- Email: [email protected]
Eggerthella lenta bacteremia associated to colonic polyps and colon adenocarcinoma
418
Letters to the Editor / Med Clin (Barc). 2017;149(9):417–421
neuromonitoring in the immediate postoperative period, with figures of ICP within normal levels and sedation break with normal neurological examination. 20 h after surgery there was an increase in ICP, with no response to first-level measures. CT angiography showed acute ischemic infarction in the right anterior cerebral artery (ACA) and the middle cerebral artery (MCA), with a significant expansive effect that determined an uncal herniation, infarction in the left MCA territory with presence of penumbra areas and vasospasm in the proximal segment of bilateral MCA and ACA and basilar artery. Intra-arterial instillation of nimodipine was performed under arteriography, with significant improvement in the immediate period. Within a few hours there was a new ICP elevation and diffuse cerebral edema, deciding to perform a decompressive craniectomy. The subsequent progression was poor, with the onset of new ischemic infarction areas in the right MCA and ACA territory, with significant expansive effect and signs of acute ischemia in the left MCA territory. The situation described and the poor response to the clinical examination of the patient after the therapeutic measures adopted led to limiting the therapeutic effort, dying 18 days after admission. The case reported, due to its clinical characteristics, is included within the PCA as part of the RCVS, with the peculiarity of its unstoppable poor progression despite the measures taken.3,4 The patient started with IPH, SAH and cerebral edema as complications, and the typical intermittent “thunderclap” headache, refractory to analgesic treatment. The differential diagnosis should be made with other causes of headache and hemorrhage, such as aneurysmal SAH, vasculitis or hematological disorders.5 In this case, the presence of aneurysms or vascular malformations was ruled out by arteriography. The presence of ANA may involve an autoimmune disorder, described in the literature as an occasional concomitant factor.4 In addition, autoimmune thrombocytopenia diagnosed during the first weeks
Eggerthella lenta bacteremia associated to colonic polyps and colon adenocarcinoma夽 Bacteriemia por Eggerthella lenta asociada a poliposis colónica y adenocarcinoma de colon Dear Editor, Phenotypic identification through the introduction of new laboratory technologies such as mass spectrometry Matrix Assisted Laser Desorption/Ionization Time of Flight (MALDI-TOF) has increased awareness of bacteraemia caused by Eggerthella lenta1–3 in clinical practice. The condition is clinically significant and has been mainly associated with abnormalities of the gastrointestinal tract and abdominal origin bacteremia.3–5 We report a case of E. lenta bacteraemia associated with colonic polyps and colon adenocarcinoma. An 82-year-old male with cardiovascular risk factors and a history of normotensive hydrocephalus diagnosed by brain CT scan and infusion test following clinical signs of gait instability and ventriculoperitoneal shunt carrier. In addition, he had Parkinson’s
夽 Please cite this article as: Soldevila Boixader L, Berbel D, Pujol M. Bacteriemia por Eggerthella lenta asociada a poliposis colónica y adenocarcinoma de colon. Med Clin (Barc). 2017;149:418–419.
of gestation may have played a precipitating role in the neurological condition described.5 Frank vasospasm of moderate to large vessels was only evident in some of the angio-CT and arteriographies, demonstrating the reversible and recurrent nature of the arterial narrowing. Conflict of interests The authors declare no conflict of interest. References 1. Singhal AB, Hajj-Ali RA, Topcuoglu MA, Fok J, Bena J, Yang D, et al. Reversible cerebral vasoconstriction syndromes: analysis of 139 cases. Arch Neurol. 2011;68:1005–12. 2. Sorensen DM. Reversible cerebral vasoconstriction syndrome. JAMA Neurol. 2016 Feb;73:232–3. 3. Fugate JE, Wijdicks EF, Parisi JE, Kallmes DF, Cloft HJ, Flemming KD, et al. Fulminant postpartum cerebral vasoconstriction syndrome. Arch Neurol. 2012;69:111–7. 4. Miller EC, Yaghi S, Boehme AK, Willey JZ, Elkind MS, Marshall RS. Mechanisms and outcomes of stroke during pregnancy and the postpartum period: a crosssectional study. Neurol Clin Pract. 2016;6:29–39. 5. Arboix A, Jiménez C, Massons J, Parra O, Besses C. Hematological disorders: a commonly unrecognized cause of acute stroke. Expert Rev Hematol. 2016;9:891–901.
˜ a,∗ , Enrique Chicote Álvarez a , Marisol Holanda Pena José Luis Vázquez Higuera b a
Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain b Servicio de Neurología, Hospital Universitario Marqués de Valdecilla, Santander, Spain ∗ Corresponding author. ˜ E-mail address: [email protected] (M. Holanda Pena).
2387-0206/ ˜ S.L.U. All rights reserved. © 2017 Elsevier Espana,
syndrome with pathological SPECT-DaT-SCAN, under pharmacological treatment with carbidopa–levodopa. The patient went to the emergency room for a 24 h-history of high fever with chills, accompanied by slight abdominal pain and constipation (the latter during several months). He had no headache or nausea. The patient did not report weight loss or other accompanying signs and symptoms. Upon arrival in the emergency room, he presented with hypotension, showing a BP of 96/56 mmHg, HR of 110 bpm and axillary fever of 38 ◦ C. The patient was eupnoeic at rest with a normal general condition. Physical examination showed no neurological focal signs or meningeal stiffness. Cardiorespiratory auscultation was normal. Non-tender abdomen, with preserved peristalsis, without pseudoperitonitis. No masses or organ enlargement. Normal rectal examination. As complementary tests, one blood test and 2 blood cultures were performed, with no significant findings. The infection of the ventriculoperitoneal shunt was assessed as unlikely, and an abdominal ultrasound was performed due to the abdominal symptoms, showing no intra-abdominal complications. Empirical IV antibiotic therapy with amoxicillin–clavulanic 1 g/8 h was initiated pending of blood culture results, assessing as high the probability of abdominal bacteraemia due to the patient’s signs and symptoms, although the complementary tests and physical examination were inconclusive. The patient presented a rapid hemodynamic improvement with serum and antibiotic therapy, maintaining a stable, afebrile and good general condition, with
Letters to the Editor / Med Clin (Barc). 2017;149(9):417–421
no abdominal signs during the Infectious Diseases Unit admission. Blood cultures isolated E. lenta after 3 days of incubation. Given the microbiological findings, an abdominal CT was performed showing colonic diverticulosis. In addition, a colonoscopy was requested in which multiple polyps were observed (in the cecum, ascending colon, transverse colon). One of the polyps was not resectable by endoscopy, becoming a candidate for surgical removal with referral to the high-risk colorectal cancer unit for evaluation. The subsequent anatomical pathology results of one of the polyps were intramucosal adenocarcinoma on tubular adenoma with low and high-grade dysplasia, with neoplasm-free margin. After knowing the antibiotic sensitivity results, with this isolate being sensitive to beta-lactams, clindamycin and metronidazole, it was decided to complete the treatment with oral metronidazole 500 mg/8 h for 14 days. The final diagnosis was E. lenta bacteraemia associated to colonic polyps and adenocarcinoma. E. lenta is an anaerobic, non-sporulated, gram-positive bacillus that forms part of the normal human intestinal microbiome of the Coriobacteriaceae family described for the first time by Eggerth AH in the year 1935.2 Until its genetic characterization in 1999 it was called Eubacterium lentum and the complete genomic sequence was not published until 2009. Published studies of antibiotic sensitivity in E. lenta are rare, but they agree that the treatment of these infections is often empirical.1 Resistance to clindamycin, moxifloxacin, vancomycin, and metronidazole has been reported and in one series resistance was found to penicillin and piperacillin–tazobactam in all isolates, therefore, the latter ones would not be recommended in case of empirical treatment.1,3 Gardiner et al.3 retrospectively described the largest published series of bacteraemia by this gram-positive anaerobic bacillus. Thirty-three patients were analyzed, most of them with positive blood culture at 3 days of incubation. Less than half of the patients had polymicrobial bacteraemia. The most frequent symptoms were fever and abdominal pain and the final diagnosis was variable, with prevalence of colonic involvement in the form of diverticula, intra-abdominal involvement with hollow viscus perforation or abdominal complication (abscess, bleeding, etc.), gastric disease and abdominal neoplasm.4 Asymptomatic bacteraemia in the
Transient antiphospholipid syndrome and splenic infarction in a patient with parvovirus B19 acute infection夽 Síndrome antifosfolípido transitorio e infarto esplénico en un paciente con infección aguda por parvovirus B19 Dear Editor, Acute parvovirus B19 infection usually develops as a mild viral process when it occurs in immunocompetent adults.1 However, it has been suggested that sometimes the cross-reaction of the antibodies against certain regions of the virus triggers the production of antiphospholipid antibodies that, in some cases, is accompanied
夽 Please cite this article as: Márquez Gómez J, Araújo Loperena O, Hernández Toboso S. Síndrome antifosfolípido transitorio e infarto esplénico en un paciente con infección aguda por parvovirus B19. Med Clin (Barc). 2017;149:419–420.
419
context of gastroenteritis is less likely, although it has also been described. It also coincides with this description the previously published retrospective analysis of 25 cases of E. lenta bacteremia.5 It is worth noting that some cases related to genitourinary tract3,5 infection have also been reported. E. lenta bacteraemia is rare and under-recognized. The association of this bacteraemia with colon abnormalities is frequent, from polyps, colonic diverticula and abdominal complications with infection or viscus perforation to uncomplicated gastroenteritis. It is also associated with abdominal neoplasm and, although less frequently, to genitourinary complication and skin and soft tissue infection. In cases of E. lenta bacteraemia, clinicians should rule out associated disease, mostly abdominal, even when the patient does not present acute abdominal symptoms. References 1. Liderot K, Ratcliffe P, Lüthje P, Thidholm E, Özenci V. Microbiological diagnosis of Eggerthella lenta blood culture isolates in a Swedish tertiary hospital: rapid identification and antimicrobial susceptibility profile. Anaerobe. 2016;38:21–4. 2. Eggerth AH. The Gram-positive non-spore-bearing anaerobic bacilli of human feces. J Bacteriol. 1935;30:277–99. 3. Gardiner BJ, Tai AY, Kotsanas D, Francis MJ, Roberts SA, Ballard SA, et al. Clinical and microbiological characteristics of Eggerthella lenta bacteremia. J Clin Microbiol. 2015;53:626–35. 4. Wong D, Aoki F, Rubinstein E. Bacteremia caused by Eggerthella lenta in an elderly man with a gastrointestinal malignancy: a case report. Can J Infect Dis Med Microbiol. 2014;25:e85–6. 5. Venugopal AA, Szpunar S, Johnson LB. Risk and prognostic factors among patients with bacteremia due to Eggerthella lenta. Anaerobe. 2012;18:475–8.
Laura Soldevila Boixader a,∗ , Damaris Berbel b , Miquel Pujol a a
Servicio de Enfermedades Infecciosas, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain b Servicio de Microbiología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain ∗ Corresponding author. E-mail address: [email protected] (L. Soldevila Boixader).
2387-0206/ ˜ S.L.U. All rights reserved. © 2017 Elsevier Espana,
by thrombotic phenomena leading to a transient antiphospholipid syndrome,1 whose clinical and laboratory manifestations revert once the acute infectious process is resolved. We report the case of a young patient with acute parvovirus B19 infection which manifested as fever, hepatosplenomegaly and in which acute hepatitis and splenic infarction were documented. The thrombophilia study was positive for anticardiolipin and lupus anticoagulant antibodies. A 33-year-old man, with no history of interest came to the emergency room for 1-week history of fever, of up to 39 ◦ C and headache. The temperature was 37.5 ◦ C and physical examination revealed painless hepatosplenomegaly. No heart murmurs were heard on auscultation. The laboratory tests showed a mild pancytopenia (Hb 11.8 mg/dl, haematocrit 35.2%, MCV 90.4 fl, MCH 30.3 g/dl, 4110 leukocytes/mm3 [PMN: 77%; L: 15.8%; M: 2.9%]), mild liver function test alterations (GOT/GPT 58/92 U/l, LDH 230 U/l, AP/GGT 142/100 U/l, TB 0.5 mg/dl), impaired coagulation (APTT/APTT ratio 56.5/1.82) and elevated CRP 202 mg/dl. The patient was admitted to our unit for study.
Letters to the Editor / Med Clin (Barc). 2017;149(9):417–421
neuromonitoring in the immediate postoperative period, with figures of ICP within normal levels and sedation break with normal neurological examination. 20 h after surgery there was an increase in ICP, with no response to first-level measures. CT angiography showed acute ischemic infarction in the right anterior cerebral artery (ACA) and the middle cerebral artery (MCA), with a significant expansive effect that determined an uncal herniation, infarction in the left MCA territory with presence of penumbra areas and vasospasm in the proximal segment of bilateral MCA and ACA and basilar artery. Intra-arterial instillation of nimodipine was performed under arteriography, with significant improvement in the immediate period. Within a few hours there was a new ICP elevation and diffuse cerebral edema, deciding to perform a decompressive craniectomy. The subsequent progression was poor, with the onset of new ischemic infarction areas in the right MCA and ACA territory, with significant expansive effect and signs of acute ischemia in the left MCA territory. The situation described and the poor response to the clinical examination of the patient after the therapeutic measures adopted led to limiting the therapeutic effort, dying 18 days after admission. The case reported, due to its clinical characteristics, is included within the PCA as part of the RCVS, with the peculiarity of its unstoppable poor progression despite the measures taken.3,4 The patient started with IPH, SAH and cerebral edema as complications, and the typical intermittent “thunderclap” headache, refractory to analgesic treatment. The differential diagnosis should be made with other causes of headache and hemorrhage, such as aneurysmal SAH, vasculitis or hematological disorders.5 In this case, the presence of aneurysms or vascular malformations was ruled out by arteriography. The presence of ANA may involve an autoimmune disorder, described in the literature as an occasional concomitant factor.4 In addition, autoimmune thrombocytopenia diagnosed during the first weeks
Eggerthella lenta bacteremia associated to colonic polyps and colon adenocarcinoma夽 Bacteriemia por Eggerthella lenta asociada a poliposis colónica y adenocarcinoma de colon Dear Editor, Phenotypic identification through the introduction of new laboratory technologies such as mass spectrometry Matrix Assisted Laser Desorption/Ionization Time of Flight (MALDI-TOF) has increased awareness of bacteraemia caused by Eggerthella lenta1–3 in clinical practice. The condition is clinically significant and has been mainly associated with abnormalities of the gastrointestinal tract and abdominal origin bacteremia.3–5 We report a case of E. lenta bacteraemia associated with colonic polyps and colon adenocarcinoma. An 82-year-old male with cardiovascular risk factors and a history of normotensive hydrocephalus diagnosed by brain CT scan and infusion test following clinical signs of gait instability and ventriculoperitoneal shunt carrier. In addition, he had Parkinson’s
夽 Please cite this article as: Soldevila Boixader L, Berbel D, Pujol M. Bacteriemia por Eggerthella lenta asociada a poliposis colónica y adenocarcinoma de colon. Med Clin (Barc). 2017;149:418–419.
of gestation may have played a precipitating role in the neurological condition described.5 Frank vasospasm of moderate to large vessels was only evident in some of the angio-CT and arteriographies, demonstrating the reversible and recurrent nature of the arterial narrowing. Conflict of interests The authors declare no conflict of interest. References 1. Singhal AB, Hajj-Ali RA, Topcuoglu MA, Fok J, Bena J, Yang D, et al. Reversible cerebral vasoconstriction syndromes: analysis of 139 cases. Arch Neurol. 2011;68:1005–12. 2. Sorensen DM. Reversible cerebral vasoconstriction syndrome. JAMA Neurol. 2016 Feb;73:232–3. 3. Fugate JE, Wijdicks EF, Parisi JE, Kallmes DF, Cloft HJ, Flemming KD, et al. Fulminant postpartum cerebral vasoconstriction syndrome. Arch Neurol. 2012;69:111–7. 4. Miller EC, Yaghi S, Boehme AK, Willey JZ, Elkind MS, Marshall RS. Mechanisms and outcomes of stroke during pregnancy and the postpartum period: a crosssectional study. Neurol Clin Pract. 2016;6:29–39. 5. Arboix A, Jiménez C, Massons J, Parra O, Besses C. Hematological disorders: a commonly unrecognized cause of acute stroke. Expert Rev Hematol. 2016;9:891–901.
˜ a,∗ , Enrique Chicote Álvarez a , Marisol Holanda Pena José Luis Vázquez Higuera b a
Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain b Servicio de Neurología, Hospital Universitario Marqués de Valdecilla, Santander, Spain ∗ Corresponding author. ˜ E-mail address: [email protected] (M. Holanda Pena).
2387-0206/ ˜ S.L.U. All rights reserved. © 2017 Elsevier Espana,
syndrome with pathological SPECT-DaT-SCAN, under pharmacological treatment with carbidopa–levodopa. The patient went to the emergency room for a 24 h-history of high fever with chills, accompanied by slight abdominal pain and constipation (the latter during several months). He had no headache or nausea. The patient did not report weight loss or other accompanying signs and symptoms. Upon arrival in the emergency room, he presented with hypotension, showing a BP of 96/56 mmHg, HR of 110 bpm and axillary fever of 38 ◦ C. The patient was eupnoeic at rest with a normal general condition. Physical examination showed no neurological focal signs or meningeal stiffness. Cardiorespiratory auscultation was normal. Non-tender abdomen, with preserved peristalsis, without pseudoperitonitis. No masses or organ enlargement. Normal rectal examination. As complementary tests, one blood test and 2 blood cultures were performed, with no significant findings. The infection of the ventriculoperitoneal shunt was assessed as unlikely, and an abdominal ultrasound was performed due to the abdominal symptoms, showing no intra-abdominal complications. Empirical IV antibiotic therapy with amoxicillin–clavulanic 1 g/8 h was initiated pending of blood culture results, assessing as high the probability of abdominal bacteraemia due to the patient’s signs and symptoms, although the complementary tests and physical examination were inconclusive. The patient presented a rapid hemodynamic improvement with serum and antibiotic therapy, maintaining a stable, afebrile and good general condition, with
Letters to the Editor / Med Clin (Barc). 2017;149(9):417–421
no abdominal signs during the Infectious Diseases Unit admission. Blood cultures isolated E. lenta after 3 days of incubation. Given the microbiological findings, an abdominal CT was performed showing colonic diverticulosis. In addition, a colonoscopy was requested in which multiple polyps were observed (in the cecum, ascending colon, transverse colon). One of the polyps was not resectable by endoscopy, becoming a candidate for surgical removal with referral to the high-risk colorectal cancer unit for evaluation. The subsequent anatomical pathology results of one of the polyps were intramucosal adenocarcinoma on tubular adenoma with low and high-grade dysplasia, with neoplasm-free margin. After knowing the antibiotic sensitivity results, with this isolate being sensitive to beta-lactams, clindamycin and metronidazole, it was decided to complete the treatment with oral metronidazole 500 mg/8 h for 14 days. The final diagnosis was E. lenta bacteraemia associated to colonic polyps and adenocarcinoma. E. lenta is an anaerobic, non-sporulated, gram-positive bacillus that forms part of the normal human intestinal microbiome of the Coriobacteriaceae family described for the first time by Eggerth AH in the year 1935.2 Until its genetic characterization in 1999 it was called Eubacterium lentum and the complete genomic sequence was not published until 2009. Published studies of antibiotic sensitivity in E. lenta are rare, but they agree that the treatment of these infections is often empirical.1 Resistance to clindamycin, moxifloxacin, vancomycin, and metronidazole has been reported and in one series resistance was found to penicillin and piperacillin–tazobactam in all isolates, therefore, the latter ones would not be recommended in case of empirical treatment.1,3 Gardiner et al.3 retrospectively described the largest published series of bacteraemia by this gram-positive anaerobic bacillus. Thirty-three patients were analyzed, most of them with positive blood culture at 3 days of incubation. Less than half of the patients had polymicrobial bacteraemia. The most frequent symptoms were fever and abdominal pain and the final diagnosis was variable, with prevalence of colonic involvement in the form of diverticula, intra-abdominal involvement with hollow viscus perforation or abdominal complication (abscess, bleeding, etc.), gastric disease and abdominal neoplasm.4 Asymptomatic bacteraemia in the
Transient antiphospholipid syndrome and splenic infarction in a patient with parvovirus B19 acute infection夽 Síndrome antifosfolípido transitorio e infarto esplénico en un paciente con infección aguda por parvovirus B19 Dear Editor, Acute parvovirus B19 infection usually develops as a mild viral process when it occurs in immunocompetent adults.1 However, it has been suggested that sometimes the cross-reaction of the antibodies against certain regions of the virus triggers the production of antiphospholipid antibodies that, in some cases, is accompanied
夽 Please cite this article as: Márquez Gómez J, Araújo Loperena O, Hernández Toboso S. Síndrome antifosfolípido transitorio e infarto esplénico en un paciente con infección aguda por parvovirus B19. Med Clin (Barc). 2017;149:419–420.
419
context of gastroenteritis is less likely, although it has also been described. It also coincides with this description the previously published retrospective analysis of 25 cases of E. lenta bacteremia.5 It is worth noting that some cases related to genitourinary tract3,5 infection have also been reported. E. lenta bacteraemia is rare and under-recognized. The association of this bacteraemia with colon abnormalities is frequent, from polyps, colonic diverticula and abdominal complications with infection or viscus perforation to uncomplicated gastroenteritis. It is also associated with abdominal neoplasm and, although less frequently, to genitourinary complication and skin and soft tissue infection. In cases of E. lenta bacteraemia, clinicians should rule out associated disease, mostly abdominal, even when the patient does not present acute abdominal symptoms. References 1. Liderot K, Ratcliffe P, Lüthje P, Thidholm E, Özenci V. Microbiological diagnosis of Eggerthella lenta blood culture isolates in a Swedish tertiary hospital: rapid identification and antimicrobial susceptibility profile. Anaerobe. 2016;38:21–4. 2. Eggerth AH. The Gram-positive non-spore-bearing anaerobic bacilli of human feces. J Bacteriol. 1935;30:277–99. 3. Gardiner BJ, Tai AY, Kotsanas D, Francis MJ, Roberts SA, Ballard SA, et al. Clinical and microbiological characteristics of Eggerthella lenta bacteremia. J Clin Microbiol. 2015;53:626–35. 4. Wong D, Aoki F, Rubinstein E. Bacteremia caused by Eggerthella lenta in an elderly man with a gastrointestinal malignancy: a case report. Can J Infect Dis Med Microbiol. 2014;25:e85–6. 5. Venugopal AA, Szpunar S, Johnson LB. Risk and prognostic factors among patients with bacteremia due to Eggerthella lenta. Anaerobe. 2012;18:475–8.
Laura Soldevila Boixader a,∗ , Damaris Berbel b , Miquel Pujol a a
Servicio de Enfermedades Infecciosas, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain b Servicio de Microbiología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain ∗ Corresponding author. E-mail address: [email protected] (L. Soldevila Boixader).
2387-0206/ ˜ S.L.U. All rights reserved. © 2017 Elsevier Espana,
by thrombotic phenomena leading to a transient antiphospholipid syndrome,1 whose clinical and laboratory manifestations revert once the acute infectious process is resolved. We report the case of a young patient with acute parvovirus B19 infection which manifested as fever, hepatosplenomegaly and in which acute hepatitis and splenic infarction were documented. The thrombophilia study was positive for anticardiolipin and lupus anticoagulant antibodies. A 33-year-old man, with no history of interest came to the emergency room for 1-week history of fever, of up to 39 ◦ C and headache. The temperature was 37.5 ◦ C and physical examination revealed painless hepatosplenomegaly. No heart murmurs were heard on auscultation. The laboratory tests showed a mild pancytopenia (Hb 11.8 mg/dl, haematocrit 35.2%, MCV 90.4 fl, MCH 30.3 g/dl, 4110 leukocytes/mm3 [PMN: 77%; L: 15.8%; M: 2.9%]), mild liver function test alterations (GOT/GPT 58/92 U/l, LDH 230 U/l, AP/GGT 142/100 U/l, TB 0.5 mg/dl), impaired coagulation (APTT/APTT ratio 56.5/1.82) and elevated CRP 202 mg/dl. The patient was admitted to our unit for study.