RESUMEN
A 58-year-old man was admitted to the hospital with acute neurological manifestations of encephalitis 15 days after a previous upper respiratory COVID-19 illness. On presentation, he was confused with altered mental status, aggressive behavior, and a Glasgow coma scale score of 10/15. Laboratory investigation, brain computed tomography (CT), and brain magnetic resonance imaging (MRI) were unremarkable with normal results. Although the cerebrospinal fluid (CSF) polymerase chain reaction (PCR) for SARS-CoV-2 was negative, we found increased concentrations of positive immunoglobulin (Ig) A and IgG antibodies in CSF, suggesting acute central nervous system (CNS) infection and indirect confirmation of virus neuroinvasion. There was no evidence of humoral auto-reactivity, and we rejected the hypothesis of autoimmune encephalitis with known autoantibodies. On the fifth day of hospitalization, myoclonic jerks emerged as a new neurological sign until the added levetiracetam led to total remission. The patient achieved full recovery after antiviral and corticosteroid therapy implementation of 10 days in the hospital. This case report emphasizes the importance of the presence of CSF IgA and IgG antibodies to diagnose encephalitis in COVID-19 patients as an indirect confirmation of CNS infection.
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INTRODUCTION: Osteomyelitis is a bone inflammation that can be related to various infectious agents. As with any other type of inflammation, the prevailing symptoms and signs may include redness, swelling, pain, and heat. Fungal osteomyelitis is rare and usually found in immune-compromised patients. CASE PRESENTATION: A non-human immunodeficiency virus immunocompromised Greek female patient, 82 years old, visited the emergency department due to a 3 day pain located mainly over the left tibia's anterior surface, accompanied by swelling and redness. There was also a subcutaneous lesion of her left breast. Medical history revealed that the patient had an unmasked close contact with pigeons, a main host of the disease. Initial x-ray imaging showed an osteolytic area in the upper third of the tibial diaphysis. The patient was admitted and underwent a computed tomography-guided biopsy. The specimen revealed a Cryptococcus neoformans infection of the bone and the breast. She was treated with 400 mg fluconazole twice a day for 3 weeks while in hospital and 200 mg twice a day upon discharge for 9 months. After that, she underwent surgical debridement because of lasting local irritation. She was closely monitored in our outpatient office, and in her last visit, 1 year after the initial admission, inflammatory signs had regressed vastly. CONCLUSIONS: To our knowledge, this is the ninth cryptococcal osteomyelitis of the tibia to be recorded since 1974, and the most unusual finding was the bifocal nature of the infection, affecting both the tibia and the breast.
Asunto(s)
Criptococosis , Cryptococcus neoformans , Osteomielitis , Femenino , Humanos , Tibia/diagnóstico por imagen , Criptococosis/diagnóstico por imagen , Criptococosis/tratamiento farmacológico , Fluconazol/uso terapéutico , Osteomielitis/diagnóstico por imagen , Osteomielitis/tratamiento farmacológico , Inflamación/complicacionesRESUMEN
VIM-1-producing Klebsiella pneumoniae (VPKP) is an emerging pathogen. A prospective observational study was conducted to evaluate the importance of VIM production on outcome of patients with K. pneumoniae bloodstream infections (BSIs). Consecutive patients with K. pneumoniae BSIs were identified and followed up until patient discharge or death. A total of 162 patients were included in the analysis; 67 (41.4%) were infected with VPKP, and 95 were infected with non-VPKP. Fourteen of the patients infected with VPKP were carbapenem resistant (Carb(r)) (MIC > 4 mug/ml), whereas none of the non-VPKP exhibited carbapenem resistance. The patients infected with a Carb(r) organism were more likely (odds ratio, 4.08; 95% confidence interval [CI], 1.29 to 12.85; P = 0.02) to receive inappropriate empirical therapy. The all-cause 14-day mortality rates were 15.8% (15 of 95) for patients infected with VIM-negative organisms, 18.9% (10 of 53) for those infected with VIM-positive carbapenem-susceptible organisms, and 42.9% (6 of 14) for those infected with VIM-positive Carb(r) organisms (P = 0.044). In Cox regression analysis, age (hazard ratio [HR], 1.03; 95% CI, 1.01 to 1.06; P = 0.021), rapidly fatal underlying disease (HR, 2.84; 95% CI, 1.26 to 6.39; P = 0.012), and carbapenem resistance (HR, 2.83; 95% CI, 1.08 to 7.41; P = 0.035) were independent predictors of death. After adjustment for inappropriate empirical or definitive therapy, the effect of carbapenem resistance on outcome was reduced to a level of nonsignificance. In patients with K. pneumoniae BSIs, carbapenem resistance, advanced, age, and severity of underlying disease were independent predictors of outcome, whereas VIM production had no effect on mortality. The higher mortality associated with carbapenem resistance was probably mediated by the failure to provide effective therapy.
Asunto(s)
Antibacterianos , Bacteriemia , Carbapenémicos , Infecciones por Klebsiella , Klebsiella pneumoniae/efectos de los fármacos , Klebsiella pneumoniae/enzimología , Resistencia betalactámica , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Bacteriemia/microbiología , Bacteriemia/mortalidad , Carbapenémicos/farmacología , Carbapenémicos/uso terapéutico , Femenino , Grecia/epidemiología , Humanos , Infecciones por Klebsiella/tratamiento farmacológico , Infecciones por Klebsiella/microbiología , Infecciones por Klebsiella/mortalidad , Klebsiella pneumoniae/genética , Klebsiella pneumoniae/aislamiento & purificación , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Estudios Prospectivos , Adulto Joven , beta-Lactamasas/genética , beta-Lactamasas/metabolismoRESUMEN
A patient who survived for 21 years since initial discovery of glucagonoma with concurrent liver metastases is described. Psychiatric symptoms, weight loss, necrolytic migratory erythema, diarrhea, and diabetes mellitus developed gradually after diagnosis of the tumor. No specific treatment was administered. The longevity of this patient may be related to the slow tumor growth expressed histologically by ischemic necrosis of the malignant cells and in imaging by extensive tumor calcifications, a very rare finding in this type of the tumor.