Microbial keratitis in Sao Paulo, Brazil: a 10-year review of laboratory results, epidemiological features, and risk factors

PURPOSE

To study epidemiological data, laboratory results, and risk factors associated with microbial keratitis.

METHODS

We conducted a retrospective study of corneal sample cultures from patients with microbial keratitis from January 2010 to December 2019. Results were analyzed according to the etiological diagnosis of bacterial, mycotic, or parasitic infection and were associated with related risk factors.

RESULTS

We analyzed 4810 corneal samples from 4047 patients (mean age 47.79 ± 20.68 years; male 53.27%). The prevalence of bacterial, fungal, and Acanthamoeba infections were 69.80%, 7.31%, and 3.51%, respectively. The most frequently isolated bacteria were coagulase-negative Staphylococcus (CoNS) (45.14%), S. aureus (10.02%), Pseudomonas spp. (8.80%), and Corynebacterium spp. (6.21%). Among CoNS, the main agent was S. epidermidis (n=665). For mycotic keratitis, Fusarium spp. (35.42%) and Candida parapsilosis (16.07%) were the most common agents among filamentous and yeasts isolates, respectively. Contact lens use was associated with a positive culture for Acanthamoeba spp. (OR = 19.04; p < 0.001) and Pseudomonas spp. (OR = 3.20; p < 0.001). Previous ocular trauma was associated with positive fungal cultures (OR = 1.80; p = 0.007), while older age was associated with positive bacterial culture (OR = 1.76; p = 0.001).

CONCLUSIONS

Our findings demonstrated a higher positivity of corneal sample cultures for bacteria. Among those, CoNS was the most frequently identified, with S. epidermidis as the main agent. In fungal keratitis, Fusarium spp. was the most commonly isolated. Contact lens wearers had higher risks of positive cultures for Acanthamoeba spp. and Pseudomonas spp. Ocular trauma increased the risk of fungal infection, while older age increased the risk of bacterial infection.

Evisceration and enucleation cases in the ophthalmologic emergency department of a tertiary Brazilian hospital

PURPOSE

To analyze the epidemiological profiles of evisceration and enucleation cases in the ophthalmologic emergency department of a Brazilian tertiary hospital.

METHODS

Patients treated in the ophthalmologic emergency department of Hospital São Paulo (Universidade Federal de São Paulo) during the period 2013 to 2018 were retrospectively evaluated. Urgent cases of evisceration or enucleation surgery were included, and elective cases were excluded. The following information was extracted from the patients' medical records: demographic data, immediate and associated reasons for the surgical procedure, informed visual acuity, symptom duration until ophthalmologic care, complications, distance from the residence to the tertiary hospital, and time of hospitalization.

RESULTS

In total, 61 enucleations and 121 eviscerations were included in this study. The patients had a mean age of 63.27 ± 18.68 years. Of the patients, 99 were male (54.40%), and 83 were female (45.60%). The indications for evisceration or enucleation were corneal perforation with (44.50%) and without (23.63%) signs of infection, endophthalmitis (15.38%), ocular trauma (14.29%), neoplasia (0.55%), burn accident (1.10%), and phthisis bulbi (0.55%). The self-reported visual acuity was no light perception (87.36%) or light perception (1.10%). However, 3.30% of the patients did not cooperate with the examination, and no information on visual acuity was available for the remaining 8.24%. The mean symptom duration before ophthalmologic care was sought was 18.32 days. Two patients had sympathetic ophthalmia after evisceration.

CONCLUSIONS

More eviscerations than enucleations were performed throughout the study period. The most common demographic characteristics were age >60 years and male sex. The main indications for urgent evisceration and enucleation procedures were corneal perforation with and without infection, endophthalmitis, and ocular trauma. The findings from this study could guide clinicians in performing preventive measures to avoid destructive eye procedures.

Twelve-Year-Old Girl with Acute Macular Neuroretinopathy: A Multimodal Retinal Evaluation

We report a 12-year-old female patient with acute macular neuroretinopathy assessed with multimodal retinal exams. Initial fluorescein angiogram and optical coherence tomography angiography (OCT-A) were both normal, and after 4 months OCT-A showed abnormal vascular flow with normal flow in superficial retina layers, choroid, and choriocapillaris.

[Minocycline for the treatment of bronchiolitis obliterans associated with rheumatoid arthritis]

We discribe a rare case of rheumatoid arthritis (RA) complicated with bronchiolitis obliterans that was successfully treated with minocycline. Sixty four-year old woman with a four-years history of RA was admitted to the hospital because of dyspnea on exertion and polyarthritis. Pulmonary function test revealed marked decrease in V25 (0.10 l/s: 6.9%) and MMFR (12.6%). High resolution CT of the lung showed scattered centri-lobular micronodules in both lung fields, mucoid impaction, and hyperinflation. These findings indicated the presence of bronchiolitis obliterans. After 3 months of the treatment with minocycline, the patient showed a significant improvement of both arthritis and pulmonary function. Chest CT findings also improved after 1 year. The present case suggests that minocycline is effective for the treatment of bronchiolitis obliterans seen in patients with RA.

[Diagnosis and treatment of intracerebral hemorrhage]

INTRODUCTION

Intracerebral hemorrhage (ICH) is the main hypertensive mechanism occurring as the consequence of structural changes in the small perforating vessels of the cerebral hemispheres and brain stem.

DEVELOPMENT

These vascular lesions cause deeply situated hemorrhages in the cerebral hemispheres (basal grey nuclei and thalamus) and brain stem (pons); less common sites are in the subcortical white matter and cerebellum. There are many non-hypertensive causes of ICH including: amyloid cerebral angiopathy, vascular malformations, intracranial tumours, the use of anticoagulant and fibrinolytic agents, sympthomimetic drugs and vasculitis. These conditions usually cause hemorrhages situated in the subcortical white matter (lobar), some predominantly in the elderly (amyloid cerebral angiopathy) and others mainly in the young (vascular malformations and consumption of sympathomimetic drugs). Radiological diagnosis of ICH is easily made on computerized tomography (CT), and magnetic resonance (MR) gives additional data such as the stage of evolution of the hemorrhage and its possible causes (vascular malformations, underlying tumours). The therapeutic managements of ICH includes: immediate emergency treatment (the need for endotracheal intubation, control of the blood pressure) and the management of the conditions causing ICH (coagulation disorders, detection of toxic substances such as cocaine and other sympathomimetic agents); treatment of intracranial hypertension (hyperventilation, osmotic diuretics, barbiturate coma); the decision to proceed to surgery (reserved for patients with cerebellar bleeding accompanied by supratentorial hydrocephalus, lobar hemorrhage of intermediate size together with progressive neurological deterioration and signs of a space occupying lesion on CT, and ventriculostomy for thalamic or caudate nucleus bleeding with hydrocephalus.

Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism

CONTEXT

Intravenous tissue-type plasminogen activator can be beneficial to some patients when given within 3 hours of stroke onset, but many patients present later after stroke onset and alternative treatments are needed.

OBJECTIVE

To determine the clinical efficacy and safety of intra-arterial (IA) recombinant prourokinase (r-proUK) in patients with acute stroke of less than 6 hours' duration caused by middle cerebral artery (MCA) occlusion.

DESIGN

PROACT II (Prolyse in Acute Cerebral Thromboembolism II), a randomized, controlled, multicenter, open-label clinical trial with blinded follow-up conducted between February 1996 and August 1998.

SETTING

Fifty-four centers in the United States and Canada.

PATIENTS

A total of 180 patients with acute ischemic stroke of less than 6 hours' duration caused by angiographically proven occlusion of the MCA and without hemorrhage or major early infarction signs on computed tomographic scan.

INTERVENTION

Patients were randomized to receive 9 mg of IA r-proUK plus heparin (n = 121) or heparin only (n = 59).

MAIN OUTCOME MEASURES

The primary outcome, analyzed by intention-to-treat, was based on the proportion of patients with slight or no neurological disability at 90 days as defined by a modified Rankin score of 2 or less. Secondary outcomes included MCA recanalization, the frequency of intracranial hemorrhage with neurological deterioration, and mortality.

RESULTS

For the primary analysis, 40% of r-proUK patients and 25% of control patients had a modified Rankin score of 2 or less (P = .04). Mortality was 25% for the r-proUK group and 27% for the control group. The recanalization rate was 66% for the r-proUK group and 18% for the control group (P<.001). Intracranial hemorrhage with neurological deterioration within 24 hours occurred in 10% of r-proUK patients and 2% of control patients (P = .06).

CONCLUSION

Despite an increased frequency of early symptomatic intracranial hemorrhage, treatment with IA r-proUK within 6 hours of the onset of acute ischemic stroke caused by MCA occlusion significantly improved clinical outcome at 90 days.

Myocardial infarction and coronary artery involvement in giant cell arteritis

PURPOSE

To describe the pathologic findings in an unusual case of giant cell arteritis that presented initially with visual loss and rapidly culminated in myocardial infarction.

CASE REPORT

After the death of the patient, a complete autopsy was performed, including bilateral enucleation. All specimens, including a temporal artery biopsy completed before the patients death, were processed for routine paraffin histology and initially stained with hematoxylin and eosin. Elastic stains were subsequently used on specimens of temporal and coronary artery. The patient presented with loss of vision in the right eye. The clinical diagnosis was anterior ischemic optic neuropathy, secondary to temporal arteritis. The temporal artery biopsy was positive. Despite high-dose corticosteroid administration, the patient progressed to neurologic impairment, and subsequently to a fatal myocardial infarction.

DISCUSSION

Previous reports of temporal arteritis with coronary involvement are summarized. Myocardial infarction may be a more common early complication of temporal arteritis than appreciated previously. This important complication can occur despite administration of high-dose corticosteroid therapy.

[Plain film and CT findings of pulmonary involvement in rheumatoid arthritis]

OBJECTIVES

To analyze the plain film and CT findings of rheumatoid arthritis (RA)-associated lung diseases and to correlate them with clinical manifestations.

METHODS/MATERIALS

We retrospectively reviewed the plain chest and CT findings of 51 RA patients with lung diseases. Sixteen CT findings were separately corded as present or absent, and drew up our classification of lung diseases as follows; 1. interstitial pneumonia/pulmonary fibrosis (IP/PF), 2. airway disease (AD), 3. parenchymal disease (PD), and 4. mixed. Four plain film findings were also recorded, and classified in IP/PF or AD group. This classification was analyzed with reference to clinical parameters and courses.

RESULTS

Fifty-one patients were classified as follows; 1. IP/PF (n = 32, 62.6%), 2. AD (n = 15, 29.4%), 3. PD (n = 3, 5.9%), 4. mixed (n = 1, 2.0%). CT findings of PD were compatible with bronchiolitis obliterans organizing pneumonia with rapid improvement. IP/PF diagnosed with CT was depicted by the plain chest in 25 patients (78.1%). There is no false positive of the plain chest diagnosis in terms of IP/PF. As compared with IP/PF, AD consisted of significantly higher prevalence in female patients and patients with severe articular involvement and sinusitis. In spite of variable outcome in patients with AD, those with IP/PF showed the progression of honeycombing, and 4 of them were died from respiratory failure.

CONCLUSIONS

CT based classification of rheumatoid lung diseases correlates with clinical manifestations and prognosis and is useful for clinical management in patients of RA. CT diagnosis is useful especially when plain chest does not demonstrate typical IP/PF pattern.

[Remission induction after pentoxifylline treatment in a patient with rheumatoid arthritis]

Pentoxifylline (POF) has been shown to have anti-inflammatory and immunomodulatory effects. including suppression of TNF-alpha production by activated macrophages, Th-1 response of T cells, and fibroblasts' proliferation and metalloproteinase production. Pentoxifylline was also reported to possess therapeutic properties in 50% of severe refractory RA in an open study. We experienced a 64 year-old man with seronegative RA, stage 2, class 3. He showed 23 swollen joints, 32 painful joints, ADL score 37/40, and ESR 135 mm/h. All these parameters were dramatically improved 3 weeks after administration of POF 300 mg/d and prednisolone 5 mg/d. Discontinuation of POF resulted in rapid exacerbation of RA. POF was restarted and the patient showed complete recovery from arthritis with normalization of ESR within 3 months and was maintained a complete remission for another 1 year. This case further supports a potential antirheumatic effect of POF on some patients with RA.

Cerebellar hemorrhagic infarction

We investigated 17 patients with 26 cerebellar hemorrhagic infarcts for their vascular anatomy, stroke mechanisms, and clinical course. Sixteen infarcts involved the superior cerebellar artery, nine the posterior inferior cerebellar artery, and one the anterior inferior cerebellar artery territories. The infarcts involved the full territory of the supplying arteries in 19 of 26 infarcts (73%). Sixteen of 17 patients were stable or improving when the hemorrhagic infarction was detected. All but one patient had an imaging study at the time of presentation that was negative for blood; hemorrhagic infarction was detected on routine serial scans performed during the first 15 days. Nine of the 17 patients were on anticoagulants when the cerebellar hemorrhagic infarct was detected; anticoagulation was maintained in eight of them with no clinical worsening. The stroke mechanism in all patients was considered embolic from cardiac and intra-arterial sources. The causes, imaging findings, and consequences of hemorrhagic infarcts in the posterior circulation are similar to those in the anterior circulation.

Acute stroke therapy trials: an introduction to recurring design issues

We discuss selected issues concerning the design of stroke treatment trials. Key issues include the type of stroke studied, the time interval from stroke onset to patient entry, and whether to include cardioembolic strokes and allow concomitant therapy.