Hypocalcemia secondary to hypomagnesemia in a patient on liraglutide.

A 73-year-old man with type 2 diabetes on Liraglutide with a history of coronary artery disease. Admitted to emergency for abdominal pain, severe diarrhea and episodes of tetany attacks. Laboratory workup reveals hypomagnesemia, hypocalcemia and normal parathormone (PTH). After intravenous administration of magnesium and calcium, the blood ionogram quickly normalized. In addition, plasma levels of intact parathyroid hormone increased immediately after magnesium administration. Strongly suggests that hypocalcemia resulted from a disruption of adequate parathyroid hormone secretion caused by hypomagnesemia which in turn was caused by severe diarrhea under treatment with Liraglutide.

Pituitary metastasis of a breast ductal adenocarcinoma.

Pituitary metastases are rare, a primary tumor of the breasts or lungs are frequently found. The clinical picture is very variable, they can be accidental discovery or revealed by a pituitary dysfunction. The prognosis is generally poor and depends on the anatomopathological type. We report the observation of a patient with a pituitary metastasis of a breast cancer evolving for 4 years, the diagnosis was suspected in front of pituitary macroadenoma images, a transphenoidal endoscopic biopsy and an anatomopathological confirmation revealing an infiltrating breast adenocarcinoma.

Epidemiological markers of Serratia marcescens isolates causing nosocomial infections in Spain (1981-1991).

The distribution of epidemiological markers (serotyping and phage-typing) of Serratia marcescens isolates from nosocomial episodes (63 nosocomial cutbreaks with 475 isolates, and 1208 sporadic cases) received in our laboratory during the period 1981-1991 was studied. The records for 1683 isolates from Spanish hospitals have been analyzed. In relation with the sporadic cases, the predominant types were serotype O6 (13.4%) and serotype O14 (11.4%); polyagglutinable strains accounted for 15.6%; in outbreaks, type O14 is clearly predominant (27.4%). Phage-typing was a good secondary marker, with a 87.9% of typability; the number of lytic patterns was very high, extended patterns (six or more phages) being the most frequent. We have studied the characteristics of S. marcescens isolates causing infections in the nosocomial environment in Spain.

An international investigation of an outbreak of Legionnaires disease among UK and French tourists.

Five cases of legionnaires disease and one death were associated with four members of a tour group from the United Kingdom (UK) and one French tourist who all visited Spain in the spring of 1993. The UK group stayed at four hotels, one of which was also used by the French tourist. Phenotypic and genotypic comparison of isolates of Legionella pneumophila obtained from one of the UK cases and the French patient demonstrated that they were indistinguishable from each other and from environmental isolates obtained from the water supply of the hotel at which all five cases had stayed. A cohort study of the UK tour group was carried out to determine the extent of the outbreak and showed that three further members of the group had respiratory illness but were serologically negative to legionella infection. International participation in this investigation has highlighted the value of a European surveillance scheme and the benefit of microbiological collaboration between legionella reference laboratories in Europe.

[Characterization of clinical and environmental isolates of Legionella associated with outbreaks and study of the infection sources]. / Caracterización de aislados clínicos y ambientales de Legionella asociados a brotes y estudio de las fuentes de infección.

BACKGROUND: The study of isolates of Legionella related with six outbreaks of community-acquired legionellosis and seven nosocomial outbreaks is presented. METHODS: The isolates were serogrouped by indirect immunofluorescence testing and those belonging to serogroup (SG) 1 L. pneumophila strains were subtyped using the international panel of monoclonal antibodies. RESULTS: SG 1 L. pneumophila appeared to be the etiologic agent of all the community outbreaks analyzed and the main one of the nosocomial cases. However, in the latter situation, cases produced by SG3, SG4, SG6, SG8, SG8, 10 y SG4,8,10 were also found. Among subgroup 1 Legionella, the Pontiac, Philadelphia 1 or Allentown 1 subtypes were responsible for four out of the six community and three of the seven nosocomial outbreaks. The Pontiac, Knoxville 1 subtype was the cause of a community-outbreak and of another nosocomial outbreak, and the Pontiac, Benidorm 030E caused a community and another hospital outbreak, also being the main agent found in another hospital. The remaining subtypes appeared in small numbers in some hospitals, where cases due to different isolates coexisted. Likewise, nosocomial cases produced by SGs other than SG1 (Sg 4, 6 and 8) were found in one hospital (with SG 8 also being found in environmental samples) and Sg 4, 8, 10 together with Sg 3 in another (both SGs were also found in different hospital facilities). The sources of infection found were air conditioning systems in two cases and the lavatory water system in the remaining cases, with no colonization being found in a series of natural sources (spring water, wells, water tanks, watering systems) also studied in several of the outbreaks. CONCLUSIONS: These results with suggest that although building installations are colonized by a large variety of species, SGs and subtypes of Legionella, only some (mainly SG 1 L. pneumophila, Pontiac subtype) actually produces outbreaks. This is specially relevant in community outbreaks, while in hospital outbreaks other species or SGs may produce infection in isolated cases or outbreaks due to the presence of highly susceptible hosts.

Hospital infections in Spain. I. Staphylococcus aureus (1978-91).

This study was undertaken to determine the distribution of phage types of Staphylococcus aureus isolates from hospital outbreaks or sporadic cases received in our laboratory during the past 14 years. The records for 15,803 isolates from 55 Spanish hospitals have been analysed. In relation to sporadic isolates we have been able to detect the predominance of phage group I and non-typable staphylococcal strains. Since 1989, we have observed a considerable increase in hospital infection caused by methicillin-resistant S. aureus strains which we could differentiate in to two groups; one belonging to phage group III (6/47/54/75/77/84/85) and other groups of nontypable strains which could be classified as phage group I-III after heat treatment (29/77/84) and with similar patterns by reverse typing (6/47/53/54/75/83A/84/85/W57/1030/18042). During 1990 and 1991, these strains have extended widely to at least six different autonomous regions creating an epidemic situation in Spain.

[Prevalence of serotype 0:12 among strains of P. aeruginosa causing nosocomial infection in Spain (1980-1991)]. / Prevalencia del serotipo 0:12 de cepas de P. aeruginosa productoras de infección nosocomial en España (1980-1991).

BACKGROUND: The aim of the present study was to characterize P. aeruginosa strains causing nosocomial infection in Spain between 1980-1990 with special emphasis on the incidence of serotype 0:12 strains. METHODS: 11,411 strains of P. aeruginosa from hospital-acquired infections were studied and epidemiologically characterized by phage-typing, serotyping and sensitivity to antimicrobial agents. The strains of the 0:12 serotype were analyzed by isoenzyme analysis. RESULTS: Although the major serotypes throughout the period studied were: 0:1, 0:6 and 0:11, the existence of serotype 0:12 strains (6%) were detected which had produced nosocomial outbreaks in surrounding countries. This serotype is homogeneous in that the epidemiologic markers and patterns of sensitivity to antibiotics and the multienzyme analysis demonstrate uniformity in the electrophoretic patterns of all the strains studied. CONCLUSIONS: The 0:12 serotype is in Spain indistinguishable by phage typing and studies of antibiotic sensitivity. It may be considered as being of clonal origin and is probably equal to that existing elsewhere in Europe.

Evidence of the presence of spotted fever group rickettsiae in dogs and dog ticks of the central provinces in Spain.

To assess canine exposure to spotted fever group rickettsiae in the central provinces of Spain, ticks removed from dogs were studied by immunofluorescence (IF) staining. Twenty-eight out of 65 (43.0%) samples from ticks were positive. Sera from 58 dogs were also collected and the presence of antibodies to Rickettsia conorii studied. Thirty-four (58.6%) dogs presented significant titers by IF. Surveillance data from these provinces show the presence of Boutonneuse fever cases during recent years, evidence that dogs could serve as an indicator of rickettsial activity in these areas.

Legionellae isolated from clinical and environmental samples in Spain (1983-90): monoclonal typing of Legionella pneumophila serogroup 1 isolates.

Legionella isolates recovered in 21 different Spanish provinces over 8 years from both clinical (67 isolates) and environmental (181) samples, mostly from case-associated buildings, are described; 92.5% of clinical isolates were L. pneumophila serogroup 1 (SG1), only five isolates belonging to other species or serogroups: two L. pneumophila SG6, two SG8 and one L. bozemanii SG1 not clearly related with clinical infection. L. pneumophila SG1 accounted for 53.6% of isolates from the environment, followed by SG8 (27.6%), SG3 (9.4%) and SG6 (7.2%). Three isolates were labelled as SG8/10. Subtyping of L. pneumophila SG1 by the standardized panel of monoclonal antibodies revealed 90.3% of clinical and 78.3% of environmental isolates as belonging to Pontiac subgroup. Pontiac isolates were further divided into 55.3% Philadelphia 1 or Allentown 1, 21.9% Benidorm 030E and 20.4% Knoxville 1. Characterization of samples from four outbreaks in which both clinical and environmental isolates had been recovered permitted the recognition of three Philadelphia 1 or Allentown 1 and one Knoxville 1 strains as the aetiological agents.

Isolation of an agent of the spotted fever group rickettsia from tick eggs in Madrid, Spain.

Ticks recovered from dogs in rural villages around Madrid (Spain) were processed to isolate rickettsiae. One sample containing mixtures of ticks and four containing eggs, in which rickettsiae had been detected by indirect immunofluorescence with a human serum highly reactive to Rickettsia conorii, were decontaminated, homogenized and inoculated onto Vero cells. Two egg samples yielded a cytopathic agent that reacted positively by immunofluorescence. One sample (14H) was successfully subcultured and identified as a member of the spotted fever group rickettsia. Tick eggs provide suitable material for isolation of rickettsia.

Serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates causing systemic infections in Spain, 1979-1989.

Serotypes and antibiotic susceptibilities were determined for 2,197 Streptococcus pneumoniae strains isolated from patients with systemic infections over an 11-year period. The predominant serogroups and serotypes, in order of decreasing frequency, were 3, 6, 23, 19, 9, 1, 5, 8, 7, 14, 4, and 15; these types accounted for more than 75% of the strains studied. Altogether, 93% of the pneumococci belonged to groups or types included in the 23-valent pneumococcal vaccine. Overall, 65.5% of pneumococci were resistant to one or more drugs. The incidence of penicillin-resistant pneumococci rose from 6% in 1979 to 44% in 1989, and the degree of penicillin resistance also increased throughout the study. Overall, the resistance rates were 28% for penicillin, 56% for tetracycline, 43% for chloramphenicol, and 5% for erythromycin. Seventy-one pneumococcal isolates resistant to all four antibiotics tested were found. The prevalence of pneumococcal resistance in Spain is, as far as we know, among the highest published to date.

Analysis of protein antigens as a potential marker for Streptococcus pneumoniae.

Protein antigens of the five more common Streptococcus pneumoniae serotypes in Spain-1, 3, 4, 5 and 23 -were studied by crossed immunoelectrophoresis and sodium dodecyl sulfate polyacrylamide gel electrophoresis. Most protein antigens defined by crossed immunoelectrophoresis appeared to be common to the five serotypes studied since the degree of cross-reaction was high. Using gel electrophoresis a considerable degree of similarity in the patterns of protein bands was also observed. Thus, protein antigens would not appear to be epidemiological marker for typing pneumococci.

Cross-reactivity among Legionella species and serogroups.

Cross-reactions of 17 members of the family Legionellaceae were studied by four different serological techniques: immunofluorescence (IF), slide agglutination (SA), microagglutination (MA) and immunodiffusion (ID), using antigens and rabbit antisera prepared in our laboratory. Results obtained corresponded closely with those described by other authors, especially for IF and SA. The 17 antigens were further tested by IF with a panel of sera previously diagnosed as positive for legionella. A high number of positive reactions with several of the antigens tested were found, half of them being positive for Legionella pneumophila serogroup 1, usually in combination with other serogroups or species. The remaining sera presented a great variety of patterns combining different antigens.

Characterization of non-typable strains of Staphylococcus aureus from cases of hospital infection.

A high percentage of non-typable (NT) Staphylococcus aureus strains was isolated in Spanish hospitals during 1984 and 1985. Several alternative methods of typing were employed to study these isolates. These were: phage-typing at 1000 X RTD, phage-typing after heat-treatment (48 degrees C), thermal shock (56 degrees C), reverse-typing and induction of additional phages. Using these methods the number of NT isolates was reduced by 60%. Best results were obtained with heat-treatment. Additional phages and reverse-typing were also useful. A scheme for the study of outbreaks and sporadic cases caused by NT strains is proposed using the methods described.

Phage-typing of Staphylococcus aureus from cases of bacteraemia.

Isolates of Staphylococcus aureus from 98 cases of bacteraemia from 16 different hospitals were phage-typed. Fifty-six isolates were associated with sporadic infections and 42 with hospital outbreaks. In the sporadic cases, group I strains, particularly types 29, 52, or 29/52, were very frequent (39.2%), followed by non-typable strains. Type 94/96 was also common (14.2%). In hospital outbreaks, mixed I and III strains (multiply-resistant) were found in 73.6% and non-typable strains in 21.4%.

Hospital infection caused by non-typable Staphylococcus aureus: application of reverse typing.

Hospital infections caused by strains of Staphylococcus aureus non-typable (NT) by phages have occurred in three Spanish hospitals since 1981. Reverse typing allowed characterization of the strains in all three cases.