A rare cause of severe esophagitis in an immunocompetent patient - double complication with an endoscopic resolution.

A 75-year-old male, without relevant medical history and negative HIV1/2 serology, presented at the emergency department with mixed shock (septic - from pleuroparenchymal origin - and hypovolemic due to upper gastrointestinal bleeding [UGIB]). Thoracoabdominal CT scan showed an esophagopleural fistula (EPF), with a large right pleural effusion (lately known to be compatible with exudate - Light's criteria) and right pneumothorax, without active bleeding. The upper gastrointestinal endoscopy (UGIE) showed a severe esophagitis and, in distal oesophagus, an ulcer with an orifice in the center. Biopsies of the edges of the ulcer were performed. Anatomopathological (AP) studies were negative for viral agents but tissue molecular studies (polymerase chain reaction [PCR]) identified cytomegalovirus (CMV) DNA. Despite no immunosuppression condition was identified, CMV severe esophagitis complicated by EPF with right-side empyema and UGIB was diagnosed. An oesophageal fully covered metal stent (FCMS), with anti-migration system, was left in place during 5-weeks and ganciclovir therapy (5mg/kg/day) was maintained for 21-days. Clinical-analytical, radiological and endoscopic improvement was noticed. No recurrence in the following year of follow-up.

Risk factors for the emergence of multidrug-resistant organisms in liver cirrhosis / Factores de riesgo para la aparición de organismos multirresistentes en la cirrosis hepática

Background: Multidrug-resistant organisms (MDROs) are a reality that can alter the paradigm of treatment and prevention of infection in patients with liver cirrhosis (LC).ObjectiveIdentify risk factors for the occurrence of MDROs in patients with LC.Patients and methods: Prospective study from October 2017 to March 2018 in consecutively hospitalized patients with decompensated LC with infection. Blood, urine and ascitic fluid cultures were analyzed. A p-value ≤0.05 was considered statistically significant. Results: MDROs isolated in 18 of 52 episodes of infection. MDROs were associated with the use of proton pump inhibitors (PPIs) (p=0.0312), antibiotic therapy in the last 90 days (p=0.0033) and discharge within preceding 30 days or current hospitalization above 48h (p=0.0082). There was higher 90-day mortality in patients with MDROs infection (71.4% versus 35.7%, p=0.0316).Conclusion: MDROs infections were prevalent in this cohort and associated with 90-day mortality. Use of PPIs and antibiotics increased the risk of MDROs infections, suggesting that its prescription should be restricted to formal indication. Hospitalization was associated with the onset of MDROs, so LC patients should stay at the hospital the least possible. It is relevant to investigate other factors predisposing to the emergence of these microorganisms, in order to prevent it. (AU)

Antecedentes: Los organismos multirresistentes (MDROs, por sus siglas en inglés) son una realidad que puede alterar el paradigma del tratamiento y la prevención de la infección en los pacientes con cirrosis hepática (LC, por sus siglas en inglés).Objetivo: Identificar los factores de riesgo para la aparición de MDROs en pacientes con LC.Pacientes y métodos: Estudio prospectivo de octubre de 2017 a marzo de 2018 en pacientes hospitalizados consecutivamente con LC descompensada con infección. Se analizaron los cultivos de sangre, orina y líquido ascítico. Se consideró estadísticamente significativo un valor de p≤0,05.Resultados: Se aislaron MDROs en 18 de los 52 episodios de infección. Los MDROs se asociaron con el uso de inhibidores de la bomba de protones (IBP) (p=0,0312), la terapia antibiótica en los últimos 90 días (p=0,0033) y el alta en los 30 días anteriores o la hospitalización actual superior a 48h (p=0,0082). Hubo una mayor mortalidad a los 90 días en los pacientes con infección por MDROs (71,4 frente al 35,7%; p=0,0316).Conclusión: Las infecciones por MDROs fueron prevalentes en esta cohorte, y se asociaron con la mortalidad a los 90 días. El uso de IBP y antibióticos aumentó el riesgo de infecciones por MDROs, lo que sugiere que su prescripción debe restringirse a la indicación formal. La hospitalización se asoció a la aparición de MDROs, por lo que los pacientes con LC deberían permanecer en el hospital el menor tiempo posible. Es relevante investigar otros factores que predisponen a la aparición de estos microorganismos para prevenirla. (AU)

Gastrointestinal Tuberculosis Mimicking Crohn's Disease.

We present the case of a 24-year-old woman with complaints of abdominal pain, bloody diarrhea, and weight loss for 3 months. An outpatient colonoscopy revealed scattered ulcers, suggestive of Crohn's disease (CD). Histopathology also favored the diagnosis of CD. However, after admission to our hospital for further investigation, a chest radiograph revealed pulmonary cavitations. A computed tomography scan suggested the diagnosis of active pulmonary tuberculosis (TB). Therefore, a bronchofibroscopy, a total colonoscopy with ileoscopy, and an upper endoscopy were performed. Not only were acid-fast bacilli present in both bronchoalveolar lavage fluid and gastric juice, but also in colonic biopsies. A complete resolution of gastrointestinal symptoms was achieved 2 weeks after starting anti-TB drugs.

Apresentamos o caso de uma mulher de 24 anos com queixas de dor abdominal, diarreia sanguinolenta e perda ponderal com 3 meses de evolução. Uma colonoscopia de ambulatório revelou, de forma descontínua, úlceras sugestivas de doença de Crohn (DC). Também a histologia era sugestiva de DC. Contudo, após admissão no nosso hospital, uma radiografia de tórax evidenciou cavitações pulmonares. A tomografia computorizada sugeriu o diagnóstico de tuberculose (TB) pulmonar ativa. Por esse motivo, foram realizadas broncofibroscopia, endoscopia digestiva alta e colonoscopia total com ileoscopia. A pesquisa de bacilos ácido-álcool resistentes foi positiva não só no lavado broncoalveolar e no suco gástrico, mas também nas biópsias do cólon. Verificouse uma resolução completa das queixas gastrointestinais 2 semanas após iniciar antibacilares.