Incidence and clinical predictors of infections in patients treated with severe systemic ANCA-associated vasculitis.

BACKGROUND: Immunosuppressive therapy has improved the outcome of ANCA-associated vasculitis (AAV), but infectious morbidity and mortality remained high. Recognizing its risk factors seems crucial for prevention, aiming to increase survival of these patients. METHODS: We investigated the incidence and types of infections and assessed predictive factors in 132 patients with severe systemic AAV. RESULTS: Patients with lower than median incidence of total infections/patient-year during induction had lower baseline serum creatinine, dialysis requirement and Charlson comorbidity index (CCI), compared to those with higher than median incidence (P = 0.037; P = 0.024; P = 0.001; respectively). In subgroups with below and above than median number of severe infections/patient-year during induction, differences were found in baseline creatinine (P = 0.002) and dialysis requirement (P = 0.001); comparing the same cohorts during maintenance immunosuppression, baseline dialysis requirement, diabetes, CCI, and dose of cyclophosphamide (CYC) administered as induction therapy differed significantly (P = 0.019; P = 0.015; P = 0.001; P = 0.015, respectively). Severe infections were predicted by baseline serum creatinine (OR 1.002 [CI 1.001-1.003]) and pulmonary manifestation (OR 2.153 [CI 1.017-4.560]) during induction immunosuppression. In multivariable Cox regression model all-cause mortality was independently predicted by severe infection (HR 1.998 [CI 1.214-3.287]). Among the 168 positive cultures Gram-negative bacteria were responsible for blood stream infections in 33%, and respiratory tract infections in 72%. CONCLUSIONS: Advanced renal failure, pulmonary involvement and high degree of comorbidities increase the risk of infection in AAV. Those who suffer infection during induction immunosuppression have worse long-term survival. Our findings indicate the need for high vigilance for infections and close follow-up of comorbidities when treating AAV.

[Water intoxication in pulmonary tuberculosis complicated by aspergillosis]. / Vízmérgezés aspergillosissal szövödött tüdötuberculosisban.

The authors found a serum sodium level of 113 mmol/l in a 70 year old confused male patient with cachexia and fever, which level rised to 125 mmol/l as a result of hypertonic sodium chloride and furosemide therapy, resulting in improving sensorium. At the same time the urine osmolality (235 mOsm/kg) was high compared to the serum osmolality (258 mOsm/kg). The physical and radiological examination showed bilateral pneumonia. The patient died in acute circulatory insufficiency. At the autopsy miliary pulmonary tuberculosis with superinfection by aspergillosis was proved. The authors discuss the possible mechanisms of water intoxication occurring with lung diseases and the difficulties regarding the diagnosis and therapy of aspergillosis.

[Pseudophaeochromocytoma (hypertensive crisis as a result of beta receptor hypersensitivity?)]. / Pseudophaeochromocytoma. (Hypertoniás krízis béta-receptor-túlérzékenység következtében?).

The diagnosis of phaeocromocytoma could be excluded in a 57 year-old man suffering from "typical" hypertensive paroxysms by using modern standardized technics. The presented disorder which has been named pseudophaeochromocytoma may include different pathogenetical entities. In the observed case the background of the disorder was thought to be "beta-receptor hyperresponsiveness" which has been confirmed by the determination of the urinary catecholamine excretion as well as by the introduction of a new isoproterenol infusion method. In response to beta-blocking agents (which are contraindicated in phaeochromocytoma) no further hypertensive crises occurred, resulting in a dramatic improvement of the patient's condition.

[Rhabdomyolysis in a medical student induced by body-building exercise (rhabdomyolysis following acute muscular exertion)]. / Rhabdomyolysis "testépító" orvostanhallgatóban (Heveny izomtúlterhelést követö rhabdomyolysis).

A medical student sportsman had been admitted to the hospital because of weakness and painful swelling of the muscle as well as dark urine appearing after carrying out an excessive body-building performance. On the basis of indirect evidences pigmenturia "per exclusionem" was a manifestation of urinary myoglobin excretion. The development of an "acute exertional rhabdomyolysis" was confirmed by the increased serum enzyme levels and myoglobinuria. The outcome of the illness was fortunate, as acute renal failure could be avoided. On the basis of survey of the literature it can be stated, that this presumably frequently occurring, but rarely recognized disease may have importance from clinical, sporting medicine and pathophysiological point of view.

[Cerebral beriberi with ophthalmoplegia as the leading symptom in an alcoholic patient]. / Ophthalmoplegia vezetö tünettel járó cerebralis beriberi alkoholista betegen.

Author has noticed bilateral ophthalmoplegia in consequence of B1 avitaminosis due to alcoholism. Recognition of the cerebral beriberi with ophthalmoplegia as a leading symptom (Wernicke's encephalopathy) is easy. The importance of the diagnosis is that this life threatening condition can be abolished promptly by the administration of Vitamin B1. On the basis of the frequent occurrence of alcoholism it seems likely, that several similar beriberi cases could be found nowadays.