Malaria in our backyard

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Abstracts

splenic infarction, may be a cause of acute abdominal pain in otherwise healthy young patients. doi:10.1016/j.ejim.2013.08.546

ID: 613 Spondylodiscitis: A review of fourteen cases M.J. Oliveiraa, M. Santosb, A. Araújoa, A. Monteiroa, F. Lourençoa, A. Rodriguesa, I. Coelhoc, D. Navarrod, A. Panarraa, N. Risoa a

Internal Medicine 7.2, Hospital Curry Cabral, CHLC, Lisbon, Portugal Oncology, Instituto Portugues de Oncologia, Lisbon, Portugal c Hematology, Instituto Portugues de Oncologia, Lisbon, Portugal d Nephrology, Hospital Curry Cabral, CHLC, Lisbon, Portugal b

Introduction: Spondylodiscitis is defined as infection accompanied by destruction of the vertebral bodies with secondary involvement of the intervertebral disks. Spondylodiscitis can be described etiologically as pyogenic, granulomatous or parasitic. Although a wide range of microorganisms have been linked with spondylodiscitis, Staphylococcus aureus is the predominant pathogen. The most common symptoms are pain, fever and neurological deficits. Diagnosis can be difficult and often delayed due to the rarity of the condition with non-specific symptoms. It's based on clinical, laboratory and radiological features. A high index of suspicion is needed to ensure improved outcomes. Prognosis has improved along the years with the findings in antimicrobial therapy and improvements in radiological and surgical tecniques. However, randomized clinical trials are needed to further explore the duration, route of administration, as well as novel therapeutic agentes. Objective: The aim of this study is to characterize the clinical and laboratory features, follow-up and clinical outcomes of spondylodiscitis patients followed in our hospital. Methods: Patients were identified through a retrospective review of clinical files in our hospital between 2008 and 2013. Results: Fourteen patients were identified, four females and ten males, with a mean age of 64 years. Eleven patients had risk factors or co-morbid diseases and two had epidemiological context. The most common signs and symptoms were pain (100%), fever (64%), astenia, anorexia and weight loss (50%) in addition to neurologic deficits (28%). An elevation of the erytrocyte sedimentation rate was observed in all cases with a mean value of 90 mm/h. Computed tomography (CT) was performed in all patients, and magnetic resonance image was performed in eight. The lumbar spine was most commonly involved (64%). We identified the pathogen in eleven patients. Staphylococcus was the most frequent, followed by Gram negative bacilli. A distant focus of infection was identified in 12 patients. All patients underwent antimicrobial therapy with a mean duration of twelve weeks while surgical treatment was performed in half. Complete response was achieved in 11 patients. 3 patients developed disability due to neurological deficit or severe pain. One patient died from uncontrolled sepsis. In our review no relapses occured. Conclusion: The review represents the reality of our hospital and is in accordance with the previously published series. However we highlight some aspects. The CT examination was crucial for diagnosis and magnetic resonance imaging was used only to better define the lesions. In some patients, it was not possible to determine the etiologic agent. In the majority of the patients the therapy was established empirically. Surgery was required in half. The evolution was favorable in most subjects, and the mortality rate was low. doi:10.1016/j.ejim.2013.08.547

ID: 621 Brucelloma diagnosis and treatment: Report of two cases G. Perez-Vazqueza, J.L. Puerto-Alonsoa, E. Campos-Davilab a

Internal Medicine Service, Servicio Andaluz de Salud, Hospital La Linea de la Concepcion, La Linea, Cadiz, Spain b Pharmacy Service, Servicio Andaluz de Salud, Hospital La Linea de la Concepcion, La Linea, Cadiz, Spain

Objective: We intend to describe two cases of brucellar liver abscess reviewing their clinical presentation, diagnostic clues, characteristic findings on imaging and special treatment needs. Material and methods: We present clinical and imaging data and review the current medical literature. We report two cases. Case One: 58-year-old man with toxic syndrome and right upper quadrant pain of three weeks of evolution. Case Two: 43-year-old man with fever, weakness and arthralgia of 4 weeks of evolution. Results: Case One: Abnormal laboratory findings were as follows: GGT 80 IU/l, ESR 77 mm, CRP 160 mg/l, and Rose Bengal positive. Wright's agglutination test was found to be positive at 1/160. Abdominal ultrasonography (US) showed a 2 cm per 2.5 cm rounded hypodense area with central calcification that was later confirmed by Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). Drainage was performed by open surgical drainage. The patient was also treated with streptomycin (1000 mg/day) and doxycycline (200 mg/day). Case Two: Abnormal laboratory findings were as follows: ESR 98 mm, AST 145 IU/L, ALT 33 IU/L, ALP 127 IU/L, CRP 110 mg/dl, and Rose Bengal positive; Wright’s agglutination test was found to be positive at 1/10 ∗ 6. Blood cultures were positive for Brucella. US showed a liver abscess of 3 cm with central calcification and heterogeneous containing. Drainage by laparotomy was performed and treatment with doxycycline (200 mg/day) and streptomycin (1000 mg/day) as well as in the other case. Both had a good early response, they were discharged with a regime of doxycycline 200 mg/day orally for another two months and had no relapse during a 6-month follow-up. Discussion: The diagnosis of brucellar liver abscess is based on the demonstration of specific antibodies at significant titers or seroconversion, like Wright's seroagglutination ≥ 1/160 or a Coombs' antibrucella test ≥ 1/320 and a pseudotumoral heterogeneous lesion with central calcification visible by US, CT and MRI. Surgical drainage and treatment with streptomycin and doxycycline appear to be the most effective option. Conclusions: Brucellar liver abscess is a very rare complication in brucellosis and is easily diagnosed by clinical suspicion supported by positive serology and characteristic image features visible by US, CT and MRI. Brucellosis is a zoonotic infection that can affect almost any organ. Although hepatic involvement is very common during the course of chronic brucellosis, hepatic abscess is a very rare complication of Brucella infection. doi:10.1016/j.ejim.2013.08.548

ID: 623 Malaria in our backyard L. Sousaa, S.T. Cunhaa, C. Fariaa, M. Cadetea, V.F. Vieiraa, J. Gonçalvesa, J. Santosa, C. Pereiraa, S. Mendesb, R. Costab a

Serviço de Medicina II, Centro Hospitalar Leiria-Pombal, Leiria, Portugal Serviço de Patologia Clinica, Centro Hospitalar Leiria-Pombal, Leiria, Portugal

b

Malaria is a disease typical of endemic areas, mainly in the southern hemisphere, and infrequent in Europe. However, as some endemic countries have a fast economic growth, these destinations

Abstracts

have become more frequently experienced and, in the context of the current economic crisis, an emigration possibility, thus increasing the incidence in the northern hemisphere. Portugal is a country in which these facts are extremely relevant due to the strong cultural and language connection it has with some of these endemic countries. Therefore a rise in the number of cases of imported malaria is expected. The authors present the statistics of malaria cases in a Portuguese district hospital. This is a retrospective study of five years, which included all patients with positive plasmodium antigen (n = 25). Our results show, as expected, a significant increase in malaria cases. Most patients contracted the disease in Angola (64%), did not do or inappropriately did prophylaxis, and the most frequent species found was Plasmodium falciparum (76%). In most cases the treatment has been carried out with doxycycline and quinine (60%). 40% of the patients needed hospitalization in an Infectious Diseases Ward. Some patients had severe forms of the disease and multiple complications, resulting in ICU admissions (12%) and surgical treatments (8%). There were no deaths. These results support the increase of malaria's importance and the need to adequately prepare our health structures. The starting point should be prevention. Travelers and emigrants should be aware of the danger of contracting malaria and be taught the adequate measures to prevent the infection. It is important that they understand the need to follow the advice given and the consequences of this disease, potentially mortal. They should also be taught to recognize the symptoms and to promptly look for medical help. On the other hand doctors must be aware that malaria is the top cause of fever in patients returning from endemic countries and should be the number one suspect, after all, malaria is a leading cause of death by an infectious disease worldwide. doi:10.1016/j.ejim.2013.08.549

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elevation (1 mm) in V2–V5, negative T-wave in II and aVF leads and isodiphasic T-wave in V3–V4. High sensitivity troponin T level was 145 ng/L and creatine kinase-MB was also elevated (12 ng/mL). An echocardiogram showed small pericardial effusion without signs of cardiac tamponade or contraction defects with normal ventricular function. Consequently, the patient was placed on a nonsteroidal anti-inflammatory agent, with improvement of general status and disappearance of chest pain. Discussion: Myopericarditis can present in various settings, varying from infectious causes to non-infectious etiologies. Purulent myopericarditis has become an uncommon disease in the modern era, due to the widespread use of broadspectrum antimicrobials. Bacterial myopericarditis can be a severe complication of infectious diseases. Purulent myopericarditis carries a high mortality rate of 30–50% despite appropriate treatment. Poor prognosis in myopericarditis is specially associated with a delay in the diagnosis and treatment. When bacterial myopericarditis is suspected, empiric broad-spectrum parenteral antibiotics should be administered immediately. Strains of E. coli from urinary tract contain more virulence factors and rare, therefore, more pathogenic than other strains. They have developed multitude of virulence factors capable of producing different types of responses in different types of tissues and cells, including cardiomyocytes. Conclusion: Despite suffering from a severe infectious disease, the present patient had only minor complaints. Although clinical signs of myopericarditis developed while she was in the hospital, the clinical picture upon admission was atypical and showed only urinary tract infection and dissociated cholestasis. This presentation would raise the question about the origin of myopericarditis, whether it was already present at admission or it was developed later. In spite of the frequency of E. coli infections, we only found one previous reported case of E. coli pericarditis, and no case of myopericarditis associated with E. coli infection. doi:10.1016/j.ejim.2013.08.550

ID: 640 Acute myopericarditis associated with urinary tract infection and cholecystitis A. González Munera, C. López González-Cobos, D. Salor Moral, M. Ferrer Civeira, B. Pinilla Llorente, A. Muiño Miguez, M. Gomez Antunez, M.V. Villalba García

ID: 672 Primary psoas abscess — An unusual clinical presentation V. Kryvonos, C. Rodrigues, J. Jácome, I. Terrahe, P. Mendonça, C. Loureiro

Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain

Internal Medicine, Hospital Curry Cabral, Centro Hospitalar Lisboa Central, Lisboa, Portugal

Introduction: Infectious myopericarditis is a major cause of heart failure. Viral infection is the most common cause in developed countries, but some protozoa and bacteria have also been identified as causal agents. The prognosis varies greatly from asymptomatic affectation to fulminant heart failure. Case report: We present the case of a 23 year-old female who was admitted to the emergency department. She complained of 5 days of nausea and high fever (up to 39.5 °C) with chills, as well as abdominal pain. Physical examination showed fever and tachycardia. At her arrival, a complete analysis showed alkaline phosphatase 230 mg/dL and gammaglutamyltransferase 230 mg/dL with normal bilirubin, elevated creatine kinase (4590 mg/dL) and urinary tract infection. ECG at admission showed sinus tachycardia with no further alterations. The patient was admitted to the internal medicine department with the diagnosis of cholestasis of uncertain origin, urinary tract infection and rhabdomyolysis secondary to fever. An empirical antibiotic treatment with amoxicillin/clavulanate was then started. On the day after admission, urine culture came positive for Escherichia coli. An ultrasound showed acute–subacute lithiasic cholecystitis. Antibiotic was switched to piperacillin/tazobactam. On the third day after admission, the patient complained of chest pain. A new ECG was performed, showing a sinus rhythm, normal PR interval, concave ST-

Introduction: A psoas abscess is a collection of pus in the iliopsoas muscle compartment, whose incidence is rare but the frequency of this diagnosis has increased with the use of computed tomography (CT). It may be classified as primary if it occurs as a result of hematogenous or lymphatic seeding from a distant site, being more frequent in children and young adults. On the other hand, it may be secondary if the abscess occurs by direct spread of infection to the psoas muscle from adjacent structures. This primary abscess is more frequent in males, being the peak incidence in the developed countries between 44 and 58 years of age. The risk factors include diabetes, intravenous drug use, HIV infection, chronic renal failure and other immunocompromised states. The most common bacterial cause is Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA). Management of psoas abscess consists of drainage and appropriate antibiotic therapy. Psoas abscess can portend significant morbidity and mortality and relapse can occur up to one year after the initial presentation. Methods: We present a case of primary psoas abscess due to MRSA, in a female patient, 78 years old, who went to the emergency room with fever, prostration and constant and intense cervical dorsal pain without aggravating or relieving factors. The physical examination was normal, except for a nuchal rigidity found, and a lumbar puncture was performed, being the cytochemical