P0685 CLOSTRIDIUM DIFFICILE: UNTREATABLE?

P0685 CLOSTRIDIUM DIFFICILE: UNTREATABLE?

S224 Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283 Case re...

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S224

Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283

Case report: First case: A 72 -year old man was admitted to a hospital because of alteration of general state and fever, consciousness loss with hyponatremia. His mental disturbance and hyponatremia gradually improved by supplementing NaCl and fluid restriction; Tubercle bacilli were detected from the sputum by the Ziehl-Neelsen staining. The Intradermo- reaction was highly positive. The chest X-ray film was normal. He was medicated with the standard antituberculosis drugs with fluid restriction. Second case: A 69 year-old woman with the chief complaint of anorexia and polyadenopathies was referred with suspicion of pulmonary tuberculosis. The serum level of natrium and osmolarity was 122 mEq/l and 265 mOsm/kgH2O, respectively, and urine level of natrium and osmolarity was respectively of 123 mEq/l and 394 mOsm. Intradermo- reaction was highly positive but direct microscopy of sputum smear was negative for acid-fast bacilli. Adenectomia showed “Necrotic granulomatous lymphadinite”. We made a clinical diagnosis of ganglionnary tuberculosis with SIADH based on detailed examinations. Treatment was started with the combination of isoniazid (INH), rifampicin, piazoline and ethambutol, Water restriction and i.v. physiological saline. Conclusion: SIADH should be considered when hyponatremia was occurred in the case of ganglionnary tuberculosis.

P0684 A CASE OF VIRAL ACUTE PANCREATITIS IN A YOUNG HEALTHY WOMAN

Marta Rosário, Nuno Ruano, Carlos Bastos, Conceição Quadrado. Hospital De Santa Maria Acute pancreatitis is thought to result from “escape” of activated pancreatic enzymes from acinar cells into surrounding tissues. Most are related to biliary tract disease (gallstones) or heavy alcohol intake. However there are enormous lists of causes of acute pancreatitis. Viral pancratitis is infrequent but have been described in association with mumps and coxsackievirus infections. Here the authors present a case of acute pancreatitis in a young and healthy woman with 20 years that came to the emergency service with fever, weakness, nausea and vomiting. She has been medicated with metoclopramide and ciprofloxacin. She didn’t get well so she return to the emergency. Laboratory findings: elevation of serum lipase and amylase, acute renal failure with elevation of serum creatinine, elevation of hepatic enzymes (AST, ALT, GGT, FA); she has also high total cholesterol and triglycerides. She has been internated for study in Internal Medicine Service. During the investigation we’ve done serologies to HIV 1 and 2 and hepatitis that became negative. The abdominal ultrasonograghy didn’t shoe anything abnormal, and excludes gallstones. Admitting possible salmonella infection we started therapeutic with cotrimoxazole that ended on 5th day for negative widal reaction and also negative blood and stool cultures. TC-scan abdominal reveles nothing abnormal. The patient get well, clinical and laboratorial, and get home waiting for some result of exams (serology’s: toxoplasmosis, Coxsackie’s, Q fever, leptospira, other infectious diseases). Return one month later to the follow-up consult, feeling better, and with serology IgM positive to coxsackie and IgG negative. The other serology’s were negative. With this case we want to show how important is to be atent to less frequent causes of abdominal pain especially if the complaints do not resolve with usual treatment.

P0685 CLOSTRIDIUM DIFFICILE: UNTREATABLE?

Sérgio Janeiro, Ana Margarida Fernandes, Sónia Serra, Maria Clara Rosa, Mário Parreira, Ermelinda Pedroso, Manuel Lourenço. Centro Hospitalar De Setúbal, E.p.e. - Internal Medicine The authors present the case of an 82 year old man, admitted to the cardiothoracic ward for excision – biopsy of a malignant lung tumor. This internment was complicated with hospital acquired pneumonia, successfully treated with piperacillin + tazobactam, but followed by aqueous diarrhea, Clostridium difficile toxin positive. He was transferred to the Internal Medicine ward, completing a ten day course of antibioterapia with oral methronidazol and vancomycin. The patient was discharged, asymptomatic, with a negative stool culture. A week later, our patient was readmitted with diarrhea, presenting the same characteristics. A fibrorectosigmoidoscopy revealed “pseudomembranes in all the observed extension” in rectum and sigmoid. Positive Clostridium difficile toxin. Again, we began treatment with oral methronidazol and vancomycin.

After 16 days, in spite subjective improvement, he maintained liquid diarrhea and positive toxin. New endoscopic exam revealed “some pseudomembranes in the rectum”. Then, we introduced the administration of vancomycin as a retention enema, 500mg every 12h, keeping oral methronidazol. With this new therapeutic approach, in eighteen days the patient was asymptomatic, with several negative Clostridium results, and a colonoscopy revealing “absence of pseudomembranes in all the extension observed”. The authors consider about therapeutic alternatives in cases of refractory or recidivate pseudo membranous colitis, frequent in elderly or immune compromised patients.

P0686 FREQUENCY OF PSYCHIATRIC COMORBIDITY IN PATIENTS WHO START TREATMENT OF HEPATITIS C VIRUS (HCV)

Jose Joaquin Portu Zapirain 1 , Ainara Jimenez Angulo 3 , Paola Tarabini-Castellani Ciordia 1 , Itziar Frago Marquinez 1 , Naiara Parraza Diez 2 , Sonia San Miguel Lopez De Uralde 1 , Gorka Arroita Gonzalez 1 , Mikel Aldamiz-Echebarria San Sebastian 1 . 1 Txagorritxu Hospital, Vitoria, Spain; 2 Research Unit of Alava, Vitoria, Spain; 3 Drug Additcion Treatment Centre, Vitoria, Spain Introduction: Psychiatric comorbidity is frequent in hepatitis C virus (HVC)infected patients with history of substance abuse, and both are the most common reasons for no inclusion in treatment. Despite the drop in rates of new HCV diagnoses, the rates of people with HCV and mental diseases is increasing. Objectives: To quantify the psychiatric comorbility in patients with history of substance abuse who have started HCV treatment. Methods: Patients with history of substance abuse treated of HCV in the period 2001-2008. According to code CIE-10, associated psychiatric comorbidity is analyzed and also human immunodeficiency virus (HIV) coinfection. Results: Of 111 patients HCV-HIV coinfected, 97,3% of whom had history of substance abuse, 17,1% (n=19) had associated psychiatric comorbility (5,3% schizophrenia, schizotypal and delusional disorders; 36,8% affective disorders; 21,1% neurotic, stress-related and somatoform disorders and 36,8% disorders of adult personality and behaviour). Of 62 HCV monoinfected patients, 98,4% of whom had history of substance abuse, 21% (n=13) had associated psychiatric comorbility (15,4% organic mental disorders; 7,7% schizophrenia, schizotypal and delusional disorders; 53,8% affective disorders; 15,4% neurotic, stress-related and somatoform disorders and 7,7% disorders of adult personality and behaviour). Discussion & conclusion: It is frequent the presence of psychiatric comorbidity in patients with history of substance abuse. A multidisciplinary approach is essential in order not to discriminate against patients with psychiatric comorbility who are subsidiary to HCV treatment. This work has partially been financed by Caja Vital Kutxa. Keywords: Treatment of Hepatitis C Virus, Psyquiatric comorbidity

P0687 EVOLUTION OF COMMUNITY ACQUIRED PNEUMONIA ACCORDING TO SEVERITY AT ADMISSION IN PATIENTS REQUIRING HOSPITALIZATION

Marco Antonio Bustamante Araujo, Claudia Erika Delgado Espinoza, Angel Nieto Sanchez, Maria Moreno Moreno, Nike Sanchez Martin, Rodrigo Sanz Lorente. Hospital Clinico San Carlos Introduction: Community acquired pneumonia (CAP) is still one of the most important causes of hospitalization in Internal Medicine departments. Many scores have been developed for helping physicians in order to decide for example who patients need admission or which antibiotic should be used. Pneumonia Severity Index (PSI), one of that scores, is used in several emergency departments because its usefulness have been demostrated. Objectives: To describe the evolution of community acquired pneumonia according to severity of illness at admission. Other objectives were to describe the associated comorbidities, antibiotics used and microbiologic findings. Materials & methods: A descriptive, retrospective study was designed. We included all patients who were discharged with diagnosis of CAP between July to December 2007. Patients were classificated in grades of severity according to PSI (grades I to V). Median of hospitalizaton stay and mortality according to severity at admission were analyzed. Epidemiologic data, comorbidities and antibiotic use were analyzed as well. Results: 88 clinical records were evaluated (62% male), median of age was