatment and close follow-up

Cystatin C: a prognostic marker after myocardial infarction in patients without chronic kidney disease

Aims: cystatin C is an endogenous marker of renal function. It is a well established better marker of glomerular filtration rate than serum creatinine. There is also evidence that cystatin C is associated with atherosclerotic disease. The present prospective study evaluated the prognostic value of cystatin C after myocardial infarction in patients without chronic kidney disease

Methods and results: a total of 127 patients who underwent coronary angiography after an acute coronary syndrome [ACS] were included. Cystatin C was associated with the severity of coronary artery disease [CAD]. Cystatin C levels were significantly higher in patients with 3-vessels disease and severe CAD according to GENSINI score [p = 0.01 and p < 0.001 respectively]. Among the patients admitted for ST elevation myocardial infarction, Cystatin C concentration was correlated with the initial TIMI flow in the culprit artery [p < 0.001]. Mean duration of the follow-up period was 10.76 [thorn] 2.1 months. High Cystatin C concentrations were associated to the occurrence of unfavourable outcomes and cardiovascular mortality during follow-up [1.19 [thorn] 0.4 vs. 1.01 [thorn] 0.35 mg/L, p = 0.01 and 1.21 [thorn] 0.36 vs. 0.96 [thorn] 0.27 mg/L, p = 0.03]. Among different laboratory parameters, cystatin C was the best marker to predict the occurrence of major adverse cardiovascular events during the follow-up [Area under the receiveroperating characteristic curve = 0.743]

Conclusion: high cystatin C levels are associated with the severity of coronary artery disease in patients presenting an acute coronary syndrome and a normal renal function. Cystatin C is also associated to unfavourable cardiovascular outcomes during follow-up and appears as a strong predictor for risk of cardiovascular events and death

[Pulmonary thromboembolism: incidence, physiopthology, diagnosis and treatment]

The objective of this work was to review current data about the pathophysiology, clinical features, and treatment of pulmonary thromboembolism. Venous thromboembolism [VTE] remains a major challenge in hospitalised especially the care of critically ill patients. Pulmonary embolism [PE] is the major complication of VTE. By occluding the pulmonary arterial bed it may lead to acute life-threatening but potentially reversible right ventricular failure. The outcome of patients with PE is quite variable depending primarily on the cardio-respiratory status and the embolus size. PE is a difficult diagnosis that may be missed because of non-specific clinical presentation. Clinical signs include hypoxia, tachypnea, and tachycardia. Severe cases of untreated PE can lead to circulatory instability, and sudden death. However, in ICU, most of patients require sedation and mechanical ventilation. The clinical manifestations usually observed in this condition [PE] cannot be exhibited by these patients and clinical presentation is usually atypical. For these reasons, the diagnosis of PE is usually suspected when un-explicated hypoxemia and/or shock and arterial hypotension were observed. Positive diagnosis is based on these clinical findings in combination with laboratory tests and imaging studies. D-dimer testing is of clinical use when there is a suspicion of DVT or pulmonary embolism PE. In Emergency department, a negative D-dimer test will virtually rule out thromboembolism with a negative predictive value at 95 to 98%. In massive and submassive PE, dysfunction of the right side of the heart can be seen on echocardiography. While the gold standard for diagnosis is the finding of a clot on pulmonary angiography, CT pulmonary angiography is the most commonly used imaging modality today. When the diagnosis is confirmed, anticoagulant therapy is the mainstay of treatment. Acutely, supportive treatments a pivotal role in the management of patients with PE. Severe cases may require thrombolysis with drugs such as tissue plasminogen activator [tPA] or may require surgical intervention via pulmonary thrombectomy. Prevention is highly warranted

Percutaneous closure of using Occlusion DeviceOstium Secundum Septal defect amplatzer occlusion device: Experience of cardiology department, Hedi Chaker Hospital, Sfax, Tunisia

To report our clinical experience with transcatheter closure of ostium secundum atrial septal defects [OS ASDs] using Amplatzer septal occluder. It's a retrospective study conducted between October 2005 and April 2010 and involving 34 patients. The procedures were conducted in the hemodynamic laboratory under general anesthesia with transthoracic [TTE] and transoesophageal echocardiographic [TEE] monitoring. Clinical and echocardiography assessments of the patients were conducted within 24 hours post procedure and several months after the procedure. From the 34 patients, 28 [82%] were females. The middle age was 27.5 years. The mean ASD diameter was 19.4 mm by TTE; 18.1 mm [12-38] by TEE, and 23.4 by angiography. The average size of the implanted devices was 23.2 mm ranging from 10 to 34 mm. The final success rate of the procedure was 90.9% [30/33]. One patient was excluded from transcatheter occlusion and three patients [8,6%] had complications including two prosthesis migrations and one large residual shunting. A total of 4 patients [11.7%] underwent surgery. No major complication [thromboembolic events, obstruction of intracardiac structures, cardiac perforation, device embolization and endocarditis] or death has occurred during follow-up and all devices were securely anchored without any persistent residual shunts. Compared to previous data of the literature, percutaneous closure of OS ASDs using Amplatzer device appears safe and effective according to our experience of the cardiology department of Hedi Chaker Hospital

Pulmonary embolism in intensive care unit: predictive factors, clinical manifestations and outcome

To determine predictive factors, clinical and demographic characteristics of patients with pulmonary embolism [PE] in ICU, and to identify factors associated with poor outcome in the hospital and in the ICU. During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study periods, all patients admitted to our ICU were classified into four groups. The first group includes all patients with confirmed PE; the second group includes some patients without clinical manifestations of PE; the third group includes patients with suspected and not confirmed PE and the fourth group includes all patients with only deep vein thromboses [DVTs] without suspicion of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion [V/Q] scan or by a spiral computed tomography [CT] scan showing one or more filling defects in the pulmonary artery or in tits branches. The diagnosis was also confirmed by echocardiography when a thrombus in the pulmonary artery was observed. During the study periods, 4408 patients were admitted in our ICU. The diagnosis of PE was confirmed in 87 patients [1.9%]. The man delay of development of PE was 7.8 +/- 9.5 days. On the day of PE diagnosis, clinical examination showed that 50 patients [57.5%] were hypotensive, 63 [72.4%] have SIRS, 15 [17.2%] have clinical manifestations of DVT and 71 [81.6%] have respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 81 cases [93.1%] and low molecular weight heparins were used in 4 cases [4.6%]. The mean ICU stay was 20.2 +/- 25.3 days and the mean hospital stay was 25.5 +/- 25 days. The mortality rate in ICU was 47.1% and the in-hospital mortality rate was 52.9%. Multivariate analysis showed that factors associated with a poor prognosis in ICU are the use of norepinephrine and epinephrine. Furthermore, factors associated with in-hospital poor outcome in multivariate analysis were a number of organ failure associated with PE >/= 3. Moreover, comparison between patients with and without pe showed that predictive factors of pe are: acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO[2]/FiO[2] ration < 300 and the absence of pharmacological prevention of venous thromboembolis, Despite the high frequency of DVT in critically ill patients, symptomatic PE remains not frequently observed, because systematic screening is not performed. Pulmonary embolism is associated with a high ICU and in-hospital mortality rate. Predictive factors of PE are acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO[2]/FiO[2] < 300 and absence of pharmacological prevention of venous thromboembolism

Primary mediastinal seminoma. Report of three cases

Primary mediastinal seminomas [PMS] are rare tumors that are morphologically similar to their testicular counterparts but may have different biologic behavior due to their particular anatomical location. New cases report of PMS. Three new cases of primary mediastinal seminoma are presented. The patients were men aged of 16, 33 and 47 years. Their clinical symptoms included cough, dyspnea, chest pain and superior vena cava syndrome. None of the patients had a previous history of testicular neoplasm or tumor elsewhere. Mediastinoscopie biopsy was performed and histological examination results revealed a seminoma. Immunohistochemical showed membranous staining with placental alkaline phosphatase in the three cases. Chemotherapy has largely replaced surgical resection and radiotherapy as the initial treatment in patients with mediastinal seminoma

[Primary hydatidosis of the chest wall. Report of 5 cases]

Hydatidosis is an endemic affection in Tunisia. Bone echinococcosis is a relatively rare entity accounting for only 0.5-2% of all hydatid cysts in humans and chest wall is an uncommon site for the disease. Report of a new case. We report about this talk 5 cases concerning 2 men and 3 women [mean of age 35,4 years] explored for parietal mass [4 cases], or chest pain [1 case]. Diagnosis was suspected on radiologic findings in all cases. All patients underwent surgery. Medical treatment was associated in 2 cases. Histopathology of resected specimen confirmed diagnosis of echinococcosis. No recurrence was observed during follow-up period

[Pulmonary inflammatory pseudotumor: difficulties in diagnosis and prognosis]

Inflammatory pseudotumors are uncommon benign lesions of the lung of unknown origin, that may show aggressive behavior. Although pseudotumors constitute less than 1% of all lung tumors, they are reported to be the most common cause of solitary lung masses in children. Complete resection, when possible, is safe and leads to excellent survival. The case presented here highlights difficulties in clinical and histologic diagnosis

Histiocytome fibreux angiomatoide: Une tumeur rare a malignite intermediaire

Angiomatoid fibrous histiocytoma is a rare humour affecting young adults. Unlike conventional malignant fibrous histiocytoma, it's extension is only local thus giving a good prognosis. We report the cases of a 9 years-old girl and a 1 6 years-old boy presenting respectively, with an axiliary tumour 5cm of diameter and a paravertebral subcutaneous tumour 1,5cm of diameter. In both cases, the diagnosis was not initially suspected. The treatment consisted in surgical resection