ABSTRACT
Background: Pulmonary aspergillosis (PA) is common among patients with tuberculosis (TB). With both infections presenting with similar clinical and radiologic features, diagnosis of PA is often made too late or missed completely due to lack of clinical suspicion and poor diagnostic laboratory capacity for mycotic infections prevalent in our settings. We present a case of preventable mortality caused by delayed diagnosis and treatment of PA in a patient with pulmonary TB (PTB). Case presentation: A 13-year-old female was diagnosed and treated for PTB, having received anti-TB regimen for 8 months in a mission hospital from where she was referred due to worsening cough, chest pain and progressive breathlessness. The patient was re-assessed and investigated, with GeneXpert detecting Mycobacterium tuberculosis, susceptible to rifampicin. Diagnosis of pulmonary tuberculosis complicated by right pneumothorax was made indicating an emergency thoracotomy and chest tube insertion and continuation of the first line anti-TB regimen. At about 2 weeks into admission, patients had features of superimposed acute bacterial sepsis with fever becoming high grade, marked neutrophilia with toxic granulation and elevated sepsis biomarker, and this necessitated empiric antibiotic treatment with parenteral meropenem and vancomycin. However, the patient only had mild clinical improvement following which there was progressively worsening respiratory symptoms and massive haemoptysis. Result of sputum fungal study was available on admission day 20 and revealed a growth of Aspergillus flavus. Treatment with intravenous voriconazole was however commenced rather late when the fungal respiratory disease could no longer be remedied. The patient died on admission day 23. Conclusion: Diagnosis of PA in patients with background TB is often made too late to guarantee timely and effective antifungal treatment with negative consequences on patients' outcomes. Improving clinical and laboratory capacities is essential to reducing mortality from PA in healthcare facilities.
Subject(s)
Humans , Tuberculosis , Diagnosis , Pulmonary Aspergillosis , Mycobacterium tuberculosis , VoriconazoleABSTRACT
Aim: Vancomycin has been widely used in the treatment of infections caused by methicillinresistant Staphylococcus aureus (MRSA). The emergence of vancomycin- intermediate and - resistant Staphylococcus aureus (VISA and VRSA, respectively) in various parts of the world has been reported. The level of vancomycin resistance phenotypically and genotypically in clinical isolates of S. aureus with or without methicillin resistance from south western region of Nigeria was determined. Methods: A total of 116 non-duplicate S. aureus previously obtained from various clinical specimens were subjected to susceptibility testing using disc and microbroth dilution including polymerase chain reaction amplification of mecA and van genes. Results: The disc susceptibility testing results depict multiple drug resistance with 100% resistance to co-amoxyclav, erythromycin and gentamicin had intermediate of 39.1 and 65.2% respectively, no strain sensitive. Vancomycin showed 100% susceptibility. The minimum inhibitory concentrations, MICs of 116 S. aureus strains against vancomycin showed the isolates to have MIC50 of 1 μg/ml and MIC90 of 2 μg/ml. Five (4.3%) of the 116 clinical isolates had intermediate MIC of 4 μg/ml. These five strains were from methicillin resistant strains and were isolated from different clinical sites and hospitals. However, none of these strains demonstrated the presence of van genes, vanA; vanB; vanC and vanH by PCR. Conclusion: There is high level of multiple antibiotic resistance in S. aureus with some MRSA also showing reduced susceptibility to vancomycin resulting in VISA. However, the VISA strains have shown no van gene as their mechanism of acquiring reduced susceptibility.