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This is a 20-year-old male patient, resident in the urban area of Medellín, student, who consulted for a spot on the right palm, asymptomatic, of two months of evolution, without previous treatment, with a single hyperpigmented macule, dark grey, without desquamation, measuring 2 cm x 1 cm, on physical examination. At dermoscopy, there was no pigment network.
With clinical suspicion of tinea nigra palmaris, the patient was sent to the Microbiology Service of the Clinical Laboratory of the Congregazione Mariana, where the scales were scraped for direct examination with 10% potassium hydroxide (KOH), which showed thick, septate, branched, olivaceous hyphae, some with hyaline endings, indicative of dematiaceous fungi.
Cultures were grown on Sabouraud agar with glucose and chloramphenicol and selective agar for dermatophyte growth, Mycosel agar, supplemented with 5% phenol red solution. Cultures were incubated at 28°C for 30 days. In the second week, the culture on Sabouraud agar showed growth of waxy black colonies without aerial mycelium, while on Mycosel agar, no growth was obtained. A new culture was made to better isolate the colonies, due to mould contamination on the lower part of the initial culture. From the initial culture, a direct examination with lactophenol blue was performed, in which the hyphae described above were observed.
In the case described, the patient presented to the specialist clinic with a dark spot on the right palm, with no other symptoms or apparent predisposing factors. Mycological examination identified H. werneckii as the causative agent of the infection. Tinea nigra is a dermatomycosis that usually affects the stratum corneum palmaris and is caused by Hortaea werneckii (formerly called Phaeoannellomyces werneckii and Exophiala werneckii).
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We present the case of an 11-year-old boy from Gambia who consulted for macroscopic haematuria predominantly at the end of micturition and dysuria of one year's duration; with no history of fever. On taking the medical history, the patient reported a recent trip to his country of origin and several baths in lakes in the region. Physical examination was unremarkable.
In view of the clinical suspicion of bilharzhiasis, the Microbiology Department of the referral hospital was contacted, where they indicated urine collection on three consecutive days, preferably at midday and at the end of urination (when egg excretion is at its peak) and a renovesical ultrasound examination was requested. The microbiological study showed Schistosoma haematobium eggs.
The bladder ultrasound revealed a parietal thickening that reached a maximum thickness of 9 mm in a radius of 20 mm, suggesting schistosomiasis, for which treatment with praziquantel was prescribed.
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A 59-year-old woman from China. No relevant medical history. She presented with fever and emesis of 10 days evolution. Last trip to China 1 year ago. No other epidemiological or exposure data of interest.
Laboratory alteration of the liver profile (Bilirubin 2.6 mg/dL and hypertransaminasemia). Isolation of Klebsiella pneumoniae bacteraemia in blood cultures. A diagnostic imaging study was completed with a CT scan, which showed an intrahepatic abscess (4x4x2cm) with thrombosis of the right suprahepatic vein. Unfavourable clinical evolution during the first few days, development of septic symptoms and respiratory failure, she was transferred to the Intensive Care Unit. Appearance of associated pleural empyema and enlargement of the abscess (6x6x3cm). Coverage with ceftriaxone and percutaneous drainage of the liver abscess was unsuccessful. Microbiological samples of the abscess isolated Enterococcus faecium and antibiotic coverage was increased with Vancomycin. After surgical drainage, the patient evolved favourably and was discharged with ciprofloxacin. She is currently being followed up in consultations and has recovered.
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"text": "patient",
"label": "HUMAN",
"start": 1004,
"end": 1011
},
{
"text": "bacteraemia",
"label": "SPECIES",
"start": 331,
"end": 342
}
] | en |
47-year-old male, resident of Cariari in Pococí de Limón. Carrier of type 2 diabetes mellitus, hypertension and chronic liver disease with Child Pugh B clinical stage, secondary to hepatitis B virus infection, with portal hypertension, oesophageal varices and hypersplenism.
The chronic treatment of this patient is tenofovir 300 mg vo per day, omeprazole 20 mg vo per day, propanolol 40 mg vo per day, folic acid 1 mg vo per day, lactulose 30 ml three times a day, spironolactone 100 mg per day and insulin glargine (lantus®) 40 units per day. Regarding his chronic liver disease, he has had no episodes of variceal bleeding and is stable with his last hepatitis B viral load <10 copies/mL; however, his diabetes is not adequately controlled and although he has no obvious target organ damage, he has suboptimal glycosylated haemoglobins, i.e. HbA1C > 7%. (12) The patient has no relevant epidemiological history except that he lives in a humid tropical region such as the province of Limón. This patient consulted for 5 months of dyspnoea at rest, productive cough and haemoptysis. Tuberculosis had previously been ruled out on an outpatient basis, and he consulted on this occasion due to exacerbation of his respiratory symptoms, fever and constitutional symptoms. He was admitted febrile, tachycardic, sweaty, normotensive, with adequate oxygen saturation, without clinical data of hepatic encephalopathy, with cardiopulmonary auscultation without pathological findings, soft abdomen without ascites. Chest X-ray showed an interstitial infiltrate. Laboratory tests on admission to the emergency department were as follows: Haemoglobin: 13.4 g/dl, Leukocytes 7900/uL, Bands 11 %, Platelets 56,000/uL , Creatinine: 0.68 mg/dl, BUN: 21 mg/dl, Glycaemia: 187mg/dl, HIV ELISA negative, HbA1C: 8.2 %,PT: 23 sec, INR: 2.03, PTT: 38 sec, ESR: 21mm3, CRP:11.1 mg/dl. Blood cultures are reported positive in both bottles taken from both upper limbs: 13 and 12 hours respectively, for Pasteurella multocida. Bronchoscopy was performed with bronchial aspirate culture positive for Streptococcus parasanguis and PCR negative for tuberculosis. The result of the biopsy showed undifferentiated lung cancer. The other laboratory tests obtained during his hospitalisation did not differ greatly from the initial ones noted above, although it should be noted here that the biomarkers improved in their entirety with the therapy given. In view of the patient's bacteraemia, he is specifically asked about contact with pets (cats or dogs), which he emphatically denies. However, there is a dog at home, but he insists that it is outside the house and that he has no direct contact with it.
The clinical management of this case was carried out empirically from the beginning with Cefotaxime at the usual doses of 2 g intravenous every 8 hours for 10 days; therefore, his clinical outcome was adequate in this hospitalisation, and the patient was discharged with subsequent monitoring in oncology and gastroenterology.
MICROBIOLOGY
Two bottles of blood culture were received in the laboratory from this patient and were positive after 12 and 13 hours of incubation in automated equipment (Bact/Alert, bioMérieux, Marcy l "Étoile, France). Gram staining showed gram-negative coccobacilli. Subcultures were subcultured from each flask on Columbia Medium with 5% ram's blood and Chocolate Agar (bioMérieux, Marcyl "Étoile, France). They were incubated in 5% CO2 atmosphere at 37 °C for 24 hours, resulting in the growth of small, non-hemolytic, greyish smooth colonies corresponding to a gram-negative, catalase-positive, oxidase-positive coccobacillus. Identification on Vitek 2 Compact GN card (bioMérieux , Marcyl "Étoile, France) was Pasteurella multocida with 95% probability in both isolates. The antibiotic sensitivity test on AST279 card (bioMérieux) is reported sensitive for Betalactams, third generation Cephalosporins, Carbapenemics, Ciprofloxacin, and Trimethoprim-Sulfamethoxazole, intermediate sensitivity for Gentamicin and resistant for Amikacin. Sensitivity to macrolides was not performed.
| [
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This is a male newborn with a perinatal history of euthecological delivery, gestational age 40 weeks, Apgar 9/9 stitches, Apgar 9/9 stitches. 2 weeks, Apgar 9/9 points and a weight of 3640 grams, who was discharged from the puerperium service at 72 hours of life and at 12 days of age is received in the Neonatology service, referred from the health area of Sandino for presenting fever of 39oC, somnolence, irritability, signs of respiratory difficulty, pallor, distal cyanosis, with a toxic-infectious aspect, tachycardia and signs of tissue hypoperfusion.
Physical examination also revealed an increase in volume of the right breast accompanied by flushing, warmth and pain on palpation; this increase in volume extended towards the posterior region of the thorax. The formation of haemorrhagic bullae, which converge in skin crepitus that rapidly progresses to a purplish-blue colouring in the form of patches, is striking.
Laboratory tests showed: haemoglobin: 12.6 mg/dl, leucocytes 13,500/mm3, PMN 48% with presence of toxic granulations in the periphery and Oski index of 0.25, platelets 100. 000/mm3, blood gas with hypochloremic metabolic acidosis with correction criteria; CSF cytochemistry normal, glycaemia 3.6 mmol/l, chest X-ray showed diffuse reticulogranular images with outline of air bronchogram.
The patient was supported on transfer to the intensive care unit with parenteral hydration according to the baby's needs, volume replacement (isotonic saline solution), inotropics (dopamine, dobutrex) and started with broad spectrum antimicrobial therapy, 3rd generation cephalosporin (cefotaxime) at 100 mg/kg/day in combination with vancomycin.
Given the rapid evolution of the clinical picture, as well as its aggressiveness, multidisciplinary consultation with Paediatric Surgery and Caumatology was requested and it was decided to perform immediate and aggressive surgical treatment, which consisted of resection with extensive and complete debridement of all affected tissues, as well as exploration with resection of necrotic tissues, placing drains in purulent collections and taking samples of secretions and blood for microbiological studies; This tissue resection was carried out without aesthetic considerations, trying to preserve the patient's life, based on the criterion that these procedures are the key to survival in these newborns.
The clinical evolution in the operating room was evaluated jointly by the Neonatology, Surgery and Caumatology services and the conduct to be followed was based on the management of nutrition, infection control, signs of shock and ventilatory mechanics, it being necessary to take him to the operating room on several occasions to evaluate new debridements over a period of 24-36 hours until no infected or necrotic tissues were observed that could affect the evolution and prognosis of this neonate.
The characteristics of the wound and the deep bed were evaluated daily by the medical staff in order to determine the appropriate time to perform a complete solution of the process. Streptococcus pyogenes was isolated in the blood culture and coagulase-positive staphylococcus in the purulent secretions, so changes in therapy were made by replacing cefotaxime with meronem at a dose of 20mg/kg/dose and vancomycin coverage was maintained, achieving control of the septic process. At one month of age, it was decided to perform a homologous graft (skin taken from the mother). He evolved favourably with a successful outcome as if it had been an autologous skin graft.
He was discharged after a 3-month stay in the neonatal medical intensive care unit (NICU) with a complete recovery and no evidence of organ damage.
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Anamnesis
No family history of note.
Personal history: no known drug allergies. No toxic habits.
Dyslipidaemia. Stage V chronic kidney disease secondary to juvenile polycystic kidney disease. He started renal replacement therapy in 1991. First kidney transplant from a related living donor (mother) on 16/4/1991, and started dialysis for chronic graft nephropathy in March 2009. Septic shock of biliary origin due to BGN requiring admission to the ICU in September 2010. After imaging tests, the patient was diagnosed with Caroli's disease and chronic pancreatitis, presenting with recurrent cholangitis, which necessitated the placement of a biliary plastic prosthesis. He was also diagnosed with chronic liver disease with portal HT with ascites, splenomegaly and grade I oesophageal varices. Hepatorenal transplant on 2/9/2011, which required quadruple immunosuppression with thymoglobulin + prednisone + mycophenolate + tacrolimus. Calorie-protein malnutrition. Emergency surgery in May 2012 for incarcerated hernia. Currently maintains baseline renal function with creatinine around 2.1-2.5 mg/dl (ClCr 35-45 ml/min). Good liver function, although he has recurrent ascites that has required repeated evacuation paracenteisis.
Oncological history: in June 2013 he presented with a painful lesion on the right shoulder and, after excision on 5/9/2013, he was diagnosed by PA as a well-differentiated infiltrating squamous cell carcinoma, which required a second surgical intervention on 12/12/2013 to enlarge the edges.
Postoperatively, he noticed a homolateral axillary nodule, for which an ultrasound and CT scan were performed, suggesting its probable metastatic origin; furthermore, a biopsy was performed, which was inconclusive. After presenting the case to the Multidisciplinary Committee, axillary lymph node removal was decided. Finally, the AP diagnosis was metastasis of squamous cell carcinoma, with images of tumour vascular invasion and extension to adjacent soft tissues, in 14/17 isolated lymph nodes.
Reason for consultation: referred to our centre for evaluation of specific treatment.
Physical examination
ECOG 0. Acceptable general condition. Weight 60 kg, height 170 cm. Multiple verrucous lesions all over the body, especially on the back. Most painful lesion on the chest with pustule due to rubbing.
Oedematous area in the lymphadenectomy scar in the right axilla, with a small nodule in the central area. Cardiopulmonary auscultation without findings. Abdomen slightly distended, dull to percussion. Limbs without findings.
Complementary tests
"CBC: Cr 2.1 mg/dl. CBC: Hb 12.6 g/dl, leukocytes and neutrophils in range, platelets 110,000.
"Chest CT scan with IV contrast (28/4/2014): extension study of squamous cell carcinoma. There are several malignant lymph nodes in the right axilla. Appearance of a single pulmonary nodule with polylobulated borders with a maximum diameter of 10 mm in the LSD, suggesting a metastatic nodule, and a lymph node with a necrotic centre in the left lower bronchopulmonary lymph node chain, probably metastatic. Areas of infectious bronchiolitis in both lung bases.
Free ascites.
Diagnosis
Advanced squamous cell carcinoma (second axillary lymph node relapse and pulmonary nodule).
Treatment
The patient underwent chemotherapy treatment according to the carboplatin + 5-FU scheme for two cycles: first cycle on 12/5/2014 and second cycle with 80% reduction due to neutropenia on 16/6/2014.
Local radiotherapy at the level of the right axilla between 2 September and 28 October 2014, receiving a total of 39 Gy in 13 sessions. Treatment had to be interrupted due to local infection.
Evolution
The administration of the treatment was complex, requiring several interruptions due to neutropenia, including a 20% reduction in the second cycle of chemotherapy. Other toxicities presented by the chemotherapy were grade 1 nausea and grade 3 asthenia. In July 2014, the patient was admitted to the ICU for septic shock of urinary origin due to Escherichia coli, with progressive recovery during admission until discharge. He received radiotherapy between September and October 2014, and it was necessary to perform a parenchymal repair due to local infection, which resolved after antibiotic treatment.
A re-evaluation CT scan was performed on 15/12/2015: intervened axillary lesion, in which lymphadenopathy and soft tissue mass persisted, although with an evident decrease in the size of all the lesions. Lung nodule in the LSD decreased in size (7 mm maximum diameter). Good evolution of the previously existing pleuropulmonary pathology. Partial response.
At this point it was decided to follow up due to the lack of progression.
The follow-up CT scan was repeated on 27/4/2015: a significant decrease in the size of the right axillary lymph node involvement was observed. Moderate reduction of the LSD nodule (5 mm maximum diameter). Stability of the centrolobulillary bronchiolitic lesions.
The patient is currently doing well, and it has been decided to follow him up quarterly with imaging tests.
| [
"Anamnesis",
"No",
"family",
"history",
"of",
"note",
".",
"Personal",
"history",
":",
"no",
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"drug",
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".",
"No",
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".",
"Dyslipidaemia",
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"Stage",
"V",
"chronic",
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".",
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".",
"First",
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"transplant",
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"a",
"related",
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"(",
"mother",
")",
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"16",
"/",
"4",
"/",
"1991",
",",
"and",
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"Septic",
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"BGN",
"requiring",
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"After",
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",",
"the",
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"'",
"s",
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",",
"presenting",
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",",
"which",
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"a",
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".",
"He",
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"also",
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"chronic",
"liver",
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"with",
"portal",
"HT",
"with",
"ascites",
",",
"splenomegaly",
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"I",
"oesophageal",
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".",
"Hepatorenal",
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"2",
"/",
"9",
"/",
"2011",
",",
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"with",
"thymoglobulin",
"+",
"prednisone",
"+",
"mycophenolate",
"+",
"tacrolimus",
".",
"Calorie-protein",
"malnutrition",
".",
"Emergency",
"surgery",
"in",
"May",
"2012",
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".",
"Currently",
"maintains",
"baseline",
"renal",
"function",
"with",
"creatinine",
"around",
"2",
".",
"1-2",
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"5",
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"/",
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"(",
"ClCr",
"35-45",
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"/",
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".",
"Good",
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",",
"although",
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"Oncological",
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"in",
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",",
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"/",
"12",
"/",
"2013",
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",",
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",",
"in",
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"/",
"17",
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"Reason",
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":",
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"Multiple",
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"Abdomen",
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",",
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"Complementary",
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"\"",
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":",
"Cr",
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"1",
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"/",
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"CBC",
":",
"Hb",
"12",
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"6",
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"/",
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",",
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",",
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"4",
"/",
"2014",
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":",
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"right",
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"Appearance",
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"Free",
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"Diagnosis",
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"+",
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":",
"first",
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"/",
"5",
"/",
"2014",
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"/",
"6",
"/",
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",",
"receiving",
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"Gy",
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".",
"Treatment",
"had",
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"Evolution",
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",",
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",",
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"1",
"nausea",
"and",
"grade",
"3",
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".",
"In",
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"2014",
",",
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",",
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",",
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",",
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"/",
"12",
"/",
"2015",
":",
"intervened",
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"scan",
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"27",
"/",
"4",
"/",
"2015",
":",
"a",
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")",
".",
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",",
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"."
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A 67-year-old man was admitted with fever, cough, nasal congestion, sore throat and diarrhoea, 20 months after an uncomplicated heart transplant. He was not hypoxic.
A chest CT scan showed peripheral, multifocal, bilateral ground-glass opacities. The white blood cell count was 4720/ml, with a lymphocyte count of 1040/ml. Blood cultures and PCR for cytomegalovirus were unremarkable. The C-reactive protein value was 0.55 mg/dl. A nasopharyngeal swab PCR for SARS-CoV-2 was positive, consistent with COVID-19 disease.
The immunosuppression regimen consisted of 500 mg mycophenolate twice daily and tacrolimus at a minimum concentration of 7.6 ng/ml on admission. Mycophenolate was withdrawn and tacrolimus was maintained at a target concentration of 7-10 ng/ml. The patient continued to have intermittent fever but never experienced hypoxia. A chest CT scan on day 6 showed worsening ground-glass opacities. On day 7 a course of hydroxychloroquine was started (400 mg twice daily on the first day, then 200 mg twice daily for 4 days). He was discharged on day 9.
He was admitted again after two days, with disorientation, anorexia and vomiting. He was conscious, oriented only to people and febrile. He had no history of confusional delirium or encephalopathy and was under treatment with venlafaxine for depression. Examination revealed intention and postural tremor, with no focal neurological deficits. The C-reactive protein value was high at 10.7 mg/dl, and there was a slight elevation of aspartate aminotransferase and alanine aminotransferase at 74 U/litre and 79 U/litre, respectively. Serum ammonia and TSH were normal. Serum sodium was low at 133 milliequivalents/litre (normal range: 135-145 milliequivalents/litre), but returned to normal on day 2 of readmission. Urea nitrogen and serum creatinine were 42 mg/dl and 1.73 mg/dl, respectively, unchanged from baseline. The tacrolimus trough concentration at readmission was 11.5 ng/ml, averaged at 10 § 1.2 ng/ml during admission. Hydroxychloroquine was withdrawn.
A cranial CT scan yielded no relevant findings. A thoracic CT scan showed minimal worsening of ground-glass opacities. A brain MRI showed mild scattered foci of subcortical and deep periventricular white matter ischaemia. There was no evidence of encephalitis, posterior reversible encephalopathy or leukoencephalopathy. A new MRI one week later showed no changes. An electroencephalogram revealed mild diffuse and non-specific multifocal brain alterations, with no evidence of seizures. A lumbar puncture showed normal values for lymphocytes, protein and glucose. Cerebrospinal fluid analysis was negative for herpes simplex PCR and cryptococcal antigens. CSF PCR, not validated for SARS-CoV-2, was negative. On day 16, C-reactive protein values started to decrease. Mental status slowly improved and the patient was discharged 13 days after readmission. Intentional function and memory remained poor, but gradually recovered to normal about 45 days after the onset of encephalopathy.
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A 75-year-old man presented with fever, chills and productive cough on 19 March 2020. His cardiovascular risk factors were hypertension, obesity, ex-smoking and renal failure. A test for severe acute respiratory distress syndrome due to coronavirus 2 was positive, and home quarantine was advised; however, worsening dyspnoea required hospitalisation.
In addition to cough, fever (38.7°C) and low oxygen saturation (88% without oxygen), laboratory tests showed elevated C-reactive protein (82 mg/m), myoglobin (636 mg/l), troponin T (ultrasensitive, 80 ng/l) and N-terminal prohormone of brain natriuretic peptide (833 ng/l).
Electrocardiogram revealed left anterior fascicular block and T-wave inversion in lead aVL.
Tests for other viruses (adenovirus; Coronaviridae 229E, HKU1, NL63, OC43; human bocavirus; metaneumovirus; rhinovirus/enterovirus; parainfluenza 1-4) were negative. Severe acute respiratory distress syndrome due to coronavirus 2 was reconfirmed in the laboratory. As troponin was increasing (191 ng/l), coronary angiography was performed on 23 March 2020, which ruled out epicardial stenosis, but left ventricular (LV) end-diastolic filling pressure was high at 14 mmHg.
An echocardiogram performed on the same day revealed normal LV and RV activity, with signs of concentric LV remodelling and no wall motion abnormalities. On 24 March 2020, a cardiac MRI was performed to evaluate possible inflammatory myocardial injury. Because of dyspnoea, the cardiac MRI (Philips 1.5 Tesla) was performed in free breathing using mainly single-take sequences. Normal LV and RV activity was observed, with no regional wall motion abnormalities. No focal fibrosis was detected with late gadolinium enhancement sequences. T2-weighted images showed global oedema as well as elevated T2 (56 ms, reference 48 § 3 ms) and T1 (1090 ms, reference 989 § 28 ms) values, suggesting acute myocardial injury. On 26 March 2020, an episode of hypoxaemic respiratory failure (saturation 80%) required mechanical ventilation.
The patient improved and was extubated; cardiac biomarker values decreased (N-terminal prohormone brain natriuretic peptide 631 ng/l, troponin 61 ng/l) progressively.
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A 54-year-old male smoker with a history of obesity, dyslipidaemia, ischaemic heart disease and intermittent claudication. He underwent vascular surgery and underwent right ilio-femoral bypass, with placement of a dacron vascular prosthesis due to critical stenosis of the iliac artery. In the immediate postoperative period he presented fever accompanied by erythema, oedema and sero-purulent exudate through the surgical wound. The patient had leukocytosis (12600/mm3) and elevated CRP (425 mg/L). Blood cultures were negative. An emergency CT scan was performed 24 hours after the operation, showing a liquid and gas collection in the abdominal wall near the implanted prosthesis, which could correspond to post-surgical changes. A culture of the exudate from the surgical wound isolated methicillin-sensitive Staphylococcus aureus. Suspecting a deep infection of the surgical wound, treatment was started with cloxacillin 2g intravenous every 6 hours for two weeks, changing at discharge to levofloxacin 750 mg/24h orally, completing a further two weeks of treatment. Symptoms progressed well and fever disappeared.
Differential diagnosis
The appearance of a sero-purulent exudate through a surgical wound raises the differential diagnosis between several entities. On the one hand, the possibility of a non-infectious process such as post-surgical serous exudate, which can occur in certain cases, should always be taken into account. The fact that the patient presented with fever, elevated acute phase reactants and isolation of S. aureus in the exudate leads us to believe that it was a surgical site infection. However, the CT findings of a periprosthetic collection of non-significant size (< 5mm) and high density (>20 U Housfield) could be justified by surgery-related changes. Assuming infection is present, we must differentiate whether it is a superficial, deep or intracavitary infection as the treatment and severity may be very different. It is difficult to differentiate between these 3 entities as all of them may produce local or systemic symptoms and purulent discharge with or without isolation of microorganisms. Among the most frequent microorganisms isolated in infections after vascular surgery are S. aureus (20-53%), enterobacteria (14-41%) and coagulase-negative S. aureus (15%). Other microorganisms such as Streptococcus spp., non-fermenting gram-negative bacilli or enterococci (10%-15%) must be taken into account. We can also find polymicrobial infections (20%), purely anaerobic (5%) or fungal infections (1-2%)1. We cannot forget about multi-resistant microorganisms such as BLEE-producing enterobacteria or methicillin-resistant S. aureus that affect patients with specific risk factors.
Evolution
One month later he was readmitted for fever and pain in the surgical area, with neutrophilia (16,000/mm3) and elevated CRP (308 mg/L). Blood cultures isolated methicillin-sensitive S. aureus. A new CT scan showed a pseudo-anuerysm at the anastomosis of the prosthesis with the distal arterial artery and a collection around the prosthesis. Abdominal-pelvic c/c CT scan: pseudoaneurysm at the anastomosis of the prosthesis. 3D vascular image by CT reconstruction showing pseudoaneurysm in the distal vascular anastomosis. The patient was re-intervened in the emergency department and underwent surgical debridement, drainage, resection of the pseudoaneurysm and the distal segment of the vascular prosthesis, and intraoperative cultures were taken, which were negative. The postoperative evolution of the wound was torpid, healing by second intention, using local dressings and a vacuum system. In view of the suspected infection of the prosthesis and the presence of potentially complicated bacteraemia due to S. aureus, antibiotic treatment was started with cloxacillin 2g every 4 hours for two weeks, with negative control blood cultures. He subsequently completed treatment with levofloxacin 750 mg and rifampicin 600 mg orally every 24 hours for 4 months on an outpatient basis. During follow-up she presented with a fistulous wound orifice, with intermittent drainage of purulent and serohaematic material. With suspicion of persistent infection of the unresected prosthesis segment, a scintigraphy with labelled leukocytes and SPECT-CT was performed, showing radiotracer uptake in the proximal segment of the recently implanted ilio-femoral prosthesis. SPECT-CT: radiotracer uptake in the proximal segment of the ilio-femoral prosthesis.
For this reason, a new operation was necessary in which all the prosthetic material was removed. Escherichia coli was isolated from the culture. The patient completed treatment with ceftriaxone 1g/24h for 7 days followed by ceftibutene 400mg/24h orally for a further week. Since then the patient remained asymptomatic, to date.
Final diagnosis
Early deep surgical wound infection with S. aureus and late vascular prosthesis infection with E. coli.
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Anamnesis
A 38-year-old woman, 19 weeks pregnant, came to the Emergency Department after suffering two episodes of generalised tonic-clonic seizures during sleep, with an interval of 15 minutes between them. She had no personal or family history of interest, except for gestational diabetes, generalised seizures in one of her previous pregnancies and headache. She had not received treatment nor had she undergone a study. She also had no personal or family history of repeated miscarriages or previous vascular pathology, cranioencephalic trauma, central nervous system infections or other predisposing factors.
Physical examination
The neurological examination showed only mild bradypsychia, with no other pathological findings, and after being seen by the gynaecology department, which found no evidence of gestational problems, she was admitted to the neurology ward.
Complementary tests
- Electrocardiogram and chest X-ray: no pathological alterations of interest.
- Blood count: haemoglobin 11 mg/dl, rest normal.
- Coagulation and complete biochemistry, including calcium and magnesium, thyroid hormones, liver profile, lipid profile: normal.
- Electroencephalogram (EEG): reported as "left hemispheric delta focus radiating contralaterally".
- Magnetic resonance imaging (MRI) of the brain: multiple hyperintense lesions were observed in the white matter of both hemispheres in periventricular location, semioval centres, subcortical, basal grey nuclei, especially the left lenticular, all suggestive of ischaemic aetiology of vasculitic origin.
- Echocardiogram: prolapse of the anterior leaflet of the mitral valve with mild insufficiency, with no other findings.
- Electromyogram: normal.
- Multimodal evoked potentials: no alterations.
- Iron profile: iron 117 μg/ml, transferrin 317 mg/dl, transferrin saturation 26.4% and ferritin 21 μg/ml.
- Erythrocyte sedimentation rate: 14 mm.
- Cerebrospinal fluid, anticardiolipin antibodies, lupus anticoagulant antibodies, rheumatoid factor, complement C3 and C4, ANCA, ACE, ANA, anti-DNA, SS-A, SS-B, immunoglobulins and proteinogram: normal.
- Serology (lues, Brucella, HIV 1 and 2, Borrellia burgdorferi) and neurotropic virus serology: no pathological alterations.
Treatment and evolution
Based on the aforementioned clinical and laboratory data, the case was diagnosed as isolated central nervous system vasculitis (CNSV). Angiographic study was contraindicated due to gestation and she had remained asymptomatic from the neurological point of view since admission, so it was decided to maintain a watchful waiting attitude, starting treatment with carbamazepine at a dose of 200 mg/8 h together with iron and oral folic acid. At 36 weeks' gestation, the baby was delivered euthecdotally and without incident. After eleven months asymptomatic and with good seizure control, she returned to the emergency department with low reactivity, slurred speech and decreased strength in the right side of the body. Her only symptom in the previous days was headache, with no other focal or associated symptoms. The systemic examination was normal. The neurological examination showed motor aphasia, right central facial paresis, right hemiparesis (muscle balance 4/5 overall in the right upper limb and right lower limb), right haemihypoaesthesia, right extensor flexor skin-plantar reflex and left flexor, with the rest of the examination being normal. Electrocardiogram, chest X-ray and laboratory tests (including carbamazepine levels) were normal. An urgent brain CT scan was performed, showing an acute hypodense lesion in the left basal ganglia. At that time there was no possibility of endovascular therapy and with the diagnosis of ischaemic stroke in the territory of the left middle cerebral artery, in the context of a probable NCAV, treatment was started with high-dose corticosteroids (1000 mg methylprednisolone/24 h), antiplatelet therapy with acetylsalicylic acid 300 mg, gastric protection with omeprazole and deep vein thrombosis prophylaxis with low molecular weight heparin at a dose of 40 subcutaneous units. The patient was left on bed rest and absolute diet, except for medication, and continued treatment with carbamazepine at the previous doses. She was treated with corticosteroid boluses for 5 days, with good tolerance, and subsequently started oral therapy and treatment with calcium and calcitriol 0.25 μg on Tuesdays and Fridays. Further laboratory tests (haemoglobin, erythrocyte sedimentation rate, complete biochemistry, urine sediment, proteinogram, immunoglobulins, rheumatoid factor, ANA and anti-DNA, ANCA, anticardiolipin antibodies, ACE, anti-SSa and anti-SSB antibodies) were performed, which were normal. A new cranial magnetic resonance imaging (MRI), echocardiogram (transthoracic, similar to the previous one, and transesophageal, which was not tolerated) and cerebral angiography were also requested. Cranial MRI showed an area of acute infarction in the left basal nuclei and multiple periventricular and subcortical lesions similar to the previous cranial MRI. Ischaemic infarction in the left basal ganglia. Multiple hyperintense lesions in the white matter of both hemispheres of periventricular location, semioval centres, subcortical, basal grey nuclei, especially the left lenticular, all suggestive of ischaemic aetiology of vasculitic origin.
Angiography showed a saciform aneurysm in the cavernous tract of the left carotid siphon (immediately infraophthalmic, with an approximate size of 5-6 mm in diameter of the sac by 2.5 mm neck) and an obstruction in the horizontal portion of the left middle cerebral artery, with obstruction of several sylvian branches filled by collateral circulation. Saciform aneurysm in the cavernous tract of the left carotid siphon. Embolised aneurysm.
Days later, the aneurysm was embolised by microcatheterisation, placing two platinum coils inside the aneurysm with satisfactory closure. The aneurysm was completely obstructed and the patient was admitted to the ward 24 hours later. Fifteen days after admission, a mild speech disorder persisted, with mild dysarthria. There was no facial paresis and muscle balance was normal, with preserved sensation and no other associated deficits.
Ten years after the initial diagnosis, she had been admitted sporadically for seizures and status epilepticus, always in the context of poor compliance with treatment. In the last admission, also for the same cause, the Mini-mental State Examination showed a score of 21/30, with a pathological Clock Test. She presented moderate cognitive impairment, mainly at the expense of calculation, concentration, reading, writing and praxis, with no other associated neurological focality. He has never presented outbreaks of systemic vasculitis. Currently, she continues to be treated with carbamazepine 200 mg/8 h, valproic acid 500-0-1,000, omeprazole 20 mg and acetylsalicylic acid 300 mg. She continues to be followed up in Neurology outpatient clinics.
Diagnosis
- Epilepsy with generalised seizures and moderate cognitive impairment secondary to isolated central nervous system (CNS) vasculitis.
- Ischaemic stroke in the left N. lenticularis secondary to arterio-arterial embolism due to aneurysm in the left carotid siphon in its intracavernous trajectory.
- Endovascular treatment of left carotid aneurysm.
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"delta",
"focus",
"radiating",
"contralaterally",
"\"",
".",
"-",
"Magnetic",
"resonance",
"imaging",
"(",
"MRI",
")",
"of",
"the",
"brain",
":",
"multiple",
"hyperintense",
"lesions",
"were",
"observed",
"in",
"the",
"white",
"matter",
"of",
"both",
"hemispheres",
"in",
"periventricular",
"location",
",",
"semioval",
"centres",
",",
"subcortical",
",",
"basal",
"grey",
"nuclei",
",",
"especially",
"the",
"left",
"lenticular",
",",
"all",
"suggestive",
"of",
"ischaemic",
"aetiology",
"of",
"vasculitic",
"origin",
".",
"-",
"Echocardiogram",
":",
"prolapse",
"of",
"the",
"anterior",
"leaflet",
"of",
"the",
"mitral",
"valve",
"with",
"mild",
"insufficiency",
",",
"with",
"no",
"other",
"findings",
".",
"-",
"Electromyogram",
":",
"normal",
".",
"-",
"Multimodal",
"evoked",
"potentials",
":",
"no",
"alterations",
".",
"-",
"Iron",
"profile",
":",
"iron",
"117",
"μg",
"/",
"ml",
",",
"transferrin",
"317",
"mg",
"/",
"dl",
",",
"transferrin",
"saturation",
"26",
".",
"4",
"%",
"and",
"ferritin",
"21",
"μg",
"/",
"ml",
".",
"-",
"Erythrocyte",
"sedimentation",
"rate",
":",
"14",
"mm",
".",
"-",
"Cerebrospinal",
"fluid",
",",
"anticardiolipin",
"antibodies",
",",
"lupus",
"anticoagulant",
"antibodies",
",",
"rheumatoid",
"factor",
",",
"complement",
"C3",
"and",
"C4",
",",
"ANCA",
",",
"ACE",
",",
"ANA",
",",
"anti-DNA",
",",
"SS-A",
",",
"SS-B",
",",
"immunoglobulins",
"and",
"proteinogram",
":",
"normal",
".",
"-",
"Serology",
"(",
"lues",
",",
"Brucella",
",",
"HIV",
"1",
"and",
"2",
",",
"Borrellia",
"burgdorferi",
")",
"and",
"neurotropic",
"virus",
"serology",
":",
"no",
"pathological",
"alterations",
".",
"Treatment",
"and",
"evolution",
"Based",
"on",
"the",
"aforementioned",
"clinical",
"and",
"laboratory",
"data",
",",
"the",
"case",
"was",
"diagnosed",
"as",
"isolated",
"central",
"nervous",
"system",
"vasculitis",
"(",
"CNSV",
")",
".",
"Angiographic",
"study",
"was",
"contraindicated",
"due",
"to",
"gestation",
"and",
"she",
"had",
"remained",
"asymptomatic",
"from",
"the",
"neurological",
"point",
"of",
"view",
"since",
"admission",
",",
"so",
"it",
"was",
"decided",
"to",
"maintain",
"a",
"watchful",
"waiting",
"attitude",
",",
"starting",
"treatment",
"with",
"carbamazepine",
"at",
"a",
"dose",
"of",
"200",
"mg",
"/",
"8",
"h",
"together",
"with",
"iron",
"and",
"oral",
"folic",
"acid",
".",
"At",
"36",
"weeks",
"'",
"gestation",
",",
"the",
"baby",
"was",
"delivered",
"euthecdotally",
"and",
"without",
"incident",
".",
"After",
"eleven",
"months",
"asymptomatic",
"and",
"with",
"good",
"seizure",
"control",
",",
"she",
"returned",
"to",
"the",
"emergency",
"department",
"with",
"low",
"reactivity",
",",
"slurred",
"speech",
"and",
"decreased",
"strength",
"in",
"the",
"right",
"side",
"of",
"the",
"body",
".",
"Her",
"only",
"symptom",
"in",
"the",
"previous",
"days",
"was",
"headache",
",",
"with",
"no",
"other",
"focal",
"or",
"associated",
"symptoms",
".",
"The",
"systemic",
"examination",
"was",
"normal",
".",
"The",
"neurological",
"examination",
"showed",
"motor",
"aphasia",
",",
"right",
"central",
"facial",
"paresis",
",",
"right",
"hemiparesis",
"(",
"muscle",
"balance",
"4",
"/",
"5",
"overall",
"in",
"the",
"right",
"upper",
"limb",
"and",
"right",
"lower",
"limb",
")",
",",
"right",
"haemihypoaesthesia",
",",
"right",
"extensor",
"flexor",
"skin-plantar",
"reflex",
"and",
"left",
"flexor",
",",
"with",
"the",
"rest",
"of",
"the",
"examination",
"being",
"normal",
".",
"Electrocardiogram",
",",
"chest",
"X-ray",
"and",
"laboratory",
"tests",
"(",
"including",
"carbamazepine",
"levels",
")",
"were",
"normal",
".",
"An",
"urgent",
"brain",
"CT",
"scan",
"was",
"performed",
",",
"showing",
"an",
"acute",
"hypodense",
"lesion",
"in",
"the",
"left",
"basal",
"ganglia",
".",
"At",
"that",
"time",
"there",
"was",
"no",
"possibility",
"of",
"endovascular",
"therapy",
"and",
"with",
"the",
"diagnosis",
"of",
"ischaemic",
"stroke",
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"the",
"territory",
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"the",
"left",
"middle",
"cerebral",
"artery",
",",
"in",
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"context",
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"a",
"probable",
"NCAV",
",",
"treatment",
"was",
"started",
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"(",
"1000",
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"/",
"24",
"h",
")",
",",
"antiplatelet",
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"acetylsalicylic",
"acid",
"300",
"mg",
",",
"gastric",
"protection",
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"omeprazole",
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"deep",
"vein",
"thrombosis",
"prophylaxis",
"with",
"low",
"molecular",
"weight",
"heparin",
"at",
"a",
"dose",
"of",
"40",
"subcutaneous",
"units",
".",
"The",
"patient",
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"left",
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"bed",
"rest",
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"absolute",
"diet",
",",
"except",
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",",
"and",
"continued",
"treatment",
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"carbamazepine",
"at",
"the",
"previous",
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".",
"She",
"was",
"treated",
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"corticosteroid",
"boluses",
"for",
"5",
"days",
",",
"with",
"good",
"tolerance",
",",
"and",
"subsequently",
"started",
"oral",
"therapy",
"and",
"treatment",
"with",
"calcium",
"and",
"calcitriol",
"0",
".",
"25",
"μg",
"on",
"Tuesdays",
"and",
"Fridays",
".",
"Further",
"laboratory",
"tests",
"(",
"haemoglobin",
",",
"erythrocyte",
"sedimentation",
"rate",
",",
"complete",
"biochemistry",
",",
"urine",
"sediment",
",",
"proteinogram",
",",
"immunoglobulins",
",",
"rheumatoid",
"factor",
",",
"ANA",
"and",
"anti-DNA",
",",
"ANCA",
",",
"anticardiolipin",
"antibodies",
",",
"ACE",
",",
"anti-SSa",
"and",
"anti-SSB",
"antibodies",
")",
"were",
"performed",
",",
"which",
"were",
"normal",
".",
"A",
"new",
"cranial",
"magnetic",
"resonance",
"imaging",
"(",
"MRI",
")",
",",
"echocardiogram",
"(",
"transthoracic",
",",
"similar",
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"the",
"previous",
"one",
",",
"and",
"transesophageal",
",",
"which",
"was",
"not",
"tolerated",
")",
"and",
"cerebral",
"angiography",
"were",
"also",
"requested",
".",
"Cranial",
"MRI",
"showed",
"an",
"area",
"of",
"acute",
"infarction",
"in",
"the",
"left",
"basal",
"nuclei",
"and",
"multiple",
"periventricular",
"and",
"subcortical",
"lesions",
"similar",
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"the",
"previous",
"cranial",
"MRI",
".",
"Ischaemic",
"infarction",
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"the",
"left",
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"ganglia",
".",
"Multiple",
"hyperintense",
"lesions",
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"the",
"white",
"matter",
"of",
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"of",
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",",
"semioval",
"centres",
",",
"subcortical",
",",
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"grey",
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",",
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"lenticular",
",",
"all",
"suggestive",
"of",
"ischaemic",
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"of",
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".",
"Angiography",
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"a",
"saciform",
"aneurysm",
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"the",
"cavernous",
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"carotid",
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"(",
"immediately",
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",",
"with",
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"5-6",
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"sac",
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"2",
".",
"5",
"mm",
"neck",
")",
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"an",
"obstruction",
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"horizontal",
"portion",
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"left",
"middle",
"cerebral",
"artery",
",",
"with",
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"sylvian",
"branches",
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".",
"Saciform",
"aneurysm",
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"cavernous",
"tract",
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"left",
"carotid",
"siphon",
".",
"Embolised",
"aneurysm",
".",
"Days",
"later",
",",
"the",
"aneurysm",
"was",
"embolised",
"by",
"microcatheterisation",
",",
"placing",
"two",
"platinum",
"coils",
"inside",
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"aneurysm",
"with",
"satisfactory",
"closure",
".",
"The",
"aneurysm",
"was",
"completely",
"obstructed",
"and",
"the",
"patient",
"was",
"admitted",
"to",
"the",
"ward",
"24",
"hours",
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".",
"Fifteen",
"days",
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",",
"a",
"mild",
"speech",
"disorder",
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",",
"with",
"mild",
"dysarthria",
".",
"There",
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"muscle",
"balance",
"was",
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",",
"with",
"preserved",
"sensation",
"and",
"no",
"other",
"associated",
"deficits",
".",
"Ten",
"years",
"after",
"the",
"initial",
"diagnosis",
",",
"she",
"had",
"been",
"admitted",
"sporadically",
"for",
"seizures",
"and",
"status",
"epilepticus",
",",
"always",
"in",
"the",
"context",
"of",
"poor",
"compliance",
"with",
"treatment",
".",
"In",
"the",
"last",
"admission",
",",
"also",
"for",
"the",
"same",
"cause",
",",
"the",
"Mini-mental",
"State",
"Examination",
"showed",
"a",
"score",
"of",
"21",
"/",
"30",
",",
"with",
"a",
"pathological",
"Clock",
"Test",
".",
"She",
"presented",
"moderate",
"cognitive",
"impairment",
",",
"mainly",
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"expense",
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",",
"concentration",
",",
"reading",
",",
"writing",
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"praxis",
",",
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".",
"He",
"has",
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".",
"Currently",
",",
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"200",
"mg",
"/",
"8",
"h",
",",
"valproic",
"acid",
"500-0-1",
",",
"000",
",",
"omeprazole",
"20",
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"acetylsalicylic",
"acid",
"300",
"mg",
".",
"She",
"continues",
"to",
"be",
"followed",
"up",
"in",
"Neurology",
"outpatient",
"clinics",
".",
"Diagnosis",
"-",
"Epilepsy",
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"moderate",
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"impairment",
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".",
"-",
"Ischaemic",
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"N",
".",
"lenticularis",
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"-",
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We present the case of a 21-year-old male, with no known drug allergies, anabolic steroid user for sporting purposes, and with a personal history of childhood hyperactivity disorder, depressive episodes currently untreated, with no other diseases or cardiovascular risk factors. After surgery for fracture of the talus a year and a half ago, he underwent a new operation in a private centre to remove the pins under spinal anaesthesia without immediate complications. The following day, after breakfast, he had a severe holocranial headache and nausea, for which he was given painkillers. Progressively, in the following hours, he began to sleep, with incomprehensible language and bruxism, and was unable to wake up, with a Glasgow Coma Scale (GCS) 10/15 points (eye opening 3, verbal response 2, motor response 5) with isochoric pupils. A cranial tomography (CT) scan was performed, in which a subarachnoid haemorrhage was suspected and it was decided to transfer him to the reference hospital. While waiting for the ambulance, he had a coma crisis for 35-40 minutes, with fine tremor and great rigidity and impossibility to place an oropharyngeal cannula, requiring diazepam and, given the poor response, a perfusion of midazolam was started. On arrival of the critical care unit (CCU) for transfer, fever of 39oC was measured and he again presented a crisis described as generalised tonic-clonic movements with sialorrhoea, tongue biting and trismus, and orotracheal intubation (OTI) was performed. When he was admitted to our hospital, he presented oxygen saturation 99% with FiO2 100%, blood pressure 125/74mmHg, heart rate 96 bpm.
On examination, there were no findings of interest with a neurological examination, under sedoanalgesia with propofol and midazolam, with isochoric pupils reactive to light. An angioCT scan was requested showing: enhancement of the vessels of the Willis polygon, with partial collapse of the mesencephalic and quadrigeminal cistern; diffuse high-density images of both hemispheric sulci; absence of hydrocephalus; no aneurysm was seen and with asymmetry of the vascularisation of the left posterior cerebral region. Laboratory tests showed leukocytosis 20,280 cells/ml with neutrophilia (92.1%), C-reactive protein 104.7mg/l and procalcitonin 17.73 ng/ml. Blood gases showed pH 7.32; pCO2 53mmHg; and bicarbonate 26.7mEq/l. In coagulation, prothrombin activity is 62%, activated partial thromboplastin time is 25.5 seconds and fibrinogen 442 mg/dl. In addition, a urine tox screen was requested, with positive results for benzodiazepines and cannabis. The chest X-ray showed a small right basal infiltrate probably related to bronchial aspiration.
Differential diagnosis
In the present case we must take into account the sudden onset of headache with subsequent neurological deterioration, the presence of fever and the fact that the patient had undergone spinal anaesthesia. Given this, the differential diagnosis should include:
- Subarachnoid haemorrhage (SAH). This is caused by the rupture of an intracranial aneurysm, and presents with severe and sudden onset of headache, usually accompanied by photophobia, sonophobia, nausea and vomiting. It may also be associated with a transient loss of consciousness, disorientation, drowsiness and coma. Cranial tomography and lumbar puncture are mandatory for diagnosis. In the case of the puncture, there is usually elevated opening pressure, haematic fluid that does not coagulate and positive xanthochromia, which is diagnostic of SAH. In addition, an angioCT should be performed to locate the source of bleeding (aneurysm, AVM) or cerebral arteriography.
- Cerebral venous thrombosis. Subacute in onset, although it can appear suddenly or chronically. The most frequent and early symptom is headache, of unspecific characteristics, progressive, intense and accompanied by symptoms and signs of intracranial hypertension. There may be transient loss of vision, focal neurological symptoms and a progressive decrease in the level of consciousness and a seizure. The aetiology of venous thrombosis is diverse, including coagulation disorders and infectious processes. (MRI) and/or angioMRI. However, cranial tomography may show indirect signs that can guide us to this diagnosis.
- Meningitis. It is usually caused by contiguity from a parameningeal infection, haematogenous dissemination or iatrogenic focus. Its clinical manifestations are explosive in onset and of short duration (within hours) with fever, stiff neck, altered level of consciousness and headache. For diagnosis, at least one of the symptoms of the classic triad must be present, and the diagnosis is based on the cytobiochemical characteristics of the CSF as well as the identification of a germ by culture and/or polymerase chain reaction. This should be considered as the primary clinical suspicion.
- Encephalitis. It usually begins as a pseudo-flu-like illness with mild behavioural disturbances, followed by fever, headache, meningeal signs, decreased level of consciousness, confusion, hallucinations and seizures. Diagnosis requires lumbar puncture showing cerebrospinal fluid with features of viral meningitis.
- Post-puncture headache. Occurs in the first few days after lumbar puncture, appears in the sitting position and improves with decubitus. It is often accompanied by stiffness of the neck, it is not pulsatile and its intensity is variable. It may be accompanied by nausea and vomiting, photophobia, somnolence, diplopia, tinnitus, etc.
Evolution
A lumbar puncture was carried out and a cloudy cerebrospinal fluid was obtained. The biochemical study showed 30,443 leukocytes/l, 95% polymorphonuclear, 3,600 red blood cells, glucose 80mg/l, lactate 90.5 mg/dl, protein 302.2 mg/dl and negative xanthochromia. After obtaining the results of the samples taken in the lumbar puncture with cytobiochemistry compatible with bacterial infection, empirical antibiotherapy was started with ceftriaxone and vancomycin together with corticotherapy. It was decided to perform an electroencephalogram (EEG) which showed no epileptiform activity, as well as a new brain scan which showed a doubtful thrombosis of the sinuses due to asymmetry of the same to be assessed by magnetic resonance imaging. After withdrawal of sedoanalgesia and mechanical ventilation, the patient remained awake without neurological focality. On arrival, a chest X-ray showed a small infiltrate related to bronchoaspiration secondary to the low level of consciousness, which disappeared in the radiological control, without incident and he was asymptomatic from the respiratory point of view.
At the analytical level, the acute phase reactants progressively decreased until normalisation. Cultures of CSF, blood and urine samples did not isolate any germ, although the 16s rRNA gene for S. salivarius was positive in CSF samples. During his admission, the haematology department was consulted due to prothrombin activity <60% in successive analytical controls, so a coagulation study was performed, which showed mild factor VII deficiency and mild hypofibrinogenemia. Once stabilised, he was transferred to the hospital ward and antibiotherapy was maintained until 14 days of treatment. In our unit, despite feeling well, he reported visual hallucinations on the first three nights of admission to the ward, with a normal neurological examination, without nuchal rigidity or other meningeal signs, for which new EEG and urgent cranial CT scan were requested, with no findings to justify the clinical condition, and a brain magnetic resonance imaging (MRI) scan showed findings compatible with cortical vein thrombosis in the right parietal region, swelling and oedema of the right superior parietal gyrus, sinus thrombosis and complete thrombosis of the transverse, right sigmoid and superior longitudinal sinuses.
In view of the MRI findings, anticoagulation with acenocoumarol was started for 3-6 months. The clinical evolution was favourable and the visual hallucinations also disappeared. The surgical wound was re-evaluated by Traumatology with good evolution and no signs of superinfection. However, the patient again presented with fever without clear infectious focality, except for coincidence with rhinorrhoea and pharyngeal discomfort with no other symptoms. A chest X-ray was performed, which showed no findings, a normal urine systemic test and samples were taken for blood and urine culture; however, a new lumbar puncture was performed with clear and transparent CSF, a normal cytobiochemical study and a negative CSF culture. The results of the blood and urine cultures were negative, and the pharyngeal symptoms and febrile fever disappeared.
Final diagnosis
- Bacterial meningitis due to S. salivarius as probable etiology.
- Thrombosis of the cortical vein and dural, transverse, right sigmoid and superior longitudinal sinuses.
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"the",
"puncture",
",",
"there",
"is",
"usually",
"elevated",
"opening",
"pressure",
",",
"haematic",
"fluid",
"that",
"does",
"not",
"coagulate",
"and",
"positive",
"xanthochromia",
",",
"which",
"is",
"diagnostic",
"of",
"SAH",
".",
"In",
"addition",
",",
"an",
"angioCT",
"should",
"be",
"performed",
"to",
"locate",
"the",
"source",
"of",
"bleeding",
"(",
"aneurysm",
",",
"AVM",
")",
"or",
"cerebral",
"arteriography",
".",
"-",
"Cerebral",
"venous",
"thrombosis",
".",
"Subacute",
"in",
"onset",
",",
"although",
"it",
"can",
"appear",
"suddenly",
"or",
"chronically",
".",
"The",
"most",
"frequent",
"and",
"early",
"symptom",
"is",
"headache",
",",
"of",
"unspecific",
"characteristics",
",",
"progressive",
",",
"intense",
"and",
"accompanied",
"by",
"symptoms",
"and",
"signs",
"of",
"intracranial",
"hypertension",
".",
"There",
"may",
"be",
"transient",
"loss",
"of",
"vision",
",",
"focal",
"neurological",
"symptoms",
"and",
"a",
"progressive",
"decrease",
"in",
"the",
"level",
"of",
"consciousness",
"and",
"a",
"seizure",
".",
"The",
"aetiology",
"of",
"venous",
"thrombosis",
"is",
"diverse",
",",
"including",
"coagulation",
"disorders",
"and",
"infectious",
"processes",
".",
"(",
"MRI",
")",
"and",
"/",
"or",
"angioMRI",
".",
"However",
",",
"cranial",
"tomography",
"may",
"show",
"indirect",
"signs",
"that",
"can",
"guide",
"us",
"to",
"this",
"diagnosis",
".",
"-",
"Meningitis",
".",
"It",
"is",
"usually",
"caused",
"by",
"contiguity",
"from",
"a",
"parameningeal",
"infection",
",",
"haematogenous",
"dissemination",
"or",
"iatrogenic",
"focus",
".",
"Its",
"clinical",
"manifestations",
"are",
"explosive",
"in",
"onset",
"and",
"of",
"short",
"duration",
"(",
"within",
"hours",
")",
"with",
"fever",
",",
"stiff",
"neck",
",",
"altered",
"level",
"of",
"consciousness",
"and",
"headache",
".",
"For",
"diagnosis",
",",
"at",
"least",
"one",
"of",
"the",
"symptoms",
"of",
"the",
"classic",
"triad",
"must",
"be",
"present",
",",
"and",
"the",
"diagnosis",
"is",
"based",
"on",
"the",
"cytobiochemical",
"characteristics",
"of",
"the",
"CSF",
"as",
"well",
"as",
"the",
"identification",
"of",
"a",
"germ",
"by",
"culture",
"and",
"/",
"or",
"polymerase",
"chain",
"reaction",
".",
"This",
"should",
"be",
"considered",
"as",
"the",
"primary",
"clinical",
"suspicion",
".",
"-",
"Encephalitis",
".",
"It",
"usually",
"begins",
"as",
"a",
"pseudo-flu-like",
"illness",
"with",
"mild",
"behavioural",
"disturbances",
",",
"followed",
"by",
"fever",
",",
"headache",
",",
"meningeal",
"signs",
",",
"decreased",
"level",
"of",
"consciousness",
",",
"confusion",
",",
"hallucinations",
"and",
"seizures",
".",
"Diagnosis",
"requires",
"lumbar",
"puncture",
"showing",
"cerebrospinal",
"fluid",
"with",
"features",
"of",
"viral",
"meningitis",
".",
"-",
"Post-puncture",
"headache",
".",
"Occurs",
"in",
"the",
"first",
"few",
"days",
"after",
"lumbar",
"puncture",
",",
"appears",
"in",
"the",
"sitting",
"position",
"and",
"improves",
"with",
"decubitus",
".",
"It",
"is",
"often",
"accompanied",
"by",
"stiffness",
"of",
"the",
"neck",
",",
"it",
"is",
"not",
"pulsatile",
"and",
"its",
"intensity",
"is",
"variable",
".",
"It",
"may",
"be",
"accompanied",
"by",
"nausea",
"and",
"vomiting",
",",
"photophobia",
",",
"somnolence",
",",
"diplopia",
",",
"tinnitus",
",",
"etc",
".",
"Evolution",
"A",
"lumbar",
"puncture",
"was",
"carried",
"out",
"and",
"a",
"cloudy",
"cerebrospinal",
"fluid",
"was",
"obtained",
".",
"The",
"biochemical",
"study",
"showed",
"30",
",",
"443",
"leukocytes",
"/",
"l",
",",
"95",
"%",
"polymorphonuclear",
",",
"3",
",",
"600",
"red",
"blood",
"cells",
",",
"glucose",
"80mg",
"/",
"l",
",",
"lactate",
"90",
".",
"5",
"mg",
"/",
"dl",
",",
"protein",
"302",
".",
"2",
"mg",
"/",
"dl",
"and",
"negative",
"xanthochromia",
".",
"After",
"obtaining",
"the",
"results",
"of",
"the",
"samples",
"taken",
"in",
"the",
"lumbar",
"puncture",
"with",
"cytobiochemistry",
"compatible",
"with",
"bacterial",
"infection",
",",
"empirical",
"antibiotherapy",
"was",
"started",
"with",
"ceftriaxone",
"and",
"vancomycin",
"together",
"with",
"corticotherapy",
".",
"It",
"was",
"decided",
"to",
"perform",
"an",
"electroencephalogram",
"(",
"EEG",
")",
"which",
"showed",
"no",
"epileptiform",
"activity",
",",
"as",
"well",
"as",
"a",
"new",
"brain",
"scan",
"which",
"showed",
"a",
"doubtful",
"thrombosis",
"of",
"the",
"sinuses",
"due",
"to",
"asymmetry",
"of",
"the",
"same",
"to",
"be",
"assessed",
"by",
"magnetic",
"resonance",
"imaging",
".",
"After",
"withdrawal",
"of",
"sedoanalgesia",
"and",
"mechanical",
"ventilation",
",",
"the",
"patient",
"remained",
"awake",
"without",
"neurological",
"focality",
".",
"On",
"arrival",
",",
"a",
"chest",
"X-ray",
"showed",
"a",
"small",
"infiltrate",
"related",
"to",
"bronchoaspiration",
"secondary",
"to",
"the",
"low",
"level",
"of",
"consciousness",
",",
"which",
"disappeared",
"in",
"the",
"radiological",
"control",
",",
"without",
"incident",
"and",
"he",
"was",
"asymptomatic",
"from",
"the",
"respiratory",
"point",
"of",
"view",
".",
"At",
"the",
"analytical",
"level",
",",
"the",
"acute",
"phase",
"reactants",
"progressively",
"decreased",
"until",
"normalisation",
".",
"Cultures",
"of",
"CSF",
",",
"blood",
"and",
"urine",
"samples",
"did",
"not",
"isolate",
"any",
"germ",
",",
"although",
"the",
"16s",
"rRNA",
"gene",
"for",
"S",
".",
"salivarius",
"was",
"positive",
"in",
"CSF",
"samples",
".",
"During",
"his",
"admission",
",",
"the",
"haematology",
"department",
"was",
"consulted",
"due",
"to",
"prothrombin",
"activity",
"<",
"60",
"%",
"in",
"successive",
"analytical",
"controls",
",",
"so",
"a",
"coagulation",
"study",
"was",
"performed",
",",
"which",
"showed",
"mild",
"factor",
"VII",
"deficiency",
"and",
"mild",
"hypofibrinogenemia",
".",
"Once",
"stabilised",
",",
"he",
"was",
"transferred",
"to",
"the",
"hospital",
"ward",
"and",
"antibiotherapy",
"was",
"maintained",
"until",
"14",
"days",
"of",
"treatment",
".",
"In",
"our",
"unit",
",",
"despite",
"feeling",
"well",
",",
"he",
"reported",
"visual",
"hallucinations",
"on",
"the",
"first",
"three",
"nights",
"of",
"admission",
"to",
"the",
"ward",
",",
"with",
"a",
"normal",
"neurological",
"examination",
",",
"without",
"nuchal",
"rigidity",
"or",
"other",
"meningeal",
"signs",
",",
"for",
"which",
"new",
"EEG",
"and",
"urgent",
"cranial",
"CT",
"scan",
"were",
"requested",
",",
"with",
"no",
"findings",
"to",
"justify",
"the",
"clinical",
"condition",
",",
"and",
"a",
"brain",
"magnetic",
"resonance",
"imaging",
"(",
"MRI",
")",
"scan",
"showed",
"findings",
"compatible",
"with",
"cortical",
"vein",
"thrombosis",
"in",
"the",
"right",
"parietal",
"region",
",",
"swelling",
"and",
"oedema",
"of",
"the",
"right",
"superior",
"parietal",
"gyrus",
",",
"sinus",
"thrombosis",
"and",
"complete",
"thrombosis",
"of",
"the",
"transverse",
",",
"right",
"sigmoid",
"and",
"superior",
"longitudinal",
"sinuses",
".",
"In",
"view",
"of",
"the",
"MRI",
"findings",
",",
"anticoagulation",
"with",
"acenocoumarol",
"was",
"started",
"for",
"3-6",
"months",
".",
"The",
"clinical",
"evolution",
"was",
"favourable",
"and",
"the",
"visual",
"hallucinations",
"also",
"disappeared",
".",
"The",
"surgical",
"wound",
"was",
"re-evaluated",
"by",
"Traumatology",
"with",
"good",
"evolution",
"and",
"no",
"signs",
"of",
"superinfection",
".",
"However",
",",
"the",
"patient",
"again",
"presented",
"with",
"fever",
"without",
"clear",
"infectious",
"focality",
",",
"except",
"for",
"coincidence",
"with",
"rhinorrhoea",
"and",
"pharyngeal",
"discomfort",
"with",
"no",
"other",
"symptoms",
".",
"A",
"chest",
"X-ray",
"was",
"performed",
",",
"which",
"showed",
"no",
"findings",
",",
"a",
"normal",
"urine",
"systemic",
"test",
"and",
"samples",
"were",
"taken",
"for",
"blood",
"and",
"urine",
"culture",
";",
"however",
",",
"a",
"new",
"lumbar",
"puncture",
"was",
"performed",
"with",
"clear",
"and",
"transparent",
"CSF",
",",
"a",
"normal",
"cytobiochemical",
"study",
"and",
"a",
"negative",
"CSF",
"culture",
".",
"The",
"results",
"of",
"the",
"blood",
"and",
"urine",
"cultures",
"were",
"negative",
",",
"and",
"the",
"pharyngeal",
"symptoms",
"and",
"febrile",
"fever",
"disappeared",
".",
"Final",
"diagnosis",
"-",
"Bacterial",
"meningitis",
"due",
"to",
"S",
".",
"salivarius",
"as",
"probable",
"etiology",
".",
"-",
"Thrombosis",
"of",
"the",
"cortical",
"vein",
"and",
"dural",
",",
"transverse",
",",
"right",
"sigmoid",
"and",
"superior",
"longitudinal",
"sinuses",
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{
"text": "S. salivarius",
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A 42 year old male traveller from Catalonia who made a 6 month trip (first half of 2001) to South America. He started his trip in the south of Argentina, then in Chile and Bolivia, ending with a month and a half in the Peruvian Amazon, specifically in Iquitos. He came to the clinic with a three-week history of symptoms, which began in Iquitos and for which he had been taking antibiotics (cloxacillin) for a week. Physical examination revealed two forunculous lesions in the dorsal region. Red lumps 0.5 cm in diameter, with a central orifice, which when pressed ooze serous fluid and cause stabbing pain and pruritus. The rest of the examination was normal.
In the case in question, from the first day of the visit until the day of the extraction, antibiotic treatment was maintained and, under the suspicion of myiasis, the orifice was occluded daily with vaseline to provoke the larvae to come out. Finally, after 10 days, and given the impossibility of the natural exit of the larva, we proceeded under local anaesthesia and with a small incision in the entrance orifice to the natural extraction of the larva, alive, being identified as Dermatoba hominis.
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] | en |
Child aged 6 weeks (March 2014).
Reason for consultation: presence of nasal mucus and cough since 3 weeks of life. During the last week there were more intense coughing spells at night, accompanied by peribuccal cyanosis on some occasions. Afebrile. No other symptoms reported.
Personal history:
- Controlled pregnancy with no notable incidents.
- Euthocic delivery at 40+6 weeks of gestational age. Birth weight 3,060 kg.
- Exclusive breastfeeding.
- Well vaccinated (1st dose HBV).
A. Family history:
- Mother aged 34 years presents seasonal allergic asthma, presenting catarrhal symptoms since 1 month, last 2 weeks refers cough predominantly at night which turns out to be very invalid, afebrile, no improvement with inhaled salbutamol. No other accompanying symptoms.
- Sister aged 2 years, healthy, correctly vaccinated. Currently asymptomatic.
- Father has allergic rhinoconjunctivitis.
- No other history of interest.
PHYSICAL EXAMINATION:
-Weight: 4.500 kg. Temperature 36.8oC. Sat O2 100%.
-Good general condition, good skin and mucous membrane colouring, well hydrated with good peripheral perfusion. Brachial and femoral pulses palpable symmetrical. Normal PCA. No signs of respiratory distress. The rest of the systematic examination was normal.
-During the examination coughing access is present, with final inspiratory rooster, coinciding with crying.
COMPLEMENTARY TESTS:
Rapid detection of Respiratory Syncytial Virus (RSV) antigen: negative.
Haemogram with 11,800/mm3 leukocytes (neutrophils: 3,700/mm3, lymphocytes: 7,000/mm3), Hb 9.9g/dl, Hct 29.1%. Platelets 505,000/mm3. Rest normal. Biochemistry normal. C-reactive protein 1.1 mg/l.
In view of the mother's symptoms, a PCR for Bordetella pertussis in nasopharyngeal exudate was performed and was positive.
Chemoprophylaxis (CP) and treatment
The infant was hospitalised in the infant unit for monitoring and received treatment with Clarithromycin 7.5 mg/kg/12 h O.V. for 7 days. He remained in hospital for 6 days, the first 72 hours he presented apnoea with hyposaturation and nasogastric tube feeding, then progressively evolved favourably, with no other significant incidents.
The mother was diagnosed and treated with Clarithromycin 500 mg/12 h, 7 days.
-Preventive Medicine was informed of these two cases confirmed with PCR for B. pertussis and chemoprophylaxis of the cohabitants with Clarithromycin was carried out.
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45-YEAR-OLD FEMALE PATIENT who comes to the clinic referred by her general dentist to evaluate the periodontal status of her mouth. The main reason for the patient's consultation is: I have noticed bad breath, bleeding and inflammation for the last 4 years despite having been undergoing periodontal treatment for 3 years. In addition, my "blades" have separated.
As for her medical history, she has a chronic autoimmune thyroiditis and therefore does not need treatment. She has been an ex-smoker for 5 years. Her dental history shows the patient's interest in solving her periodontal problem, as she has just had periodontal access surgery on her jaw 4 weeks ago and has had frequent prophylaxis for a long time. She also had orthodontic treatment 9 years ago.
In the extraoral examination, no notable signs were found, while the intraoral examination revealed a congenital diastema between the central incisors for which he was treated 9 years ago; an overbite of 6 mm with occlusal trauma in protrusive (eccentric fringes). Regarding the gingival aspect, there was an evident increase in size, a change in colour with reddened gums, very swollen, especially in sextant II, as well as loss of the scalloped and fine shape and usual texture compatible with gingival health. In view of the suspicion of periodontitis, the patient was offered a complete radiographic examination. The patient had an orthopantomography and given her thyroid situation the decision was made not to do a complete periapical series. Two periapical radiographs were taken of the anterosuperior sextant, the area most affected by insertion loss and marginal bone loss.
A complete clinical examination was also performed with recording of all periodontal parameters reflected in the periodontogram (Florida Probe System® FL, USA). His results showed periodontal pockets ≥ 6 mm in 70 % of the sites, a bleeding rate of 100 % and a plaque index of 48 %. In addition, he had grade I mobility of the upper incisors.
As complementary diagnostic tests, volatile sulphur compounds were measured, as this was one of her concerns at the time of consultation (Oral Chroma®). A qualitative microbiological analysis was also carried out, taking into account the inflammation pattern despite the fact that the patient had been undergoing periodontal treatment with her regular dentist for 3 years and without clinical improvement, using a DNA probe (Sunstar, Guidor). Her result reveals the presence of Porphyromonas Gingivalis, Tannerella Forshytia and Treponema Denticola, all belonging to the "Red" series (World Workshop 1996), as well as others belonging to the "Orange" series (Prevotella Intermedia Porvimonas Micros and Fusebacterium Nucleatum).
According to the Armitage classification, in 2013 the patient was diagnosed with generalised moderate chronic periodontitis, localised advanced and 100% bleeding on probing. With regard to the interarch relationship, there was a vertical crosslinking of 6 mm and horizontal crosslinking of 4 mm, as well as occlusal trauma and fringing in eccentric disclusion on the anterior front and increased congenital interincisal diastema. Periodontal deinflammatory treatment consisting of oral hygiene instructions and scaling and root planing within 24 hours (Full Mouth Disinfection-Kinane 2004) was proposed and carried out. After 4 weeks, complete periodontal records were taken to evaluate the response as seen in the photographs and periodontal data (periodontogram S. Florida).
Subsequently, advanced regenerative periodontal treatment was performed on sextant II with removal of irritants and polishing of the developmental sulcus on the root surface of #11 mesiopalatal, and application of enamel-derived proteins (Emdogain®, Straumann), as well as a regimen of metronidazole 500 mg every 8 hours for 7 days.
According to the New Classification of the 2017 World Workshop on Periodontal and Peri-implant Diseases and Conditions ("the World Workshop"), this patient would have been classified as stage III grade B periodontitis.
To classify the patient's periodontitis into stages and grades, we can refer to the decision-making algorithm. Given the suspicion of periodontitis in our patient, the loss of attachment (PIC) in more than 1 tooth was assessed and specific X-rays were taken in the anterior sextant (most affected area) and periodontal probing to record the loss of interproximal attachment which was not solely due to local factors, and a complete periodontogram was carried out. The patient had periodontitis as probing depths > 4 mm were found in several locations. Once the patient has been diagnosed with periodontitis, the stage and degree must be established.
First we will assess the extent of the disease by analysing whether clinical attachment loss (ICL) or bone loss (LO) affects more than 30 % of the sites, as in our case, which will be classified as generalised periodontitis. To establish the stage of periodontitis in this patient, we will assess the severity (using ICP, PO and PDP, which are the periodontal tooth losses) and the complexity (by assessing the PS: probing depth) of the periodontitis. In this patient we are dealing with generalised periodontitis stage III (pockets in more than 30% of locations, vertical defect in #11), grade B due to the PO/age ratio and absence of risk factors.
Fortunately, in this case we have information on its evolution 5 years later. Both clinical images and periodontal and radiographic records show periodontal stability, and in some areas even gain of clinical attachment as well as partial correction of the diastema.
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{
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{
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] | en |
We present the case of a 45-year-old man who presented to the emergency department with progressive dyspnoea for approximately two weeks accompanied by palpitations. He worked in a florist's shop and reported no past history of interest. He denied recent travel or exposure to environmental toxic agents. Physical examination revealed fever of 38oC, tachypnoea, tachycardia, oxygen saturation of 93% on room air and bilateral midfield crackles. Chest X-ray showed bilateral parahilar alveolar opacification, and blood tests showed a leukocyte count of 16,920 leukocytes/μL and a C-reactive protein value of 23 mg/dL, in addition to blood gases with: pH, 7.55; pCO2, 22 mmHg; bicarbonate, 19 mEq/L; and pO2, 56 mmHg.
On admission, treatment with levofloxacin and ceftriaxone was started, with poor response, and fever and general malaise persisted. A high-resolution computed tomography (HRCT) scan of the lung showed areas of increased density in both upper lobes and segment 6 suggestive of inflammatory-infectious lung disease. Pneumococcal and Legionella antigenuria, blood cultures and serology (acute phase) for Mycoplasma, Chlamydia, Legionella and Coxiella were negative. Azithromycin (500 mg/ 24 hours) was then added on suspicion of atypical infection. Due to the poor response, bronchofibroscopy with transbronchial biopsy was performed. Pathology showed type II pneumocytic hyperplasia, inflammation of the alveolar wall and myxomatous degeneration of the alveolar septa, all compatible with acute organised fibrinoid pneumonia. Following the anatomopathological findings, treatment with prednisone 0.5 mg/kg was started and the fever and dyspnoea disappeared.
During the follow-up in consultations, the dose of corticosteroids was gradually reduced until it was discontinued after 3 months. The last follow-up chest CT scan showed no condensation or pulmonary lesions.
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] | en |
BACKGROUND:
77-year-old woman, allergic to metamizole, and with medical history of arterial hypertension, type 2 diabetes mellitus (insulin-dependent), permanent atrial fibrillation and asmabronchial. Under follow-up by cardiology for rheumatic mitral valve disease with severe mitral stenosis operated by surgical commissurotomy in 1991 and later prosthetic valve replacement in 2007 using Carbomedics metal prosthesis no 27.During follow-up she also developed severe aortic valve stenosis without symptoms.She was on treatment with acenocoumarol, bisoprolol, furosemide, spironolactone,olmesartan, insulin and bronchodilators on demand.
CURRENT ILLNESS:
The patient attended the emergency department for colicky abdominal pain and fever of 38.2 oC,labelled acute gastroenteritis which resolved with conservative treatment on an ambulatory basis. Five days later, she returned to our centre with a new febrile peak and abdominal pain located in the left iliac fossa that required hospital admission for suspected acute diverticulitis. Bacteroides fragilis was isolated in two blood cultures and antibiotic treatment was prescribed with good subsequent evolution. Twenty days later, he was admitted again for a new febrile peak with positive blood cultures for the same pathogen; an abdominal CT scan showed diverticulosis with no signs of acute infection, so given his history, it was decided to perform an echocardiogram to rule out infective endocarditis (IE).
PHYSICAL EXAMINATION
Temperature 38.3 oC. Blood pressure 105/70 mmHg. Heart rate 68 bpm. Conscious, oriented, well perfused. No Osler's nodules or Roth's spots on the skin. Increased jugular venous pulse with venous pulse under the mandibular angle at 90o with prominent "v" waves. Cardiac auscultation: rhythmic heart sounds at 74 bpm with systolic murmur 3/6 in the aortic focus and second sound abolished, radiating to the left sternal border and apex. Pulmonary auscultation: left basal hypoventilation. No oedema in the lower extremities.
COMPLEMENTARY TESTS
ANALYTICS on admission: urea 0.36 g/l, creatinine 0.73 mg/dl; CKD-EPI 79.6 ml/min/1.73 m2, ions and transaminases without significant alterations. NT-proBNP 2,797 pg/ml. ESR 102 mm, Creactive protein 0.81 mg/dl. Haemogram: Hb 10.2 g/dl, Ht 30%, 13,900/mm3 (neutrophils 91.1%).
THORAX RADIGRAPHY: radiological cardiomegaly. Mid sternotomy sutures. Pinching of both costophrenic sinuses (greater on the left side). Prominent vascular bundles.
Haemocultures (x3): positive for Bacteroides fragilis.
Transesophageal echocardiography: severely dilated left atrium. Intact septum: atrial appendage occupied by an image suggestive of a thrombus with little echodense. Double hemidisc mitral prosthesis with good opening (gradients similar to previous studies); several eccentric intraprosthesis regurgitation jets are observed without flow reversal in the pulmonary veins. Two vegetative images implanted in the prosthetic annulus of 12 x 3 mm and 10 x 3 mm mobile, not interfering with the movement of the discs; no periannular abscesses were detected. Left ventricle neither dilated nor hypertrophied with preserved ejection fraction and no segmental alterations. Thickened, trivalve aortic valve with significantly reduced effective area; no regurgitation. Dilated right chambers; reduced right ventricular contractility (TAPSE 14 mm). Thickened tricuspid valve with good opening and mobility; severe regurgitation. Moderate pulmonary hypertension. No pericardial effusion.
CLINICAL COURSE
With the diagnosis of infective endocarditis on prosthetic valve due to Bacteroides fragilis, treatment was started with metronidazole 500 mg/8 hours and amoxicillin-clavulanic acid 1000 mg/200mg/8 hours intravenous. The patient remained afebrile throughout admission, blood cultures were negative early and she progressed favourably from her slight cardiac decompensation with diuretic treatment. After 6 weeks of targeted intravenous antibiotic treatment, being haemodynamically stable and in good functional class, he was discharged from hospital.
DIAGNOSIS
Endocarditis on mitral metallic prosthesis due to anaerobes (Bacteroides fragilis) without associated prosthetic dysfunction. Bacteraemia due to Bacteroides fragilis of possible gastrointestinal origin. Diverticulosis without diverticulitis.
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] | en |
Anamnesis
A 36-year-old woman, with no past history of interest, consulted for headache and blurred vision. In the 3 weeks prior to admission she presented a febrile syndrome with temperatures up to 38 oC, and 5 days before admission she had a predominantly frontal headache and bilateral blurred vision with retroocular pain.
Physical examination
Fever of 37.5 oC. Visual acuity was 0.2 in both eyes and bilateral papillary oedema. The rest of the neurological and systemic examination was normal. Blurring of the papillary borders and bilateral papillary elevation. Several small yellowish nodular lesions were visualised in the nasal retina.
Complementary tests
- CBC: normal. ESR 22 mm, CRP normal. Beta-2-microglobulin 2.81.
- Autoimmunity (ANA and ACA) negative.
- Ocular angiofluorescein: compatible with bilateral optic neuritis.
- Brain MRI: small frontal lesion compatible with meningioma as the only finding.
- Lumbar puncture on admission: normal opening pressure, glucose 45 (simultaneous blood 110). Hyperproteinorraquia of 126, 70 cells predominantly mononuclear (97%), red blood cells 3,600, ADA 7.9. BOC negative. Similar serial lumbar punctures, compatible with lymphocytic meningitis.
- Lumbar puncture (after tuberculostatic treatment): glucose 53 (simultaneous 114), 66 proteins, leukocytes 7, red blood cells 6.
- Serology in serum and CSF for Borrelia, Brucella, lupus, HIV, Bartonella, herpes, cryptococcus antigen: negative.
- Mantoux, mycobacterial culture, PCR for tuberculosis negative.
- Chest X-ray: no notable alterations.
- ECG: normal sinus rhythm.
- Thoracic-abdominal CT scan: small non-specific mediastinal lymphadenopathy, and a single abdominal lymphadenopathy near the celiac trunk, without suggesting any abnormality.
Diagnosis
Initial diagnosis: meningitis and tuberculous optic neuritis as first possibility.
Definitive diagnosis: sarcoidosis.
Treatment
Initially, treatment with antituberculous drugs and corticosteroids (for one month) is started. Seven months after the new diagnosis, corticotherapy and immunosuppression with methotrexate were started.
Evolution
Since the first admission, she was re-evaluated after 2 months, where she was afebrile and asymptomatic, except for a slight bilateral visual deficit. Despite the negative results confirming tuberculous meningitis, the clinical-analytical improvement (lumbar puncture was repeated) led to maintaining treatment with tuberculostatics. Seven months later he was readmitted a third time for left peripheral facial paralysis. On this admission, the diagnosis was reconsidered and the tests were repeated. The lumbar puncture was similar to previous ones (persistent hyperproteinorrache, borderline glucose and low cellularity with 8 mononuclear cells), CSF ACE was negative and serum ACE was 54 (normal reference value 52); however, the thoracic-abdominal CT scan showed enlarged mediastinal and abdominal adenopathies with the appearance of bilateral pulmonary infiltrates. In view of this finding, fibrobronchoscopy of the lymphadenopathies was performed with bronchoalveolar lavage and biopsies were taken, with a low CD4/CD8 ratio (which did not favour, but did not exclude, the diagnosis of sarcoidosis). Still awaiting pathological anatomy and review of the results at the outpatient clinic, she was admitted a fourth time 2 months later for right facial paralysis, before it resolved on the contralateral side. The results of the pathological anatomy revealed non-necrotising granulomatous sarcoid-type granulomatous inflammation. At this point, tuberculostatic treatment was discontinued and it was decided to start immunosuppressive treatment with corticosteroids and methotrexate.
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HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION
Male, 36 years old.
History
AHT
Stage III chronic renal failure secondary to vesicoureteral reflux Current illness The patient reported fever and vomiting for 3 days, general malaise, generalised aches and pains, dystrophic sensation, chills, sweating and vomiting.
Physical examination
BP: 100/40
Ta: 39.5 °C
Normal colour, hydrated and perfused.
Eupneic at 0°.
Cardiac auscultation: rhythmic with systolic murmur in EIB
Pulmonary auscultation: VCM
Abdomen: no evidence of peritoneal irritation.
COMPLEMENTARY TESTS
ECHOCARDIOGRAPHY: RS, BCRIHH.
Chest X-ray: normal.
Laboratory tests: biochemistry: creatinine 7.99 mg/gl; Na 131 mEq/l; K 4.59 mEq/l, CRP 23.09 mg/dl. Gases: pH 7.23, pCO2 36 mmHg, pO2 14 mmHg, HCO3 15 mmol/l, Ebb - 11.6 mmol/l.
Haemogram: Hb 11.6 g/dl, platelets 80 x1000/ul, leucocytes 16.30x1000/ ul, neutrophils 94.7%.
Coagulation: prothrombin activity 65%, INR 1.34.
Abdominal CT scan with chest sections: abdomen normal. Chest sections included in the study showed a 1 cm nodule in LID, two in LII (the largest measuring 5 mm) and another in the anterior part of the lingula, all undetermined, with an infectious aetiology to be assessed.
Blood cultures: methicillin-sensitive S. aureus.
Transthoracic echocardiogram: image compatible with endocardial wart of 15x10 mm anchored to the IV septum. Restrictive ventricular septal defect. Transesophageal echocardiogram recommended. Transesophageal echocardiogram: ruled out involvement of other valves.
EVOLUTION
In view of the febrile syndrome presented by the patient, two sets of blood cultures were requested. A possible abdominal focus was suspected based on the clinical manifestations and an abdominal CT scan was performed, which ruled it out, although there was evidence of possible infectious foci in the lungs.
Two sets of blood cultures were taken and were positive for Staphylococcus aureus. After isolation of S. aureus in both sets and the presence of previously unknown left bundle branch block and murmur, a transthoracic echocardiogram was performed showing an endocardial wart dependent on the tricuspid subvalvular apparatus or the interventricular septum; and a restrictive ventricular septal defect (GP max 140 mmHg). Antibiotic therapy with intravenous cloxacillin was started, after which the patient remained afebrile, asymptomatic, with a decrease in acute phase reactants and sterile serial blood cultures. A control transthoracic echocardiogram was performed 7 days after starting antibiotic therapy and it was found that the image of the wart had not decreased in size. A wait-and-see attitude was maintained and 14 days after starting antibiotic treatment, a new echocardiographic check-up was performed, which showed no changes with respect to the diagnostic echocardiogram. Given the persistence of the vegetation, surgical intervention was indicated in conjunction with the Cardiac Surgery Service. The possibilities were explained to the patient and he accepted. The vegetation was resected and the VSD was closed with direct suture. The patient evolves favourably and is included in the haemodialysis programme.
DIAGNOSIS
Tricuspid endocarditis due to S. aureus.
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"text": "methicillin-sensitive S. aureus",
"label": "SPECIES",
"start": 1231,
"end": 1262
},
{
"text": "S. aureus",
"label": "SPECIES",
"start": 1253,
"end": 1262
},
{
"text": "patient",
"label": "HUMAN",
"start": 1586,
"end": 1593
},
{
"text": "Staphylococcus aureus",
"label": "SPECIES",
"start": 1906,
"end": 1927
},
{
"text": "patient",
"label": "HUMAN",
"start": 2341,
"end": 2348
},
{
"text": "patient",
"label": "HUMAN",
"start": 2996,
"end": 3003
},
{
"text": "patient",
"label": "HUMAN",
"start": 3096,
"end": 3103
},
{
"text": "S. aureus",
"label": "SPECIES",
"start": 1948,
"end": 1957
},
{
"text": "S. aureus",
"label": "SPECIES",
"start": 3212,
"end": 3221
}
] | en |
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LivingNER: Named entity recognition, normalization & classification of species, pathogens and food
Dataset Summary
The LivingNER Gold Standard corpus is a collection of 2000 clinical case reports covering a broad range of medical specialities, i.e. infectious diseases (including Covid-19 cases), cardiology, neurology, oncology, dentistry, pediatrics, endocrinology, primary care, allergology, radiology, psychiatry, ophthalmology, urology, internal medicine, emergency and intensive care medicine, tropical medicine, and dermatology annotated with species [SPECIES] (including living organisms and microorganisms) and infectious diseases [ENFERMEDAD] mentions. Species mentions include many pathogens and infectious agents, but also food, allergens, pets or other species, taxonomic groups and organisms of clinical relevance.
The LivingNER corpus has also annotations of mentions of humans (tag HUMAN), including the patients itself, family members, healhcare professionals or other persons mentioned in the case reports. Thus it can be useful to extract family history information of patients or information about the social and healthcare personal environment and interactions.
All mentions have been exhaustively manually mapped by experts to their corresponding (NCBI Taxonomy)[https://www.ncbi.nlm.nih.gov/taxonomy] identifiers.
It was used for the (LivingNER)[https://temu.bsc.es/livingner/] Shared Task on pathogens and living beings detection and normalization in Spanish medical documents, which was celebrated as part of IberLEF 2022.
Usage
from datasets import load_dataset
# Load the dataset
dataset = load_dataset('path/to/dataset', '{lang}')
# Access splits
train_data = dataset['train']
test_data = dataset['test']
Labels
The following entity types are annotated in this dataset: ['O', 'B-HUMAN', 'I-HUMAN', 'B-SPECIES', 'I-SPECIES']
Citation Information
@article{amiranda2022nlp,
title={Mention detection, normalization \& classification of species, pathogens, humans and food in clinical documents: Overview of LivingNER shared task and resources},
author={Miranda-Escalada, Antonio and Farr{\'e}-Maduell, Eul{`a}lia and Lima-L{\'o}pez, Salvador and Estrada, Darryl and Gasc{\'o}, Luis and Krallinger, Martin},
journal = {Procesamiento del Lenguaje Natural}, year={2022}
}
@dataset{miranda_escalada_2022_7684093,
author = {Miranda-Escalada, Antonio and
Farré-Maduell, Eulàlia and
Lima-López, Salvador and
González Gacio, Gloria and
Krallinger, Martin},
title = {LivingNER corpus: Named entity recognition,
normalization \& classification of species,
pathogens and food
},
month = jun,
year = 2022,
publisher = {Zenodo},
version = {6.3.1},
doi = {10.5281/zenodo.7684093},
url = {https://doi.org/10.5281/zenodo.7684093},
}
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