Double Outlet Right Ventricle Infective Endocarditis: A Rare Combination and a Therapeutic Challenge

Infective endocarditis involving the right side of the heart occurs rarely and often involves the tricuspid valve. The isolated pulmonary valve infective endocarditis (IPVIE) is a less common condition that occurs in specific population. The double outlet right ventricle (DORV) is an unusual congenital heart disease. The association of DORV and IPVIE darkens the prognosis. We report two cases of the association of DORV and IPVIE. The transthoracic echocardiography (TTE) is the base to the diagnosis. Right sided infective endocarditis in the lack of a guided strategy remains a therapeutic challenge.

Pneumothorax and its etiology

Introduction: Air in the pleural space is defined as Pneumothorax. A case of pneumothorax is a medical emergency which can itself be serious and may endanger the life of the patient because of respiratory insufficiency. Aim of the study: To study the etiological factors of pneumothorax and hydropneumothorax, the inter-relation of spontaneous pneumothorax with different age groups, sexes and precipitating factors. Study the associated complications, degree of collapse of pulmonary parenchyma and outcome of the treatment. Materials and methods: Fifty cases of pneumothorax presenting to the department were admitted and investigated. Cases of pneumothorax with or without fluid, pus or blood in the pleural cavity; accidental and iatrogenic pneumothorax were also included. Pneumothorax is diagnosed by taking standard chest radiographs and computed tomograms (CT) of the chest wherever necessary. Results: A vast majority of the patients in this study were of poor socio economic background. Male to female ratio is 7:1. Of the 50 cases, 16 (32%) had pneumothorax only, 22 (44%) had pyopneumothorax and 10 (20%) had hydropneumothorax. Hemopneumothorax was found in 2 (4%) cases. Conclusion: Spontaneous pneumothorax is generally due to an underlying lung disease. It is important that pneumothorax is managed promptly and in an appropriate manner. Immediate management is largely determined by the extent of cardio-respiratory compromise, degree of symptoms and size of pneumothorax and may involve observation alone, needle aspiration or chest drain insertion.

Multidrug-resistant Bacteroides fragilis Isolated from a Case of Pyopneumothorax.

Aim: The aim of this case report is to present an unusual case of multidrug- resistant Bacteroides fragilis from a patient with pyopneumothorax who had a blunt injury to the thorax and got admitted in a tertiary care hospital, South India. Presentation of Case: The patient developed pyopneumothorax after a blunt injury and on admission was treated empirically with piperacillin-tazobactam and metronidazole. Following antibiotic sensitivity testing the B. fragilis strain isolated showed multidrug resistance including metronidazole. Imipenem was initiated replacing empiric therapy with a successful clinical outcome. Discussion: Bacteroides species are obligate anaerobic bacteria that are usually found in the gastrointestinal tract of the human body. Bacteroides species are the most commonly isolated anaerobic organisms from intra-abdominal lesions and rarely from intrathoracic disease conditions like pyopneumothorax. Pyopneumothorax caused by Bacteroides species is associated with high treatment failure and mortality rates in antibiotic-resistant cases. Though metronidazole is the mainstay of treating anaerobic infections, attention has to be given to the possibility of multidrug resistance when treating critical diseases. Conclusion: This case report summarizes the multidrug- resistance in Bacteroides fragilis strain isolated from a case of pyopneumothorax. The situation calls attention to the possibility of multidrug-resistance being underestimated when given as empirical therapy and institution of appropriate and timely antibiotic policy measures to prevent mortality.

The different treatment modalities of pyopneumothorax- Study of 50 cases.

Background: Pyopneumothorax is defined as a collection of pus and air in the pleural cavity. It may be localised (encapsulated) or it may involve the entire pleural cavity. In India, Pyopneumothorax with pre-existing disease is treated with antimicrobial multiple antituberculous drugs and Intercostal drainage tube or surgery. Aims & Objective: (1) To know the age and sex incidence. (2) To study clinical presentation and characteristics of mode of onset (3) To obtain relationship with smoking. (4) To emphasise the importance of radiological and other investigations as an aid to diagnosis and management. (5) To find out the underlying lung pathology if any. (6) To decide the response to various modes of treatment. (7) To understand the complications of Pyopneumothorax. Material and Methods: This is a progressive study of 50 Indoor patients with pyopneumothorax admitted in the civil hospital, Ahmedabad in consecutive 3 years. Traumatic pyopneumothorax patients were excluded from the Study. The response to various modes of treatment and complications were noted. Results: The age incidences indicate that it was high in 21-30 years of age. Most common complaints were cough followed by dyspnoea and chest pain. The mycobacterium tuberculosis was the most common etiological factor. The best modality of treatment was intercostal drainage by tube with antibiotic coverage. Conclusion: Tuberculosis is main etiology in country like India. Intercostal drainage with under water seal was the treatment of choice in most of the patients. The commonest complication following ICD was surgical emphysema.

A rare case of community acquired Burkholderia cepacia infection presenting as pyopneumothorax in an immunocompetent individual

Burkholderia cepacia (B. cepacia) infection is rarely reported in an immunocompetent host. It is a well known occurence in patients with cystic fibrosis and chronic granulomatous disease where it increases both morbidity and mortality. It has also been included in the list of organisms causing nosocomial infections in an immunocompetent host, most of them transmitted from the immunocompromised patient in which this organism harbors. We report a rare case of isolation of B. cepacia from the bronchoalveolar lavage fluid of an immunocompetent agriculturist who presented with productive cough and fever associated with a pyopneumothorax. This is the first case of community acquired infection reported in an immunocompetent person in India.

Pleural nocardiosis.

Pleural involvement in nocardiosis is rarely documented in India. We report two cases of pleural nocardiosis. In both the cases, the aetiologic agent was isolated from pleural fluid and was later identified as Nocardia asteroides in one case and as Nocardia brasiliensis in the second case. The former case of pyopneumothorax died before the diagnosis was made and the latter with pleural effusion showed excellent response to six months of therapy with trimethoprim-sulfamethoxazole.