Relapsing klebsiella pneumoniae liver abscesses in a non-asian diabetic man / Abcessos hepáticos recidivantes provocados por klebsiella pneumoniae num homem diabético não asiático

The Klebsiella pneumoniae invasive syndrome, first described in Asia, is being reported in other parts of the world. It causes liver abcsesses, with or without extrahepatic lesions. Diabetes mellitus is the most common hosts' underlying condition. It's frequent among asian people, even outside Asia, appearing to exist genetic factors, not yet established, increasing the risk. We present a case of a 55-year-old portuguese white diabetic man, who had a previous hospital admittion due to Klebsiella penumoniae pneumonia and a two-week latter diagnosis of liver abcsess. 4 years latter he was readmitted with nausea, chills, fever and myalgias. He had elevated inflammatory markers and the CT-scan showed 2 liver abscesses. Klebsiella pneumoniae was isolated in blood and antibiotics were given with complete clinical and imaging resolution. We present this case of relapsing Klebsiella pneumonia liver abscesses in a non-asian man emphasizing the growing incidence of this condition in Europe.

O síndrome invasivo provocado por Klebsiella pneumoniae, descrito pela primeira vez na Ásia, tem vindo a ser reportado em outras partes do mundo. Provoca abcessos hepáticos, com ou sem lesões extra-hepáticas associadas. A diabetes mellitus é a condição predisponente do hospedeiro mais comum. É frequente nos indivíduos asiáticos, mesmo fora da Ásia, parecendo existir factores genéticos, ainda não estabelecidos, que aumentam o risco da infecção. Apresentamos o caso de um homem português de 55 anos, diabético que tinha uma admissão prévia no hospital por pneumonia provocada por Klebsiella pneumoniae, com diagnóstico de abcesso hepático 2 semanas depois. 4 anos mais tarde, foi readmitido com um quadro clínico de nauseas, calafrios, febre e mialgias. Apresentava parâmetros inflamatórios elevados e a tomografia computorizada (TC) abdominal revelou 2 abcessos. Foi isolada Klebsiella pneumoniae em hemoculturas e foram administrados antibióticos com completa resolução clínica e imagiológica. Apresentamos este caso de abcessos hepáticos recidivantes por Klebsiella pneumoniae num homem não asiático, enfatizando a incidência crescente desta entidade na Europa.

Abcesso cerebral num doente com Rendu-Osler-Weber / Cerebral abscess in a patient with Rendu-Osler-Weber

A telangiectasia hemorrágica hereditária é uma doença familiar rara, descrita pela primeira vez no final do século 19, caracterizada por telangiectasias mucocutâneas e viscerais, e por malformações arteriovenosas. Manifestações neurológicas ocorrem em 8 a 12% dos doentes e resultam em mais de metade dos casos de malformações arteriovenosas pulmonares. A telangiectasia hemorrágica hereditária é uma das causas mais frequentes de abcessos cerebrais recorrentes, múltiplos e bilaterais, tendendo estes a ocorrerem na 3a para a 5a década. Apresentamos o caso de uma mulher de 88 anos admitida por prostração, febre e insuficiência respiratória, com a suspeita de metastização pulmonar de neoplasia oculta, cuja investigação revelou, entretanto, um abcesso cerebral secundário a malformações arteriovenosas pulmonares. Apesar da antibioterapia e da drenagem cirúrgica do abcesso, a paciente veio a falecer. O prognóstico após drenagem dos abcessos sem ressecção das lesões pulmonares é desfavorável, podendo sua elevada mortalidade refletir um atraso diagnóstico pela falta de reconhecimento dessa associação.

Hereditary hemorrhagic telangiectasia is a rare familial disorder, first described in the late 19th century characterized by multiple mucocutaneous and visceral telangiectases and arteriovenous malformations. Neurologic manifestations occur in 8 to 12% of patients and result from pulmonary arteriovenous malformations in 50% of cases. Hereditary hemorrhagic telangiectasia is one of the most frequent causes of recurrent, multiple and bilateral cerebral abscess and these tend to occur in the 3rd to 5th decade. We present the case of an 88-year-old woman admitted for prostration, fever and respiratory failure who was thought to have pulmonary metastasis of an unknown tumor but investigation revealed a brain abscess secondary to pulmonary arteriovenous malformations. Despite antibiotics and surgical drainage the patient died. The prognosis of brain abscess drainage without resection of the pulmonary lesions is not favorable. The high mortality of brain abscess in these patients may reflect a delay in diagnosis due to lack of recognition of this association.

Panniculitis - A Rare Manifestation of Acute Pancreatitis.

Pancreatic panniculitis is a rare skin disorder that occurs in 2-3% of pancreatic diseases, mostly associated with acute or chronic pancreatitis. Its pathophysiology is still unclear, but the release of pancreatic enzymes in circulation can be responsible for this disorder. The typical histological features are adipocyte necrosis with neutrophils infiltrate and typical "ghost cells". Its treatment, clinical course and prognosis are usually related with the pancreatic disease. We present a case of a 39-year-old man who presented with fever, abdominal pain, nausea and vomiting after a copious alcohol ingestion. Acute alcohol-induced pancreatitis was diagnosed. 9 days after admission he developed tender erythematous subcutaneous nodules, whose biopsy was consistent with pancreatic panniculitis. There was clinical and laboratory improvement with supportive treatment as well as skin nodules regression. Although pancreatic panniculitis is a rare condition, physicians must be aware of it to avoid delay in the diagnosis.

A paniculite pancreática é uma condição cutânea rara que ocorre em 2­3% das doenças pancreáticas, estando sobretudo associada às pancreatites aguda e crónica. A sua fisiopatologia ainda é incerta, mas a libertação de enzimas pancreáticas na circulação parece estar implicada. Os aspectos histológicos característicos consistem em necrose dos adipócitos com infiltrado neutrofílico e as típicas "ghost cells". O seu tratamento, evolução clínica e prognóstico estão habitualmente relacionados com a doença pancreática.Apresentamos o caso de um homem de 39 anos com um quadro de febre, dor abdominal, náuseas e vómitos após uma ingestão copiosa de álcool. Foi diagnosticada uma pancreatite aguda alcoólica. 9 dias após a admissão, surgiram nódulos eritematosos subcutâneos dolorosos, cuja biópsia foi consistente com paniculite pancreática. Houve melhoria clinica e laboratorial com o tratamento de suporte, assim como regressão dos nódulos cutâneos.Embora a paniculite pancreática seja uma condição rara, os médicos devem tê-la presente para evitar o atraso no diagnóstico.

Aortic and tricuspid endocarditis due to Streptococcus gallolyticus in an immunocompetent patient with a normal heart.

Endocarditis due to Streptococcus gallolyticus, an agent previously included in the Streptococcus bovis denomination is a serious disease, often associated with lesions of the colon mucosa. Aortic valve is more often affected and tricuspid involvement is quite rare. We present a case of a 56-year-old man who was admitted with a 2-month history of fever. Echocardiogram revealed vegetations on the aortic and tricuspid valve and blood cultures grew S. gallolyticus. Thoracic X-ray and computed tomography were consistent with septic pulmonary embolism. Despite optimal antibiotic therapy he developed an ischemic stroke and acute aortic regurgitation, which led to emergent surgery. Colonoscopy found a benign adenoma which was excised, and the patient had a full recovery.

Neutrophilic dermatosis of the dorsal hands associated with chronic hepatitis C virus infection.

Neutrophilic dermatosis of the dorsal hands, a localized form of Sweet's syndrome, was recently described, and can be associated with several diseases including infections. Chronic hepatitis C virus infection has been proposed as a possible triggering factor. The authors present a case in which the clinical and laboratory workup diagnosis only revealed positive serology for hepatitis C virus. Although a cause-effect relation could not be proved, it might be advisable to include serology for this virus in the initial evaluation of patients with neutrophilic dermatosis.

Mycoplasma pneumoniae-associated mucositis with minimal skin manifestations.

Mycoplasma pneumoniae-associated mucositis is a rarely described complication of M. pneumoniae infection presenting with ocular, oral, and genital involvement but without the typical skin lesions seen in Stevens-Johnson syndrome. A 27-year-old man with a past history of asthma presented at the emergency room with a 1-week history of cough (initially non-productive but subsequently associated with non-bloody mucopurulent sputum), fever, myalgias, headache, and progressive dyspnea. Two days before admission he had commenced amoxicillin/clavulanic acid with no improvement. The patient reported bilateral conjunctival injection and hemorrhagic ulcers on the lips commencing the day prior to admission. Physical examination revealed fever (39 degrees C), bilateral exudative conjunctivitis, painful hemorrhagic ulcers on the lips, tongue, and oral mucosa, small scrotal erosions, erythema of the penile meatus, and small erythematous bullae on the dorsum of each hand; subsequently, the patient developed bullae at the venipuncture site on his right arm. Laboratory tests revealed positive IgM serology for M. pneumoniae, with titer elevation. The patient was successfully treated with levofloxacin and prednisolone. Our case appears to be the first adult patient described with M. pneumoniae-associated mucositis, which has previously been reported only in pediatric patients. This is also the first reported instance of a case of M. pneumoniae-associated mucositis treated with levofloxacin and prednisolone. M. pneumoniae infection should be considered in all cases of mucositis, and treatment of this condition with levofloxacin and prednisolone seems to be effective.

A misplaced surgical towel - a rare cause of fever of unknown origin.

Retained surgical towels, usually called gossypiboma, are rare, but can cause important morbidity and mortality. Usually they are discovered during the first few days after surgery, but may remain undetected for many years. Bowel obstruction, perforation, pseudotumor or peritonitis are most often the clinical presentation, but in some cases only constitutional symptoms prevail. Diagnosis can be difficult, mostly because of low clinical suspicion. We report a case of a woman who presented with fever and weight loss three and half years after an abdominal surgery. After an extensive workup, a gossypiboma was finally discovered and removed, leading to a complete cure.