A patient with infective endocarditis caused by community-acquired Pseudomonas aeruginosa infection

An 85-year-old woman complaining of nausea was admitted to our hospital after being found to have complete atrioventricular block. We diagnosed the patient with infective endocarditis after observing vegetation on transesophageal echocardiography (TEE) and detecting Pseudomonas aeruginosa in a blood culture. The patient had no history of intravenous drug use, instrumentation or valvular disease. Although sensitive antibiotics were administered intravenously, the second TEE performed on the 10th day demonstrated increased vegetation. The patient developed septic shock and died on the 14th day. To our knowledge, this is the first report of infective endocarditis caused by community-acquired Pseudomonas aeruginosa in Japan.

[Deficiency of selenium in pneumonia: an accident or regularity? Problem of nutriciology and gastroenterology]

THE AIM

Study of features of community-acquired pneumonia in young adults with deficiency of trace element selenium and the development directions of optimization of treatment.

MATERIAL AND METHODS

The study of 114 patients with community-acquired pneumonia, were evaluated nutritional deficiencies, the level of selenium in the blood plasma and the efficiency of application selenium biologically active additives in treatment of community acquired pneumonia.

THE RESULTS

The vast majority of the 114 patients with community-acquired pneumonia is marked by malnutrition and selenium varying degrees of symptoms.

CONCLUSION

Application of selenium dietary supplement in patients with community-acquired pneumonia contributes to earlier periods of permission of pneumonia and increase outcomes from full resolution infiltrative pulmonary field changes according to the radiographic study in patients of this category.

[Possibilities of therapeutic intervention in severe infections]

Severe infections of the respiratory system are the most important causes of hospital mortality and often unfold as severe sepsis or septic shock. Systemic inflammatory response syndrome (SIRS) with infection evidence (known as sepsis) and septic shock (severe sepsis with hemodynamic instability relentless on fluid resuscitation) are major healthcare problems, affecting millions of individuals around the world and killing about one-third affected every year. Similarly to myocardial infarction or severe trauma rapid onset and appropriateness of medical management in the first hours of sepsis are key point for clinical outcome.

Intracerebral hemorrhages in adults with community associated bacterial meningitis in adults: should we reconsider anticoagulant therapy?

Objective

To study the incidence, clinical presentation and outcome of intracranial hemorrhagic complications in adult patients with community associated bacterial meningitis.

Methods

Nationwide prospective cohort study from all hospitals in the Netherlands, from 1 March 2006, through 31 December 2010.

Results

Of the 860 episodes of bacterial meningitis that were included, 24 were diagnosed with intracranial hemorrhagic complications: 8 upon presentation and 16 during clinical course. Clinical presentation between patients with or without intracranial hemorrhage was similar. Causative bacteria were Streptococcus pneumoniae in 16 patients (67%), Staphylococcus aureus in 5 (21%), Pseudomonas aeruginosa and Listeria monocytogenes both in 1 patient (4%). Occurrence of intracranial hemorrhage was associated with death (63% vs. 15%, P<0.001) and unfavorable outcome (94% vs. 34%, P<0.001). The use of anticoagulants on admission was associated with a higher incidence of intracranial hemorrhages (odds ratio 5.84, 95% confidence interval 2.17–15.76).

Conclusion

Intracranial hemorrhage is a rare but devastating complication in patients with community-associated bacterial meningitis. Since anticoagulant therapy use is associated with increased risk for intracranial hemorrhage, physicians may consider reversing or temporarily discontinuing anticoagulation in patients with bacterial meningitis.

The use of non-invasive ventilation during acute respiratory failure due to pneumonia

The use of non-invasive ventilation in patients with community-acquired pneumonia is controversial since this is associated with high rates of treatment failure, compared with other causes of severe acute respiratory failure. The populations of patients with community-acquired pneumonia who have demonstrated better response to non-invasive ventilation are those with previous cardiac or respiratory disease, particularly chronic obstructive pulmonary disease. By contrast, the use of non-invasive ventilation in patients with community-acquired pneumonia without these pre-existing diseases should be very cautious and under strict monitoring conditions, since there are increasing evidences that the unnecessary delay in intubation of those patients who fail treatment with non-invasive ventilation is associated with lower survival. Pulmonary complications of immunosuppressed patients are associated with high rates of intubation and mortality. The use of non-invasive ventilation in these patients may decrease the need for intubation and improve the poor outcome associated with these complications. Continuous positive airway pressure has been used to treat acute respiratory failure in several conditions characterised by alveolar collapse. While this is extremely useful in patients with acute cardiogenic pulmonary oedema, the efficacy in pneumonia seems limited to immunosuppressed patients with pulmonary complications. Conversely, there are no sufficient evidences on the efficacy of continuous positive airway pressure in immunocompetent patients with pneumonia and severe acute respiratory failure.

Severe sepsis in community-acquired pneumonia--early recognition and treatment

Despite remarkable advances in its management, community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality leading to significant consumption of health, social and economic resources. The assessment of CAP severity is a cornerstone in its management, facilitating selection of the most appropriate site of care and empirical antibiotic therapy. Several clinical scoring systems based on 30-day mortality have been developed to identify those patients with the highest risk of death. Although well validated in appropriate patient groups, each system has its own limitations and each exhibits different sensitivity and specificity values. These problems have increased interest in the use of biomarkers to predict CAP severity. Although so far no ideal solution has been identified, recent advances in bacterial genomic load quantification have made this tool very attractive. Early antibiotic therapy is essential to the reduction of CAP mortality and the selection of antibiotic treatment according to clinical guidelines is also associated with an improved outcome. In addition, the addition of a macrolide to standard empirical therapy seems to improve outcome in severe CAP although the mechanism of this is unclear. Finally, the role of adjuvant therapy has not yet been satisfactorily established. In this review we will present our opinion on current best practice in the assessment of severity and treatment of severe CAP.

Prospective comparison of severity scores for predicting mortality in community-acquired pneumonia

INTRODUCTION

Specific prognostic models for community acquired pneumonia (CAP) to guide treatment decisions have been developed, such us the Pneumonia Severity Index (PSI) and the Confusion, Urea nitrogen, Respiratory rate, Blood pressure and age ≥ 65 years index (CURB-65). Additionally, general models are available such as the Mortality Probability Model (MPM-II). So far, which score performs better in CAP remains controversial. The objective was to compare PSI and CURB-65 and the general model, MPM-II, for predicting 30-day mortality in patients admitted with CAP.

METHODS

Prospective observational study including all consecutive patients hospitalised with a confirmed diagnosis of CAP and treated according to the hospital guidelines. Comparison of the overall discriminatory power of the models was performed by calculating the area under a receiver operator characteristic curve (AUC ROC curve) and calibration through the Goodness-of-fit test.

RESULTS

One hundred and fifty two patients were included (mean age 73.0 years; 69.1% male; 75.0% with more than one comorbid condition). Seventy-five percent of the patients were classified as high-risk subjects according to the PSI, versus 61.2% according to the CURB-65. The 30-day mortality rate was 11.8%. All three scores obtained acceptable and similar values of the AUCs of the ROC curve for predicting mortality. Despite all rules showed good calibration, this seemed to be better for CURB-65. CURB-65 also revealed the highest positive likelihood ratio.

CONCLUSIONS

CURB-65 performs similar to PSI or MPMII for predicting 30-day mortality in patients with CAP. Consequently, this simple model can be regarded as a valid alternative to the more complex rules.

Invasive thymoma in a child: a rare case report

Thymomas are neoplasms of the anterior mediastinum and generally occur between the fourth and sixth decades of life. In children, they are rare, with few reported cases. We describe a 9-year-old boy with invasive thymoma treated successfully by surgery alone. The patient was previously healthy and under treatment for a community-acquired pneumonia. A chest radiograph showed an opacity at the left lung base, and thoracic computed tomographic scan showed a mass with thick walls and liquid content situated in the lingula with no cleavage plane with the mediastinum. The patient underwent a left anterolateral thoracotomy, which showed a mass extending from the anterior mediastinum, infiltrating the left upper lobe of lung, phrenic nerve, and pericardium. A left upper lobectomy and resection of the mediastinal mass and lymph nodes were carried out. The pathologic analysis showed it to be a type B3 fusiform-cell thymoma, infiltrating the left upper lobe and 1 peribronchial lymph node. A multidisciplined tumor group decided to observe the patient and followed with thoracic computed tomographic scans every 3 months. After 2 years of follow-up, the patient has no evidence of recurrent disease.

Bronchogenic cyst and pharyngeal fistular in an 81 year old female: A case report

Bronchogenic cyst is a rare clinical; entity that occurs due to an anomalous development of the ventral foregut; they are usually single but may be multiple and can be filled with fluid or mucus. They have been found all along the transoesophageal course, in perihilar or intraparenchymal sites, with predilection for the area around the carina. The location of the cyst depends on the embryonic stage of development at which the anomaly occurs. When the abnormal budding occurs during the early development, the cyst tends to be located along the tracheobronchial tree. The cysts that develop later during the late development are more peripheral and may be located within the lung parenchyma. Bronchogenic cysts have also been described in more remote locations, including neck, interatrial septum, abdomen, and retroperitoneal space. Past reports emphasised that a bronchogenic cyst is usually asymptomatic and presents as an incidental finding, but more recent reports suggest that the majority of adults with bronchogenic cysts ultimately become symptomatic. The actual natural history and percentage of asymptomatic bronchogenic cyst in adults are not known because of the absence of long-term follow up of a large group of patients with asymptomatic cyst. Symptomatic patients usually present with symptomatic related to cyst infection or compression of adjacent structures. Presentation in the elderly population is quite rare. It has been reported that approximately 0.6% of such cyst are noted in patients above the age of 60 years. Total documented cases of patients presenting after the age of 70 years have been noted to be only 8 in 2002.

[Mycoplasma pneumoniae and Stevens-Johnson syndrome]

Mycoplasma pneumoniae causes up to 10-40 % of community-acquired pneumonias. The incidence of M. pneumoniae pneumonia is greatest among children and young adults. The symptoms of M. pneumoniae upper and lower respiratory infections are usually mild and often self-limited. The most frequent extrapulmonary complications present in CNS, heart and skin. The skin affiliations are usually transient erythematous maculopapular or vesicular rashes but may sometimes evolve into Stevens-Johnson syndrome. M. pneumoniae is one of the most common microbe behind the infectious causes of SJS. We present a patient who developed incomplete Stevens-Johnson syndrome concomitant of Mycoplasma pneumoniae pneumonia.

Delayed recurrent ischemic stroke after initial good recovery from pneumococcal meningitis

We describe unusual delayed recurrent episodes of ischemic stroke in a patient with initial good recovery from pneumococcal meningitis due to progressive arterial stenosis for over 3 months. We postulate that any of the following may have been responsible for his condition: widespread cerebral vasculopathy due to the effects of purulent material bathing the base of the brain, an immune-mediated para-infectious condition, or a rebound effect of the primary inflammatory reaction that was initially suppressed by dexamethasone. This case demonstrates that progressive arterial stenosis can evolve months after bacterial meningitis and should be recognized as a potential vascular complication.

[Epidemiology and prophylaxis of ENT diseases in the cadets of the Nakhimov Naval School]

The objective of the present study was to determine the prevalence of otorhinolaryngological morbidity among the cadets of the Nakhimov Naval School and propose the effective measures for its reduction and prevention. A total of 335 children at the age from 11 to 17 years were available for the examination. The analysis of otorhinolaryngological morbidity during September and October 2011 revealed the high frequency of acute respiratory diseases (46 cases) and maxillary sinus symptoms (12 cases). The newly recruited children accounted for 40% of the affected patients. The results of the screening carried out in the military educational institution suggest the necessity of improvement of the quality of primary medical screening, timely diagnostics and correction of pathological conditions. They can be used to formulate the long-range objectives for the improvement of individual recommendations for the medical observation of the cadets presenting with chronic ENT diseases.

Fatal community-acquired primary Candida pneumonia in an alcoholic patient

A 54-year-old alcoholic woman developed fulminant community-acquired pneumonia. Despite receiving intensive support measures, she died four days after admission. An autopsy revealed bronchopneumonia with clusters of pseudohyphae and yeast-like fungi, and Candida albicans was isolated from both tracheal aspiration specimens obtained on admission and the postmortem lungs. The absence of vessel invasion or any other organ involvement led to a diagnosis of primary Candida pneumonia secondary to aspiration, rather than pulmonary seeding from systemic infection. Candida species isolated from respiratory tract samples are usually regarded as originating from colonization; however, the possibility for true Candida pneumonia should be taken into account, even in the setting of community-acquired pneumonia.

[Legionella pneumophila pneumonia and ataxia]

Legionella pneumophila is responsible for approximately 6-14% of hospital admitted community acquired pneumonia (CAP) cases. It is associated with a significant severity. In untreated patients is associated with 80% mortality and in patients with comorbidities mortality is approximately 100%. The authors present a case of Legionella pneumophila pneumonia with cerebellar dysfunction. Cerebellar dysfunction is a rare disorder (3.7% of cases), but is well documented and has been reported in the first cases of the disease. The authors warn for the relevance of the epidemiological context and emphasize the importance of reporting cases to identify outbreaks, tracing the source of contamination and preventing new cases.

[The short-term prognosis for hospitalized acute myocardial infarction patients: the impact of complication by community-acquired pneumonia]

OBJECTIVE

To analyze the correlation between the complication by community-acquired pneumonia (CAP) and the short-term prognosis in hospitalized acute myocardial infarction (AMI) patients.

METHODS

Five thousand five hundred and twenty-four AMI patients hospitalized in the PLA General Hospital from January 1993 to December 2009 were enrolled for clinical data, incidence of complications and 30-day mortality. The data from patients with and without CAP complications were compared. Multivariate logistic regression analysis was employed to assess the impact of CAP on the short-term prognosis of these patients.

RESULTS

In all 5 524 AMI patients studied, 477 cases of CAP was found (8.6%) . In comparison with those without CAP complication, these patients had higher age (74.3 ± 6.5 vs. 67.8 ± 4.5). The incidence of comorbidities [including old myocardial infarction (20.8% vs. 11.5%), hypertension (54.3% vs. 48.9%), diabetic mellitus (32.7% vs. 22.6%), cerebral-vascular disease (8.2% vs. 3.5%), chronic renal dysfunction (10.5% vs. 3.0%)], and complications [including arrhythmia (8.8% vs. 4.6%), gastrointestinal bleeding (5.0% vs. 0.8%) and shock (8.6% vs. 3.1%)] were all significantly higher, and hyperlipidemia (18.9% vs. 30.6%) was significantly lower (P < 0.05 or P < 0.01) in CAP complicated patients. The 30-day mortality was also significantly higher (32.1% vs. 9.7%, P < 0.01). Multivariate logistic regression analysis identified CAP and chronic renal dysfunction as an independent predictor of short-term mortality [odds ratio (OR) of CAP 3.693, 95% confidence interval (95%CI) 2.340 ~ 5.829, P < 0.01; OR of chronic renal dysfunction 12.608, 95%CI 4.448 ~ 35.739, P < 0.01].

CONCLUSIONS

The incidence of CAP complication was higher in AMI patients with higher age.CAP complicated patients were more likely to develop comorbidities/complications, and had higher short-term mortality. CAP was an independent risk factor of short-term mortality.

Extracorporeal membrane oxygenation for ARDS in adults

A 41-year-old woman presents with severe community-acquired pneumococcal pneumonia. Chest radiography reveals diffuse bilateral infiltrates, and hypoxemic respiratory failure develops despite appropriate antibiotic therapy. She is intubated and mechanical ventilation is initiated with a volume- and pressure-limited approach for the acute respiratory distress syndrome (ARDS). Over the ensuing 24 hours, her partial pressure of arterial oxygen (Pao2) decreases to 40 mm Hg, despite ventilatory support with a fraction of inspired oxygen (Fio2) of 1.0 and a positive end-expiratory pressure (PEEP) of 20 cm of water. She is placed in the prone position and a neuromuscular blocking agent is administered, without improvement in her Pao2. An intensive care specialist recommends the initiation of extracorporeal membrane oxygenation (ECMO).

Performance of PSI, CURB-65, and SCAP scores in predicting the outcome of patients with community-acquired and healthcare-associated pneumonia

The objective was to compare three score systems, pneumonia severity index (PSI), the Confusion-Urea-Respiratory Rate-Blood pressure-65 (CURB-65), and severe community-acquired pneumonia (SCAP), for prediction of the outcomes in a cohort of patients with community-acquired (CAP) and healthcare-associated pneumonia (HCAP). Large multi-center, prospective, observational study was conducted in 55 hospitals. HCAP patients were included in the high classes of CURB-65, PSI and SCAP scores have a mortality rate higher than that of CAP patients. HCAP patients included in the low class of the three severity rules have a significantly higher incidence of adverse events, including development of septic shock, transfer into an ICU, and death (p < 0.01). At multivariate Cox regression analysis, inclusion in the severe classes of PSI, CURB-65, or SCAP scores and receipt of an empirical therapy not adherent to international guidelines prove to be risk factors independently associated with poor outcome. PSI, CURB-65, and SCAP score have a good performance in patients with CAP but are less useful in patients with HCAP, especially in patients classified in the low-risk classes.

Diagnostic approach of pneumonia in an elderly patient with comorbidities--case report

Dyspnea is one of the symptoms that has a major impact on patients' health, with a negative influence on the quality of life. The main causes of dyspnea are cardiac, pulmonary and mixed (cardiac or pulmonary). There are several other causes such as metabolic conditions (acidosis), pain, neuromuscular disorders, otorhinolaryngeal disorders, anxiety, panic disorders and hyperventilation. Acute pneumonia in the elderly is a common occurrence and its incidence grows as the elderly population increases. We report the case of a 76 years old patient with a known cardiovascular condition, recently hospitalized for right pulmonary infarction. He presented to our clinic for influenced general state, rest dyspnea, fever, shiver, and productive cough in the last two days. Current medication included oral anticoagulants and triple antihypertensive treatment (responsible for his low blood pressure). Laboratory results showed a nonspecific inflammatory syndrome with leukocytosis and neutrophilia and mild normochromic normocytic anemia; D-dimers were within normal range, fibrin degradation products 1+; myocardial enzyme testing showed no alteration, and BPN (beta natriuretic peptide) was 790 pg/ml. Chest X-ray showed diffuse bilateral reticular shadows (more pronounced on the right side) and left costodiafragmatic opacification. It appears that age-related increase in morbidity and mortality in community-acquired pneumonia is not due to age per se, but to interactions between the immune system, systemic diseases and nutritional factors. Community-acquired pneumonia in the elderly is known to have a high mortality. Although the diagnosis can be easy, the physician must also investigate for less obvious causes of dyspnea such as the presence of comorbidities and fragility of the elderly patient.

Cardiac complications in patients with community-acquired pneumonia: a systematic review and meta-analysis of observational studies

BACKGROUND

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality. CAP can trigger acute cardiac events. We sought to determine the incidence of major cardiac complications in CAP patients to characterize the magnitude of this problem.

METHODS AND FINDINGS

Two investigators searched MEDLINE, Scopus, and EMBASE for observational studies of immunocompetent adults with clinical and radiological evidence of CAP that reported any of the following: overall cardiac complications, incident heart failure, acute coronary syndromes (ACS), or incident cardiac arrhythmias occurring within 30 days of CAP diagnosis. At a minimum, studies had to establish enrolment procedures and inclusion and exclusion criteria, enroll their patients sequentially, and report the incidence of cardiac complications as a function of their entire cohorts. Studies with focus on nosocomial or health care-associated pneumonia were not included. Review of 2,176 citations yielded 25 articles that met eligibility and minimum quality criteria. Seventeen articles (68%) reported cohorts of CAP inpatients. In this group, the pooled incidence rates for overall cardiac complications (six cohorts, 2,119 patients), incident heart failure (eight cohorts, 4,215 patients), acute coronary syndromes (six cohorts, 2,657 patients), and incident cardiac arrhythmias (six cohorts, 2,596 patients), were 17.7% (confidence interval [CI] 13.9-22.2), 14.1% (9.3-20.6), 5.3% (3.2-8.6), and 4.7% (2.4-8.9), respectively. One article reported cardiac complications in CAP outpatients, four in low-risk (not severely ill) inpatients, and three in high-risk inpatients. The incidences for all outcomes except overall cardiac complications were lower in the two former groups and higher in the latter. One additional study reported on CAP outpatients and low-risk inpatients without discriminating between these groups. Twelve studies (48%) asserted the evaluation of cardiac complications in their methods but only six (24%) provided a definition for them. Only three studies, all examining ACS, carried out risk factor analysis for these events. No study analyzed the association between cardiac complications and other medical complications or their impact on other CAP outcomes.

CONCLUSIONS

Major cardiac complications occur in a substantial proportion of patients with CAP. Physicians and patients need to appreciate the significance of this association for timely recognition and management of these events. Strategies aimed at preventing pneumonia (i.e., influenza and pneumococcal vaccination) in high-risk populations need to be optimized. Further research is needed to understand the mechanisms underlying this association, measure the impact of cardiac complications on other CAP outcomes, identify those patients with CAP at high risk of developing cardiac complications, and design strategies to prevent their occurrence in this population.

Vascular complications are associated with poor outcome in community-acquired pneumonia

BACKGROUND

Recognition of cardiovascular risk factors is important for primary and secondary prevention strategies. Recent evidence has linked lower respiratory tract infections with the development of acute myocardial infarction.

AIM

The aim of this study was to determine the frequency of cardiovascular and cerebrovascular events and the clinical outcomes, during hospitalization for community-acquired pneumonia (CAP).

DESIGN

We performed a retrospective study of 4408 patients with CAP presenting to five hospitals over a 2-year period. Clinical information, co-morbidities, cardiovascular events and 90-day mortality were collected from review of medical case notes. The relationship between cardiovascular events and outcomes were analysed using multivariable logistic regression.

RESULTS

From a total of 4408 patients, 2.2% developed stroke, 5% acute coronary syndrome or myocardial infarction and 9.3% new onset atrial fibrillation. These were associated with increased 90-day mortality [odds ratio (OR), 1.49 95% CI 1.18-1.87, P=0.0006]. Vascular events were independently associated with increased length of hospital stay-median 12 days (IQR 5-22), compared to patients with no vascular events 8 days (IQR 3-17 days, P<0.0001).

CONCLUSION

Cardiovascular and cerebrovascular events are common during hospitalization for CAP and are associated with increased 90-day mortality.

Antibiotic treatment schemes for very severe community-acquired pneumonia in children: a randomized clinical study

OBJECTIVE

To compare clinical response to initial empiric treatment with oxacillin plus ceftriaxone and amoxicillin plus clavulanic acid in hospitalized children diagnosed with very severe community-acquired pneumonia (CAP).

METHODS

A prospective randomized clinical study was conducted among children 2 months to 5 years old with a diagnosis of very severe CAP in the pediatric ward of São Paulo State University Hospital in Botucatu, São Paulo, Brazil, from April 2007 to May 2008. Patients were randomly divided into two groups by type of treatment: an oxacillin/ceftriaxone group (OCG, n = 48) and an amoxicillin/clavulanic acid group (ACG, n = 56). Analyzed outcomes were: time to clinical improvement (fever and tachypnea), time on oxygen therapy, length of stay in hospital, need to widen antimicrobial spectrum, and complications (including pleural effusion).

RESULTS

The two groups did not differ statistically for age, sex, symptom duration before admission, or previous antibiotic treatment. Time to improve tachypnea was less among ACG patients than OCG patients (4.8 ± 2.2 versus 5.8 ± 2.4 days respectively; P = 0.028), as was length of hospital stay (11.0 ± 6.2 versus 14.4 ± 4.5 days respectively; P = 0.002). There were no statistically significant differences between the two groups for fever improvement time, time on oxygen therapy, need to widen antimicrobial spectrum, or frequency of pleural effusion.

CONCLUSIONS

Both treatment plans are effective in treating very severe CAP in 2-month-to 5-year-old hospitalized children. The only analyzed outcome that favored amoxicillin/clavulanic acid treatment was time required to improve tachypnea.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT01166932.