The incidence of acute renal failure and high mortality rate in elderly patients hospitalized with community acquired pneumonia.

Community acquired pneumonia is associated with high mortality and health care costs, especially in old age. The clinical presentation of pneumonia in the elderly may be asymptomatic or atypical. One of the known complication is an acute kidney injury. The purpose of our study was to estimate the incidence of this complication in elderly patients hospitalized with pneumonia in our geriatric hospital. From a group of 180 elderly patients hospitalized with community-acquired pneumonia 34.4 % developed acute kidney injury. In this group, 51.6 % of patients died compared to 14.4 % in the group of patients without acute kidney injury (p < 0.001). The lower level of e-GFR was significantly associated with mortality (p < 0.001): out of seven patients with e-GFR level of 15-29 mg/mmol, five patients died (71.4 %). Elderly patients with community-acquired pneumonia suffering acute kidney injury experienced worse in-hospital outcomes; mortality rate was significantly higher in our study. We found a relationship between low level of e-GFR and mortality. Clinicians should be alert for early detection and prevention of kidney injury in patients admitted with pneumonia.

Closure of loop ileostomies: is early discharge safe and achievable?

A prospective audit of the complications associated with reversal of a loop ileostomy was carried out between March 2000 and March 2005. The complication rate, length of inpatient hospitalisation and re-admission rate were assessed in 100 patients, in a single clinical practice. The median (interquartile range) length of time between the primary procedure and closure was 133 days (120-270) days. Median length of inpatient stay was two days (one - three) days. The overall complication rate was 18%. One patient had a post-operative leak leading to local abscess formation. This was drained surgically after initial failure with radiological drainage. A second patient had a late leak, three weeks after closure, leading to fistula formation. This patient required surgical resection of the anastomosis after failure of conservative management. Twelve patients were re-admitted with small bowel obstruction (12%), of whom 11 were managed conservatively, while one underwent further surgery. There was one post- operative death as a result of acute cardiac failure secondary to undiagnosed hypertensive cardiomyopathy. Thus early discharge following closure of a loop ileostomy, can be achieved with an acceptably low serious complication rate.

The imaging appearances of hydatid disease at some unusual sites.

On reviewing our cases of hydatid disease seen over a period of 20 years (1978-1998), we encountered a number of unusual radiological appearances and sites, which are demonstrated in this pictorial review. We briefly discuss the pathology of hydatid disease and its complications.

Neurological complications of brucella spondylitis.

Twenty-two patients with brucella spondylitis and neurobrucellosis were studied during a 2-year period. The diagnosis was based on history of exposure, compatible signs and symptoms, high antibody titre and/or positive culture of a clinical specimen(s). Spondylitis was confirmed by plain radiographs, bone scan, CT and in some cases by histology. Neurobrucellosis was confirmed by CSF examination and culture, myelography, NCV, EMG and CT head. The spondylitis was early in 4 cases, chronic active in 12, smouldering "partially healed" in 3 and healed in 3 cases. Of these, 15 patients (68%) had neurological complications of various types. Plain radiographs were not a good index of activity of spondylitis. Tc99 bone scan was not specific and it remained positive long after the completion of therapy. CT was superior in revealing details of bone destruction, soft tissue swelling and entrapment of nerve roots and cord. The 3 modalities were complementary. Spondylitis is commonly associated with neurobrucellosis and symptoms of one may over shadow those of the other and in some cases neurobrucellosis may be subclinical. In all cases of spondylitis, a thorough search for neurobrucellosis should be made and vice versa. Prolonged treatment with a combination of 3 anti-brucella drugs is recommended and prolonged follow-up is necessary.

Brucellar sternoclavicular arthritis, the forgotten complication.

Of 511 cases of brucellosis studied between December 1983 and February 1986, four (0.8%) had sternoclavicular (STCL) arthritis. Two were male and two female, and only one was younger than 50 years old. All four cases had significantly high specific IgG antibody titres (1 of 1280), measured by the indirect immunofluorescent (IIF) test, and two had Brucella melitensis isolated from their blood. In two cases, STCL arthritis was the presenting problem, and it was associated in one with ankle arthritis, hepatitis, renal impairment, orogenital ulcers and a haematological picture of myelodysplasia; in the other it was a relapsing STCL arthritis. In the remaining two cases, STCL arthritis was part of an extensive osteoarticular disease, which was associated in one with cachexia, liver cirrhosis, heart failure and prostatitis with urine retention, and in the other with severe thrombocytopenia. Excellent results were obtained from six to eight weeks' therapy with streptomycin, rifampicin and cotrimoxazole or tetracycline.

Disseminated pelvic hydatidosis presenting as ovarian carcinomatosis: successful post-operative treatment with mebendazole.

The case of a female with disseminated pelvic cystic hydatidosis presenting as ovarian carcinomatosis 2.5 years after repeated abdominal paracentesis is reported. The diagnosis was made during surgery and confirmed by serology and histological examination. Over 100 cysts were removed from the abdominal cavity and wall. Innumerable small cysts studded the viscera; these and larger inaccessible ones were untouched. Medical cure in this patient was achieved with a combination of partial resection and special irrigation, broad spectrum antibiotic for coverage of infectious episodes and high dose long term mebendazole therapy for 25 months. The danger of blind aspiration in patients coming from endemic areas is emphasized.

The high rate of prevalence of CT-detected basal ganglia calcification in neuropsychiatric (CNS) brucellosis.

Of 65 cases presenting with neuropsychiatric manifestations of brucellosis (CNS-brucellosis), 9(13.8%) had CT-detected basal ganglia calcification (BGC). Of these, 5 had meningitis and 4 had psychiatric manifestations as presenting features. The diagnosis of brucellosis was made by the finding of consistent history and physical findings and the presence of significantly elevated antibody titres and/or positive culture in the blood and/or CSF. In all the cases, BGC was in the form of punctate hyperdense non-enhancing shadows with average density 44.5-58.4 and maximum density 49-64HU. The calcification was unilateral in 3 cases, bilateral and symmetrical in 4 and bilateral but asymmetrical in 2. None of the cases had other predisposing conditions to BGC and in one of the cases did specific anti-brucella treatment effect a detectable change in the BGC. The finding of CT-detected BGC in patients coming from areas endemic for brucellosis should alert physicians to the possibility of underlying brucellar infection.

Osteoarticular complications of brucellosis: a study of 169 cases.

Of 452 patients with brucellosis, 169 (111 male and 58 female) had osteoarticular complications. Brucella melitensis was isolated from the blood in 7.7% of the cases. Fever, chills, arthralgia, backache, high levels of C-reactive protein, positive rheumatoid factor, and splenomegaly were more frequent in osteoarticular brucellosis than in nonosteoarticular disease. Arthritis occurred in the hip joint in 90 cases (53%), knees in 61 (36%), sacroiliacs in 33 (20%), ankles in 25 (15%), elbows in nine (5.3%), shoulders in eight (5%), wrists in six (3.5%), and sternoclavicular arthritis occurred in three cases (1.8%). Spondylitis occurred in 10 cases (6%), osteomyelitis in four (2.4%), and tendinitis or bursitis in two (1.2%). Treatment with tetracycline or trimethoprim-sulfamethoxazole (TMP-SMZ) alone (four to eight weeks) or in combination with streptomycin (two to four weeks) resulted in a relapse rate of 16.6%. No relapses occurred in seven patients treated with repeated four- to six-weeks courses of rifampin plus tetracycline or TMP-SMZ plus streptomycin.

Human cystic hydatid disease: treatment with interrupted courses of mebendazole.

Ten patients suffering from intra-abdominal cystic hydatid disease, confirmed by serological tests and CT scan were treated with mebendazole. Each received 1800 mg day-1 either as a continuous therapy for 18 weeks, or as interrupted 6-week courses for a minimum of three courses, with intervals of 19-22 weeks between the courses. One patient dropped out of the study because of the development of jaundice 11 days after initiation of treatment. Nine patients were treated and followed up for the minimum of 20 months; of these, three patients received continuous therapy and six received interrupted therapy. One patient from the continuous therapy group showed progressive regression of his cyst, one showed minimal radiological changes only, while the third patient showed minimal radiological changes plus per-operative evidence of partial destruction of the cyst. Of those treated with interrupted therapy, one patient showed continuous progression in the size of the cyst with the appearance of a new cyst, although there was radiological and operative evidence of partial destruction of the cyst. One patient initially showed regression, but later progression of his cyst, while four patients showed no benefit from the treatment.

Brucella meningitis: presentation, diagnosis and treatment--a prospective study of ten cases.

Diagnosis of brucella meningitis was made in 10 patients by serological tests on blood and cerebrospinal fluid using Rose Bengal, standard agglutination, indirect immunofluorescent and enzyme-linked immunosorbent assay (ELISA) tests and by blood and CSF culture. All patients had significantly elevated antibody titres. In three Br. melitensis was isolated both from blood and CSF and in a further three from blood only. Eight patients were 30 years old or less and seven were female. Seven patients had a history of contact with livestock and had consumed raw milk. Meningitis occurred in five, meningoencephalitis with hemiplegia in one, paraplegia and cranial nerve palsies in one and psychosis and/or nightmares in three. Transient Parkinsonism was seen in one patient and generalized rigidity and non-Parkinsonian tremors in another. Computerized tomography revealed ventricular dilation in one patient and punctate hyperdense, non-enhancing shadows in the lentiform nuclei in two others. Treatment with a combination of tetracycline, rifampicin and streptomycin was successful.

Abdominal hydatid disease: follow-up of mebendazole therapy by CT and ultrasonography.

Computed tomography (CT) and Ultrasonography (US) were used for the diagnosis and follow-up of 10 cases of abdominal hydatid disease receiving treatment with Mebendazole because of a relative contraindication to surgery. With the exception of one case, the duration of follow-up varied from 20-36 months. There was an estimated 60% decrease in cyst size in one case, 10% decrease in another, unchanged in six (mostly calcified ones) and 60% increase in one case. CT density measurements of fluid content of the cysts increased in three cases accompanied by increased internal echoes on US in one case. The number and size of daughter cysts were reduced in one case and more calcification was noted in two cases. There was an overall slow and poor response to treatment and four cases eventually had surgery.