ABSTRACT
Objectives: Differences in demographic factors, symptoms, and laboratory data between bacterial and non-bacterial arthritis have not been defined. We aimed to identify predictors of bacterial arthritis, excluding synovial testing. Methods: This retrospective cross-sectional survey was performed at a university hospital. All patients included received arthrocentesis from January 1, 2010, to December 31, 2020. Clinical information was gathered from medical charts from the time of synovial fluid sample collection. Factors potentially predictive of bacterial arthritis were analyzed using the Student's t-test or chi-squared test, and the chi-squared automatic interaction detector decision tree analysis. The resulting subgroups were divided into three groups according to the risk of bacterial arthritis: low-risk, intermediate-risk, or high-risk groups. Results: A total of 460 patients (male/female = 229/231; mean ± standard deviation age, 70.26 ± 17.66 years) were included, of whom 68 patients (14.8%) had bacterial arthritis. The chi-squared automatic interaction detector decision tree analysis revealed that patients with C-reactive protein > 21.09 mg/dL (incidence of septic arthritis: 48.7%) and C-reactive protein ⩽ 21.09 mg/dL plus 27.70 < platelet count ⩽ 30.70 × 104/µL (incidence: 36.1%) were high-risk groups. Conclusions: Our results emphasize that patients categorized as high risk of bacterial arthritis, and appropriate treatment could be initiated as soon as possible.
ABSTRACT
Purpose: Knee distraction (KD) treatment for young (<65) patients with end-stage knee osteoarthritis (OA) has previously been shown to successfully postpone a knee arthroplasty for years by reducing pain, improving function, and inducing joint tissue repair. During KD treatment, the tibia and femur are separated ~5 mm for ~6 weeks using an external fixation device. The studies performed thus far have used proof-of-concept medical devices intended for other applications than KD. Recently, the first device specifically designed and intended for KD treatment has been developed. The purpose of the current study was to evaluate the clinical efficacy of this intended device. Method(s): In 5 hospitals, 65 patients with end-stage knee OA, in general practice considered for arthroplasty or high tibial osteotomy, were offered KD treatment by their orthopedic surgeon. Inclusion criteria were judged by the orthopedic surgeon and included age <=65 years, BMI <35 kg/m2 with weight <=110 kg, sufficient knee stability and physical condition, KL grade >=2, malalignment <=10 degrees, no history of inflammatory or septic arthritis. KD was performed according to a standardized protocol. Before and 1 and 2 years after treatment, standardized knee radiographs were performed and patients filled out WOMAC (for pain and function, 0-100, primary clinical outcome) and SF-36 (for quality of life, 0-100, secondary outcome) questionnaires. From the radiographs, minimum joint space width (JSW, mm, primary structural outcome) was measured by one experienced observer and KL grade at baseline was determined. Use of self-reported pain medication (paracetamol, opioids, NSAIDs) and intra-articular injections were registered as well, as were adverse events. Changes over 2 years were evaluated for statistical significance with paired t-tests for continuous variables and McNemar's tests for categorical variables. For the primary clinical outcome (WOMAC), clinical significance was evaluated as well, on group level defined as an increase of >=15 points and on individual level using OARSI-OMERACT response criteria. The influence of adverse effects on 2-year changes in primary outcomes was analyzed with independent t-tests. Result(s): Of the 65 treated patients (age: 53.3+/-6.7;BMI: 28.0+/-3.2;sex: 38 (55%) male;KL grade 0/1/2/3/4: 0 (0%) / 7 (11%) / 26 (40%) / 23 (36%) / 9 (14%)), 50 patients completed 2 years follow-up: 6 patients received partial or total arthroplasty (of which 3 in the 1st year) and 8 patients were lost to follow-up in the 2nd year (primarily due to COVID restrictions). The total WOMAC score (Figure 1A/B) showed a statistically and clinically significant improvement over 1 (+28.4 points;p<0.001) and 2 (+26.2 points;p<0.001) years, as did all the subscales (all p<0.001). After 1 year 72% of patients were OARSI-OMERACT responders, while after 2 years this was 51%. The minimum JSW (Figure 1C/D) significantly improved over 1 (+0.5 mm;p<0.001) and 2 (+0.4 mm;p=0.015) years as well. The physical component scale of the SF36 (Figure 2A/B) showed statistically significant improvement over 1 (+10.5 points;p<0.001) and 2 (+9.8;p<0.001) years, while the mental component scale (Figure 2C/D) did not (both p>0.26). The most common adverse event (Table 1) was pin tract skin infections, experienced by 46 (71%) of patients. In most cases (36;78% of cases) they could be treated with oral antibiotics, while in 3 of the cases (5% of treated patients) hospitalization and/or intravenous antibiotics were needed. Also, 8 (12%) of patients experienced device related complications. Experiencing pin tract infections or device complications did not significantly influence 2-year changes in primary outcomes in these patients (both p>0.05). Before treatment, 39 (60%) of patients used pain medication (Table 2), most often paracetamol (20;31%) or NSAIDs (16;25%). Around half used them daily. After treatment, significantly less patients used pain medication (p<0.001), with 35% at 1 year and 36% at 2 years. In total 12 (18%) patients had received an intra-arti ular injection before KD treatment, of whom 5 (8%) steroids and 3 (5%) hyaluronic acid. Both in the 1st and 2nd year after treatment, 1 patient (2%) received an injection. Conclusion(s): Patients treated with the first device intended for KD treatment showed significant clinical and structural improvement after 1 and 2 years. Importantly, the effect was clinically relevant, as a majority of patients were clinical responders and pain medication use decreased. Long-term evaluation will show whether arthroplasty can be postponed successfully as well. [Formula presented] [Formula presented] [Formula presented] [Formula presented]Copyright © 2023
ABSTRACT
In the COVID-19 pandemic, to minimize aerosol-generating procedures, cardiac magnetic resonance imaging (CMR) was utilized at our institution as an alternative to transesophageal echocardiography (TEE) for diagnosing infective endocarditis (IE). This retrospective study evaluated the clinical utility of CMR for detecting IE among 14 patients growing typical microorganisms on blood cultures or meeting modified Duke Criteria. Seven cases were treated for IE. In 2 cases, CMR results were notable for possible leaflet vegetations and were clinically meaningful in guiding antibiotic therapy, obtaining further imaging, and/or pursuing surgical intervention. In 2 cases, vegetations were missed on CMR but detected on TEE. In 3 cases, CMR was non-diagnostic, but patients were treated empirically. There was no difference in antibiotic duration or outcomes over 1 year. CMR demonstrated mixed results in diagnosing valvular vegetations and guiding clinical decision-making. Further prospective controlled trials of CMR Vs TEE are warranted. © 2022 Elsevier Inc.
ABSTRACT
The proceedings contain 68 papers. The topics discussed include: post-transplant lymphoproliferative disorder (PTLD) in a patient with rheumatoid arthritis;cancer, covid and control of RA - a toxic combination?;continuation of golimumab (anti-TNF) in a patient with SpA and low-risk prostate cancer, what is the right decision?;orbital lymphoma in a 72-year-old lady with rheumatoid arthritis: an argument for rituximab;a case of cancer mimicking inflammatory arthritis;managing relapsing and refractory lupus nephritis in juvenile systemic lupus erythematosus: a case report;a case of juvenile systemic lupus erythematosus with pyrexia of unknown origin;recurring brachial plexopathy- the zebra among the horses;and Neisseria meningitidis as a cause of isolated bilateral polyarticular native knee joint septic arthritis.
ABSTRACT
The proceedings contain 68 papers. The topics discussed include: post-transplant lymphoproliferative disorder (PTLD) in a patient with rheumatoid arthritis;cancer, covid and control of RA - a toxic combination?;continuation of golimumab (anti-TNF) in a patient with SpA and low-risk prostate cancer, what is the right decision?;orbital lymphoma in a 72-year-old lady with rheumatoid arthritis: an argument for rituximab;a case of cancer mimicking inflammatory arthritis;managing relapsing and refractory lupus nephritis in juvenile systemic lupus erythematosus: a case report;a case of juvenile systemic lupus erythematosus with pyrexia of unknown origin;recurring brachial plexopathy- the zebra among the horses;and Neisseria meningitidis as a cause of isolated bilateral polyarticular native knee joint septic arthritis.
ABSTRACT
Introduction The zoonotic infection with Brucella melitensis can be acquired by inges-tion of unpasteurized goat's or sheep's milk. The infection is common in Eastern Mediterranean countries (EMC), but rare in western Europe (6 cases in Switzerland, 2021). When evaluating patients with symptoms of septic arthritis, brucellosis is not the foremost differential diagnosis. How-ever, with the increasing population of people from EMC in western Eu-rope, the incidence may be rising. We present a patient who was initially suspected to suffer from Long-COVID-Syndrome (LCS), which underscores the relevance of this case in a pandemic situation. Methods/Results A 58-year-old male patient was admitted to the emergency department with a painful right knee effusion after a minor trauma. Additionally, he suffered from fatigue, subfebrile temperatures, back pain and myalgias for more than two months. He was suspected to suffer from LCS after a mild COVID-19 three months earlier. The culture of the arthrocentesis (14.400 cells/mul with 61% polynuclear cells) unexpectedly turned positive for B. melitensis. The patient declared that he had been drinking three liters of unpasteurized goat's milk to cure the presumptive LCS. To ensure staff safety, arthroscopic lavage was postponed until brucella-active antibiotics had been administered for at least 24 hours. Surgery was performed under strict infection control measures to avoid generating aerosols. According to Duke, one major (continuous bacteremia over 14 days) and 2 minor criteria (fever, most probably septic embolic gonarthritis) were fulfilled. Therefore, possible endocarditis had to be assumed although transesophageal echocardiography was normal. Antibiotic treatment was escalated to a quadruple regimen (intravenous gentamicin for three weeks;as well as oral doxycycline, trimethoprim/sulfomethoxazole and rifampin for at least 3 months). The clinical recovery - still under treatment - is protracted with slowly improving knee pain and normalizing signs of inflammation. Conclusion Although B. melitensis is a rare pathogen in Switzerland, orthopedic sur-geons, rheumatologists and infectious disease specialists need to be aware of diseases with low incidence and non-specific symptoms espe-cially in times of a global pandemia. A high index of suspicion is needed in patients related to EMC. When brucellosis is confirmed, strict infection control measures to protect staff involved in aerosol generating proce-dures must be adopted.
ABSTRACT
Background: Opportunistic and chronic infections can arise in the context of treatment used for Autoimmune Rheumatic Diseases (ARDs). Although it is recognized that screening procedures and prophylactic measures must be followed, clinical practice is largely heterogeneous, with relevant recommendations not currently developed or disparately located across the literature. Objectives: To conduct a systematic literature review (SLR) focusing on the screening and prophylaxis of opportunistic and chronic infections in ARDs. This is preparatory work done by members of the respective EULAR task force (TF). Methods: Following the EULAR standardised operating procedures, we conducted an SLR with the following 5 search domains;1) Infection: infectious agents identifed by a scoping review and expert opinion (TF members), 2) Rheumatic Diseases: all ARDs, 3) Immunosuppression: all immunosuppressives/immunomodulators used in rheumatology, 4) Screening: general and specifc (e.g mantoux test) terms, 5) Prophylaxis: general and specifc (e.g trimethop-rim) terms. Articles were retrieved having the terms from domains 1 AND 2 AND 3, plus terms from domains 4 OR 5. Databases searched: Pubmed, Embase, Cochrane. Exclusion criteria: post-operative infections, pediatric ARDs, not ARDs (e.g septic arthritis), not concerning screening or prophylaxis, Covid-19 studies, articles concerning vaccinations and non-Εnglish literature. Quality of studies included was assessed as follows: Newcastle Ottawa scale for non-randomized controlled trials (RCTs), RoB-Cochrane tool for RCTs, AMSTAR2 for SLRs. Results: 5641 studies were initially retrieved (Figure 1). After title and screening and removal of duplicates, 568 full-text articles were assessed for eligibility. Finally, 293 articles were included in the SLR. Most studies were of medium quality. Reasons for exclusion are shown in Figure 1. Results categorized as per type of microbe, are as follows: For Tuberculosis;evidence suggests that tuberculin skin test (TST) is affected by treatment with glucocorticoids and conventional synthetic DMARDs (csDMARDs) and its performance is inferior to interferon gamma release assay (IGRA). Agreement between TST and IGRA is moderate to low. Conversion of TST/IGRA occurs in about 10-15% of patients treated with biologic DMARDs (bDMARDs). Various prophylactic schemes have been used for latent TB, including isoniazide for 9 months, rifampicin for 4 months, isoniazide/rifampicin for 3-4 months. For hepatitis B (HBV): there is evidence that risk of reactivation is increased in patients positive for hepatitis B surface antigen. These patients should be referred for HBV treatment. Patients who are positive for anti-HBcore antibodies, are at low risk for reactivation when treated with glucocorticoids, cDMARDs and bDMARDs but should be monitored periodically with liver function tests and HBV-viral load. Patients treated with rituximab display higher risk for HBV reactivation especially when anti-HBs titers are low. Risk for reactivation in hepatitis C RNA positive patients, treated with bDMARDs is low. However, all patients should be referred for antiviral treatment and monitored periodically. For pneumocystis jirovecii: prophylaxis with trimeth-oprim/sulfamethoxazole (alternatively with atovaquone or pentamidine) should be considered in patients treated with prednisolone: 15-30mg/day for more than 4 weeks. Few data exist for screening and prophylaxis from viruses like E B V, CMV and Varicella Zoster Virus. Expert opinion supports the screening of rare bugs like histoplasma and trypanosoma in patients considered to be at high risk (e.g living in endemic areas). Conclusion: The risk of chronic and opportunistic infections should be considered in all patients prior to treatment with immunosuppressives/immunomod-ulators. Different screening and prophylaxis approaches are described in the literature, partly determined by individual patient and disease characteristics. Collaboration between different disciplines is important.
ABSTRACT
Introduction: Melioidosis is an infectious disease caused by Gramnegative bacterium Burkholderia pseudomallei. It is a potentially fatal disease endemic to tropical and subtropical regions. Bacteria spread by contact with contaminated water and soil. The presentation of this disease is variable ranging from localized infection to fulminant septicemia and multi-organ dysfunction. Objective: The purpose of this study is to look into clinical presentation, treatment, and outcomes of confirmed melioidosis cases in a tertiary care hospital. Materials and methods: This is a retrospective case series of patients in a single tertiary care center between January 2018 and September 2021. We present a series of 19 cases admitted with a confirmed diagnosis of melioidosis. Three of 19 cases discontinued treatment in between but were included in the analysis. Results: We report 19 cases of melioidosis admitted to our hospital in a span of 3 years (17 males and 2 females). The median age of presentation was 47 years. The disease had varied presentation with lung involvement in 11 cases (57%), solid organ abscesses in 8 cases (42%), osteomyelitis and septic arthritis in 5 (26%), and acute pyelonephritis in 2 cases (10%). Lung involvement was seen as consolidation, septic emboli, and solid nodular lesions. Most common risk factor associated with disseminated disease was diabetes. Diabetes was seen in 17 cases (89.4%). All patients had uncontrolled blood sugars and 2 cases presented in DKA. Other comorbidities seen were systemic hypertension (16%), coronary artery disease (10%), chronic liver disease (10%), post COVID (10%), and SLE (5%). ARDS complicating lung condition was seen in 6 patients (54%) of which 3 patients were managed with NIV and 3 patients required invasive mechanical ventilation. AKI was seen in 11 patients (57.8%) of which 8 patients recovered from AKI and 3 patients required renal replacement therapy. One patient with associated lupus nephritis required long-term hemodialysis. Altered liver function test was seen in 11 patients (57.8%). Bone marrow suppression is common. Three patients had pancytopenia and 10 patients had thrombocytopenia. Hyponatremia was the most common electrolyte abnormality seen in 7 patients (36.8%). Of the 19 cases admitted three patients did not continue treatment. Median hospital stay for the remaining 16 cases was 16 days. 15 out of 16 cases survived with a survival rate of 93.7% and one mortality (6.2%). Conclusion: Melioidosis is a potentially fatal disease. High index of suspicion is required for diagnosing this condition due to its varied presentation. Early diagnosis and appropriate treatment is the cornerstone in improving the outcome. Though mortality was less than 6%, they have significant morbidity with prolonged ICU and hospital stay leading to increased economic burden.
ABSTRACT
Introduction: Transient synovitis is a common cause of hip pain in children. Patients present with acute limp, hip pain or referred pain to the knee. The mainstay of treatment consists of antiinflammatory medications and activity limitations. While the exact etiology of transient synovitis is unknown, there has been a noted relationship with an antecedent viral illness. We present one of the first reported cases of transient synovitis caused by COVID-19. Case Description: A 10-year-old male presented with concerns for left knee pain and limp. Five days prior, the patient developed general URI symptoms and was diagnosed with COVID-19, via rapid testing. His maximum temperature was 38.5°C at home and his respiratory symptoms resolved. Two days prior to presentation, he complained of left knee pain, which progressed to limp, and refusal to bear weight. He denied known injuries, trauma, visible bruising, swelling, redness, or warmth. He was afebrile and non-weight-bearing on his left leg, otherwise in no apparent distress. On physical exam, he exhibited full, painless range of motion of left knee, no bony tenderness, effusion, or cutaneous changes. There was refusal to bear weight on left leg, and significant pain with internal rotation of left hip. Lab work revealed there was no leukocytosis. C-reactive protein level and sedimentation rate were unremarkable. Radiographs of bilateral hip and pelvis, and left knee were obtained, which revealed no osseous abnormalities or significant effusion. Patient was given ibuprofen and on follow up exam he exhibited improved discomfort and willingness to bear weight. With a negative workup and clinical improvement, he was discharged with crutches, instructions for supportive care, and outpatient follow-up. Mother reported no complications during his recovery. He was able to wean from the crutches within a few days and returned to his usual gait within 3 weeks. Discussion: Transient synovitis can be clinically distinguished from septic arthritis with features of overall well appearance, lack of swelling or redness to the joint, and normal range of motion with mild pain. For our patient, Kocher criteria were helpful in distinguishing transient synovitis from septic arthritis, as well as the clinical improvement with NSAIDs. A clinical dilemma could occur if elevated inflammatory markers were present, as one might expect with acute COVID-19. Though transient synovitis is thought to be related to a viral etiology, there does not appear to be an increase in cases amidst the pandemic described in published literature. Conclusion: This case illustrates a patient who had COVID-19 with transient synovitis, a previously unreported sequela. When evaluating similar patients, providers should consider the possibility of COVID-19 and ensure appropriate testing and isolation.
ABSTRACT
CASE: A 69-year-old male smoker with stage 3b prostate cancer managed with abiraterone and prednisone, prior severe COVID-19 pneumonia requiring mechanical ventilation, and history of perforated sigmoid diverticulitis presented with 3 days of anorexia, watery diarrhea, and left lower abdominal pain. Two weeks earlier he developed a mild dry cough without fever, dyspnea, or chest pain. There were no sick contacts or recent travel. He was afebrile, and initial routine chemistries and a complete blood count were unremarkable. An abdomino-pelvic CT revealed acute diverticulitis of the distal descending and sigmoid colon. A consolidation at the right lung base was also incidentally noted. Follow up imaging confirmed a multifocal pneumonia on chest Xray. Legionella antigen was detected in the urine. Metronidazole and levofloxacin were initiated with clinical improvement and the patient was discharged home to complete a 10-day course of antibiotics IMPACT/DISCUSSION: Legionella bacteria are gram negative organisms found widespread in soil and bodies of water including lakes, streams, and artificial reservoirs. Transmission is via inhalation of aerosols and a high innoculum is typically needed to cause infection. Host risk factors for infection include older age, impaired cellular immunity, smoking, male sex, and medical co-morbidities such as diabetes mellitus, renal, lung and cardiovascular disease. The two most commonly known syndromes associated with Legionella infection are Legionnaire's disease, a pneumonia occurring typically in the late summer or early autumn months (as in our patient), and Pontiac fever, an acute self- limited febrile illness. The mortality rate for hospitalized Legionnaire's is up to 10%. Extra-pulmonary manifestations are rare and can include skin and soft tissue infections, septic arthritis, endocarditis, myocarditis, peritonitis, pyelonephritis, meningitis, brain abscesses, and surgical site infections. The diagnosis of extra-pulmonary disease requires detection of Legionella at the affected site by culture or polymerase chain reaction. In the absence of a known local Legionella outbreak, our patient's age, sex, smoking status, and underlying immune suppression most likely increased his risk for this sporadic infection. We postulate that the acute diarrhea associated with Legionnaire's disease may have triggered inflammation of his diverticula or the acute diverticulitis was an extra-pulmonary manifestation. To our knowledge, we are the first to report a case of Legionnaire's disease presenting as acute diverticulitis. CONCLUSION: Legionnaire's is a typical disease with many atypical and extra-pulmonary presentations. We present a case of Legionnaire's disease masquerading as acute diverticulitis and urge timely consideration and testing for Legionella in at-risk patients presenting with predominantly GI symptoms and subtle or no respiratory complaints, as it can be life-saving.
ABSTRACT
Introduction: The systemic side-effects of anti-SARS CoV-2 vaccination are described for all types of vaccines. We describe a case of a likely adverse reaction to the Spikevax Moderna vaccine, manifested by septic arthritis of the left sternoclavicular joint, mediastinitis and pulmonary embolism. Case Report: 22-year- old female soldier developed symptoms of fever, chest and limb discomfort in her left upper arm around 10 days after receiving her first dose of Spikevax Moderna vaccine, necessitating hospitalization 14 days after. Septic arthritis of the left sternoclavicular joint, mediastinitis, deep vein thrombosis of the left upper limb, and pulmonary embolism were diagnosed. The blood culture result showed the development of Staphylococcus aureus. The patient was treated with antibiotic therapy and with anticoagulant therapy. There was a rapid improvement in clinical conditions, allowing the patient to be discharged 10 days after admission. Conclusions: The vaccination's causative role in the formation of the clinical picture is extremely likely in this case, but with a plausible not-specific pathogenetic mechanisms. There have been reports of septic arthritis following SARS CoV2 vaccination, especially of the shoulder joint, but the novelty of our finding stems from the fact that it would be the first case of septic arthritis after vaccination involving a sternoclavicular localization. This case emphasizes the importance of maintaining a high degree of attention when administering vaccines and keeping a close eye on the patient in the days after the vaccine.
ABSTRACT
Objective: To evaluate the significance of infections in the structure of comorbid pathology in patients with inflammatory diseases of the joint (IDJ) during a single-stage retrospective study. Methods: The study included 437 patients with IDJ (259 women, 178 men, mean age 45 y): 172 -rheumatoid arthritis, 169 -ankylosing spondylitis, 74 -psoriatic arthritis, 22 -undifferentiated spondylarthritis. The majority of patients (n=343) received immunosuppressive therapy (glucocorticoids, methotrexate, leflunomide, biological drugs). The patients were interviewed by a research doctor with the completion of a unified questionnaire. Additional information was obtained from medical records. Results: The following comorbid pathology was documented in patients with IDJ: cardiovascular diseases -30.1%, gastrointestinal diseases -27.2%, respiratory diseases -12.5%, endocrine system diseases -10.9%, urogenital diseases -9.1%, skin diseases, except for psoriasis -4.2%. 653 cases of respiratory tract infections (RTI) and ENT organs and 537 cases of infections of other localization were diagnosed. RTI and ENT organs included acute nasopharyngitis (n=273), tonsillitis (n=110), pneumonia (n=69, including 29 caused by the SARS-CoV2 virus), acute bronchitis (n=54), sinusitis (n=52), influenza (n=47), otitis (n=41), tuberculosis (n=7). Infections of other localizations were represented by herpes-viral infections (n=184), mycoses (n=121), urinary tract infections (n=84), conjunctivitis and blepharitis (n=63), skin infections (n=26), intestinal infections (n=25), genital infections (n=22), osteomyelitis, purulent arthritis, nervous system infections (2 cases each), chronic hepatitis A, B and C, rubella, measles, HIV infection (1 case each). After the debut of IDJ, an increase in the frequency of acute nasopharyngitis, acute bronchitis, sinusitis, herpes-viral infections, and mycoses was noted. Serious infections requiring hospitalization and/or intravenous administration of antibiotics were diagnosed in 78 patients. of these, 64%of cases were caused by RTJ and ENT organs (pneumonia, including those caused by the SARS-CoV2 virus, acute bronchitis, sinusitis, purulent otitis), 36% -by other infections (intestinal infections, purulent paraproctitis, acute salpingitis, purulent endometritis). Conclusion: The problem of infections in patients with IDJ still remains relevant. Further studies are needed on large samples of patients with the aim of studying the prevalence of infections depending on the therapy (primarily, biological drugs), as well as the search for significant risk factors.
ABSTRACT
Background: During SARS-CoV-2 pandemic management of internist patient is even more complex: hospital acquired infection, resources devolved to CoViD-19, round visit with PPE, minor interrelation, post-CoViD patients. Presentation of the case series: 1. A 75-year old man had dysphagia, fever, low back pain, shoulder pain. Anamnesis: CoViD pneumonia (P/F143, TTS18/20), goiter, bladder neoplasm, T2DM. CT showed pneumomediastinum, pneumotorax, iliopsoas haematoma. He underwent broad spectrum antibiotic, arthrocentesis, culture tests. We concluded for pneumomediastinum due to CoViD-19 pneumonia, MSSA sepsis, septic arthritis, dysphagia due to goiter and pneumomediastinum, UTI. He is transferred to OSCO (surgery delayed) - 2. A 72-year old woman presented respiratory failure, fever, bacterial pneumonia. Anamnesis: stroke at age 50, APS diagnosis, AOCP, kidney failure. We performed antibiotics. Near to discharge, she had profuse haematemesis due to acute esophageal necrosis. She underwent PPI infusion and tests for risk factors and triggers (as APS or neoplasm). - 3. A 45-year old man had severe sepsis and intestinal obstruction. Anamnesis: paraplegia, previous intestinal obstruction. He underwent antibiotics, rehydration, NGT. Colonoscopy and gastrografin enema ruled out stenosis, but occlusion persisted. After collegial discussion surgical approach was proposed, but the patient had unfavorable outcome due to CoViD-19 infection. Discussion: These cases share high level of complexity: need of subintensive care, difficult management of patients' need. Clinical judgment, assessment of EBM priorities are essentials, underestimated skills.
ABSTRACT
Case report-IntroductionBacterial and fungal infections are recognised complications of viral pneumonia, particularly in patients who are critically ill. We describe a case of fungal sacroiliitis complicating severe COVID-19 pneumonia following a prolonged intensive care unit (ICU) admission.Candida albicans sacroilitis is a rarely reported infection with few case reports in the literature. Candida osteoarticular infections can present as septic arthritis, with knee involvement in 75% of cases, or osteomyelitis. The latter presentation differs based on age-vertebral involvement (51%) is more common in adults while children are more likely to present with infection in the long bones, ribs, or sternum.Case report-Case descriptionA 48-year-old Afro-Caribbean gentleman with a history of hypertension and obesity was admitted to the ICU with clinical, laboratory and radiographic features of COVID-19 infection despite persistently negative swabs. Whilst in ICU he required mechanical ventilation. His stay was further complicated by multiple infections, pulmonary emboli, and the presence of a cavitating lesion in the left lung. Cultures from bronchoalveolar lavage and a central venous catheter line grew Serratia Mascense, candida glabrata and pseudomonas were isolated from his urine. He was treated with multiple antibiotics including meropenem, tazocin, ceftazidime and avibactam.After 61 days in the ICU he was transferred to the ward. He developed severe pain in his right hip which was worse on movement. This was followed by urinary incontinence and sensory deficit in the right L2/L3 dermatome. He underwent magnetic resonance imaging (MRI) of his spine and sacroiliac joints which showed right sided sacroiliitis and oedema around the iliopsoas muscle. He was started on vancomycin, later changed to ceftazidime avibactam and metronidazole. An echocardiogram did not show any vegetations. He underwent a biopsy of his sacroiliac joints which confirmed the presence of leucocytes, extended cultures yielded candida albicans in one out of two biopsy specimens.Considering ongoing pyrexia, pain and inflammatory markers, intravenous fluconazole was added to his antibiotic regimen which resulted in a marked improvement in mobility. After four weeks, ceftazidime, metronidazole and avibactam were stopped, and fluconazole was administered as oral tablets. 6 days later he became febrile and IV fluconazole was restarted.A repeat chest CT showed resolution of the cavity but ongoing changes suggestive of organising pneumonia. A repeat MRI of the sacroiliac joints revealed minor improvement. Intravenous Fluconazole was continued for a total of 8 weeks and was changed to tablets for complete a total of 12 weeks.Case report-DiscussionThis is a severe case of COVID-19 infection who despite 9 negative PCR tests, on day 53, had positive IgG for SARS-CoV-2 infection, confirming our clinical suspicion. Particularly in the ICU setting, individuals are approximately ten times more likely to have secondary bacterial/fungal infections with more frequent detection of multidrug-resistant Gram-negative pathogens.This case highlights several difficulties. Urine cultures had confirmed candida albicans, likely to be related to catheter related urinary tract infections, and a possible source for our patient but also a resistant pseudomonas aeruginosa species. Furthermore, cultures were positive for Serratia Mascense, candida glabrata. He had also already been treated with prolonged, broad spectrum antimicrobial treatment. Considering this, establishing the aetiology of the septic sacroiliitis was challenging. The rarity of candida sacroiliitis and presence of the organism in just one specimen made this more difficult. This led to the decision of a repeat sacroiliac biopsy to supply sufficient samples for further microbial analyses such as 16S, 18S and mycobacteria culture, all of which were negative.He became febrile after the discontinuation of antimicrobials and a switch to oral fluconazole therapy. He was extensively re-investigated and despite resolution of t e lung cavity, there were changes which could have been consistent with an organising pneumonia. At this point he was neutropenic, mildly eosinophilic, and therefore a drug reaction was also considered.Repeat MRI revealed resolving muscle inflammation and minimal change at the bone site, with erosions and possible reactive bone marrow oedema. Following discussion with microbiology the decision was made to persist with intravenous Fluconazole. He continued to improve, and his inflammatory markers normalised after 8 weeks of treatment. Prednisolone was started for COVID-19 related pneumonitis. Long-term antifungal treatment is advisable, and we aim to complete 12 weeks of treatment.Case report-Key learning points Patients with SARS-CoV-2 infection, particularly those requiring ICU admission were at risk of developing superinfections with multidrug-resistant Gram-negative bacteria or fungal infections.Candida albicans sacroiliitis is rare therefore early aspiration/biopsy is essential for the management.Longer treatment is needed in osteoarticular candida infections, even up to 6 or 12 months, therefor long-term close monitoring of this patients is essential.The utility and timing of reimaging patients following such infections is still unclearClose multidisciplinary and interdisciplinary team collaboration is essential in the management of this complex patients.