Pneumatosis intestinalis in COVID-19.

INTRODUCTION: COVID-19 is a respiratory illness due to novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), described in December 2019 in Wuhan (China) and rapidly evolved into a pandemic. Gastrointestinal (GI) tract can also be involved. CASE PRESENTATION: A 44-year-old man was hospitalised for COVID-19-associated pneumonia. A rapid recovery of respiratory and general symptoms was observed after 1 week of treatment with lopinavir/ritonavir plus hydroxychloroquine and broad-spectrum antibiotics (piperacillin-tazobactam plus teicoplanin). No GI symptoms were reported during hospitalisation, but a lung contrast-enhancement CT (CE-CT) excluding thromboembolism showed, as collateral finding, intraperitoneal free bubbles not present on a previous CT examination; the subsequent abdominal CE-CT described pneumatosis intestinalis (PI) involving the caecum and the right colon. Ciprofloxacin plus metronidazole was started, and the 2-week follow-up CT showed the complete resolution of PI. DISCUSSION: The pathogenesis of PI is poorly understood. PI involving the caecum and right colon has been described for HIV and Cytomegalovirus infections, but, to our best knowledge, never before in COVID-19. We hypothesise a multifactorial aetiopathogenesis for PI, with a possible role of the bowel wall damage and microbiota impairment due to SARS-CoV-2 infection, and we suggest a conservative management in the absence of symptoms.

Clinical outcomes of elderly patients with bloodstream infections due to extended-spectrum ß-lactamase-producing Enterobacteriaceae in an Italian Internal Medicine ward.

PURPOSE: Infections caused by ESBL-producing Enterobacteriaceae (ESBL-EB) are a major health problem, but data regarding elderly patients is lacking. METHODS: We performed a retrospective observational study quantifying the effects of antimicrobial treatment and primary infection site on clinical outcomes in an historical case series of 42 patients aged 80.7±10years admitted to an Internal Medicine ward in Italy for ESBL-EB bloodstream infections (BSI). RESULTS: At multivariate risk analysis, we found that urinary tract as primary infection site (RR=0.181 [0.037-0.886], p=0.035) and definitive antibiotic therapy (RR=0.517 [0.147-0.799], p=0.038) decreased the relative risk of a negative clinical response, while the respiratory tract origin increased the relative risk (RR=2.788 [1.407-9.228], p=0.025). Also regarding 30days mortality, multivariate risk analysis identified that urinary tract as primary infection site (RR=0.098 [0.011-0.743], p=0.025) and definitive antibiotic therapy (RR=0.236 [0.058-0.961], p=0.044) decreased the relative risk, while the respiratory origin increased the relative risk (RR=4.241 [1.040-17.295], p=0.014). We observed similar outcomes in patients definitively treated with carbapenems or with carbapenem-free treatments. Additionally, an initially inappropriate therapy did not correlate with worse outcomes if a switch to an effective definitive treatment was performed promptly. CONCLUSIONS: Carbapenem-sparing regimens (e.g. piperacillin-tazobactam alone or with an aminoglycoside) could be empirically safely used in elderly patients at high risk of ESBL-EB BSI and for definitive treatment of ascertained cases if the primary site is the urinary tract, leaving early carbapenem use for cases at higher risk of death, such as those with pneumonia.

Left Atrial Mass Invasion from Pulmonary Neoplasm Extension via the Right Upper Pulmonary Vein Presenting as Ipsilateral Stroke.

Left atrial invasion by lung cancer via haematogenous pathways is a relatively uncommon but potentially life-threatening event. While several cardiac complications of cardiac involvement have been previously described, the evolution towards cerebral stroke has been rarely reported. In this case report, we describe an atypical case of haematogenous metastatic invasion of the left atrium from pulmonary neoplasm extension presenting as an ipsilateral stroke whose ASCO classification changed during the clinical management.

Compliance with therapy in hypertensive patients.

OBJECTIVE: This study investigated pharmacological compliance in hypertensive patients recruited during a 24-month period at the Hypertension Clinic of the S. Maria Nuova Hospital. METHODS: The compliance profile scale was developed in order to classify compliance as sufficient, or poor. Compliance was evaluated according to patients' (1) global cardiovascular risk (hypertensive) and (2) complexity of prescribed treatment at enrolment (drug, number of pills). RESULTS: A total of 367 patients were recruited; 82 were excluded owing to changes in therapeutic schedule or medication necessitated by other medical or surgical disease. Compliance was evaluated in 285 patients, 66% were male; the mean age was 72 +/- 12 years. Compliance was evaluated at a series of follow-ups at 3-month intervals and at 36 months of observation. Compliance at 36 months was good or sufficient in 56% of patients, but differed according to hypertensive and drug status. Compliance was better in patients with a higher level vs. lower level of hypertension severity. Specifically, compliance was better in hypertensives with co-morbidity (76%) than in hypertensives without co-morbidity (37%) or hypertensives with risk factors (65%). Moreover, compliance was better in patients with a more complex therapeutic regimen (drug 1 through 3: 47, 59 and 66%). CONCLUSIONS: These data demonstrate a relationship between disease severity and compliance, independent of the prescribed therapeutic regimen. This suggests that the most important factor for therapy adherence is disease awareness and severity, and patients with a higher level of disease are more likely to be compliant.