Sudden death due to infective endocarditis caused by Streptococcus constellatus: A case report

@#Infective endocarditis (IE) is a relatively uncommon disease, but has been challenging to diagnose over the years. With the increasing incidence, variety of causative agents and the resistance of microorganisms towards antibiotics, there is still an occurrence of sudden death due to undiagnosed IE. The most common microorganism causing IE is Staphylococcus aureus. However, there is increasing prevalence of other microorganisms causing IE. This case report highlights a case of sudden death due to IE caused by a rare pathogen, Streptococcus constellatus which belongs to the Streptococcus anginosus group (Milleri group). A study noted the crude incidence of IE in 6 world regions ranged between 1.5 and 11.6 cases per 100,000 people. To date, there has been no previous report on sudden death due to IE caused by Streptococcus constellatus in Malaysia, neither in the forensic nor clinical setting. This case report underlined the characteristics and pathological features of this microorganism. The increasing incidence and variety of causative organisms in IE are important public health issues. It is vital for future studies to examine the risk factors of IE related to Streptococcus constellatus, to enhance better understanding, insight and awareness regarding the course of this disease. This in turn may facilitate preventive measures to avoid morbidity and mortality from this condition.

Serum levels of bone-specific alkaline phosphatase and procollagen type I carboxyterminal peptide in vitamin D deficiency.

Vitamin D deficiency in adults causes osteomalacia where there is a defect in bone mineralization resulting in an excess of unmineralised osteoid in the bone matrix. The aim of this study was to evaluate the markers of bone formation: total (TALP), bone-specific alkaline phosphatase (BSALP) and procollagen type I carboxyterminal peptide (PICP) in vitamin D deficiency. We studied 100 vitamin D deficient subjects and 82 gender-matched controls. Vitamin D deficiency was defined as serum 25-hydroxyvitamin D level of less than 7 ng/ml, and greater than 10 ng/ml for normal controls. Serum TALP assay was performed by a standard automated method, BSALP and PICP were measured by enzyme immunoassays (Metra Biosystems) and vitamin D by radioimmunoassay. There was significant difference in the TALP between female vitamin D deficient and control subjects (mean +/- sem = 99.8 +/- 8.2 vs 70.5 +/- 2.8 iu/l, p<0.001). Elevated serum TALP (>130 iu/l) was found in 20% (20/100) of the vitamin D deficient patients. There were no significant differences in BSALP or PICP between vitamin D deficient patients and gender-matched control subjects. There was no correlation between vitamin D and PICP in patients but in control subjects, a significant negative correlation (r= -0.431, p<0.0001) was found. In conclusion, although elevated TALP was observed in a minority of vitamin D deficient patients, it is a better marker than PICP. The lack of PICP response in vitamin D deficient subjects suggests the possibility of vitamin D deficiency leading to a block in osteoblast differentiation.

External quality assurance in Malaysia.

An activity supportive of the MOH QA Programme, the National EQAS for clinical chemistry monitors for analytical performance in core routine biochemical testing by the pathology laboratories, with unsatisfactory performance scores serving to alert against deficiencies or problems and the scores in subsequent challenges providing the feedback of effectiveness of remedial actions taken. While unacceptable individual analyte performance score (variance index score, VIS) indicated problems in instruments, reagent and calibrators, or the use of inherently poorer methods, repeated occurrence of unsatisfactory OMRVIS was traceable to generally poor laboratory management of usually inadequately-equipment small laboratories. The outcome has been one of slow but gradual improvement in the overall performance of participating laboratories, with a move towards methods upgrading and standardization to achieve greater concordance of results. Presently, the programme is limited to 61 government and 4 private hospital laboratories in the country for 12 commonly assayed clinical biochemistry analytes. It is hoped that the NEQAS could be extended to the other private laboratories and that of academic institutions. However, this is dependent to a large extent on the manpower and financial support obtainable by the organizing body of the programme in the future. Belk and Sunderman, 1947 demonstrated that laboratories participating in an quality assessment scheme could rapidly and dramatically improve their analytical performance. In some countries, participation has become mandatory, and acceptable performance is a requirement in laboratory accreditation. The need and value of the NEQAP is, therefore, evident. While there may be limitations in the national programme. efforts are being made at improving the programme within the means and resources of the organising body. The goals of the NEQAP are not just to monitor performance but also to educate. On this, matters related to and supportive of these goals have also been pursued. The annual workshop/forum on quality controls had allowed exchange of information between representatives of participating laboratories and the organising body. Recently in the 1997 MOH Quality Improvement evaluation, Quality Control has been evaluated together with the other 17 such activities. The study on knowledge, attitude and practice has provided the necessary feedback and will be used for future planning in making efforts at increasing the effectiveness and benefits of the all QC activities including this NEQAP for clinical chemistry. In addition, there is a need to look into areas such as selection of methods and test systems, and improvement of continuing education, training as well as research in quality improvement as suggested by the Quality Improvement evaluation.