A RARE CAUSE OF FEVER OF UNKNOWN ORIGIN IN THE ELDERLY

S8

Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112

his brother, both with early kidney affection and severe left ventricular hypertrophy, without other conditions. After reviewing the literature, no patients were identified as carriers of this mutation. Conclusion: – The mutation g.6177T>A is pathogenic for Fabry disease and has not been previously identified. – It may be related to a mixed cardio-renal phenotype with severe early onset of the condition, unlike single cardiac or renal variants. ACUTE PYELONEPHRITIS: MICROBIOLOGY AND ANTIMICROBIAL THERAPY Miguel Ángel Artacho Rodríguez1, Cristina Díez Romero1, Itxasne Cabezón Estévanez1, Paloma Díez Romero1, María Torrea Valdepérez1, María Olmedo Samperio1, Chiara Fanciulli1, Isabel Pérez Tamayo1, Jesús Millán Núñez-Cortés1, José Santiago Filgueira Rubio1. 1Medicina Interna III. Hospital General Universitario Gregorio Marañón Background: Urinary tract infections are the major cause of nosocomial infection. Escherichia coli is the most common germ involved. Since it has been firmly documented the variability of sensitivity and resistance pattern depending on the population studied, the aim of our study is to assess the pattern in the Department of Internal Medicine HGU Gregorio Marañón. Methods: A restrospective study was carried out in a cohort of 82 patients admitted, with the diagnosis of acute pyelonephritis (AP), in the first half of 2011. Epidemiologycal and microbiologycal data were collected. The statistical analysis was done with the SPSS v. 18.0. Results: Of our population, 75.6% were females. Average age was 44.3 ± 20.3 years. It was taken out urine and blood cultures at 91.2% and 87.8% of our patients, being “positive” in 75.6% and 20.8% respectively. The agent most frequently isolated was E. coli (65.9%) founding a 100% sensitivity to fosfomycin. It was followed by K. pneumoniae (2.4%), E. faecalis (2.4%), S. saprophyticus (1.2%) and P. mirabilis (1.2%). Third generation cephalosporin was the most frecuently antimicrobial used for treatment. Almost 5% of patients were transferred to hospital home care. There being no deaths and only 12 patients had a recurrence of the disease. Conclusions: Acute pyelonephritis mainly affects females, being E. coli the most common organism. Despite of we found a 100% E. coli sensitive to fosfomycin, we used 3rd generation cephalosporin as empirical treatment. We would stress the importance of microbiological analysis for the identification and targeted treatment. SPECTRUM OF FOOT PROBLEMS IN PATIENTS WITH DIABETES MELLITUS (DM) TYPE II BASED ON OUR EXPERIENCE. ANOTHER LOOK AT THE SIGNIFICANT ROLE OF PRIMARY HEALTH CARE IN THE PREVENTION AND EARLY DETECTION OF DIABETIC FOOT COMPLICATIONS Dafni Koumoutsea1, Ioannis Megas1, Damianos Aslanoglou1,5, Pantelis Kapralos1,6, Vasilios Tsiligiris2, Konstantinos Karamitsos3, Georgios Stavgiannoudakis3, Panagiota Thalassinou4, Nikolaos Thalassinos4, Ioannis Hatzigeorgiou7, Ioannis Angelakas2, Evangelos Nanos2. 1First Department of Internal Medicine and Division of Endocrinology, 401 General Military Hospital of Athens, Greece; 2Departments of General and Vascular Surgery, 401 General Military Hospital of Athens, Greece; 3Department of Nephrology, 401 General Military Hospital of Athens and 417 Veterans Affairs Hospital of Athens, Greece; 4Sixth IKA Hospital of Athens, Greece; 5Health Center of Patmos, Greece; 6 Health Center of Karpathos, Greece; 7General Hospital of Syros, Greece Purpose/Aim: To review the spectrum of foot problems in patients with DM type II and the underlying etiologic factors. Moreover, to emphasize the significant role of primary health care in the prevention and early detection of diabetic foot complications. Materials/Methods: Retrospective study was conducted between June 2002 and June 2010. 72 patients with diabetic foot infection were admitted to the surgical departments of our hospital. The medical records of the above study group were reviewed. The variables analysed were age, gender, family history of DM type II, kind of treatment (oral hypoglycemic drugs or insulin), concomitant neuropathy and clinical presentation (gangrene, infected ulcers, cellulites etc.). Results: Among 72 patients who were thoroughly examined, there were 56 males and 16 females with a mean age of 68,9 years. Most of them (94,5%) were elderly relatives of the military personnel, who were living in very distant rural

areas or isolated islands (mainly frontier regions) and they had been admitted for foot problems to a general hospital for the first time. 47 patients had a family history of DM type II. 50 were being controlled by oral hypoglycemic drugs and 22 were insulin-dependent. 5 patients had been newly detected to have diabetes for the first time. On admission, all patients were started on antibiotic treatment covering aerobic and anaerobic organisms whilst awaiting the results of discharges culture and sensitivity tests. 58 patients had an operative intervention for their condition, 18 were treated successfully with simple drainage and debridement, 17 patients had a big toe amputation, 12 patients had other toes amputations, 9 patients underwent below knee amputations and 2 patients underwent above knee amputations. As far as concomitant neuropathy is concerned, there was no significant difference in clinical presentation among patients controlled by oral hypoglycemic drugs as compared with those on insulin prior to admission. A diabetic history had a major effect on the severity of clinical presentation and it was observed that the longer was the history of diabetes; the more severe was the clinical presentation. Conclusions: Diabetes is a very common disease in which several medical specialties are implicated. The above results demonstrate that programs for prevention and early detection of complications are mainly needed in the primary health care, espesially in the family medicine departments and in the community medicine departments of isolated rural areas and islands, including foot screening, provision of appropriate footwear and foot care. The establishment of diabetic foot clinics – not only in general hospitals of urban and suburban areas but in primary health care as well – is needed to follow up and treat diabetic complications as early as possible, because the above complications would have been minor if they had been detected earlier. It is certain that limited access to basic foot care and protective footwear may contribute to diabetic foot complications. HEPATOSPLENIC SCHISTOSOMIASIS AS RARE CAUSE OF HEMATEMESIS Panagiota Athanasopoulou, Maria Pirounaki, Georgios Alafostergios, Christos Koutsianas, Styliani Klonari, Stamatia Athanasopoulou, Ioannis Ketikoglou, Antonios Moulakakis. Internal Medicine Department, Hippokration Hospital, Athens, Greece Background: Schistosomiasis is endemic in tropical and subtropical areas but it is rarely found in Europe. This paper describes a case of an egg-negative patient with hepatosplenic schistosomiasis presenting as hematemesis in an Egyptian immigrant. Case report: A previously asymptomatic 23-year-old man who migrated to Greece from a rural region of Egypt presented with hematemesis and melena due to ruptured esophageal varices. He had normal hepatic function and ultrasonography revealed portal hypertension, splenomegaly and absence of hepatic or portal vein thrombosis. Although the microscopic examination of stool and urine for eggs was negative, a diagnosis of schistosomiasis was based on the presence of relevant epidemiologic history, positive serologic tests for antibodies to schistosomes, iron defficienchy anemia, elevated IgE concentrations, and a liver biopsy revealing periportal fibrosis, focal epithelioid granulomas, lymphocytes, plasma cells and eosinophils, indicative of a parasitic infection. Coinfection with HIV, HBV, HCV was excluded. ANA and anti-Jo1 antibodies were positive. The patient improved on endoscopic treatment and prazicuantel. Discussion: Chronic schistosomiasis is an immune complex disease with various complications. Concurrent infection with HIV, HBV, HCV viruses and alcoholic cirrhosis worsens the prognosis. Elevated ANA and anti-Jo1 antibodies were considered as reactive to the helminthic infection as there were no laboratory or clinical features of polymyositis. Conclusion: Population movements and international travel have increased schistosomiasis prevalence in Europe, therefore it should be considered in the differential diagnosis of patients with upper GI bleeding. A RARE CAUSE OF FEVER OF UNKNOWN ORIGIN IN THE ELDERLY Paula Augusto, Mónica Levy, Samaher Tannira, Francisco Silva, José Graça. Serviço de Medicina II, Hospital de Egas Moniz – CHLO, Portugal Background: Adult-onset Still’s disease (AOSD) is an uncommon febrile disorder of unknown aetiology, with seronegative poliarthritis in association with a sistemic inflammatory illness. Methods: A 74 year old woman without relevant past medical history was admitted to an Internal Medicine Department for workup and diagnosis on a

Abstracts from 10th Congress of the European Federation of Internal Medicine/European Journal of Internal Medicine 22S (2011) S1–S112 2 months evolution of spiking fever (39°C), maculopapular rash on the upper trunk and weight loss. Results: Laboratory results revealed microcytic anemia (Hb 8,3g/dL, MCV 67fL), neutrophilic leucocytosis (12000/uL), elevated C-reactive protein (8,5mg/dL) and erythrocyte sedimentation rate (120mm/h), hyperferritinemia (>10000ng/mL), absence of rheumatoid factor and antinuclear antibodies. Sequential blood cultures and serological tests performed were negative. Endoscopic studies showed superficial inflammation of gastric and colonic mucosa. Echocardiography detected a small pericardial effusion. Computer tomography revealed homogenous hepatosplenomegaly and bone marrow study had no malignant infiltration. After exclusion of common causes of fever in the elderly, the patient was given the provisional diagnosis of AOSD and started combination therapy with Ibuprofen (400 mg/day) and Prednisolone (1 mg/kg/day), becoming assymptomatic after 3 days, with laboratorial values back to reference range in 8 weeks. A gradual tapering of corticotherapy was attempted, but then fever recurred and arthralgias located to both wrists appeared, with radiologic and echographic findings sugestive of AOSD, helping to confirm the diagnosis. Conclusions: Although rare, AOSD is a serious disease and must be considered in the geriatric population. It has no pathognomonic findings, still being a diagnosis of exclusion. THE AGGRESSIVE FACE OF BENIGNITY Luísa Azevedo, Teresa Souto Moura, Sandra Gouveia, Nataliya Polishchuk, Isabel Germano, José Rola. Serviço de Medicina 1.4, Hospital de S. José – CHLC, EPE. Lisbon, Portugal Due to historical relationships with Africa, Portugal is witnessing a growing number of patients with human immunodeficiency virus type 2 (HIV-2) infection, which is classically associated with a benign course compared to its counterpart - type 1. Indeed, HIV-2 carries a slightly reduced risk of transmission and patients usually have a lower viral load; therefore, the infection tends to progress more slowly to acquired immune deficiency syndrome (AIDS). However, in the final stages of the natural history, the clinical spectrum can be virtually overlapped. The authors report the case of a 69-year-old black woman, from GuineaBissau, who presented to a Gastroenterology consult due to symptoms of dyspepsia. An upper gastrointestinal endoscopy was performed, revealing candida esophagitis and elevated lesions at the stomach body and distal duodenum. In this context, the diagnosis of HIV-2 infection was made and the patient was referred to our Internal Medicine/Immunodeficiency consult, where immunovirulogic staging showed a low CD4 cell count (34/mm3) and a HIV-2 viral load of 36.923 copies/mL. In a following consultation, the patient complained of fever, weight loss, anorexia, and asthenia, with cervical and submaxilar adenopathies (the largest with a 4cm-diameter) at examination. Admitted to our ward, the investigation revealed concomitant expression of multiple opportunistic diseases - candida esophagitis, systemic tuberculosis, cytomegalovirus colitis and gastrointestinal Kaposi’s sarcoma. With this communication the authors aim to point out some peculiarities inherent to research and therapeutic approach of patients with late presentation of HIV infection, common event with HIV-1 and also possible, as illustrated, with HIV-2. Keywords: HIV-2, opportunistic diseases, late presentation

S9

Only 68% had any form of consent documented. Pleural effusion (59%) and pneumothorax (31%) accounted for most of the indications. 38% of the procedures performed out of hours and all of them were justified. Majority (85%) were inserted by senior doctors (ST3+ level). Bedside Ultrasound was used in 80% of pleural effusion cases. The nursing drain observation chart was maintained in 88% cases. 8% minor immediate complication reported, no death or organ damage directly related to the procedure. Conclusion: This audit has demonstrated improving safety awareness that includes, most of procedure performed by trained doctors and use of bedside ultrasound. But it has highlited lack of training at junior doctors level, including thoracic ultrasound. Following this audit we have introduced the safety check list and training programme for junior doctors including ultrasound training. References T Havelock, BTS Pleural procedure guidelines 2010 NPSA Rapid response Report- NPSA/2008/RRR003 EFFICACY OF AUTOMATIC BLOOD PRESSURE DEVICE TO DETERMINE RELIABLY THE ANKLE BRACHIAL INDEX (ABI) Konstantina Bakalakou1, Athanasios Marinakos2, Anastasia Nouli2, Efstathios Taxiarchou2, Chrisanthi Margariti2, Kimon Papanikitas2, Sotirios Patsilinakos2, Ioannis Ioannidis1. 12nd Department Of Internal Medicine Konstantopoulio General Hospital N. Ionia Athens Greece; 2Cardiology Department, Konstantopoulio General Hospital N. Ionia Athens Greece Introduction: ABI constitutes a useful tool to detect peripheral arterial disease (PAD) and consequently identifies individuals with subclinical arteriosclerosis. Nevertheless, is rarely used in routine daily clinical practice probably because the gold-standard method for ABI measurement requires Doppler device and trained physicians. Aim: The aim of this study was to evaluate the ability of automatic blood pressure device to measure ABI accurately. Material - Method: ABI measurements with two different methods: with the automatic blood pressure device, Omron M4 (autoABI) and with the Doppler device Minidop ES-100VX 8Hz and a regular sphygmomanometer (dABI) were obtained sequentially in 130 participants (men 86, mean age 67 ± 7 years). 65 measurements were made first by autoABI and the rest 66 first by dABI (randomly). The results were compared by the Student paired t-test. To determine the reliability of the autoABI in diagnosing PAD, we calculated the sensitivity, specificity, positive predictive value, negative predictive value, and the area under the ROC curve Results: The mean dABI was 0,987 ± 0,178 vs an autoABI of 0,9947 ± 0.2 (p =0,4) The agreement among two methods was high (Cohen’s kappa coefficient= 0,841). The area under the curve (AUC) was 0.90 (95% confidence interval [CI], 0,863 to 0,97); while sensitivity was 80,49%, specificity 94,68%, positive predictive value 86,84% and negative predictive value 91,75%. Conclusion: ABI measurement with automatic commercial oscillometric devices is an easy and reliable method that would provide a practical tool for physicians not specifically trained to use the Doppler device.

UTILITY OF FRAX ALGORITHM AND QUS DENSITOMETRY AMONG WOMEN IN AN AREA OF SOUTHEASTERN GREECE

Amrithraj Bhatta, Imran Satia, Ram Sundar, Imran Aziz. Department of Respiratory Medicine, Royal Albert Edward Infirmary, Wigan, U.K.

Sofoclis Bakides, Foteini Papouli, Anna Zannou, Constantinos Soumbassis, Mihail Kotis, Theodora Dimaresi, Stephanos Varvaressos, Angelos Charamis, George Sakellariadis, George Papageorgiou. Molaoi General, Health Promoting Hospital of the W.H.O., Lakonia, Greece

Background: Intercostal Chest Drain (ICD) insertion is an invasive procedure indicated in certain emergency and elective scenarios. The practice is changing with more importance given to training, safety and use of ultrasound image guidance. The aim of this audit was to access current awareness & training level of junior doctors and level of practice. Methods: First part of audit includes questionnaire survey on awareness and competency. In the second part, 38 consecutive cases were audited retrospectively. Results: Of the 26 respondent, 61% were independently competent at ICD insertion, but only 9% of them performed more than 10 procedures in last one year. Only 23% of doctors had thoracic ultrasound training.

Background: Osteoporosis-related fractures cause substantial disability, health care costs, and increase mortality. Methods: We examined a sample of 177 postmenopausal women, aged 40-84 years. Bone mineral density was measured using heel QUS, clinical risk factors were evaluated by the FRAX® algorithm and, also, ten-year major osteoporotic fracture risk and hip fracture risk. Results: Mean age was 60,55 years and mean BMI was 28,51 kg/m2. In total 38 out of 177 were found eligible for treatment after DEXA measurement according to the N.O.F. guidelines. For women over 65, we have found 29,and also 2 and 7 for the age groups 40-49 and 50-65, respectively,which are depicted on the following Table:

AUDIT ON PLEURAL PROCEDURE IN A UK DISTRICT GENERAL HOSPITAL