Coxiella Endocarditis as the Cause of Recurrent Fever and Brain Abscess in a Patient with Complex Congenital Heart Disease: A Case Report and Literature Review.

INTRODUCTION: Blood culture-negative infective endocarditis (BCNIE) can present subtly and is associated with a diagnostic delay leading to increased morbidity and mortality. Case Report. We present the case of an 18-year-old male with a history of complex congenital heart disease and 3-year intermittent episodes of fever of unknown origin, who was referred to our hospital for upper and lower extremity focal seizures. Laboratory blood tests were normal, blood cultures were negative, and brain imaging revealed an abscess. Cardiology consultation was requested, and transthoracic echocardiography revealed an intracardiac vegetation. Empiric antibiotic treatment with sultamicillin, gentamycin, and meropenem was initiated. Serology testing was positive for Coxiella burnetii, and the diagnosis of BCNIE was established. The antibiotic course was changed to oral doxycycline for 36 months and led to resolution of IE, with no vegetation detected on TTE after 15 months. CONCLUSION: BCNIE is a life-threatening disease entity that can lead to severe complications, such as valve regurgitation, emboli, and death. Patients with congenital heart disease are particularly vulnerable to IE. Timely diagnosis and antibiotic management are of paramount importance in order to avoid the potentially fatal sequelae.

Pyoderma gangrenosum in a patient with chronic granulomatous disease: A case report.

RATIONALE: The simultaneous occurrence of pyoderma gangrenosum (PG) and chronic granulomatous disease (CGD) is uncommon and few cases have been reported worldwide. PATIENT CONCERNS: PG is a rare, chronic, ulcerative, neutrophilic skin disease of unknown etiology that requires immunosuppressive treatment. CGD belongs to Primary Immune Deficiencies in which the main defect lies in an inability of the phagocytic cells to generate superoxide making patients susceptible to serious, potentially life-threatening bacterial and fungal infections. DIAGNOSES: In this manuscript, we present a case of ulcerative pyoderma gangrenosum in a 28-year-old man with recent diagnosis of chronic granulomatous disease during hospitalization for resistant pulmonary tuberculosis complicated with Aspergillus infection. INTERVENTIONS: Second-line therapy with dapsone and intravenous immunoglobulin was initially administered but eventually corticosteroids were added to treatment because of disease progression and further ulceration. OUTCOMES: Patient's ulcers were gradually healed with no side effects. LESSONS: Corticosteroids could be used under close monitoring for the treatment of PG in a patient with CGD, despite the increased risk for infections.

Patient With Severe Hyponatremia Caused by Adrenal Insufficiency Due to Ectopic Posterior Pituitary Lobe and Miscommunication Between Hypothalamus and Pituitary: A Case Report.

Hyponatremia may be one of the clinical manifestations of adrenal insufficiency (AI) and during the diagnostic workup of hyponatremic patients investigation of AI should be included.We report the case of an 82-year-old patient who was admitted to our hospital with clinical symptoms and laboratory findings of hyponatremia. Following the diagnostic algorithm of hyponatremia we reached the diagnosis of AI. Clinician's attention must focus on the underlying cause of AI which in this case was hidden in a miscommunication between hypothalamus and pituitary due to an ectopic posterior pituitary lobe and became apparent by a pituitary magnetic resonance imaging (MRI) scan. Treatment with oral hydrocortisone resulted in full clinical recovery and electrolyte balance, which was maintained after 7 months of follow-up.Secondary AI is related with hyponatremia through increased ADH secretion. Although a hyponatremic episode may be the first presentation of AI, clinical suspicion is of high importance in order to place the right diagnosis. Disruption of communication between hypothalamus and pituitary is a rare but considerable cause of AI.

Primary pyomyositis and disseminated septic pulmonary emboli: a reactivated staphylococcal infection?

Staphylococcal pyomyositis is a severe invasive soft tissue infection with high mortality rate that is increasingly being recognized even in temperate climates. In most cases predisposing factors are identified that include either source of skin penetration or/and impaired host immunocompetence. A case of primary, community-acquired pyomyositis of the left iliopsoas muscle in a 59-year-old immunecompetent woman, which was complicated with septic pulmonary emboli within 24 h after hospital admission, is presented. The patient was subjected to abscess drainage under computed tomography guidance. Both pus aspiration and blood cultures revealed methicillin-susceptible Staphylococcus aureus. Given the absolute absence of predisposing factors and a remote history of staphylococcal osteomyelitis in the same anatomical region 53 years ago, reactivation of a staphylococcal soft tissue infection was postulated. Systematic review of the literature revealed a few interesting cases of reactivated staphylococcal infection after decades of latency, although the exact pathophysiological mechanisms still need to be elucidated.

Primary pyomyositis and disseminated septic pulmonary emboli: a reactivated staphylococcal infection?

Staphylococcal pyomyositis is a severe invasive soft tissue infection with high mortality rate that is increasingly being recognized even in temperate climates. In most cases predisposing factors are identified that include either source of skin penetration or/and impaired host immunocompetence. A case of primary, community-acquired pyomyositis of the left iliopsoas muscle in a 59-year-old immunocompetent woman, which was complicated with septic pulmonary emboli within 24h after hospital admission, is presented. The patient was subjected to abscess drainage under computed tomography guidance. Both pus aspiration and blood cultures revealed methicillin-susceptible Staphylococcus aureus. Given the absolute absence of predisposing factors and a remote history of staphylococcal osteomyelitis in the same anatomical region 53 years ago, reactivation of a staphylococcal soft tissue infection was postulated. Systematic review of the literature revealed a few interesting cases of reactivated staphylococcal infection after decades of latency, although the exact pathophysiological mechanisms still need to be elucidated.

The adverse consequences of pyoderma gangrenosum in a 13 year old child.

INTRODUCTION: Pyoderma gangrenosum (PG) is an uncommon, but serious, non infectious, neutrophilic dermatosis that causes cutaneous necrosis with a characteristically rapid evolution. PRESENTATION OF CASE: A 13 year-old girl was admitted with a postoperative infected wound, which was surgically debrided. A new more aggressive lesion on the left upper extremity led the patient to the intensive care unit. Clinical diagnosis of pyoderma gangrenosum was introduced with a crucial delay. An immediate clinical improvement after immunosuppressive therapy with systemic corticosteroids and cyclosporine was observed. The extensive cutaneous deficits were covered with keratinocyte cultured cells with an aesthetically good outcome. DISCUSSION: Diagnosis of PG in young children is very difficult, especially without dermatological evaluation. This deforming ulcerative skin disease is probably a result of altered immunologic reactivity. Its early recognition may prevent unnecessary surgical treatment which leads to dangerous complications. CONCLUSION: To our knowledge this is the first case of PG with such a widespread distribution reported in a child, as a consequence of iatrogenic pathergy.

Penetration of moxifloxacin into sternal bone of patients undergoing routine cardiopulmonary bypass surgery.

This study investigated plasma and bone concentrations of moxifloxacin following a single intravenous dose of 400mg to consider its potential role in the treatment of osteomyelitis. Eight patients who underwent routine cardiopulmonary bypass surgery were enrolled in the study. Plasma and bone samples were collected 2h and 5h after the end of infusion. High performance liquid chromatography was used for the determination of moxifloxacin concentrations. Mean plasma concentrations were 3.36 microg/mL and 2.93 microg/mL at 2h and 5h after the end of infusion. The concentrations in the body and manubrium of the sternal bone were 1.65 microg/g and 1.64 microg/g at 2h and 1.4 microg/g and 1.45 microg/g at 5h, respectively. Moxifloxacin showed good penetration into bone and could be considered for the treatment of osteomyelitis.

Vancomycin-resistant enterococci, colonizing the intestinal tract of patients in a university hospital in greece

OBJECTIVE: Determine the prevalence of Vancomycin-resistant enterococci (VRE) colonizing the intestinal tract of hospitalized patients and define risk factors. MATERIAL AND METHODS: A point prevalence survey of VRE fecal carriage was carried out among patients who stayed at a 600-bed teaching hospital for at least two days. Resistance to vancomycin was detected by the E-test method. Epidemiological data was recorded for all patients included in the study and was used for the risk factor analysis. RESULTS: A total of 128 patients hospitalized for at least two days were enrolled in this investigation. Thirty-nine patients (30.5 percent) were colonized with vancomycin-resistant enterococci. Twenty-three of the 39 strains were identified as Enterococcus faecium, 13 were identified as Enterococcus gallinarum and three strains as Enterococcus casseliflavus. The risk factors that were significantly associated with VRE colonization included length of hospital stay (13.2 days vs. 8.6 days), age (60.7 years vs. 47.7 years) and the presence of underlying malignancies (28.2 percent vs. 11.2 percent). An association was found between VRE colonization and the use of antimicrobials with anaerobic activity, such as metronidazole, piperacillin/tazobactam and imipenem. The use of vancomycin was associated with VRE colonization in the intensive care unit. CONCLUSIONS: VRE colonization must be monitored, and risk factors should be determined, because they are useful for screening hospitalized patients for VRE colonization in order to establish prevention and control measures.

Vancomycin-resistant enterococci, colonizing the intestinal tract of patients in a university hospital in Greece.

OBJECTIVE: Determine the prevalence of Vancomycin-resistant enterococci (VRE) colonizing the intestinal tract of hospitalized patients and define risk factors. MATERIAL AND METHODS: A point prevalence survey of VRE fecal carriage was carried out among patients who stayed at a 600-bed teaching hospital for at least two days. Resistance to vancomycin was detected by the E-test method. Epidemiological data was recorded for all patients included in the study and was used for the risk factor analysis. RESULTS: A total of 128 patients hospitalized for at least two days were enrolled in this investigation. Thirty-nine patients (30.5%) were colonized with vancomycin-resistant enterococci. Twenty-three of the 39 strains were identified as Enterococcus faecium, 13 were identified as Enterococcus gallinarum and three strains as Enterococcus casseliflavus. The risk factors that were significantly associated with VRE colonization included length of hospital stay (13.2 days vs. 8.6 days), age (60.7 years vs. 47.7 years) and the presence of underlying malignancies (28.2% vs. 11.2%). An association was found between VRE colonization and the use of antimicrobials with anaerobic activity, such as metronidazole, piperacillin/tazobactam and imipenem. The use of vancomycin was associated with VRE colonization in the intensive care unit. CONCLUSIONS: VRE colonization must be monitored, and risk factors should be determined, because they are useful for screening hospitalized patients for VRE colonization in order to establish prevention and control measures.