Pulmonary Embolism in a Young Immunocompetent Adult Infected with Cytomegalovirus. Are Novel Oral Anticoagulants an Efficient Alternative?

BACKGROUND/AIM: Cytomegalovirus (CMV) infection is a common disease especially in young adults. Thromboembolism like deep vein thrombosis and pulmonary embolism is increased among patients with CMV infection. Most cases represent immunocompromised patients usually treated with low molecular weight heparin. CASE REPORT: Herein, we describe a 25-year-old immunocompetent male who presented at the emergency department with sudden onset of chest pain. One month prior to admission, he had developed persistent fever and cough and the diagnosis of CMV infection had been established. After extensive workup, the diagnosis of pulmonary embolism after CMV infection was set and he was treated with rivaroxaban. During the next six months the patient continued on the same anticoagulant therapy with no other episode of pulmonary embolism at 1-year follow-up. CONCLUSION: To our knowledge, this is the first case of CMV-associated pulmonary embolism treated with novel oral anticoagulants (NOACs). NOACs, such as rivaroxaban, seem to be safe and may represent an attractive alternative with promising results in this particular group of patients. Studies incorporating a greater cohort of patients are needed in order to draw safe conclusions regarding the relationship between NOACs and CMV infection.

Immunomodulatory intervention in sepsis by multidrug-resistant Pseudomonas aeruginosa with thalidomide: an experimental study.

BACKGROUND: Thalidomide is an inhibitor of tumour necrosis factor-alpha (TNFalpha) that has been proven effective for the treatment of experimental sepsis by Escherichia coli. It was tested whether it might behave as an effective immunomodulator in experimental sepsis by multidrug-resistant (MDR) Pseudomonas aeruginosa. METHODS: Sepsis was induced by the intraperitoneal injection of 1 x 10(8) cfu/kg inoculum of the test isolate in a total of 10(9) Wistar rats divided in three groups as follows: group A controls; group B administered seed oil 30 minutes before bacterial challenge; and group C administered 50 mg/kg of thalidomide diluted in seed oil 30 minutes before bacterial challenge. Blood was sampled for estimation of endotoxins (LPS), TNFalpha, interferon-gamma (IFNgamma), nitric oxide (NO) and malondialdehyde (MDA). LPS was measured by the QCL-1000 LAL assay, TNFalpha and IFNgamma by ELISA, NO by a colorimetric assay and MDA by the thiobarbiturate assay. RESULTS: Mean (+/- SE) survival of groups A, B and C were 18.60 +/- 1.84, 12.60 +/- 0.60 and 30.50 +/- 6.62 hours (p of comparisons A to C equal to 0.043 and B to C equal to 0.002). Decreased TNFalpha and NO levels were found in sera of animals of group C compared to group A. Plasma levels of LPS, MDA and IFNgamma did not differ between groups. CONCLUSION: Intake of thalidomide considerably prolonged survival in experimental sepsis by MDR P. aeruginosa an effect probably attributed to decrease of serum TNFalpha.

Immunomodulatory clarithromycin treatment of experimental sepsis and acute pyelonephritis caused by multidrug-resistant Pseudomonas aeruginosa.

Clarithromycin was administered intravenously to 55 rabbits to evaluate its effect on experimental sepsis caused by multidrug-resistant Pseudomonas aeruginosa. Acute pyelonephritis was induced after ligation of the right ureter and injection of 10(8) CFU of the test isolate per kg of body weight into the renal pelvis. The animals were divided into six groups: group A, controls; group B, rabbits that received one intravenous dose of 80 mg of clarithromycin per kg concomitantly with bacterial challenge; group C, rabbits that received two doses of clarithromycin, the second one of which was given 2 h after the first one; group D, rabbits that received 15 mg of amikacin per kg; group E, rabbits that received one dose of clarithromycin and amikacin; and group F, rabbits that received two doses of clarithromycin and amikacin. Serum endotoxin levels were estimated by the QCL-1000 Limulus amoebocyte lysate assay, tumor necrosis factor alpha (TNF-alpha) levels were measured by a bioassay, and malondialdehyde (MDA) levels were measured by the thiobarbiturate assay. Viable bacterial counts in various tissue samples were also assessed. The mean survival times of the animals in groups A, B, C, D, E, and F were 4.50, 7.69, 4.07, 4.55, 11.55, and 11.60 days, respectively (P = 0.033 for group D versus group F, P = 0.006 for group D versus group E, P = not significant for group B versus group E, P = 0.042 for group C versus group F). Serum endotoxin levels were similar between groups at all sampling times; TNF-alpha and MDA levels in groups B, C, E, and F decreased significantly over follow-up. The numbers of viable bacterial cells in the infected kidney were similar among the groups; those in the liver, spleen, lungs, and mesenteral lymph nodes were significantly decreased in groups B, E, and F compared to those in groups A and D. It is concluded that a prolongation of survival in animals with experimental sepsis caused by multidrug-resistant P. aeruginosa was achieved after coadministration of clarithromycin and amikacin and that the increased survival was probably attributable to the immunomodulatory properties of clarithromycin.