RESUMO

We present the case of a 28-year-old man with a long-standing history of cocaine abuse and Child-Pugh class C alcoholic liver cirrhosis who developed severe lower respiratory tract infection complicated with septic shock and multiple organ dysfunction. He was managed in the intensive care unit. On the eighth day after admission, he developed a nose discolouration, which was initially thought to be associated with high-dose vasopressors. Despite the reduction of vasopressors, the lesion progressed rapidly. It was later diagnosed as rhinocerebral mucormycosis. Amphotericin B was administered, but unfortunately the patient succumbed to the complications postinfection. The association between alcoholic liver cirrhosis and rhinocerebral mucormycosis should be known and prompt recognition warrants immediate treatment.

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RESUMO

We evaluated the prevalence and the clinical relevance of bacterial and nonbacterial infections in predominantly alcoholic cirrhotic patients, admitted to an intermediate complexity hospital, and we also compared the clinical characteristics, laboratory and evolution of these patients with and without bacterial infection in a prospective study of cohort. A total of 211 consecutive admissions in 132 cirrhotic patients, between April 2004 and July 2007, were included. The mean age was 51.8 (+/-8) years, being 84.8% male. The alcoholic etiology of cirrhosis was present in 95.4%. One hundred and twenty nine episodes of bacterial infections were diagnosed in 99/211 (46.9%) admissions, community-acquired in 79 (61.2%) and hospital-acquired in 50 (38.8%): spontaneous bacterial peritonitis (23.3%); urinary tract infection (21.7%); pneumonia (17.8%); infection of the skin and soft parts (17.1%), sepsis by spontaneous bacteremia (7.7%); other bacterial infections (12.4%). Gram-positive organisms were responsible for 52.2% of total bacterial infections documented cases. There were eight serious cases of tuberculosis, fungal and parasitic infections; the prevalence of tuberculosis was 6% with an annual mortality of 62.5%; 28.1% (9/32) of the coproparasitological examination had Strongyloides stercolaris. The in-hospital mortality was significantly higher in patients with bacterial infection than in non-infected patients (32.4% vs. 13.2%; p=0.02). The independent factors associated with mortality were bacterial infections, the score of Child-Pügh and creatininemia > 1.5 mg/dl. By the multivariate analysis, leukocytosis and hepatic encephalopathy degree III/IV were independent factors associated to bacterial infection. This study confirms that bacterial and nonbacterial infections are a frequent and severe complication in hospitalized cirrhotic patients, with an increase of in-hospital mortality.

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Evaluamos la prevalecencia y relevancia clínica de las infecciones bacterianas y no bacterianas en pacientes cirróticos predominantemente alcohólicos internados en un hospital de mediana complejidad, y comparamos las características clínicas, de laboratorio y la evolución de pacientes con y sin infección bacteriana en un estudio prospectivo de cohorte. Se incluyeron 211 internaciones consecutivas de 132 pacientes con diagnóstico de cirrosis, de abril 2004 a julio 2007. El promedio de edad (±DS) fue 51.8 (±8) años, 112 fueron hombres (84.8%); etiología alcohólica 95.4%. Se diagnosticaron 129 episodios de infecciones bacterianas en 99/211 (46.9%) internaciones, adquiridos en la comunidad 79 (61.2%) y 50 (38.8%) intrahospitalarios: peritonitis bacteriana espontánea (23.3%); infección urinaria (21.7%); neumonías (17.8%); infecciones de piel y partes blandas (17.1%); sepsis por bacteriemia espontánea (7.7%); otras infecciones bacterianas (12.4%). El 52.2% fueron por gérmenes gram-positivos. Hubo ocho casos de tuberculosis e infecciones graves por hongos y parásitos. La prevalecencia de tuberculosis fue del 6% con una mortalidad anual de 62.5%. El 28.1% (9/32) de los exámenes coproparasitológicos tuvieron Strongyloides stercolaris. La mortalidad hospitalaria fue mayor en los pacientes con infección bacteriana (32.4% vs. 13.2%; p=0.02). Fueron identificados como predictores independientes de mortalidad: las infecciones bacterianas, el score de Child-Pügh y creatininemia > 1.5 mg/dl. En el análisis multivariado fueron factores independientes asociados a infección bacteriana la leucocitosis y la encefalopatía hepática grado III/IV. Este estudio confirma que las infecciones bacterianas y no bacterianas son una complicación frecuente y grave en pacientes cirróticos internados, con un aumento de la mortalidad hospitalaria.

We evaluated the prevalence and the clinical relevance of bacterial and nonbacterial infections in predominantly alcoholic cirrhotic patients, admitted to an intermediate complexity hospital, and we also compared the clinical characteristics, laboratory and evolution of these patients with and without bacterial infection in a prospective study of cohort. A total of 211 consecutive admissions in 132 cirrhotic patients, between April 2004 and July 2007, were included. The mean age was 51.8 (±8) years, being 84.8% male. The alcoholic etiology of cirrhosis was present in 95.4%. One hundred and twenty nine episodes of bacterial infections were diagnosed in 99/211 (46.9%) admissions, community- acquired in 79 (61.2%) and hospital-acquired in 50 (38.8%): spontaneous bacterial peritonitis (23.3%); urinary tract infection (21.7%); pneumonia (17.8%); infection of the skin and soft parts (17.1%), sepsis by spontaneous bacteremia (7.7%); other bacterial infections (12.4%). Gram-positive organisms were responsible for 52.2% of total bacterial infections documented cases. There were eight serious cases of tuberculosis, fungal and parasitic infections; the prevalence of tuberculosis was 6% with an annual mortality of 62.5%; 28.1% (9/32) of the coproparasitological examination had Strongyloides stercolaris. The in-hospital mortality was significantly higher in patients with bacterial infection than in non-infected patients (32.4% vs. 13.2%; p=0.02). The independent factors associated with mortality were bacterial infections, the score of Child-Pügh and creatininemia > 1.5 mg/dl. By the multivariate analysis, leukocytosis and hepatic encephalopathy degree III/IV were independent factors associated to bacterial infection. This study confirms that bacterial and nonbacterial infections are a frequent and severe complication in hospitalized cirrhotic patients, with an increase of in-hospital mortality.

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BACKGROUND: Small intestinal bacterial overgrowth generates endogenous ethanol production both in experimental animals and humans. Patients with cirrhosis have small intestinal bacterial overgrowth, but endogenous ethanol production has not been studied in them. AIM: To investigate endogenous ethanol production in patients with cirrhosis, altered intestinal motility and small intestinal bacterial overgrowth. PATIENTS AND METHODS: Eight patients with cirrhosis of different etiologies and altered gastrointestinal motility, consisting in changes in the migrating motor complex, were studied. All had also small intestinal bacterial overgrowth, measured by means of the H2 breath test with lactulose. Plasma ethanol levels were measured by gas liquid chromatography in fasting conditions and 120 min after a carbohydrate rich meal. RESULTS: In fasting conditions, no patient had endogenous ethanol production. Alter the meal, ethanol in concentrations of 11.3 and 8.2 mg/del were detected in two patients. Negligible amounts of ethanol were detected in 4 patients and two patients had undetectable alcohol levels. CONCLUSIONS: A low endogenous production of ethanol was demonstrated in six of eight patients with cirrhosis.

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RESUMO

BACKGROUND: Small intestinal bacterial overgrowth generates endogenous ethanol production both in experimental animals and humans. Patients with cirrhosis have small intestinal bacterial overgrowth, but endogenous ethanol production has not been studied in them. AIM: To investigate endogenous ethanol production in patients with cirrhosis, altered intestinal motility and small intestinal bacterial overgrowth. PATIENTS AND METHODS: Eight patients with cirrhosis of different etiologies and altered gastrointestinal motility, consisting in changes in the migrating motor complex, were studied. All had also small intestinal bacterial overgrowth, measured by means of the H2 breath test with lactulose. Plasma ethanol levels were measured by gas liquid chromatography in fasting conditions and 120 min after a carbohydrate rich meal. RESULTS: In fasting conditions, no patient had endogenous ethanol production. Alter the meal, ethanol in concentrations of 11.3 and 8.2 mg/del were detected in two patients. Negligible amounts of ethanol were detected in 4 patients and two patients had undetectable alcohol levels. CONCLUSIONS: A low endogenous production of ethanol was demonstrated in six of eight patients with cirrhosis.

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RESUMO

OBJECTIVE: Infections are regarded as a major complication and an important cause of death in cirrhotics. Alcohol is a predisposing factor to infections in such patients. This study was undertaken to compare the frequency and evolution of bacterial infection among alcoholic and nonalcoholic cirrhotics. METHODS: To observe this relationship, we retrospectively studied a cohort of 382 cirrhotic inpatients, 201 of whom were alcoholic (alcohol intake > or =80 g/day for > or =10 yr) and 181 of whom were nonalcoholic. RESULTS: A total of 128 (33.5%) patients presented with infection upon hospitalization, 78 of whom were alcoholic and 50 of whom were nonalcoholic (p = 0.02). A total of 157 cases of infection were diagnosed, with spontaneous bacterial peritonitis as the most prevalent one (54.1%), followed by pneumonia (18.5%), infection of the soft parts (10.8%), and urinary tract infection (7.0%). Infection and deaths were more frequent in patients with Child-Pugh C than in those with Child-Pugh A/B (p = 0.003, p = 0.0002 respectively). Alcoholic patients with Child-Pugh A/B were more susceptible to infection compared to nonalcoholic patients (p = 0.02), although no difference was noted as to the number of deaths (p = 0.1). With regard to patients with Child-Pugh C, no statistical difference was found in the infections or deaths among alcoholics and nonalcoholics (p = 0.8, p = 0.8). CONCLUSIONS: Our findings suggest that, despite the fact that bacterial infections are more common in cirrhotic alcoholics, its seems that the mortality rate is associated more with the severity than with the etiology of the hepatic disease.

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